INFORMATION GOVERNANCE
Kpatel
TheTransformingWorldofHealthInformationManagement.pptxChapter 1
The Transforming World of Health Information Management
The Case for an Enterprise Solution
The St. Rita’s Case
Who appointed the EIM team?
CIO Joan Morton
Why was EIM the team appointed?
Sort out the root causes of data integrity issues at St. Rita’s
Determine the feasibility of developing an enterprise division to assure data integrity
The St. Rita’s Case
The initial members of the EIM team
Denise – HIM professional
Bob – Business analyst
Linda – Decision support analyst
Val – Project manager
Shirlee – Clinical analyst
Monte – Systems analyst
The St. Rita’s Case
The EIM team’s charge
Study St. Rita’s data problems
Recommend new ideas and improvements
Assess feasibility of an EIM division
Develop an action plan to implement improvements
Enterprise Information Management
Enterprise information management (EIM)
A set of functions used by organization to plan, organize, and coordinate people, processes, technology, and content for managing information as a corporate asset that ensures data quality, safety, and ease of use.
Data Governance
Data governance (DG)
A specific EIM function that supports coordination among all other EIM functions by establishing data standards, policies, procedures, and accountabilities that span the entire organization.
Definition of health information
Definition of Health Information
Definition dependent upon the context
Information about health science and health-related issues published by an authoritative source
For example, journals, magazines, web sources
Secondary patient-related data
For example, aggregated data in registries
Primary patient-related data
For example, specific patient data used for healthcare delivery
Electronic Health Records: Differing Definitions
EMR – Electronic medical record
Electronic record
Health-related information about an individual
Is created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization
National Alliance for Health Information Technology
Electronic Health Records: Differing Definitions
EHR – Electronic health record
Electronic record
Health-related information about an individual
Conforms to nationally recognized interoperability standards
Is created, gathered, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
National Alliance for Health Information Technology
Electronic Health Records: Differing Definitions
PHR – Personal health record
Electronic record
Health-related information about an individual
Conforms to nationally recognized interoperability standards
Is drawn from multiple sources
Managed, shared, and controlled by the individual
National Alliance for Health Information Technology
Complexity of data flow and retrieval
Clinic Appointment and Visit Example
Healthcare Data Flow Across Users
Healthcare Information Exchanges (HIEs)
Federal-state collaboration
Enable and expand secure electronic movement and use of health information among organizations
Goal is to improve quality and efficiency of healthcare
HIE Example
Health Information Content
Clinical Documentation Definition
Documentation that is a detailed account of pertinent facts, findings, and observations relating to a patient’s health history, examinations, tests, treatments, procedures, and supportive care
Primary communication tool among healthcare providers
Facilitates patient care planning and care
Clinical Documentation Uses
Supports:
Direct patient care
Evaluation of the appropriateness, adequacy, and outcomes of healthcare delivery
Clinical research
Meeting accreditation and legislative mandates
Reimbursement claims
Risk management
Clinical Documentation Best Practices
Best practices must be followed to support clinical documentation uses:
Policies must be established
Procedures to implement policies must be implemented
Monitoring of compliance with policies and procedures must be in place
Legal and Administrative Documentation
Supports:
Administrative functions
Demographic information
Insurance information
Legal requirements
Meet accreditation standards
Comply with legislative or regulatory mandates
Consents
Authorizations and acknowledgements
Uses and Users of Health information
Primary Uses of Health Information
Uses that support the delivery of patient care:
Patient uses
Patient care delivery uses
Patient care management uses
Patient care support uses
Business and legal uses
Secondary Uses of Health Information
Uses that influence the environment in which patient care is delivered:
Education uses
Accreditation, licensure, regulation, legal uses
Research uses
Public health uses
Policy making uses
Users of Health Information
Healthcare delivery organizations
Quality management and monitoring organizations
Reimbursement services organizations
Research and data collection organizations
Educational institutions
Healthcare accreditation agencies
Policy-making bodies and organizations
ST. Rita’s EIM Team first steps
EIM Team Consensus
Starting point for an EIM program:
Target initial efforts to internal users of health information with an eye toward data exchange and interoperability
Full spectrum of EHR functionality must be a goal pursued by St. Rita’s Healthcare System
External users would be downstream beneficiaries
