Health Care Informatics

LESSON 11 Organizing and Protecting Health Information LECTURE NOTES ______________________________________________________________________________________

Organization and Structure of Health Records To be usable, the health record must be organized in a fashion that allows users to quickly find

the section of the record they need to review and provide their services. For paper-based records,

a chart is used, such as a three-ringed binder or other such device, to hold the information. Some

form of organization of the chart is adopted across an organization, and the information is

arranged in a similar format for ease of training and access to records. As the record or chart is

typically located in a central file or rack, access to the record is easy for both authorized and

unauthorized users.

For the electronic health record, the information is accessed via a device that provides a visible

screen for the user to view the information. This typically requires a user name and password to

enter the record system. It allows the record to be more secure than a paper-based system and

can be programmed to allow access to only certain areas by the user. The organization of the

record is somewhat dependent on the software being used, but some customization is typically

required and is allowed as part of the software system.

HIPAA and Security As we have mentioned in other lessons, being able to access the health record in a safe and

secure mode has become a critical challenge for the health information specialist. If access is

heavily restricted, a user might be unable to access the patient’s record, treatment could be

delayed, or an error in treatment could occur. However, if access is too easy, unauthorized

individuals might gain entry into the health record. Policies and procedures are necessary to

maintain the balance. For the electronic health record, the use of software solutions is required

to assure that only authorized individuals access the proper location and information for a

patient.

Primary and Secondary Health Records The primary record is considered to be the collection of information about a specific patient. This

would include the patient’s history, current state of health, observations by the providers, tests

provided, treatments ordered and provided, a record of outcomes, and other forms, documents, and

information needed to effectively care for the patient.

Secondary health records are those documents that are extracted from individual patient records.

Logs are a secondary record and are frequently used to list patients who utilize services for a

specific event. A delivery log is an example of this. Information about each patient who

delivers a baby in a hospital is entered into a delivery log with predefined information gathered

for each delivery. An operating room log is another example that might be used to record what

patient received which procedure as well as what health care professionals were involved in the

procedure.

These logs are typically considered to be an internal document that a health care organization

maintains for their own use. However, they are often required for mandatory reporting to state

and federal agencies and are used to monitor performance, track community-wide health events

(disease outbreaks), or used for statistical purposes in reporting health care outcomes.

Indexes (or indices) are used in health care organizations so that specific information can be

maintained. The basic indices that virtually all health care organizations maintain are the master

patient index (MPI), the disease or diagnosis index (DI), the procedure index, and the physician

index. For example, each of these indices enables a health care organization to readily identify

the health record pertaining to a specific patient. Another example would be if a hospital wants

to analyze the efficacy of their surgical department. Their procedure index would allow them to

identify and further study the record of each surgery performed within a specific time frame.

Registries contain disease or event information. This information is gathered by health care

organizations but is generally provided to outside entities as well. For example, California has a

birth defects monitoring registry. State law requires that health care organizations provide

specific information to a nonprofit organization regarding infants who are noted to have birth

defects. This nonprofit organization is contracted with the state to track birth defects and look

for causation, which is part of the quality improvement process. Such information could lead to

the adoption of evidence-based practices that may provide better patient outcomes.

Records Storage A requirement for any health information department is to create policies, procedures, and

protocols for the safe and secure storage of health information records, regardless of whether

they are in a paper-based format or they are full electronic records. The information needs to be

safe, yet accessible, for the health care provider to retrieve. There are rules and requirements

developed by governmental entities and voluntary organizations for the storage and retention of

health records, and they may vary by jurisdiction. Such requirements might include retention

time periods, charges for copying records, destruction of records, access to records, etc.

Other Areas of Technology

There are other areas of health care delivery that have technology systems that need to be included in

the health record. They supply critical information for providers so they can access the record as

needed to diagnose, order treatments, and otherwise assess patients. This includes the pharmacy,

laboratory, radiology (imaging), social services, therapists, dietitians, etc. These ancillary service

providers have record systems that may be in multi-formats that need a location in either the paper or

electronic version of the health record.

For example, image recording has moved from a film-based X-ray to an electronic X-ray, called

PACS. These images can be put onto paper but are best viewed on a computer or other projection

system such as a computer monitor. For paper-based systems, the image is printed on paper and then

stored in the record. For electronic-based systems, the image is stored in the system and then

accessed through the use of imaging software.