Unit 1


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Unit 1

  1. 1. Hospital and Healthcare Information Management Unit 1Unit 1 Introduction to Health Information ManagementStructure1.1 Introduction Learning Objectives1.2 Basic terms and functions of HIM Definition of a Hospital Information Management Health Information Management1.3 Transition from Medical Records to Health Information Management Common Functions of Health Information Professionals Job Responsibilities of various groups of staff1.4 Evolving Role of Health Information Evolving Role of Health Information Health Information Consultant Services1.5 Managing the Transition1.6 Summary1.7 Terminal Questions1.8 Answers1.1 IntroductionThis unit is going to introduce you to health information management. Thepurpose of this book is to equip you with the necessary knowledge on healthinformation management and how important is its role for the success andefficacy of the health care system. In this unit you will be reading about thebasic terms that will be used throughout the book.ObjectivesAfter reading the chapter you should be able to: Define Health Information and Health Information Management Tell the functions of health information management Explain the transition of Medical Records to Health Information ManagementSikkim Manipal University Page No.: 1
  2. 2. Hospital and Healthcare Information Management Unit 1 List the functions and job responsibilities of Health Information Management Professionals Describe the evolving role of health information1.2 Basic terms and functions of Health Information ManagementThe scope and functions of a hospital have undergone tremendous changesin the last century. In the early days the functions of a hospital were mainlycurative; in other words hospitals existed mainly to treat and cure the sick.Over the years, the preventive and rehabilitative aspects also began to berecognized as important functions of a hospital. Preventive functionsincluded immunization, health education, early detection of diseases,antenatal care etc. Rehabilitation meant not only physical but also socialand psychological restoration. Many hospitals started to reach out tocommunities and help people in their environment, rather than wait forpatients to come to the hospital. In addition to the curative, preventive andrehabilitative functions, which are known as “service functions”, certain otherfunctions such as teaching, training, research also started to gain importance.With the enormous number of services being added into the healthcarespectrum, managing the healthcare information became important.Before we go into the management of Health Information System, it will beuseful to have an understanding of the basic terminologies.Definition of a hospital: Considering the scope, functions and philosophyof hospitals in the present scenario, the WHO defined a hospital as:“Hospital is an integral part of the social and medical organization of thecommunity, the functions of which are complete health care, and whoseoutpatient services reach out to the family in its home environment; it is alsoa centre for training of hospital/health workers and provides facilities forbiosocial research”.American Hospital Association defines a hospital as a health care institutionwith an organized medical and professional staff, and with patient bedsavailable round-the-clock, whose primary functions are to provide inpatientmedical, nursing and other health-related services to patients for bothsurgical and non surgical conditions, and that usually provides someoutpatient services, particularly emergency care.Sikkim Manipal University Page No.: 2
  3. 3. Hospital and Healthcare Information Management Unit 1Information Management: The process of planning, organizing, directingand evaluating systems for collecting, maintaining, analyzing anddisseminating the data and information resources of an organization.Health Information Management: It is the profession that focuses onhealthcare data and the management of healthcare information resources.This stream addresses the nature, structure, and translation of data intousable forms of information for the advancement of health and healthcare ofindividuals and populations.Health information professionals collect, integrate, and analyze primaryand secondary health care data; disseminate information; and manageinformation resources related to research, planning, provision, andevaluation of health care services.Self Assessment Questions1. In earlier times, hospitals existed only for to offer ___________ services.2. What is the difference between information management and health information management?3. Over the years ________________ and _____________ aspects were also considered as functions of the hospital.4. Give the WHO definition of a hospital.5. _________________ is the process of planning, organizing, directing and evaluating systems for collecting, maintaining, analyzing and disseminating the data and information resources of an organization.6. _______________ is the profession that focuses on healthcare data and the management of healthcare information resources.1.3 Transition from Medical Records to Health InformationManagement (HIM)The terms health information and health information management are usedthroughout this unit to represent the medical record and medical recorddepartment. In the early 1990’s the American Medical Record Association(AMRA) changed its name to the American Health Information ManagementAssociation (AHIMA) to better reflect the role of the medical recordprofessional. The new terminology recognized the maintenance of clinicalinformation in a variety of formats, and the evolution of the role of a medicalSikkim Manipal University Page No.: 3
  4. 4. Hospital and Healthcare Information Management Unit 1record director to one whose role is to manage health information beyondthe medical record.Common functions performed by Health Information ProfessionalsA professional in health information should be able to perform and train onall of the functions of a Health Information Coordinator, as well as many ofthe functions of the Health Unit Coordinator. The following functions areunique to the role of health information professional. Ability to provide assistance and function as a key resource for the development, transition, and maintenance of an electronic medical record. Assist with implementation and function as a key resource on the Health Insurance Portability and Accountability Act (HIPAA) including information system security issues and privacy. Provide expertise on compliance issues and the integration of clinical documentation and coding with the billing process. Develop, implement and monitor health information department policy and procedures and job descriptions. Make recommendations or assist with implementation of corporate policies. Provide training and orientation to health information personnel on functions of the department and staff on documentation. Develop and maintain health information systems and processes that meet regulatory requirements (both state and federal), professional practice standards, legal standards, and management/corporate policy. Establish a process for systematically reviewing documentation on an ongoing basis for both quality and quantity of documentation. Ability to complete documentation/medical record audits and monitoring with an ability to assess the quality of documentation. Ability to recommend corrective actions for findings on medical record audits/monitoring. Initiate clinical record systems and indexes. Assist with forms development and forms analysis/flow. Support compliance process of facility/organization. Support quality assurance/quality improvement process of the facility/organization.Sikkim Manipal University Page No.: 4
  5. 5. Hospital and Healthcare Information Management Unit 1 Train staff on quality assurance/quality improvement process related to health information management and appropriate methods for the collection of data. Provide resources to the facility on health information, documentation, regulations, standards of practice, etc. Develop consultation reports in a timely manner. Communicate findings and recommendations effectively to hospital administration and interdisciplinary team members. Maintain good communication with MRD (Medical Records Department) staff and interdisciplinary team members. Empower MRD staff to work independently.Job responsibilities of a qualified HIM professionalThe following functions are recommended for a credentialed healthinformation practitioner, and represent the core functions for healthinformation. MRD size, admission and discharge rates, department staffingand other non-HIM responsibilities assigned to the position should all beconsidered when developing the final job description for an MRD staff. In adepartment that also employs health unit coordinators; some of thefunctions outlined may be managed by this position but performed by thehealth unit coordinator.1. Supervisory/Management Functions Maintain current policy and procedures and job descriptions for the health information department. Manage human resource functions for the department including interviewing, hiring, staff scheduling, performance evaluation, disciplinary actions, and termination. Supervise health information staff to assure staff competency and performance. Provide guidance, motivation and support to health information staff. Monitor department budget as directed. Serve as the Privacy Officer under HIPAA (Health Information Portability and Accountability Act of 1996 United States) and may serve as the Security Officer depending on expertise and facility need.Sikkim Manipal University Page No.: 5
  6. 6. Hospital and Healthcare Information Management Unit 12. Quality Monitoring and Quality Assurance Functions Participate in the quality assurance committee and process. Optional: Coordinate the quality assurance program. Maintain a qualitative and quantitative audit/quality monitoring process. Collect and report data from audit findings to QA committee. Report, monitor and follow-up on problems/concerns. Maintain routine audit and monitoring systems (admission, MDS, concurrent, acute problem, discharge) and focus audits on problem areas, QA concerns, and Quality Indicator and survey issues.3. Health Information Policy Management Functions Maintain security of health information systems and medical records. Assure physical protection is in place to prevent loss, destruction and unauthorized use of both manual and electronic records. For example, assure safeguards are in place such as record sign-out systems, assignment of computer passwords/log-ons, and systems for securing file cabinets and file rooms where overflow and discharge records are stored. Assure systems are in place to maintain confidentiality of both manual and electronic health information. Manage the release of information functions for the hospital including review and processing of all requests for information. Maintain hospital policies and standards of practice to assure release of information requests are appropriate and meet legal standards. Maintain a forms management system for development, review, and reproduction of forms. Maintain a master forms manual. Maintain systems for filing, retention and destruction of overflow/thinned records and discharge records. Develop systems for retention and destruction of medical records stored in an electronic format. Complete hospital statistical reports such as monthly statistics, daily census, and licensure reports as applicable. Participate in meetings and committees such as daily stand-up, administrative/department head, quality assurance/quality improvement, and Medicare documentation review. Provide in-service education as applicable on health information issues.Sikkim Manipal University Page No.: 6
  7. 7. Hospital and Healthcare Information Management Unit 1 Provide orientation to new employees on topics such as the medical record organization and content, record completion, confidentiality, documentation standards and error correction procedures. Support and assist in carrying out corporate compliance initiatives as assigned by administrator. Manage the credentialing process for physicians and other professional staff when applicable.4. Computerization/Automation Understand all aspects of clinical computer system. Participate in decisions related to the computer system, including systems selection, planning, and future expansion. Provide resources for training on computer system and use of clinical applications.Self Assessment Questions 7. List the common functions performed by health information professional. 8. What are the job responsibilities of a qualified HIM professional? 9. The expansion of MRD is _____________.10. The expansion of HIPAA is ___________.1.4 Evolving Role of Health InformationAs computerization continues to evolve, the role of the HIM practitioner willalso change. Although some traditional functions in maintenance of amanual record may be eliminated, new issues will take their place. The HIMrole will continue to be responsible for oversight of confidentiality,compliance, privacy and security management programs, ongoing auditingof the electronic medical record, and audit trails. HIM practitioners should beresponsible for orientation and ongoing training of clinical staff on theinformation system, and overall administration of the information system.Even with a computerized record system, many of the routine HIM functionswill still need to be carried out.With the implementation of HIPAA (United States), the HIM practitioner willsee new roles as a privacy officer and possibly a security officer. Expertiseon code sets will also be necessary for proper coding and reporting underSikkim Manipal University Page No.: 7
  8. 8. Hospital and Healthcare Information Management Unit 1the federal regulation. The HIM role in corporate compliance and billingshould also evolve to assure that documentation supports services billed bythe provider.Health Information Department StaffingStaffing the health information department is based on five criticalissues: The time requirements for functions under the responsibility of the health information department Patient acuity and complexity. Census based on number of inpatients Number of patient exchanges (admission, discharge, hospital transfer and hospital return). Availability of information technology.Health Information Consultant ServicesA health information consultant provides a healthcare provider or corporateoffice with professional expertise on health information, medical records,and documentation based on their education, skills and experience. At atime in the industry when quality of documentation for survey and litigation,coding, confidentiality and security are emerging as critical issues; theconsultant is an invaluable resource for a provider. Consultants provideassistance with monitoring potential fraud and abuse issues, assistance withcorporate compliance plans, and evaluation of documentation that supportsthe billing process.Self Assessment Questions11. Which are the criteria to be considered for health information department staffing?1.5 Managing the transition: Challenge to Health InformationProfessionalsThe 20 years spanning 1990 to 2010 will mark the active development anddeployment of computer-based and electronic patient records as a unifyingprinciple within organizational clinical information systems. The tasks beforehealth information professionals focus on multiple parallel efforts. Stagingthe technology development and deployment is only one facet of this longSikkim Manipal University Page No.: 8
  9. 9. Hospital and Healthcare Information Management Unit 1range goal. A number of coordinated milestones must be acknowledged andappropriate management direction adopted. Let us consider a set ofessential activities that must occur. We need to lead and facilitate theseactivities, so that moving ahead to technology improvements becomesfeasible, particularly in the direction of the EHR (Electronic Health Records).Here are some ideas for moving ahead now:a) Educate health care organizations, practitioners, and consumers to prepare them for the changes. The technology today invites those in health care organizations to communicate with their peers, their practitioners, and their patients in new and innovative ways. Educating users to rely on computers to supply their data needs is a continuing agenda for professional organizations and institutions. This educational initiative requires that we track the progress of EHR developments. We need to understand clearly how EHR advances affect documentation, as well as patient data availability for the care process. We know, for instance, that record availability issues decrease when information can be retrieved through a local workstation. The consumer will also need education as we become more efficient in delivering and coordinating consumers. As providers can rely on up-to-the-minute data and research to communicate with patients, we will foster a different kind of patient – one who can function as a stronger member of the health care team.b) Recognize that the technology itself must be in place. Electronic data system and the networks required to link them within organizations continue to be dependent on fundamental and affordable technology. Foundation systems are needed to provide daily transaction processing for all health services, and enough workstations, must be deployed to afford clinicians ready and rear-to-care access. Until there are sufficient numbers, the shift to replacing the dependence on paper and increasing direct dependence on paper and increasing direct use of computer systems by providers will not occur. For many organizations, this will take up the better part of the next decade. On the business operations side, managers are already expected to use computers in their own daily activities, including budgeting, data analysis, and writing and communication. Active participation in planning and implementation of technology within organizations will strengthen manager’s skills and better prepare them to understand technological needs.Sikkim Manipal University Page No.: 9
  10. 10. Hospital and Healthcare Information Management Unit 1c) Address the crucial acceptance factors: This includes working to secure sponsor endorsement, engaging clinical “champions” to assist in marketing to their peers, and selecting and marketing demonstration pilots to move ahead in incremental steps. Ease of use is a crucial acceptance factor for workstations. Another acceptance issue is the necessary preparation to manage confidentiality adequately. Patients, and those associated with the user communities, are concerned about privacy and worry about who has access to their data. This is likely that we will need participation in public forums on this topic.d) Model demonstrated quality and cost incentives to encourage individual organizations to adapt aggressive programs: To do this, a sound business cost-benefit rationale is required. Closer scrutiny will be directed to systems development projects to be sure that clear cost containment targets are included in the planning, and the opportunity for “nice-to-have computer system” will give way to “cost-justified computer systems”. Managers will apply cost-benefit tools in their forecasting with greater discipline than ever before. A realistic analysis is essential. For example, consider bringing transcription reports or consultation referral letters on line to build components of EHR in your organization. As an HIM manager, be sure you fully understand the business process and current costs of transcription. Gather facts about bringing transcription on line experienced by peer organizations, including production increases or decreases, to demonstrate full understanding of cost. Then make the case.e) Upgrade organizational policies and procedures to redefine the patient record and move from a paper record to a combined record: This work can be led at national and state association levels, as well as within individual institutions. We need to find ways to combine multimedia patient health information into a clinically designated “virtual” record. This helps formalize the data system’s content as part of the patient record. f) Coordinate programs that stage EHR related development within information systems master plans: This endorses the concept of a unifying principle. Institutional strategies serve as the basis for incremental steps to automate more and more clinical data. Some of these go hand in hand to cover the most return on investment and at theSikkim Manipal University Page No.: 10
  11. 11. Hospital and Healthcare Information Management Unit 1 same time, extend value added to multiple customers. Systems must become more affordable, dependable, and useful to more customers. A new clinical laboratory system, added to a large organization’s integrated clinical systems development plan, can drive the results reporting for clinicians and send data to a clinical repository in which a growing EHR is maintained. It may also offer a new service to generate mailed test result reports to patients. Your organization may be in the process of providing increasing patient data from laboratory and pharmacy to radiology images, electrocardiograms, and more to a clinical data repository or data warehouse. It is important to contribute to and use a master information technology plan to map out and confirm a step-wise process that builds toward EHR systems.g) Endorse and support revised legal frame works so that federal and state legislation allows the transition from paper to electronic media to occur: State laws are in the progress of being realigned with federal requirements in these areas. New definitions of the patient record accepted changes in storage requirements, and automated authentication techniques are all needed to advance the work.h) Find ways to deliver better clinical information from the current information systems now: Propose that EHR components be introduced, evaluated, and rapidly deployed. The best illustration of this strategy is the production of mini summaries that show the “patient at a glance,” for example, problem list, medications, and laboratory test results or a specific patient care plan, perhaps designed to manage a chronic disease. This strategy focuses on the experience that bringing technology to the eager customers first- particularly clinicians- accelerates technology diffusion. Happy customers market the technology most effectively. At this point in health information systems development, there are many demonstrations that illustrate this experience. If we provide new data or data in new and more effective formats, clinical customers will be more willing to modify their data collection behaviors to contribute the value added. i) Monitor the work on clinical guidelines and protocols and find ways to introduce them into the organization: Not only are they needed for reasonable support to medical providers, but they are clearly a resource for inclusion in EHR systems. In the simplest form, guidelines can beSikkim Manipal University Page No.: 11
  12. 12. Hospital and Healthcare Information Management Unit 1 stored electronically and lookup features can be provided. In the more sophisticated approaches, organizations may tailor guidelines for internal use and may incorporate advice and reminder protocols in developing systems. Experiments that connect individual patient data to guidelines to offer feedback before, during, and after the care delivery process will best illustrate the requirements expected of EHR systems. Today, the event monitoring capability places this process in the decision support realm. j) Study the known barriers already published to develop action plans to overcome them – learn from others mistakes: We need to survey the deployment tactics and identify the success benchmarks. Sharing experiences with other organizations will help to develop a collective wisdom as we move to such new environment. To illustrate a simple case, many health professionals have not learned to type. This means that introducing computer systems – even point-of-care systems – to personnel who do not possess simple keyboarding skills, will require expensive pertaining in the technology itself before a specific application can be taught. Time is also needed to adjust from character-based terminal screens to the newer graphical user interfaces. It must be clear that newer user interface styles are going to be more effective. In some cases, such as a high-volume prescription data entry function, icons and a Windows user interface style may not be the most efficient for the organization, but evidence indicates that the interface benefits have led to easier and more intuitive learning for information system users.k) Lead and participate in reengineering current user processes: We need to prepare the operational environment for change. One of the driving forces of this decade is reengineering. We have learned that simply installing computer systems for existing business processes fails to realize the benefits. Business processes, the way we move patients through appointment, check-in, care, and follow-up, must be reexamined. Along with other business processes, this work flow requires careful review to see if there are more efficient ways to accomplish it. This would apply to the way we organize and use the patient record content and formats. The notion of continuously improving our business processes to be sure that the best methods are in place fits in with the total quality management philosophy and practices that haveSikkim Manipal University Page No.: 12
  13. 13. Hospital and Healthcare Information Management Unit 1 been used with positive results since the late 1980s. We can expect to reengineer the way patients are seen and treated for long-term services and to update the processes used to move the information around and use it more effectively. Reengineering means fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in the performance such as cost, quality, service, and speed. Considering that providers are expected to incorporate new technology in direct are practices, examining how data capture and retrieval can occur most efficiently can lead to better alternatives. l) Once an EHR project is under way, incorporate a thorough knowledge of the impact of change on the workforce into strong project leadership from a top-down approach: We know that technology affects organizational culture, including structure and design. It changes work flows and brings in new job designs and responsibilities. Staff requires new skills and knowledge to perform their work. Worker motivation and incentives call for new communications and operations policies and procedures to build the kind of strong teamwork required to absorb change. Human resources personnel are strategic partners for all managers in the long-term change agent tasks, and new skills are required for managers as well as workers. Assembling and participating in strong teams are essential. HIM professionals are already assuming leadership roles with project management requirements.Self Assessment Questions12. What is the role of Health Information Professionals in reengineering current user processes?13. What is the role of Health Information Professionals in EHR Project? Activity Visit a Healthcare Centre near your location and ask them whether they are using Information system. If yes, find about the advantages of Health Information system.Sikkim Manipal University Page No.: 13
  14. 14. Hospital and Healthcare Information Management Unit 11.6 SummaryThe medical record professional plays a major role in the ever-expandinghealth care field. To provide competent assistance to health professionalsinvolved in the complex process of quality patient care, he is called upon toadvance daily by continuing his own education and maintaining a thoroughknowledge of his specialty. The health information professional oftendonates valuable time and assistance to health care administrative activitiesand other health related organizations and agencies to advance the art andscience of medical record administration.Glossary Terms Description Healthcare The efforts taken by professionals to restore and maintain health of people Health Information It is the profession that focuses on healthcare data and Management the management of healthcare information resources. This stream addresses the nature, structure, and translation of data into usable forms of information for the advancement of health and healthcare of individuals and populations HIM professional Is one who work on the Health Information Systems EHR Electronic Health Record. Systematic collection of electronic health information about patients.1.7 Terminal Questions1) Discuss the transition of Medical Records to Health Information Management.2) What are the challenges faced by the Health Information Professionals as a result of transition? How should they manage?Sikkim Manipal University Page No.: 14
  15. 15. Hospital and Healthcare Information Management Unit 11.8 AnswersSelf Assessment Questions 1. Curative 2. Information management is a general term. For this you have to write about basic management functions. And for health information management you have to specify the management functions taken up for handling the patient health information. 3. Preventive and rehabilitative 4. Refer 1.2 5. Information management 6. Health Information Management 7. For this you have to list the various management functions generally taken up by the medical record officer. The function includes the management and handling of patient information for analysis and also for providing reports for various impersonal uses of medical records. 8. For this additional management functions which have been delegated to the qualified HIM professional have to be performed. The functions like supervisory functions, quality assurance, quality monitoring, and management of various policies restricted to patient information control and computerization of the information have to be discussed. 9. Medical Records Department10. Health Information Portability and Accountability Act11. Refer to section 1.4. Five criteria given in this section have to be listed for this answer.12. Refer to section 1.5 point k. You have to include how reengineering and redesigning can change radical redesign of business processes to achieve dramatic improvements in the performance such as cost, quality, service, and speed. As the providers are expected to incorporate new technology into their practices, examining how data capture and retrieval can occur most efficiently, you can suggest better alternatives.13. Refer to section 1.5 point l. For this you have to know about EHR and its advantages over the paper source and computerized medical records. For this project you have to do data designing and format designing for the system.Sikkim Manipal University Page No.: 15
  16. 16. Hospital and Healthcare Information Management Unit 1Terminal Questions1) Refer to section 1.3. For answering this question you have to first understand the trend of health care delivery systems. From the crude early documentation methods the evolution of current trends should be discussed (refer Management of medical records by Edna Huffman). Various management functions taken up by health information professionals must be listed.2) Refer to section 1.5. This answer should cover all the points given in this section from the challenges faced by the HIM professions due to transition from paper source medical records to EMR. It should include all the points from orientation programs to health care providers and caregivers, teaching programs about the technology, policies and procedures to be followed and various guidelines for reengineering process and system designing.Sikkim Manipal University Page No.: 16