School of Health Sciences Week 8! AHIMA Practice Briefs

1. School of Health Sciences Week 8! AHIMA Practice Briefs Healthcare Delivery & Information Management HI 125 Instructor: Alisa Hayes, MSA, RHIA, CCRC

2. Class Reminders School of Health Science • Contact Information • AIM:AlisaCHayes • Email: ahayes@kaplan.edu • Office Hours • By Appointment • Chat conversations during class • Please keep conversations focused on class. • Type “pause” to comment and “?” to ask a question

3. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science • Objectives •Contrast the differences between paper and electronic health records •  Describe  the basic elements in the conversion process to an electronic record • List the functions of an electronic health record system

4. AHIMA Practice BriefsAutomation of Health Information Functions • Information systems- only as good as their data • A set of data elements with clearly defined names and definitions, offer validity and reliability of the data • Data Dictionary- a descriptive list of names, definitions, and attributes of data elements to be collected in an information system or database • Creation and maintenance of the data dictionary is pivotal to the success of an EHR system • Why create a Data Dictionary? • Interoperability • Improves data validity and reliability • Improved Communication • Consistency School of Health Science

5. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science Problems with not using a data dictionary • May not collect all of the information it needs or it may be unable to combine or map data across systems because the definitions are not identical • May combine data elements it believes to be equivalent and draws incorrect inferences from the invalid data • Affect the information flow as well as the workflow

6. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science • Data dictionary development • Plan for the development, implementation, and continuing maintenance of the data dictionary. • Data dictionary that integrates common data elements used across an enterprise. • Collaborative involvement and buy-in of all key stakeholders when data requirements are being defined for an information system. • Approvals process and documentation trail for all initial data dictionary decisions and for ongoing updates and maintenance

7. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science • Data Dictionary Development Con’t- • Identify and retain details of data versions across all applications and databases • Flexibility and growth capabilities into the data dictionary • Room for expansion of field values over time • Follow established ISO/IECguidelines • Adopt nationally recognized standards and normalize field definitions across data sets • Beware of differing standards • Geographic codes • Test the information system to demonstrate conformance to standards • Ongoing education and training • Consistency of information sharing and avoid duplication

8. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science • Data content for EHR • HIM professionals play a critical role in managing the quality of health information and must be actively involved in the standardization of data content for EHRs. • HIM professionals must understand what a data dictionary is and what it contains. They should also help evaluate the EHR system’s data dictionary to confirm that the necessary information required for patient care is present in the EHR. • Establishing a data dictionary for the EHR- definitions of data content for EHR systems promote data quality through data consistency across the organization.

9. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science • Importance of Data Standards • Data within the EHR can serve many purposes, including biosurveillance, public health reporting, and performance measurement • ensure consistency in the flow and processes of data capture that ultimately affect the management of health information • To ensure patient information is collected and analyzed by the system correctly, keeping the data content as consistent as possible is key

10. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science • Data content for EHR • Defining clinical data content for the history and physical report, consultation report, operative report, and discharge summary • History and Physical-should include chief complaint; history of present illness; review of systems; past, family, and social history; physical examination; and impressions to comply with documentation requirements. • Consultations- report must include information about the source and reason for the request, evidence that the consultant reviewed the patient’s medical record and examined the patient, and documentation of his or her pertinent findings, opinions, and recommendations

11. AHIMA Practice BriefsAutomation of Health Information Functions School of Health Science • Data content for EHR con’t • Operative report- documents the significant procedures performed during the hospital stay • Discharge Summary-summarize the patient’s condition at the beginning of treatment and basic information about tests, examinations, procedures, and results occurring as a result of treatment. The conclusion at termination of care is called a discharge summary

12. Current Week School of Health Science • 9/21/11-9/27/11 • Complete Reading (AHIMA practice briefs) • Discussion participation • Term Project PHR due by 9/27 at 11:59 PM- worth 200 points!!! • AHIMA practice brief 400-500 word response paper on unit 8 “learning activity” questions • See Docsharing for updated “links” document for websites

13. Next Week School of Health Science • 9/28/11-10/4/11 • Read chapter 1, 2, 3 of the Electronic Health Records Text (Hamilton text in docsharing) • Read AHIMA Practice Brief, Update: Maintaining a Legally Sound Health Record • Complete your discussion question • Assignment is: Install SpringCharts software and download and complete Scavenger Hunt exercises 1 & 2, located in docsharing

14. Any questions?? School of Health Science