standards for health information governances3.amazonaws.com › rdcms-himss › files › production...

Standards for Health Information Governance

AHIMA Global Health Information Governance and Standards Initiative

Monday, May 2, 2016

12:00-1:00 pm ET

http://www.ahima.org/about/global

Speakers

Linda Bailey-Woods, RHIA, CPHIMS Principal, Health IT Consulting, Plante Moran. E-mail: [email protected]

Sandra Huyck, RHIT, CCS-P, CPC, CPC-H Compliance Audit Specialist, Beaumont Health. E-mail: [email protected]

Lee Wise, MS, RHIA, CHCO CDI/Coding Supervisor, Carson Tahoe Health E-mail: [email protected]

mailto:[email protected]



Acknowledgements

Kathleen Addison, Alberta Health Services Linda Bailey-Woods, Plante Moran Kevin Baldwin, UCLA Susan Clark, eHealthcare Consulting Alane Combs, Coastal Healthcare Vicki Delgado, Kindred Hospital Albuquerque Elisa Gorton, St.Vincent's Medical Center Aaron Haskett, Data & Coding Compliance Consultant Sandra Huyck, Beaumont Health Katherine Lusk, Dallas Children’s Medical Center Satyendra Kaith, Kaplan Higher Education Group

Susan Lucci, Just Associates Lori McNeil Tolley, Boston Children's Hospital Sharon Meyer, Ministry Health Care Megan Munns, Just Associates Neysa Noreen, Children's Hospitals and Clinics of Minnesota Sandra Nunn, KAMC Consulting Michael Nusbaum, M.H. Nusbaum & Associates Ltd. Anna Orlova, AHIMA Bill Reisbick, Esq., Newcastle WA. Harry Rhodes, AHIMA DeAnn Tucker, Owensboro Health Diana Warner, AHIMA Valerie Wilson, HCA Information Technology Lee Wise, Carson Tahoe Health

AHIMA Task Force: HIT Standards for HIM Practices

AHIMA

The American Health Information Management Association (AHIMA) is the premier association of health information management (HIM) professionals worldwide. Serving 52 affiliated component state associations and more than 103,000 health information professionals, it is recognized as the leading source of "HIM knowledge," a respected authority for rigorous professional education and training. Founded in 1928 to improve health record quality, AHIMA has played a leadership role in the effective management of health data and medical records needed to deliver quality healthcare to the public.

http://www.ahima.org/

http://www.ahima.org/

• The Need • Collaboration with Health IT Vendors • Approach

– Business Requirements – HIM Practice Checklists – Use Cases – Standards Review

Outline

The Need: Challenges with HIT Adoption • Health Information Systems (HIS) design flaws • Poor HIS usability and improper use • Inappropriate documentation capture in HIS

• Errors related to design and use of clinical decision support

• Errors related to faulty support of HIM practices in HIS

• Outdated organizational policies to support information capture,

management, sharing and use in electronic environment because these

policies were developed for the paper-based environment

• Inadequate training for HIM personnel and clinicians to operate HIS and

• Errors related to vendor’s upgrades of HIS systems (product release

cycle management)

American Health Information Management Association (AHIMA) and Integrating Healthcare Enterprise (IHE). Health Information Standards for Health Information Practices. White Paper. 2015. URL: http://qrs.ly/lb4vec0

http://qrs.ly/lb4vec0

The Need: Patient Care Safety and HIT

National Institute of Standards and Technology (NIST). Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization. NISTIR 7804-1 . September 2015. URL: http://dx.doi.org/10.6028/NIST.IR.7804-1

Addressing issues with EHR adoption:

1. Clinically relevant information is not available at the task at hand

2. Inadequate documentation

3. Inaccurate information and

4. Irretrievable information

National Institute of Standards and Technology (NIST). Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization. NISTIR 7804-1 . September 2015. URL: http://dx.doi.org/10.6028/NIST.IR.7804-1

Addressing Challenges with HIT Adoption

Health Information Systems Should Support Information Governance (IG) Practices

Standards Developers Should be Informed about IG Practices

Health Information Systems (HIS) Built Based on Standards Should Support IG Practices

Addressing Challenges with HIT Adoption

2015 AHIMA-IHE White Paper HIT Standards for HIM Practices Published September 18, 2015

Addressing HIT Adoption Challenges Through Collaboration with HIT Vendors

ftp://ftp.ihe.net/IT_Infrastructure/iheitiyr13-2015-2016/Planning_Cmte/WorkItems/HIM_Practices/FINAL/Final.pdf





Outline

To address challenges with HIT adoption, in 2015, AHIMA joined the Integrating the Healthcare Enterprise (IHE). IHE is an international collaborative of HIT vendors, professionals associations and governmental entities to develop interoperability standards in healthcare to improve the quality, value, and safety of healthcare by enabling rapid, scalable, and secure access to health information at the point of care. IHE engages public and private entities to develop, test, implement, and use standards-based solutions for all health information needs.

AHIMA Collaborates with HIT Vendors

http://www.ihe.net/

9

Clinicians, Health Information Managers, Public Health and

Software Developers Working Together to Deliver

Interoperable Health Information Systems in the Enterprise

and Across Care Settings

Integrating the Healthcare Enterprise (IHE) specifies harmonized interoperability standards (Technical Frameworks, Integration Profiles, Content Profiles) for:

• Information Technology Infrastructure (ITI) • Patient Care Coordination (PCC) • Laboratory • Cardiology • Radiology • Quality Research and Public Health (QRPH) • Medical Devices • and other domains

Integrating the Healthcare Enterprise (IHE)

IHE Develops Interoperability Standards

http://www.ihe.net/

IHE Participants


http://www.ihe.net/

• NIST serves as a proctor for the tests.

• Passing tests is a pre-requisite to participation in HIMSS Interoperability Showcase™.

• IHE Connectathons are held in:

– North America – Europe – Asia and Japan – Australia

IHE Connectathon: Interoperability Standards Testing Event


http://www.nist.gov/

http://www.interoperabilityshowcase.org/



http://iheusa.org/connectathon.aspx?utm_source=epush&utm_medium=email&utm_content=week_overview&utm_campaign=connectathon

http://www.ihe.net/

Successfully Tested Standards Demonstrated at the

HIMSS Interoperability Showcase™ Major HIT event conducted at

Health Information Management and Systems Society (HIMSS) Annual Conventions.

Scripted Use Case Scenarios are played at the vendors’ kiosks.

Attended by thousands of clinicians and CIOs from various healthcare organizations and practices worldwide.

HIMSS

IHE profiles are the foundation of the HIMSS Interoperability Showcase™

http://www.himss.org/

• The Need • Collaboration with Health IT Vendors • AHIMA Approach


Outline

The White Paper -- part of AHIMA’s globally-focused Information Governance (IG) initiative -- marks the first time effort for HIT vendors and HIM professionals to work together to ensure that interoperability will be addressed from an HIM perspective. “Identifying HIM practice needs and a means to address them in standards is the first step in achieving our shared goal of the interoperability and overall governance of health information” (AHIMA, 2015).

AHIMA-IHE White Paper: Health IT (HIT) Standards for HIM

Practices



“Recognized as a healthcare imperative, information governance (IG) establishes the policy-level rules, investment priorities and accountabilities for managing the lifecycle of information.”

In healthcare – Information is necessary…

•for safe, quality and effective care of individuals, •for improving the health of population(s) •for reducing per capita costs of healthcare which requires operational excellence

Define: Information Governance (IG)

AHIMA. Information Governance Principles for Healthcare (IGPHC). Chicago, IL. 2014. URL: http://www.ahima.org/~/media/AHIMA/Files/HIM-Trends/IG_Principles.ashx

Source: D. Green. Presentation at Health Datapalooza, June 2014

http://www.ahima.org/~/media/AHIMA/Files/HIM-Trends/IG_Principles.ashx

http://www.ahima.org/~/media/AHIMA/Files/HIM-Trends/IG_Principles.ashx

AHIMA Information Governance Framework: Organizational Policies & Processes for Information Lifecycle

1. Specify business requirements by Information Governance Principle

2. Specify functional requirements for HIT products via HIM Practice Checklist and specific Use Cases by Information Governance Principle

3. �Conduct standards gap analysis by Information Governance Principle

4. Develop recommendations for developing HIT standards to support HIM practices

From IG Principles to HIT Standards: Our Methodology



IG Principles

HIM Business Requirements by Principle

Use Cases

HIM Practice Checklist

HIT Standards

From IG Principles to HIT Standards: Our Methodology





Outline

IG Principles

HIM Business Requirements by

Principle

From IG Principles to HIT Standards: Business Requirements

1. Accountability 2. Transparency 3. Integrity 4. Protection 5. Compliance 6. Availability 7. Retention 8. Disposition

Specification of Business Requirements by IG Principle

Under public comment through June 13, 2016

Specifying Business Requirements: Definition

American Health Information Management Association (AHIMA). Specification of Business Requirements for AHIMA Information Governance Principles for Health Care (IGPHC). Draft for Public Comments. May 2016.

Definition

Health Information Availability is defined as the ability of an organization to maintain information in a manner that ensures timely, accurate, and efficient retrieval of information by authorized entity. For example, information shall be available upon request by any authorized entity in the required output format (e.g. a viewable display for online and paper-based output).

Principle of Health Information Availability: Business Requirements

Specifying Business Requirements


Health Information Availability: Business Requirements 1. Ability to capture and maintain information in a manner that ensures timely, accurate (complete and correct), and efficient access and retrieval. – See Integrity #1, #5, Protection #9, Accountability #7, Transparency #5

2. Ability to access information across various systems (electronic and manual) and across patient populations, payers, labor resource management and research . This includes the abilities to search, identify, locate, and retrieve (see item 3 below) the information required to support organization’s ongoing activities via queries. This requirement is focused on how information from various sources is accessed. – See Integrity #5,#7, Retention #1,#6 3. Ability to search, identify, locate and retrieve individual’s specific information in continually expanding volumes of information and across multiple systems including various electronic HIT, data warehouses, payer data systems, business and research information systems, and manual repositories (paper-based document locations, storages, etc.). This requirement is focused on tracking sources where information resides (HITs, other HICT products and manual repositories). – See Integrity #5 4. Ability to assemble (via search, identify, locate and retrieve) information in a consistent and coordinated fashion (timely and accurate (complete and correct)) from disparate electronic systems, both internal and external to the organization. – See Integrity #5

5. Ability to present/provide information for a specific purpose from disparate electronic systems, both internal and external to the organization. – See Integrity #5, #15

6. Ability to link (semantically and contextually), map, couple, group or integrate clinical and business information in a timely, accurate manner to support organizational business requirements. – See Integrity #5, #7, #15, & #16 7. Ability to address multiple demands for having the right information available at the right time for the right requestor.

8 Ability to access information created with legacy hardware and software systems within an organization. In case of impending system obsolescence, information with organizational value should be migrated to currently supported hardware and/or converted/migrated into a compatible format from non-compatible media (MAC vs PC) and non-compatible software versions. See Integrity #5

Specification of HIM Business Requirements

Information Governance Principles: Business Requirements

2015 (Updated in 2016) 2016 1.Information availability 2. Information integrity 3. Information protection

4.Information accountability 5. Information compliance 6. Information transparency 7. Information retention 8. Information disposition




Outline

• Based on the literature review we developed HIM Practice Checklist of HIM work activities by IG Business Requirement.

• Checklist specifies HIM best practices in executing business requirements.

Functional Requirements by IG Principle: HIM Practice Checklist

American Health Information Management Association (AHIMA). Specification of Checklists and Use Cases for AHIMA Information Governance Principles for Health Care (IGPHC). Work in Progress. 2016.

Functional Requirements by IG Principle: Example of HIM Practice Checklist


• Based on the checklist, we developed the HIM Practice Use Cases that specifies HIM work activities (actions) that require the use of information technology.

Functional Requirements by IG Principle: Use Cases


• The Need

• Collaboration with Health IT Vendors

• AHIMA Approach


Outline

HIM Use Cases

HIM Use Cases for HIT Standards 2015 2016

1. All documents in the episode of care

record are accounted for 2. Episode of care record is complete and

closed 3. Release of Information (ROI) to external

requestor 4. Audit for the episode of care record 5. Audit for the ROI

1. Patient registration 2. Copy and paste 3. Data quality 4. Patient matching 5. Transition of care


Use Case Example: Patient Registration


• The Need

• Collaboration with Health IT Vendors

• AHIMA Approach – Business Requirements – HIM Practice Checklists – Use Cases – Standards Review

Outline

Preliminary Standards Gap Analysis in 2015

ASTM E-31 Standards on HIM Practices IHE IT Infrastructure (ITI) Technical Framework Standards

o Cross-Document Workflow o Cross-Document Sharing o Privacy and Security

HL7 Standards o Electronic Health Record (EHR) Functional Model o EHR Record Management/Evidentiary Support o EHR Interoperability o Mobile Health o Community Based Collaborative Care

ISO Technical Committee (TC) 215 Health Informatics Standards o Privacy and Security



• XDS: ITI-61 Register On-Demand Document Entry • XDS: ITI-52 Update Document Set (Metadata Update Supplement) • XDS: ITI-62 Delete Document Set (Metadata Update Supplement) • XCDR: ITI-80 Cross-Gateway Document Provide (Supplement) • XDS: ITI-43 Retrieve Document Set • XCA: ITI-39 Cross Gateway Retrieve • XDM: ITI-32 Distribute Document Set on Media • XDS: ITI-18 Registry Stored Query • XCA: ITI-38 Cross Gateway Query • MPQ: ITI-51 Multi-Patient Query • XCF: ITI-63 Cross Gateway Fetch • MHD: ITI-65 Provide Document Bundle • MHD: ITI-66 Find Document Manifests • MHD: ITI-67 Find Document References • MHD: ITI-68 Retrieve Document

Detailed Standards Gap Analysis: IHE Standards


http://www.ihe.net/

http://www.ihe.net/

1. IHE ITI White Paper: Template for Cross-Document Sharing Affinity Domain Deployment Planning

2. Patient Identifier Cross-Referencing (PIX)

3. Patient Demographics Query (PDQ)

4. Basic Patient Privacy Consents (BPPC)

5. Advanced Patient Privacy Consents (APPC)

Detailed Standards Gap Analysis in 2016: Selected IHE Standards


http://www.ihe.net/

Recommendations

HIM Professionals Join AHIMA Standards Task Force to Comment on AHIMA Specification of HIM Business

Requirements by IG Principle Harmonize/standardize HIM practices via Checklists Define HIM needs for HIT standards via Use Cases Inform the development of HIT standards at IHE

Standards Development Organizations (HL7, ISO) Enable standard development activities to support HIM

practices Address necessary revisions in existing HIT standards Develop new HIT standards that address HIM needs

Join AHIMA Standards Task Force Efforts: Recap

1. Specification of HIM Business Requirements for All 8 Information Governance Principles – Public Comments, May 16-June 23

2. Specification of HIM Practice Checklists and Use Cases –

Work in Progress

3. IHE Standards Review – Work in Progress

Find documents listed above at AHIMA Information Governance Standards Project Wiki. URL: http://wiki.ihe.net/index.php?title=HIT_Standards_for_HIM_Practices2016#Project_Description

http://wiki.ihe.net/index.php?title=HIT_Standards_for_HIM_Practices2016


AHIMA Standards Task Force need subject matter experts (SMEs) with the expertise in

• legal aspects of information management and use to work on standards for policy representation in HIT products

• patient identity management to work on patient identification and matching standards

• information privacy and security to work on patient consent standards • clinical documentation improvement (CDI) and coding to work on

terminology standards • data quality and documentation integrity to work on document

management standards • health information exchanges to work on information sharing standards

and so on.

Help Wanted

For more information contact: Diana Warner, MS, RHIA, CHPS, FAHIMA Director of HIM Practice Excellence, AHIMA [email protected] Harry Rhodes, MBA, RHIA, CHPS, CDIP, FAHIMA Director of National Standards, AHIMA [email protected]

Join AHIMA Standards Task Force



1. American Health Information Management Association (AHIMA) and Integrating Healthcare Enterprise (IHE). Health Information Standards for Health Information Practices. White Paper. 2015. URL: http://qrs.ly/lb4vec0

2. AHIMA Information Governance Standards Project Wiki. URL: http://wiki.ihe.net/index.php?title=HIT_Standards_for_HIM_Practices2016#Project_Description

Resources




Questions

standards for health information governances3.amazonaws.com › rdcms-himss › files › production...

Documents