copyright © 2007 by saunders, inc., an imprint of elsevier inc. health information management...

Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.

Health Information Management

Chapter 15

Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Slide 2

Introduction

Health information management is a relatively new field that continues to grow in popularity among students of the health professions.

The advent of computer-based medical records makes this a high-demand career opportunity.


This chapter will examine:

How health information is used

Characteristics of high-quality data

Concerns of quality assurance

Importance of HIPAA

Functions of the NCHS

Types of healthcare statistics kept

Total quality management


Evolution of the Profession

American Health Information Management Association (AHIMA)

Began as the Association of Record Librarians of North America

Changed name to American Medical Record Association in 1970

Evolved into AHIMA in 1991


Advances in technology have brought healthcare from a paper-based environment to a computer-based environment.

Physicians and other healthcare providers can usually access patient and statistical information in a matter of seconds.

Evolution of the Profession


Move toward Computer-Based Records

In 2005, one quarter of the nation’s physicians used some form of computer-based medical records.


How Use of Electronic Records Reduces Medical Errors

Keeps prescriptions organized

Notes allergies clearly

Reduces costs by avoiding duplicate tests

Can reduce staffing needs

Note: Information entered into the computer is only as reliable as the person who entered the data.


Characteristics of High-Quality Health Data

Experts agree on nine characteristics of high-quality health data, which are:

Validity Reliability Completeness Recognizability Timeliness

Relevance Accessibility Security Legality



Validity: synonymous with accuracy. Healthcare information must be accurate to be usable.

Reliability: Healthcare professionals must be able to rely on the information presented.



Completeness: Incomplete records may lack vital information needed to care for the patient.

Recognizability: All users of health information must be able to interpret the data that are presented in the health record.



Timeliness: Health information must be entered into the record as soon as it becomes available so that decisions made are supported by the latest information about the patient’s condition.

Relevance: Information in the record must be relevant to be useful.



Accessibility: Healthcare data must be accessible to multiple users at one time.

Security: Precautions must be taken to prohibit intruders from accessing medical records.

Legality: The record must be completely legible and properly authenticated.


Quality Assurance

Activities designed to increase the quality of a product or service through process or system changes that increase efficiency or effectiveness.

Many people assume that quality is only a result of patient satisfaction surveys. This is actually only a small part of the quality-assurance process.


Challenges of Quality-Assurance Problems

Quality assurance is concerned with issues revolving around healthcare services, such as:• Overuse

• Underuse

• Misuse


Some Overused Treatments

Hysterectomies

Tympanostomy tubes

Antibiotics


Some Underused Treatments

Mammograms

Cervical cancer screenings

Beta-blockers for heart patients

Eye examinations for diabetic patients


Some Underused Treatments (cont’d)


Misuses of Healthcare Services

Laboratory tests that provide erroneous results

Medication errors

Hospital injuries to patients

Nosocomial infections


Discharge Rates

Percentages of people who leave a hospital without dying.

These rates are higher in some areas of the country than in others.


HIPAA

Health Insurance Portability and Accountability Act (HIPAA)

Became law in 1996

Became effective April 14, 2003

Applies to records that are created or maintained by healthcare providers, health plans, and healthcare clearinghouses that engage in electronic transactions


HIPAA Regulation

HIPAA is regulated by the Office of Civil Rights (OCR), which is a division of the Department of Health and Human Services.


Provisions of HIPAA’s Privacy Rule

Patients must give specific authorization before protected information can be disclosed.

Covered entities must provide patients with a copy of their privacy practices.



Pharmacies, health plans, and other covered entities must have specific patient permission before sending marketing materials.

Covered entities cannot use business associate agreements to circumvent the rule’s marketing provisions.



Patients generally can access their personal medical records and request changes to correct any errors.

Patients can request an accounting of nonroutine uses and disclosures of their personal health information.


Patient Confidentiality

Patients have the right to expect patient confidentiality with regard to their health records.


National Center for Health Statistics (NCHS)

Division of the Centers for Disease Control and Prevention (CDC)

Primary provider of health information statistics


NCHS Functions

Documentation of health status of the population and its subgroups

Identification of disparities in health status and use of healthcare by socioeconomic factors

Description of experiences with the healthcare system

Evaluation of the impact of health policies and programs


NCHS Functions

Monitoring of trends in health status and healthcare delivery

Identification of health problems

Support for biomedical and health services research

Provision of information for making changes in public policies and programs


Types of NCHS Statistics

Teenage pregnancy

Incidence of HIV infection

Alcohol and drug use

Births

Deaths

Communicable diseases

Infant health and mortality

Leading causes of death

Life expectancy

Sexually transmitted diseases

Suicide


Total Quality Management (TQM)

TQM consists of management and control activities designed to enhance the quality of services provided to patients.


Total Quality Management (TQM) (cont’d)


TQM Concept

Much of today’s TQM concepts originated with W. Edwards Deming.

Deming stressed an emphasis on quality rather than quantity, applying his principles to various types of businesses and managers.


Deming’s 14 Points for Management

Create constancy of purpose toward improvement of product and service.

Adopt the new philosophy.

Cease dependence on inspection to achieve quality.

End the practice of awarding business on the basis of price tag.



Constantly improve the system of production and service.

Institute training on the job.

Institute leadership.

Drive out fear so that everyone can work effectively for the company.

Break down barriers between departments.



Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity.

Remove barriers that rob the hourly worker of his right to pride of workmanship.

Remove barriers that rob people in management and in engineering of their right to pride of workmanship.



Institute a vigorous program of education and self-improvement.

Make the company transformation everyone’s job.


The Joint Commission (TJC)

Nonprofit organization

Provides accreditation services to healthcare facilities

Voluntary process, but vital to healthcare organizations


Risk Management

Any occurrence that could result in patient injury or any type of financial loss to the facility is called a risk. Risk management efforts focus on:

Loss prevention

Avoiding patient injury

Avoiding any financial loss resulting from liability

Avoidance of negative publicity resulting from sentinel events

copyright © 2007 by saunders, inc., an imprint of elsevier inc. health information management...

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