HIM 500 Milestone One Guidelines and Rubric Overview: Imagine you have been contracted to consult on the recent developments at the Featherfall Medical Center. Featherfall has been struggling of late; it has had a series of problems that have prompted your hiring. It has faced the following issues: 1. Featherfall has recently violated several government regulations regarding the current state of its technology and how it is being used. The technology system is vastly out of date, and staff are not always using the technology that is in place or they are using the technology inappropriately. These problems have lost the institution lots of money for not meeting government regulations and have caused operational and ethical problems from inefficient and ineffective use of technology. 2. The staff at Featherfall are not well-trained on the use of technology and do not communicate appropriately about technology use. The roles that pertinent to your consult are the health information management team, the clinical staff (doctors, nurses, etc.), and administrative staff. The health information management team uses proper coding practices, and the current technology system serves them well, despite its age. However, other roles in the hospital have had issues with the system. Clinical staff, for instance, have had record-keeping issues both due to lack of training on the system and the system itself being out of date. Administrative staff within the organization have taken issue with the lack of communication about the technology and its use between the various roles. When the current technology system was chosen many years ago, the needs of these various roles were not considered. In this milestone, you will submit a discussion of the history of healthcare information management/informatics and the current landscape in terms of technology. This milestone will set the stage for your project. Specifically the following critical elements must be addressed: I. Preparation for Consult: In this section of your final project, you will prepare for your consultation on the organization’s technology choice. To prepare, you will analyze the field of health information management for determining standard technologies and guidelines related to technology use in order to inform your technology selection. A. Analyze key historical events in the field of health informatics for how technology has been used that could inform the management of health information. Be sure to support your response with appropriate examples. B. Determine guidelines for technology use in the field of health information management that Featherfall could implement. Be sure to support your response with research. C. Determine the standard technologies currently used in the field of health information management. Be sure to support your response with research. For example, what record-keeping technologies are typically used in the field? D. Dev ...

1. HIM 500 Milestone One Guidelines and Rubric
Overview: Imagine you have been contracted to consult on the
recent developments at the Featherfall Medical Center.
Featherfall has been struggling of late; it
has had a series of problems that have prompted your hiring. It
has faced the following issues:
1. Featherfall has recently violated several government
regulations regarding the current state of its technology and
how it is being used. The technology
system is vastly out of date, and staff are not always using the
technology that is in place or they are using the technology
inappropriately. These
problems have lost the institution lots of money for not meeting
government regulations and have caused operational and ethical
problems from
inefficient and ineffective use of technology.
2. The staff at Featherfall are not well-trained on the use of
technology and do not communicate appropriately about
technology use. The roles that
pertinent to your consult are the health information management
team, the clinical staff (doctors, nurses, etc.), and
administrative staff. The health
information management team uses proper coding practices, and
the current technology system serves them well, despite its age.
However, other roles
in the hospital have had issues with the system. Clinical staff,

2. for instance, have had record-keeping issues both due to lack of
training on the system and
the system itself being out of date. Administrative staff within
the organization have taken issue with the lack of
communication about the technology
and its use between the various roles. When the current
technology system was chosen many years ago, the needs of
these various roles were not
considered.
In this milestone, you will submit a discussion of the history of
healthcare information management/informatics and the current
landscape in terms of
technology. This milestone will set the stage for your project.
Specifically the following critical elements must be addressed:
I. Preparation for Consult: In this section of your final project,
you will prepare for your consultation on the organization’s
technology choice. To prepare,
you will analyze the field of health information management for
determining standard technologies and guidelines related to
technology use in order to
inform your technology selection.
A. Analyze key historical events in the field of health
informatics for how technology has been used that could inform
the management of health
information. Be sure to support your response with appropriate
examples.
B. Determine guidelines for technology use in the field of
health information management that Featherfall could
implement. Be sure to support

3. your response with research.
C. Determine the standard technologies currently used in the
field of health information management. Be sure to support your
response with
research. For example, what record-keeping technologies are
typically used in the field?
D. Develop an overview of how the pertinent roles described at
Featherfall would interact with technology.
E. Describe the process you would use to evaluate new health
information technology systems. Be sure that your process will
evaluate new
systems based on how they meet the needs of the organization
and how they are compliant with health regulations and laws.
Rubric
Guidelines for Submission: This milestone must be 2–3 pages in
length (plus a cover page and references) and must be written in
APA format. Use double
spacing, 12-point Times New Roman font, and one-inch
margins. All references cited in APA format.
Critical Elements Proficient (100%) Needs Improvement (75%)
Not Evident (0%) Value
Preparation for Consult:
Key Historical Events

4. Analyzes key historical events in
the field of health informatics for
how technology has been used
historically that could inform the
management of health
information, supporting response
with appropriate examples
Analyzes key historical events in
the field of health informatics for
how technology has been used
historically that could inform the
management of health
information, supporting response
with examples, but analysis is
cursory or illogical or examples
are inappropriate
Does not analyze key historical
events in the field of health
informatics
18
Preparation for Consult:
Guidelines
Determines guidelines for
technology use in the field of
health information management
that Featherfall could implement,
supporting response with
research
Determines guidelines for
technology use in the field of

5. health information management
that Featherfall could implement,
supporting response with
research, but determined
guidelines are inappropriate, or
supporting research is misaligned
Does not determine guidelines for
technology use in the field of
health information management
18
Preparation for Consult:
Standard Technologies
Determines the standard
technologies currently used in the
field of health information
management, supporting
response with research
Determines technologies used in
the field of health information
management, supporting
response with research, but
determined technologies are not
standard currently in the field, or
supporting research is misaligned
Does not determine technologies
used in the field of health
information management
18

6. Preparation for Consult:
Roles
Develops an overview of how the
various roles at the healthcare
institution interact with
technology and the health
information management team
Develops an overview of how the
roles at the healthcare institution
interact with technology and the
health information management
team, but overview is cursory
Does not develop an overview of
how the roles at the healthcare
institution interact with
technology and the health
information management team
18
Preparation for Consult:
Evaluate
Describes the process that would
be used to evaluate new health
information technology systems
for the institution that meet the
needs of the organization and
how they are compliant with
health regulations and laws

7. Describes the process that would
be used to evaluate new health
information technology systems
for the institution, but description
is cursory or misaligned with the
needs of the organization or
health laws and regulations
Does not describe the process
that would be used to evaluate
new health information
technology systems for the
institution
18
Articulation of Response Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact readability
and articulation of main ideas
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas
10
Total 100%

8. Samantha Romano
HIM 500: Healthcare Informatics
Module 3 Activity
1. What is an EHR?
a. An EHR is an Electronic Health Record. According to Green
& Bowie (2016), it is “an electronic record of health-related
information on an individual that conforms to nationally
recognized interoperability standards that can be created,
managed, and consulted by authorized clinicians and staff
across more than one health care organization”. It is different
than an electronic medical record because an EMR is only held
within one health care organization (Green & Bowie, 2016).
These automated record systems document patient care using a
computer (Green & Bowie, 2016). EHRs were supported by
President George W. Bush in 2004 to help improve care and to
reduce medical mistakes and costs (Green & Bowie, 2016).
EHRs can be found in all different kinds of facilities throughout
healthcare but no two facilities have the same systems (Green &
Bowie, 2016).
2. What types of information are found in an EHR?
a. Within an HER there is information about schedules,
admissions, registration, discharges, finances, patient
demographics, patient health background, patient insurance
information, test (lab and radiology) results, pharmaceutical
information, doctor’s or nurses notes, and any other important
information that can help with the care of the patient (Green &
Bowie, 2016).
3. Who manages an EHR?
a. EHR’s are managed by healthcare workers, both
administrative and clinical. There is not only one specific
person who handles the entire EHR (Green & Bowie, 2016). In
my current place of work, there are a number of people who
handle a patient’s EHR. The first person to work on it is

9. whoever answers the phone to schedule their first visit, usually
the front desk. Then it is handed off to the insurance specialist
who will update the insurance information for the patient.
During the patient’s first visit, they will fill out new patient
forms (background information, health history) and functional
outcome assessments which are added to the EHR. After they
check in, I take them back to evaluate them before the doctor
comes in. I go over their forms with them, take blood pressure
and pulse, assess range of motion, ask any additional questions
I need, answer any of their questions and input this information
into the EHR. Then the doctor will come in and perform an
exam which I enter into the EHR. After this visit, the front desk
will update the financial information and collect payment which
is all updated in the EHR. When the patient comes back, another
staff member will input information about their visits and
treatment into the EHR. The doctors will include information
when they feel they need to as they look over the notes. As it is
in our office, there are many organizations where a number of
people will manage an EHR.
4. How is it used?
a. EHRs are used in a clinical and administrative way. Specific
applications include: patient scheduling, admission,
registration, business/financial functions, management
applications, patient monitoring systems, pharmacy
applications, laboratory applications, radiology applications,
nursing applications, medical documentation applications, and
patient access application (Green & Bowie, 2016). The EHRs
are used with these applications and functions to help give the
best patient care possible. It is easier with electronic records to
find someone’s information, store it, and display it. An
organization can also include medical records from other
organizations or offices to help compile a full record for a
patient.
5. Does an EHR follow the patient to other health facilities?
Explain.
a. An EHR can follow a patient to other health facilities and an

10. electronic medical record is held specifically in one
organization (Green & Bowie, 2016). The EHR collects, stores,
and displays clinical information that can be organized and sent
to other health care organizations (Green & Bowie, 2016).
Reference:
Green, M. A., & Bowie, M. J. (2016). Essentials of health
information management: Principles and practices (3rd ed.).
Clifton Park, NY: Cengage Custom. ISBN: 978-1-305-26541-7
HIM 500: Healthcare Informatics
Module Three Activity
By: Stephanie Shea
7/7/2017
What is an EHR?
EHR stands for electronic health record and is a digital record
of health information. Unlike paper medical charts, information
found in an EHR is in real time and can be accessed by several
authorized users at once. (“What is”, 2013). Not only does an
EHR improve access to patient information, it also reduces
paper record storage and ensures increased security of sensitive
patient information. The National Alliance for Health

11. Information Technology (NAHIT), defines the EHR as “an
electronic health record of health-related information on an
individual that conforms to nationally recognized
interoperability standards and that can be created, managed, and
consulted by authorized clinicians and staff across more than
one health care organization.” (Green, 2015).
What types of information are found in an EHR?
All kinds of clinical and administrative data can be found in the
medical record. Administrative data includes basic registration
and financial information such as name, date of birth, contact
information, and insurance. Clinical information may include
past medical history, active problem lists, medications,
treatment plans, vital signs, allergies, radiology, and lab/test
results. Additionally, there are progress notes in an EHR which
contains information from all clinicians involved in patient
care.
Who manages an EHR?
As mentioned above, any authorized clinician involved in the
patient’s care can manage information within the EHR.
Physicians are the main discipline involved in managing
information. They enter orders, history and physicals,
discharge summaries, progress notes, and review test results.
However, other members of the interdisciplinary team include
nurses, physical/occupational therapists, speech language
pathologists, dietitians, respiratory therapists, social workers,
case managers, coding/billing specialists, pharmacists,
laboratory, and radiology techs to name a few. These
disciplines may not enter orders but will document in patient
flowsheets, test results, and progress notes. It is important to
reinforce that only members of the medical team providing care
to the patient can manage health information. Reviewing
protected health information without authorization is not
allowed.
How is it used?
Information within the EHR can be used in a variety of ways
depending on the discipline. The overarching theme for how

12. the EHR is used is to provide communication and clear, legible
documentation regarding the patient’s care. However, an EHR
typically goes beyond documentation. Instead it incorporates
more individual practice workflows which can help to improve
coordination of care, quality of care, cost savings, and improved
efficiency. (Practice Fusion, 2016).
Does an EHR follow the patient to other health facilities?
Explain.
Several of our readings indicate that yes, the EHR does follow
the patient to other health care facilities. This can include
laboratories, specialists, medical imaging facilities, pharmacies,
emergency facilities, and clinics. However, I have not fully
experienced this in practice yet, mainly because so many
facilities have different EHR systems.
I’ve worked in two large academic medical centers throughout
my career and neither has been able to electronically send or
receive information from the EHR, unless they are coming from
one of the other sites within the hospital enterprise. In my
experience, when patients are transferred and received from
other facilities, key documents are printed and faxed over by the
social worker or case manager; essentially creating a paper
chart. This has caused some problems because sometimes not
all information is available from all disciplines. For example,
as a dietitian, often the clinical nutrition notes are missing.
Therefore, a phone call to the facility is usually required to
determine the patient’s nutritional status prior to admission or
to handoff care plan recommendations. One initiative we are
working on is improving these transitions of care, ideally
through IT innovations. Additionally, we are working on an
initiative in collaboration with a subacute rehab facility across
the street from our hospital where oncology patients can be
transferred back and forth as needed for blood transfusions.
There is an IT subgroup working on the challenges of dealing
with two different EHRs and how our providers (the more
specialized team) will be able to access the patient information
to assess if the patient requires a transfusion. There are barriers

13. to accessing lab work at two different facilities that need to be
overcome. I suppose this is one of the key differences between
an electronic health record (EHR) and electronic medical record
(EMR). Health information within an EHR is supposed to
easily move with the patient; while an EMR is not designed to
be shared or travel outside of the facility. (Practice Fusion,
2016).
References
What is an electronic health record (EHR)?. (2013). Retrieved
on July 7th, 2017 from
https://www.healthit.gov/providers-professionals/faqs/what-
electronic-health-record-ehr
Green, M. A., & Bowie, M. J. (2015). Essentials of health
information management: principles
and practices. Boston, MA: Cengage Learning.
Practice Fusion (2016). EMR vs. EHR. Retrieved on July 7th,
2017 from
http://www.practicefusion.com/blog/ehr-vs-emr/
HIM 500 Module Three Activity Guidelines and Rubric
This activity will introduce you to the electronic health record
(EHR), the types of information in an EHR, how the records are
used, and who uses them.
For this activity, complete the following:

14. 1. Complete the MindTap Quick Check for Chapters 4 and 5 in
Essentials of Health Information Management: Principles and
Practices.
2. Complete the MindTap Learning Lab for Chapters 4 and 5 in
Essentials of Health Information Management: Principles and
Practices.
3. Answer the following questions:
Explain.
Note on the MindTap activities: Click on the Cengage MindTap
link to access this resource.
Guidelines for Submission: Complete the MindTap activities
within MindTap. The answers to the questions should be in a
Word document and should be a
minimum of 1 page in length. All sources should be cited using
APA style.
Critical Elements Proficient (100%) Needs Improvement (70%)
Not Evident (0%) Value
Electronic Health Record Defines and explains the

15. purpose of the electronic health
record
Explains the electronic health
record, but lacks detail or clarity
Does not explain the electronic
health record
22.5
Information Explains the types of information
in an electronic health record
Explains the types of information
in an electronic health record,
but lacks detail or clarity
Does not explain the types of
information in an electronic
health record
22.5
Manages Explains who manages an
electronic health record
Explains who manages an
electronic health record, but
lacks detail or clarity
Does not explain who manages
an electronic health record
22.5

16. Health Facilities Explains whether an electronic
health record follows a patient
to other health facilities
Explains whether an electronic
health record follows a patient
to other health facilities, but
lacks detail or clarity
Does not explain whether an
electronic health record follows
a patient to other health
facilities
22.5
Articulation of Response Submission is free of errors of
organization and grammar
Submission contains errors of
organization and grammar, but
errors are limited enough so that
the submission can be
understood
Submission contains errors of
organization and grammar
making the submission difficult
to understand
10
Total 100%