1. 1. DeVry Memorial Hospital Practicum Presentation HIT170 By: Daryle A. Cook DeVry University Professor: Michelle Levack June 27, 2015
2. 2. Healthcare Data Management Healthcare Data Management consists of Data and information that are provided in most every healthcare setting to deliver the common facts of magnitudes. These facts are called data elements describing the patients age, gender, health conditions, procedures, and the health insurance company which they may or may not have. They may be disabled, retired, or still working; however, speaking they still must be registered into the healthcare system. This information must then be stored in a database for a common purpose to show the diagnosis of patients that are required for treatment and care in a healthcare organization. The information is used to determine what method of billing are required for payment of services. The information given are necessary for the HIM professionals to understand what may have or had transpired between patients and physicians. The content will support the interoperability and connectivity of healthcare information of EHRs extensive. The guidelines are used by AHIMA , and e-HIM Workgroup on a EHR database. Also with the information given will help develop a data dictionary implementing the new EHR system. The data will assist in the design plan, development of an enterprise data dictionary, to ensure collaborative involvement and buy-in, as well as the flexibility of growth, design, expansion of field values. The adoption of a nationally recognized standard, and normalize field of definitions across the board with data sets etc. Healthcare Data Sets and Standards describes the initial efforts at developing standardized data sets for use in different types of healthcare settings. This includes acute care, ambulatory care, long-term care, and home care. Typical health information functions are record processing, monitoring of record completion, transcription, release of patient information, clinical coding, abstracting, and clinical data analysis. However there are more HIM functions in some departments like research and statistics, cancer and/or trauma registries, and birth certificate completion. Secondary Data Sources are contained in registries and similar databases; unlike, Primary data sources are considered the health record because the patient is documented by professionals who provided care of service. Ethical issues in the health information management are to maintain such activities like research, clinical trials, reimbursement, also the accreditations, and exchanging of information for the safety of patients rights.
3. 3. Health Data Structure Clinical Quality Performance Improvement and Management - The purposes of quality performance are patient safety research, administration, population of health reporting and evaluation. The most important concept discussed in quality is that of measurement, dealing with issues that involved in healthcare quality, healthcare professionals that have struggled with where to put their focus and resources. The key to improvement lay in the measurement of the characteristics of their practices. Performance improvement (PI) in healthcare is the process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations. Performance monitoring is data driven base on internal and external data is the foundation of all PI activities. Important areas must be monitor for high-risk, high- volume, or problem-prone. What is at stake is the outcome of care, customer feedback, and the requirements of regulatory agencies in which consider prioritizing performance measures. Example for organization-wide performance improvement process are identify performance measures, measure performance, analyze and compare internal/external data, identify improvement opportunity, and perform ongoing monitoring.
4. 4. Healthcare Information Requirements, and Standards Health Information Functions and Secondary Data Sources First HIM functions are information-centered, the means are ensuring information quality, security, and availability. The medium in which the information is stored will dictate how specific functions are carried out. The goal of the health record system is to ensure that accurate information is available to authorized users to support quality patient care. Example is storage of information in paper-based records involves different types of tasks than does storage of information in electronic records. The requirements are to record processing (concurrent and retrospective analysis and monitoring of health record content, Record completion, Storage and retrieval of health records (including monitoring and tracking of health records location), Release of patient information, Clinical coding of diagnoses and procedures, Transcription of medical reports (excluding pathology and radiology reports), Statistical and internal report generation, and Cancer and trauma registry. Standards are fixed rules that must be followed for every form (for example, where the form title should be located). Guidelines provides general direction about the design of a form (for example, usual size of the font used), number tracking, testing and evaluation plan, checking the quality of new forms, systematizing storage, inventory, and distribution, and establishing a forms database.
5. 5. Data Storage and Retrieval Fundamentals of Electronic Information Systems are discussing the major components of an information system, identifying principal activities of information systems, describing major types of information systems with example of each, identifying between the purposes and functions of MIS, DSS, ES, and KMS. There are different types of computers, steps in the systems development life cycle, learning the vendor selection process, and learning to identify the main three types of system software and providing examples of each. It entails learning the purpose of electronic database and describing the purpose of a database.
6. 6. Health Record Documentation Requirements Purpose and Function of the Health Record - Primary purposes are patient care delivery, the health record documents the services provided by clinical professional and allied health professionals working together in a variety of settings, and patient care management, in which patient care management refers to all the activities related to managing the healthcare services provided to patients. The health record assists providers in analyzing various illnesses, formulating practice guidelines, and evaluating the quality of care. There is patient care support processes, financial and other administrative processes, and patient self-management, in which individual have become more actively involved in managing their own health and healthcare to become a primary user of the health record. Content and Structure of the Health Record are determined by primarily practice needs and significant standards. Standard statements are the expected behavior or reference points against which structures, processes, or outcomes can be measured. Therefore, the main four sources are Facility-specific standards found in a facility policies and procedures organization. Licensure requirements that provide services, in most healthcare organizations must be licensed by government entities such as the stat or country in which they are located and must maintain a license as long as care is provided. Certification standards government reimbursement program standards are applied to facilities that choose to participate in federal programs such as Medicare and Medicaid. These standards are titled conditions of participation or condition for coverage that certifies standard services are met. Accreditation standards is the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization.
7. 7. Information and Communication Technologies Introduction Electronic to Health Information Systems are the healthcare information systems (ISs) running the gamut from patient-specific clinical ISs to administrative or financial systems to fully integrated systems that combine clinical and administrative/financial information. Such systems can exist within a single institution or across organizations. The development and use of healthcare information systems is not new. The enormously complex, both in their organization structure, and in terms of the information they manage can be difficult to implement healthcare information systems effectively. The cost of support and to maintain are at the national level, and has been directed toward the expanded use of information technology (IT). Electronic Health Records related information on a 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 healthcare organization. Principles of Organization and Work Planning are critical elements in implementing the mission of an organization and achieving its long-term strategic goals and short-term operational goal. The goals are achieved through application of the organizations resources, including its human, financial, and physical assets ensuring that the organization perform the right activities in the best ways possible to achieve its mission.
8. 8. Health Organization Structure Healthcare Delivery Systems are complex and at times can be stressful. Evidence-based guidelines suggest diagnostic or therapeutic interventions would improve the patient health by regularly monitoring and giving therapies in managing pain. The quality of healthcare, the chance of patients getting well, proven effectiveness in managing pain. The excellence in performing quality care to patients are recommendations for treatment by health professionals, developing standards to assess the clinical practice of individual health professional, education and training of health professionals, assisting patients to make informed decisions and improving communication between patient and health professionals. The development of integrated healthcare delivery systems (IDS) also referred to as Integrated Delivery Network or IDN are made up with a number of associated medical facilities that furnish coordination in healthcare services. Some examples are ambulatory surgery centers, physician office practices, outpatient clinics, acute care hospitals, and skilled nursing facilities (SNFs), MCOs, and etc. The main purpose are to integrate delivery systems for a continuing of care, maximize effectiveness, and reduce costs. Focusing on holistic care rather than fragmented care among specialists. Examples are different levels of care.
9. 9. DeVry Memorial Hospital Overview Over the 21st century HIM profession in the healthcare industry has embarked on some of the greatest transformation in the history of the U.S. healthcare system. Shifting into a fast pace challenge expanding the traditional HIM role as medical record custodian and keeper of clinical information. The transformation in the HIM profession is necessary to cease tangible product or tool as it becomes electronic. Information accuracy and content will continue to be critical; however, clinical information will become intellectual property, organizational capital, and competitive intelligence. Payers, providers, researchers, lawyers, and regulators will require credible information to create knowledge that provides sustainable competitive advantages for their organizations. The changes will have directly impacted health information practice and cannot be done successfully without HIM best practices and leadership. Building the best practices and influence policy, the HIM profession is called upon to articulate lessons learned from the implementation of electronic medical records, ICD-10-CM/PCS planning and training to achieve meaningful use of computer-assisted coding initiatives, advances in health information exchanges, and the introduction of patient- centered care models such as the medical (healthcare) home and accountable care organizations (ACOs). The health information management (HIM) profession continue to grow and change, becoming highly visible in the national arena as federal laws have evolved to protect patient privacy, to advance technologies, collect and maintain patient data accurately and securely. The adoption classification systems increases the quality of data in clinical documentation, and to encourage the use of electronic health records as the primary source for monitoring quality of care.
10. 10. Mission, Value, and Vision My mission is the same as AHIMAs mission to be professional at all times, and increase healthcare by advancing with the best of practices. I would follow the health information management guidelines, stay trusted with the education, research, and professions of a license healthcare organization. The record department values are to show accurate and confidential personal health information. HIMs provide leadership in the areas required by HIM practices with standards universal, I will also adhere to the AHIMA Code of Ethics, promote disciplinary cooperation with other professionals in a healthcare organization. The Vision is to remain focused at all times, and show quality performance that would enhance healthcare with valued information.
11. 11. Management of Information Technology The potential and appropriate information of technology can be accomplish by organizational and management goal setting. In a formal organization the structure of planning and management is critical for HITs, and they must be careful for finance purposes where they get their information resources from. High quality, cost- effective healthcare services depend on the availability of accurate information. The structure of administration and function criterias must be organized and executed, to ensure information means be managed. Calculated planning and operations with a broad oversight organizations infrastructure systems in place. Many of the organization matters will require the support of a chief information officer (CIO), HIM, chief security officer (CSO), or a chief privacy officer (CPO).
12. 12. The Preparation The Course preparation consisted of knowing how the healthcare data sets and standards relate to medical records. The functions of health information shows how secondary data sources are used, ethical behavior patterns and problem solving issues are handled, acknowledging clinical quality performance improvements, and giving management protocols. I watched short movies and was given short quizzes, also working with digital filing terminal systems, and retrieving incorrect medical records from the medical charts. I was also given assignments for moving to an EHR System, learning data integrity deficiencies slips, and on organizational charts. I worked in the Quadramed and made journal entries weekly, also learned about positions in a hospital with assignments etc.
13. 13. Summary Considering my new occupation as a health information technician, I have learned a great deal about how the healthcare organization works. I acknowledged my goal to be the one of the best HIT as possible, I look back at what I have learned and am still learning from my experience in the HIT170 practicum course. First I can start by thanking my Professor Levack and DeVry University for allowing me to be an participant in this prestigious course. By being determined to finish the course I must think about the beginning where I started from, reading, studying and researching about the course of studies. I looked at the short movies, answered questions on quizzes, participated in discussions panels, asked the professor about things I was not sure of, learning about the purpose and functions of HIM, content and structure, clinical vocabularies and classifications, the digital filing systems, master index, registries indexes, and ethical standards of the healthcare organization. I studied the positions in a hospital, healthcare delivery in the U.S., moving to an EHR system along with transcripts. It was a pleasure learning about deficiency slips, retrieving medical records, and about duplications. There are so much more to talk about, but I would be sharing this information all day. The organizational chart I find very meaningful, the discharge-planning, and writing in a journal. What I acknowledged from all of this course, I have been enlightened to adapt in my next conquest of being a good HIT. I thank all those who inspired me to be the best I can in achieving my degree.