The document discusses the functions, purpose, and users of health information. It describes the primary purposes of the health record as patient care, management of patient care, and administrative processes. Some key users of health records are healthcare providers, patients, researchers, and various institutional organizations. The document also outlines health information management functions in both paper-based and electronic environments, such as record processing, clinical coding, and the release of patient information.

1. © 2016
Chapter 3: Health Information
Functions, Purpose, and Users
Health Information Management
Technology: An Applied Approach
Introduction
• Who, what, when, why, and how of patient
care
• Data
• Information
Primary Purposes of the Health Record
• Patient care
• Management of patient care
• Administrative processes
Secondary Purposes

2. • Education of healthcare professionals
• Legal, accreditation, and policy development
• Public health and research
Formats of the Health Record
• Paper health record
• Electronic health record
• Hybrid health record
Users of the Health Record
• Healthcare providers are primary users
o Uses
• Patient record
• Aggregated
• De-identification
Users of the Health Record
• Individual Users

3. o Patient care providers
o Patient care managers and support staff
o Coding and billing staff
o Patients
o Employers
o Lawyers
Users of the Health Record
• Individual users continued
o Law enforcement officials
o Healthcare researchers and clinical investigators
o Government policy makers
Users of the Health Record
• Institutional users
o Healthcare delivery organizations
o Third-party payers
o Medical review organizations

4. o Research organizations
o Educational organizations
Users of the Health Record
• Institutional users continued
o Accreditation organizations
o Government licensing agencies
o Policy-making bodies
HIM Functions
• Common HIM functions
o Record processing
o Monitoring of record completion
o Transcription
o Release of patient information
o Clinical coding, abstracting and clinical data
analysis

5. HIM Functions
• Other functions
o Research and statistics
o Registries
o Birth and death certificates
HIM Functions
• Work with other departments
o Patient care
o Information governance
o Quality management
o Billing
o Patient registration
Master Patient Index
• Permanent record of all patients treated at
facility
o Demographics
o Used in numeric filing system

6. o Enterprise master patient index
Master Patient Index – Recommended
Core Data Elements
• Internal patient
identification
• Person name
• Date of birth
• Gender
• Race
• Ethnicity
• Address
• Telephone number
• Alias, previous, or maiden
names
• Social Security number
• Facility identification
• Universal patient identifier
• Account or visit number
• Admission or visit number
• Admission, encounter, or
visit data
• Discharge or departure date
• Encounter service type
• Encounter primary
physician
• Patient disposition

7. Master Patient Index
• Quality issues in MPI systems
o Typographical errors
o Outdated demographic information
o Incorrect names
o Duplicate
o Overlay
o Overlap
Master Patient Index
• MPI quality control
o Algorithms
• Deterministic
• Probabilistic
• Rules-based
Identification Systems

8. • Health record number: a unique identifier
• Paper-based health record
o Serial numbering
o Unit numbering
o Serial-unit numbering
o Alphabetic
Identification Systems
• Electronic health records
o Unit health record
o Patient account number
HIM Functions in Paper-Based
Environment
• Record storage and retrieval functions
o Alphabetic
o Numeric
• Straight numeric
• Terminal–digit

9. • Alphanumeric
o Centralized unit
HIM Functions in Paper-Based
Environment
• Record storage and retrieval functions
o Filing cabinets
o Shelving units
• Open
• Compressible
HIM Functions in Paper-Based
Environment
• Purging of health record depends on:
o Space
o Readmission rate
o Access to record
HIM Functions in Paper-Based

10. Environment
• File folder
o Color coding
• Microfilm
o Roll
o Jacket
o microfiche
HIM Functions in Paper-Based
Environment
• Off-site storage
o Facility or commercial company
o Protect records
• Privacy
• Physical
o Access
HIM Functions in Paper-Based
Environment

11. • Image-based
o Scanned document
o Index
o Cannot search
HIM Functions in Paper-Based
Environment
• Retrieval and tracking
o Outguide
o Loose material
o Requisition
o Chart tracking system
HIM Functions in Paper-Based
Environment
• Record processing of paper-based records
o Organize
o Meet standards
o Record reconciliation

12. o Assembly
o Analysis
• Qualitative
• Quantitative
HIM Functions in Paper-Based
Environment
• Completion
o Incomplete record
o Delinquent record
HIM Functions in Paper-Based
Environment
• Corrections
o Draw line
o Write “error”
o Sign, date and time correction
• Addendum
o Date of addendum
o Signed and timed
• Amendment
o Dated, timed, and signed

13. HIM Functions in Paper-Based
Environment
• Forms design
o Easy to use
o Include all necessary data
o Users involved in development
HIM Functions in Paper-Based
Environment
• Form design principles
o Unique form identification
o Date created or revised
o Title
o Facility name and logo
o Patient identification information
o Signature line
HIM Functions in Paper-Based
Environment

14. • Form design principles
o Content in order of data entry, if appropriate
o OCR and barcodes – upper corner
o 8.5 x 11
o Black ink on white paper
o Sufficient space to write
HIM Functions in Paper-Based
Environment
• Clinical forms committee
o Interdisciplinary
o Standards for forms
o Tracking system
o Testing and evaluation of forms
o Approve new and revised forms
o Storage, inventory and distribution
o Database
HIM Functions in Paper-Based

15. Environment
• Quality control
o Standards
o Monitoring
• Misfiles
• Timeliness of storage and retrieval
o Record completion
HIM Functions in an Electronic
Environment
• Electronic health record
• Reducing storage of paper records
• Audit trail
• Indexing
• Record completion
• Work queue
HIM Functions in an Electronic
Environment

16. • Version control
• Free text
• Structured data
HIM Functions in an Electronic
Environment
• Copy and paste
o Inaccurate or outdated information
o Redundant information
o Inability to identify the author or intent of
documentation
o Inability to identify when the documentation was first
created
o Propagation of false information
o Internally inconsistent progress notes
o Unnecessarily lengthy progress notes
HIM Functions in an Electronic
Environment
• Digital dictation
• Voice recognition
o Natural language processing
• Reconciliation

17. • “other” documentation
o E-mail, voice mail, EKG, and more
HIM Functions in an Electronic
Environment
• Materials from other facilities
o Policies
o State laws
o Consult attorney
• Search, retrieve, and manipulate health data
o Data mining
HIM Functions in an Electronic
Environment
• Amendments and corrections
o Lock documents when authenticated
o Control who can unlock
o Share change with other systems

18. HIM Functions in an Electronic
Environment
• Quality control
o Control data entered in EHR
• Scanning
• Data entry
• Barcodes
• Transfer of data
HIM Functions in an Electronic
Environment
• Quality control
o Data entry
• Input mask
• Drop down box
• Check box
• Radio buttons
HIM Functions in an Electronic

19. Environment
• Screen design
o Clear navigations buttons
o Labeling of buttons and fields
o Limit abbreviations
o Consistent location of navigation buttons
o Alerts
o References
o Check
HIM Functions in an Electronic
Environment
• Screen design
o Logical organization
o Neutral colors
o Undo buttons
o Confirmation buttons
o Require fields
o Title for screen

20. HIM Functions in an Electronic
Environment
• Screen design
o Minimize keystrokes
o Appropriate field type
o Select from predefined lists when possible
o Data validation checks
Hybrid Record
• Part paper and part electronic
• Processes for both used
• Document management system
o Workflow
• Difficult to identify legal health record
Medical Transcription
• HIM or centralized department
• Outsourcing

21. o Liaison
• Commonly transcribed documents
o History and physical
o Discharge summary
o Pathology report
o Radiology report
Medical Transcription
• Monitor document for quality and timeliness
• Speech recognition
o Front-end
o Back-end
Release of Information
• Receive request for patient information
• Ensures request is appropriate
• Provides patient information
• Monitor quality of release and timeliness
• Record what is released

22. Clinical Coding
• Assign codes to diagnoses and procedures
• Abstracting
o Date of surgery
o Surgeon
o Disposition
HIM Interdepartmental Relationships
• Patient registration
• Billing department
• Patient care departments
• Information systems
• Quality management
• Virtual HIM
HIM Software
• Release of information

23. • Chart tracking
• Coding
• Registries
• Billing
• Quality improvement
HIM Software
• Electronic health record
o Meaningful use
• Certified electronic health record
• Personal health records