Hth 1304, health information technology and systems 1

1. HTH 1304, Health Information Technology and Systems 1
Course Learning Outcomes for Unit V
Upon completion of this unit, students should be able to:
3. Summarize current issues related to health information
systems.
3.1 Describe data collection issues that could arise in specific
health information systems.
4. Differentiate various health information standards in terms of
their ability to support the requirements
of a health care enterprise.
4.1 Describe a specialized health information system used in
specific health care departments.
Course/Unit
Learning Outcomes
Learning Activity
3.1
Unit Lesson
Chapter 3

2. Unit V Research Paper
4.1
Unit Lesson
Chapter 3
Unit V Research Paper
Required Unit Resources
Chapter 3: Sources of Data
Unit Lesson
Modern health care has vastly expanded and grown into a wide-
ranging industry involving many different
scopes of medical practice and expertise. This expansion of
health care services has given birth to a variety
of health care facilities and health care settings that specialize
in certain areas of medicine. This unit will build
on what you have learned about data sets, code sets, and data
collection and provide a deeper insight on
how specific care settings collect, transmit, and analyze health
information. From outpatient care to inpatient
care, there are dozens of care settings that use information
differently and follow different regulations set by
licensing entities. As a health information management (HIM)
professional, it is important to be familiar with
how different health care settings’ information systems operate
and what potential issues could arise from
those systems. Below are various health care settings and brief
outlines of their functions and characteristics
about their health information systems.

3. Ambulatory Surgical Facilities
The terms ambulatory care and outpatient care can be used
synonymously as both of these terms refer to
care where the patient is not admitted to a hospital and usually
only receives care for a maximum of 24 hours.
With this knowledge, ambulatory surgery is defined as an
outpatient medical operation where the patient is
released shortly after the procedure. These types of facilities are
becoming more popular as they are often
less expensive and lack other liabilities. One attractive feature
of ambulatory surgical facilities is their
separation from inpatient surgery centers where the risk for
exposure to germs, viruses, and bacteria is
higher. Patients in inpatient care are often admitted to recover
from diseases and/or illnesses making the
inpatient setting more susceptible to surgical infection. HIM
professionals who code for ambulatory services
use the procedural coding system health care common procedure
coding/current procedure terminology
(HCPCS/CPT) as there are no diagnostic services offered in this
setting. Reimbursement professionals
dealing with ambulatory surgeries use the UB-04 claim form to
bill for services provided.
UNIT V STUDY GUIDE
Care Settings and Health
Information Management

4. HTH 1304, Health Information Technology and Systems 2
UNIT x STUDY GUIDE
Title
Physician Office
Doctor visits are another type of ambulatory service. These
outpatient facilities vary in locale as some are
adjacent to major hospitals while some are attached to the
physician’s home (Davis & LaCour, 2017). In this
care setting, the physician is usually the primary care provider,
and physicians may partner with each other
and operate with a shared interest in the facility. This is called a
group practice. Physicians’ offices are a
common and popular care setting with a familiar health care
workflow. A patient sets an appointment with a
physician, is then seen by the physician who conducts an
examination on the patient, and finally, the
physician makes a medical decision regarding a treatment plan.
While these are the major workflow stages of
a doctor’s visit, there are more intricate steps that take place i n
between them in which information is sent and
received through many channels. This care setting uses the
diagnostic tool ICD-10-CM, which stands for
International Classification of Diseases, 10th revision, Clinical
Modification, to code for diagnoses as well as
HCPCS/CPT to code for supplies, procedures, and services.
HIM professionals for this care setting uses the
CMS-1500 health insurance claim form.
Dialysis Centers

5. Dialysis centers are also considered ambulatory or
outpatient settings. Dialysis is the removal of waste products
from a patient’s bloodstream (Davis & LaCour, 2017). These
types of facilities have become widespread, and the need
for these facilities has grown as our country deals with
increased health problems that require the purifying of
blood. Kidney disease is a major cause for dialysis
treatments, and the demand for this service is high, which is
one reason why dialysis centers now have their own identity
and have separated themselves from hospitals. Like other
ambulatory services, coders in dialysis facilities use the
procedural coding system HCPCS/CPT.
Emergency Departments
One of the more well-known outpatient
facilities is known as the Emergency
Department/EmergencyRoom or (ED/ER).
EDs offer a wide range of services for issues
ranging from minor respiratory problems to heart attacks.
Patients seen in the ED are often
dealing with more serious or even life-threatening injuries, and
during the registration process,
the level of severity is determined. Trauma patients or patients
at higher risk of severe morbidity
or mortality are given priority. There is a great benefit provided
if EDs are part of a hospital. If,
after the ED examination, it is determined that the patient needs
to be admitted to the hospital,
the patient is easily transitioned into inpatient care. As you can
imagine, data collection in EDs
can be hectic if an effective system is not in place. EDs usually
use multiple data sets as well as
a combination of paper and electronic collection methods. HIM

6. professionals who code for EDs
use the procedural coding system HCPCS/CPT as well as ICD-
10-CM. Reimbursement
professionals working in EDs use the UB-04 claim form to bill
for services provided.
Urgent Care Facilities
Urgent care centers provide services for medical needs that may
not be serious enough to warrant a visit to
the ED but cannot wait for a scheduled doctor visit. The
operation of an urgent care is similar to an ED in that
it is first come, first serve, but more severe cases are granted
precedence over less severe cases. For
example, someone experiencing chest pains would be seen
before someone who has been under the
weather with a cold. These facilities have also increased in
number, helping with the volume of patients that
would normally go to a hospital’s ED for urgent care needs.
Like with EDs, if a patient has needs that are
beyond the scope of care that the urgent care center can
provide, an ambulance can be called to transport
the patient to a hospital. Coding and reimbursement for urgent
care facilities are similar to EDs.
(China, 2011; Sanchez, 2017; Davis, 2010;
Mondberg, 2012)

7. HTH 1304, Health Information Technology and Systems 3
UNIT x STUDY GUIDE
Title
Radiology Departments
This care setting is very important in helping clinical
professionals diagnose patients. Radiology departments
services such as diagnostic imaging and scanning that can help
care providers better visualize issues the
patient may be experiencing. These departments serve both
inpatient and outpatient care settings and are
most of the time located in or near inpatient facilities such as
hospitals. A few of the imaging services that
radiology departments provide are magnetic resonance imaging
(MRI) scans, computed tomography (CT)
scans, and ultrasounds. One trend that is developing in
radiology is the introduction of mobile imaging
services, and its most important characteristic is convenience
(Davis & LaCour, 2017). Now, for those
patients who have to sacrifice a lot of time and effort to travel
for these services, they can undergo testing
closer to home or even at home in some cases. The use of
information systems in radiology is vital. One
system that is commonly used in radiology is picture archiving
and communication system (PACS). This
system allows many different images from various devices to be
archived and accessed from any computer
terminal in the network (Davis & LaCour, 2017). This is
valuable when you have multiple stakeholders that
need to have access to patient radiology images. HCPCS/CPT

8. coding is used in radiology as well as ICD-10.
Laboratory Departments
Laboratory services are similar to radiology services in that
they serve both inpatient and outpatient settings.
The laboratory’s main task is to test human specimens for
diagnostic and treatment purposes. Laboratories
can test blood, urine, saliva, and other bodily secretions. An
example of how the lab can be used to assist in
diagnostics is the testing of a patient’s blood for iron
deficiency. A patient comes into a doctor’s office
complaining of symptoms that alerts the physician of a vitamin
deficiency. To confirm, the doctor draws the
patient’s blood, and it is taken to the lab for testing. The results
of that test will help the physician determine a
treatment plan. HCPCS/CPT coding is used in this department
as well as ICD-10.
Hospitals
These facilities are a staple of traditional health care. Hospitals
are inpatient facilities where patients must be
admitted with the goal of nursing the patient back to health. Not
only do hospitals serve patients with
lifesaving services, they also serve other health care needs such
as childbirth and routine surgeries. There
are several other inpatient care settings that make up a hospital.
Two major divisions within hospitals are the
intensive care unit (ICU) and non-intensive care units, such as
rehabilitation centers. Rehabilitation centers
can serve as outpatient settings. Therefore, professionals in this
field will use ICD-10-CM and ICD-10-PCS for
inpatient coding and HCPCS/CPT for outpatient procedures.
Reimbursement for inpatient services can be
comprehensive and requires great attention to detail. Coders and

9. reimbursement professionals in hospitals
must become familiar with using all billing formats to include
UB-04 and CMS 1500.
Behavioral Health Facilities
This care setting provides services for a wide range of
psychological and behavioral disorders (Davis &
LaCour, 2017). Behavioral health facilities, like
rehabilitation centers, can serve as both inpatient and
outpatient settings. Professionals in this care setting
utilize ICD-10-CM and ICD-10-PCS for inpatient coding
and HCPCS/CPT for outpatient procedures. When you
think about the problems facing our country with drug
addiction and alcohol abuse, cognitive disorders, and
psychiatric disorders, these facilities can become a
beacon of hope for millions of Americans.
Long-Term Care Facilities
Long-term care (LTC) centers are inpatient facilities in
which the patients are residents receiving a variety of
services, depending on the patient’s condition. LTC
facilities are often confused with nursing homes. Nursing
home residents get assistance with daily life activities
(Guinazu, 2014; agilemktg1, 2016; Ybarbo,
2011; Sunkel, 2017)

10. HTH 1304, Health Information Technology and Systems 4
UNIT x STUDY GUIDE
Title
such as bathing, transferring from beds to chairs, and eating.
Other types of LTC facilities include assisted
living homes and skilled nursing centers. Skilled nursing care is
directed at those LTC patients that have an
illness that requires advanced care from a clinical professional.
Skilled nursing care centers, like nursing
homes, assist with daily life activities but on a more intensive
basis. LTC facilities also provide their residents
with recreational services as comfortability is a focus of this
care setting. Payment for LTC services can come
from various payers to include private insurance plans and
Medicare. LTC facilities do not administer many
procedures, so professionals in that field work limitedly with
ICD-10-PCS. However, they do need to be
familiar with ICD-10-CM. Billing is done using the UB-04.
Home Health Care
One of the fastest growing sectors in the health care industry is
an outpatient care setting called home health
care. As mentioned in previous units, the Baby Boomer
population is approaching Medicare age, and that is
one major reason for the growth in this sector. This population
can now use Medicare funds to receive health
services in the comfort of their homes. As stated above, when
discussing ambulatory care, health care

11. services that are offered outside of a hospital decrease the risk
for infection. Along with convenience, this is
another notable feature of home health care. Depending on the
services provided, many different health care
professionals can administer care in this setting. In some
circumstances, home health care can be ordered in
the event that a patient is unable to perform household tasks due
to their medical condition. The home health
caregiver can shop, cook, wash laundry, and in some cases, just
spend time and converse with the patient.
This type of care could be life-changing for some individuals
who may not be able to afford their desired long-
term care setting. The Outcome and Assessment Information Set
(OASIS) is the predominant data set used
in home health care to monitor and transmit patient information.
Home health care is billed using the UB-04.
The common bond of all the health care settings described in
this unit is the ability to collect, store, and
transmit information using data sets. Interoperability, or the
ability of systems to be able to exchange
information without human interaction, is vital when one is
working in the health industry as there are
many stakeholders that need access to patient information.
Although information systems need to work
together, there is also a need for those systems to be specific to
the care setting. For example, a data set that
is used in the ED is The Data Elements for Emergency
Department Systems (DEEDS). This system is
specific to emergency departments, but the data set contains
information that may have been collected
previously or will need to be sent to another department, such
as reimbursement. All of these settings use
some type of information system in the collection and
dissemination of information, and each one is important
in its own right.

12. References
Agilemktg1. (2016). Nurse measuring blood pressure of senior
woman at home. Looking at camera, smiling
[Photograph]. Flickr.
https://www.flickr.com/photos/[email protected]/29609189672
China, H. (2011). Wilford Hall now an ambulatory surgical
center [Photograph]. 59th Medical Wing.
http://www.59mdw.af.mil/News/Photos/igphoto/2000218940/
Davis, B. J. (2010). David Grant USAF Medical Center [Image].
59th Medical Wing.
http://www.af.mil/News/Photos/igphoto/2000316503/
Davis, N., & LaCour, M. (2017). Foundations of health
information management (4th ed.). Elsevier.
Guinazu, C. (2014). UCC; Caring for the body and soul [Image].
Mountain Home Air Force Base.
http://www.mountainhome.af.mil/News/Photos/igphoto/2000811
575
Mondberg. (2012). Entrance of the Emergency Department of
the Cairns Base Hospital, Cairns, Queensland,
Australia [Image]. Wikimedia.
https://commons.wikimedia.org/wiki/File:Cbh_emergencydepart
ment1.jpg

13. HTH 1304, Health Information Technology and Systems 5
UNIT x STUDY GUIDE
Title
Sanchez, M. (2017). Army Lt. Col. Owen Johnson III, a plastic
surgeon at William Beaumont Army Medical
Center at Fort Bliss, Texas, discusses options available for
reconstructive surgery with a patient
[Image]. Military Health System.
https://health.mil/News/Articles/2017/10/30/Breast-
reconstruction-
can-aidpsychological-healing
Sunkel, P. (2017). Lab tech draws CPI to reduce steps, improve
process [Image]. U.S. Air Force.
http://www.airforcemedicine.af.mil/Media-
Center/Art/igphoto/2001779067/
Ybarbo, B. (2011). MRI [Photograph]. Air Combat Command.
http://www.acc.af.mil/News/Photos/igphoto/2000294045/

14. Learning Activities (Nongraded)
Nongraded Learning Activities are provided to aid students in
their course of study. You do not have to submit
them. If you have questions, contact your instructor for further
guidance and information.
• Chapter 3: Competency Milestone and Critical Thinking
Questions, pp. 113–114
Course Learning Outcomes for Unit VRequired Unit
ResourcesUnit LessonAmbulatory Surgical FacilitiesPhysician
OfficeDialysis CentersEmergency DepartmentsUrgent Care
FacilitiesRadiology DepartmentsLaboratory
DepartmentsHospitalsBehavioral Health FacilitiesLong-Term
Care FacilitiesHome Health CareReferencesLearning Activities
(Nongraded)