HM311

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Introduction to Information Systems
for Health Information Technology
Chapter 6: Computers in Health Information Management
© 2020 American Health Information Management
Association

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Learning Objectives
Identify the information systems needed to support efficient
operations in the health information management (H I M) department
Differentiate between the various software products used in the H I
M department
Improve the quality of the data within the H I M systems

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Introduction
Health informatics: The scientific discipline concerned with
cognitive, information-processing, and communication tasks of
healthcare practice, education, and research, including information
science and technology to support these tasks

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Computers in H I M, 1
Release of information (R O I) and disclosure management systems
Encoder and grouper system
Cancer and other registry systems
Chart locator system
Birth certificate system

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Computers in H I M, 2
Chart deficiency system
Transcription system
Healthcare quality indicators system
Dictation system
Computer-assisted coding (C A C) system
Clinical documentation improvement (CDI) system

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Release of Information and Disclosure Management
Systems
Release of information (R O I) system: Manages the processing of
requests for protected health information (P H I) received and
processed by the H I M department
Disclosure management system: Tracks the disclosures made
throughout the healthcare facility for reporting purposes.
Disclosure: The release, transfer, provision of access to, or
divulging in any manner of information outside the healthcare facility
holding the information

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R O I Functionality
R O I staff also can use the system to check on the status of
requests
Status of a request must be updated and kept current:
• Details about issues encountered,
• Need for review by risk management,
• Need for health record or microfilm to be pulled, or
• Other action required

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R O I Data Elements, 1
Patient name
Health record number
Patient type
Date request received
Type of requester

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R O I Data Elements, 2
Name of requester
Name of contact at requester
Address of requester
Type of request (insurance, patient, attorney, or patient care)

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R O I Data Elements, 3
Assigned to
Action taken (request completed, type of letter sent, records
requested, valid authorization needed, etc.)
Date action taken
Date request completed
Information sent (specific documents and dates of reports)

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R O I Data Elements, 4
Charges
Amount paid
Amount due
Comments

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R O I Reports, 1
Requests that have not been processed
Requests that have been processed
Turnaround time of requests
Revenue collected
Accounts receivable

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R O I Reports, 2
Productivity by individual staff members
Overall productivity
List of frequent requesters
Multiple customized letters

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Customized Letters/Forms, 1
Notify requester that healthcare facility does not have record of the
patient being treated at the healthcare facility or on that date
Remind requesters they have an outstanding balance for copies of
health records
Request that copies of health records be paid prior to their release

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Customized Letters/Forms, 2
Provide cover letter for health records being sent
Notify requester that the authorization is invalid
Notify requester that an authorization is needed
Notify requester that there will be a delay in the release of the
information

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Customized Letters/Forms, 3
Notify requester the health records will be released as soon as
healthcare facility has received prepayment for copies
Generate invoices for copies of health record
Generate reminder invoices when payment is not received in a
timely manner

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R O I System Functionality
Monitor efficiency of R O I staff through multitude of management
reports
Information on various functions: turnaround times, productivity,
backlogs, revenue, and accounts receivable
Report include requests by employee, by requester type, by specific
requester, or all requests

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Encoder and Grouper, 1
Encoder: Specialty software used by coders to select the
appropriate code for the diagnosis(es) and procedure(s) supported
by the health record
Grouper: Software that uses specific data elements to assign the
diagnostic and procedural codes entered into the encoder into the
appropriate Medicare severity diagnosis-related group (MS-DRG) or
other diagnosis-related group (DRG)

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Types of Encoders, 1
Rules-based encoder
• Requires coder to type in name or portion of name of diagnosis or procedure
• Entry into the encoder generates a list of suggestions from which the coder
selects

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Types of Encoders, 2
Automated codebook encoder
• Lists diagnoses and procedures in alphabetic order much like the alphabetic
index located in
• International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
• Current Procedural Terminology (CPT) code books

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Encoder and Grouper, 2
Most common groupers are the MS-DRG grouper and ambulatory
payment classification (APC) grouper
Other insurers, including some Medicaid programs, have developed
their own groupers for use in determining payment to the healthcare
facility

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Encoder and Grouper Functionality
Coding quality and MS-DRG assignment are not ensured using an
encoder
• Code selected is only as good as the data entered into the information system
One of the biggest advantages in the use of an encoder or grouper
is prompts

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Data Elements Needed, 1
Admitting diagnosis
Principal diagnosis
Secondary diagnoses
Principal procedure
Secondary procedure
Age of patient (or date of birth)

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Data Elements Needed, 2
Discharge disposition
Gender
Patient name
Health record number
Account number

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Encoder and Grouper System Reporting
Does not contribute heavily to reporting
Encoder used to assign codes and MS-DRGs using edits to assist
the coder in proper assignment of codes and other information
transferred to the hospital financial system
The information system may be used to generate a report listing all
of the codes and respective MS-DRGs or APCs assigned
MS-DRG and APC analysis

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Cancer and Other Registries, 1
A registry is a collection of care information related to a specific
disease, condition, or procedure that makes health record
information available for analysis and comparison
Registries track conditions such as cancer, diabetes, trauma, and
transplants
Generally require basic demographic information, reporting,
treatment, description of condition, and frequently long-term patient
tracking

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Cancer and Other Registries, 2
Commonly found data elements across registries include
• Patient name
• Health record number
• Dates of service
• Physician
• Date of birth
• Date of diagnosis

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Cancer (Tumor) Registry
Cancer registry information system: Tracks information about the
patient’s cancer from the time of diagnosis to the patient’s death

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Data Elements, 1
Site of cancer
Type of cancer
Treatment received
Date of last contact
TNM (tumor, node, metastasis) stage
Number of lymph nodes involved

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Data Elements, 2
Behavior type
Date of death
Grade of neoplasm
Size of mass
Physician name
Accession number

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Cancer Registry Functionality
Once data on all identified cancer cases for an identified time period
(usually monthly) are verified by the cancer registrar (or designee) of
the HCO
Programmed report is automatically generated and transmitted to
respective state-wide cancer registry normally housed in the state’s
Department of Health

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Cancer Registry Reporting
Management reports
• Productivity
• Reports on the content of the registry
Common reports include
• Life expectancy
• Follow-up rate
• List of patients due for follow-up
• Patients lost to follow-up
• Follow-up letters to patients and physicians

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Trauma Registry
Tracks patients with traumatic injuries from initial trauma treatment
to death

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Trauma Registry Functionality and Reporting, 1
Site of injury
Type of injury
How injury occurred
Date of injury
Time of injury
Work-related injury

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Trauma Registry Functionality and Reporting, 2
ICD-10-CM and ICD-10-PCS codes
Safety equipment
Registry number
Autopsy performed
Emergency department arrival time

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Trauma Registry Functionality and Reporting, 3
Outcomes
Follow-up rates
Best practices for patient care
I S would provide statistics on cause of injuries, types of injuries, and
other descriptive statistics (ICD-10-CM codes)

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Chart Locator System
Chart locator system (chart tracking system): Designed to
identify the current location of the paper health record
Tracking important because paper records are moved from place to
place for patient care, quality reviews, coding, etc.
The Joint Commission regulations require health records be readily
accessible for patient care

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Chart Locator System Functionality and Reporting
The data in chart locator system identifies
• Where the record is currently physically located
• How long it has been in that location
• When the record is due for return to the H I M department
• When a record is overdue to be returned
• Who checked out the health record

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Data elements in chart locator system, 1
Patient name
Health record number
Volume
Location to which the record is checked out

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Data elements in chart locator system, 2
Date record checked out
Date record returned
Who checked out/checked in the record

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Chart Locator System: Functionality & Reporting
Management uses chart locator reporting for multiple purposes
• Identification of most user requests of health records
• Productivity tracking
• Identification of trends in the volume of health record retrievals
• And identification of areas of the healthcare facility for which records are not
returned in a timely manner

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Chart Deficiency, 1
Documentation requirements based on accreditation regulations,
state licensure regulations, federal requirements, and other
standards or regulations that the HCO is subject to
Specific documentation requirements mandate when reports such as
the history and physical examination should be dictated or written
Should also mandate content of various reports analyzed and
deadline by which entire health record should be complete

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Chart Deficiency, 2
Deficiencies in paper, imaged, or electronic records depending on
the I S
With imaged or electronic records, physician can complete
• Office
• Home
• Other location
Paper records must come to the designated area in the HCO

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Common Data Elements, 1
Patient name
Health record number
Discharge date
Physician needing to complete deficiency

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Common Data Elements, 2
Type of document with deficiency (for example, history and physical
examination, discharge summary, or progress note)
Type of deficiency (for example, sign or dictate)
Date of surgery
Comments
Date physician last worked on records

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Chart Deficiency System: Functionality and Reporting
Used to age deficiencies for Joint Commission tracking
Generate report listing all physicians suspended for delinquent
health records—an incomplete record not finished or made complete
within the time frame determined by the medical staff of the facility
• Track when physicians are suspended (for use in medical staff credentialing)
• Monitor the volume of deficiencies by physician and service

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Birth Certificate System
Reports births occurring in the healthcare organization to state
health agency
Birth certificate software will capture the minimum data set
Content established by the National Center for Health Statistics
(NCHS) and any state-required data

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Birth Certificate Information Systems Functionality, 1
Collecting data mandated by NCHS
Reporting standard information such as name of healthcare
organization automatically
Allowing users to choose from obstetrical physicians table
Capturing demographic information from hospital information system
to improve efficiency

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Birth Certificate Information Systems Functionality, 2
Preventing omissions of required data before birth certificate is sent
to the state using mandatory fields and edit checks
Submitting birth certificate data to the health department
Submitting parent’s request for social security number to the Social
Security Administration

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Birth Certificate Information Systems Functionality, 3
Printing out data captured for parent(s) to proof
Creating birth log, eliminating need for paper log
Using drop-down boxes to improve data consistency
Using edits to improve data quality
Allowing parent(s) to order copy of birth certificate

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Birth Certificate System Functionality and Reporting
Generate statistical reports such as caesarean section rate or
trending births rates
Key reporting capability is the ability to report births to the state in
the approved format
State may use birth certificate data reported via birth certificate
system to feed other databases, such as immunization registry to
enhance tracking of childhood immunizations

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Dictation and Transcription Systems, 1
Dictation system
• Used by physicians to dictate various medical reports
• History and physical examinations
• Discharge summaries
• Radiology reports
• Autopsy reports
• Catheterization reports
• Other designated reports into the dictation system

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Dictation and Transcription Systems, 2
Dictating is the process of recording a physician’s voice as he or she
verbally describes a scenario, problem note, or some other type of
report that is recorded electronically

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Dictation and Transcription Systems: Functionality and
Reporting, 1
Transcription is the process of deciphering the provider’s recorded
dictation and typing the medical document
The transcription system should be interfaced with the hospital
information system so that the patient name, health record, and date
of service are already populated within the information system

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Dictation and Transcription Systems: Functionality and
Reporting, 2
Key reporting focus for dictation system is workload
System is able to track volume of work dictated and how much is
remaining to be transcribed

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Dictation and Transcription Systems: Functionality and
Reporting, 3
Information can be used to determine
• Transcription staffing levels
• Overtime workload justifications
• Trends and patterns in dictation usage
Expander: Allows transcriptionists to type acronyms such as “CHF”
and the full phrase “congestive heart failure” will automatically be
spelled out
• Saving keystrokes and time
• Can typically be controlled by the HCO

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Dictation and Transcription Systems: Functionality and
Reporting, 4
Transcription software products are designed to work seamlessly
with
• Dictation systems
• Voice recognition systems
Promote efficiency in the entire process
Designed for transcriptionists to work from home as appropriate

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Dictation and Transcription Systems: Functionality and
Reporting, 5
Track productivity
• Critical because transcriptionists usually are paid based on it
Calculate incentive pay (bonuses and rewards) automatically based
on criteria established by the healthcare facility
Monitor overall volume by report type to help identify trends and
needs

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Healthcare Quality Indicator
Abstracting system that records information about the patient, the
care provided to the patient, and the healthcare practitioner(s)
involved in the care delivered
Abstracting: Process of extracting information from document or
data elements from a database to create a brief summary of
patient’s illness, treatment, and outcome and entering summary into
an automated system
A quality indicator is a standard against which actual care may be
measured to identify a level of performance for that standard

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Healthcare Quality Indicator: Functionality and Reporting
Reports may include:
• Monitoring healthcare facility infection rate
• Number of deaths by physician
• Blood incompatibility
• Surgical errors
• Maternal deaths
• Outcomes

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Computer-Assisted Coding (C A C) System, 1
Computer-assisted coding (C A C) system: Analyzes the clinical
data found in an electronic health record
• C A C is the process of extracting and translating dictated and then transcribed
free-text data (or dictated and then computer-generated discrete data) into
ICD-10-CM, ICD-10-PCS, and CPT procedural codes and evaluation and
management codes for billing and coding purposes

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Computer-Assisted Coding (C A C) System, 2
Uses natural language processing (NLP) to analyze clinical data to
identify diagnoses and procedures and to assign the appropriate
ICD-10-CM, ICD-10-PCS, and CPT code to the C A C system
NLP: Technology that converts human language (structured or
unstructured) into data that can be translated then manipulated by
information systems

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Computer-Assisted Coding System: Functionality and
Reporting
C A C system generates productivity reports
Can generate reports on number of health records where the codes
were changed from what the software originally recommended
Reports are important to evaluate quality, accuracy, & completeness
of codes generated by the C A C system
Evaluation or review can be combined with financial information to
determine what impact this may have on reimbursement claims &
revenue cycle functions

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Clinical Documentation Improvement
CDI: The process a healthcare entity undertakes that will improve
clinical specificity and documentation that will allow coders to assign
more concise disease and procedural classification codes

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Clinical Documentation Improvement: Functionality and
Reporting
Clinical documentation improvement (CDI) system assists in
identifying ways to improve clinical documentation in the health
record