Health Information Functions Lecture 9

1. Health Information FunctionsLecture 9 Health Information Management Technology: An Applied ApproachFourth Edition

2. HIM Functions and Services • Typical HIM functions • Storage and retrieval • Record processing • Monitoring of record completion • Transcription • Clinical coding

3. Storage and Retrieval Paper-based system • Patient care information documented on paper and housed in file folders. • Records retrieved for patient care purposes, quality improvement studies, audits, and other authorized uses. • Records are delivered to the nursing units, outpatient surgery, and the emergency room as the patient is admitted or being treated.

4. Storage and Retrieval Hybrid system • Patient care information documented both on paper and in the computer. • Record is accessible to patient care areas via the computer by use of an electronic document management system (EDMS).

5. Storage and Retrieval EHR • Patient care information captured at point of service and/or electronically transmitted to the EHR. • Record resides entirely in electronic format with work processes performed via the computer.

6. Record processing/ completion Paper-based: • After the patient is discharged from the hospital, the record is retrieved from the nursing unit. • Record reconciliation. • After the record is assembled, it is analysed for deficiencies • Complete deficiencies in records. • Re-analyse the record, and deficiencies are cleared from the computer.

7. Record processing/ completion Hybrid system: • Portions of the record can be directly inputted into the EHR through computer interfaces. • Record reconciliation. • Complete the record, remotely. • The deficiency system is updated automatically. • Records are analyzed for deficiencies either manually by the HIM staff and/or by rules built into the computer system.

8. Record processing/ completion EHR system: • Receipt of the health record is checked with a discharge list in a process called record reconciliation. • Entire health record available via the computer for completion. Work queues in the computer are used to route health records to appropriate person or area for completion.

9. Transcription Paper-based system: • Dictation system. • Reports commonly transcribed include: operative reports, history and physicals, discharge summaries, radiology reports, pathology reports, and consultations.

10. Transcription Hybrid and EHR system: • The process is basically the same as in the paper-based system, except that the transcribed reports are electronically added to the health record that resides within the computer. • Speech recognition technology may be applied.

11. Clinical coding Paper-based system: • A code number(s) is/are assigned to the diagnoses and procedures documented in the health record. • The coder looks the code number up in a coding book or by entering key words into the computer using software called an encoder. • ICD-9-CM and CPT are the two primary coding systems used in a hospital setting.

12. Clinical coding Hybrid and EHR system: • The process is the same as the paper-based system, except that in the EHR environment, the record that is reviewed is the electronic health record. • Coding may be remote to hospital; home-based coding is possible.

13. Health Information Exchange • Sharing health information among two or more entities • Local or state geographical regions • Nationwide Health Information Network • Standardize health information exchange practices • Link medical records from multiple organizations

14. Identification Methods • Probabilistic matching on multiple data elements

15. Identification Systems • Health record number • Unique personal identification number • Social Security Number should not be patient identifier.

16. Identification Systems for Paper-based Health Records • Serial numbering system • Unique numerical identifier for each admission • Separate health records • Inefficiencies • Unit numbering system • Commonly used in large healthcare facilities • Unique health record number assigned at first visit and retained for all subsequent visits • Patient encounters are filed/linked together

17. Identification Systems for Paper-based Health Records • Serial-unit numbering system • New health record number assigned each visit • Records brought forward into newest number • Alphabetic identification and filing system • Based on patient’s last name • Date of birth is used when more than one person with same name

18. Identification Systems Used for Electronic Health Records • Unit numbering most common • Search is usually based on health record number or patient name

19. HIM Functions in Electronic Environment • Record is completely electronic • Contains clinical decision support • The EHR automates and streamlines the clinician’s workflow • The EHR has the ability to generate a complete record of a clinical patient encounter

20. Transition Functions to an EHR • Planning process • Workflow analysis • Standardization of forms and processes • Bar coding of forms • Privacy and security procedures established • Change management • Training of staff and medical staff

21. Record Filing and Tracking of EHRs • Record filing • Either eliminated or greatly reduced • May have to manage paper documents in EDMS as they await destruction • Tracking • Replaced by monitoring of access

22. Record Processing of EHRs • Loose reports are indexed • Record completion performed electronically using in-box and work list • Work queues • Accessible to multiple physicians

23. Version Control of EHRs • Multiple versions of documents • Example: one signed and one unsigned • Must have policies and procedures regarding which version is viewable • Documents must be flagged • Lock document from changes • Create user profiles that limit who may edit entries

24. Handling Amendments and Corrections in EHRs • Examples of policies • Addendum required to amend document which has been signed • Maintain original version of document • Document “final copy,” “preliminary copy,” etc. • Lock documents once final signature is applied. • Appearance of added information should look different from original entry

25. Managing Other Electronic Documentation • Patient information should be included in EHR from: • E-mail • Voice mail

26. Search, Retrieval and Manipulation Functions of EHRs • Data mining • Analytical tools • Finding correlations or patterns

27. Medical Transcription • Physicians and other clinicians dictate report • Common dictated reports: • History and physical • Consultation • Operative report • Discharge summary • Radiology reports • Transcribed in word-processing system

28. Management of Medical Transcription • Historically part of HIM department • May be centralized or outsourced • Voice recognition • Frontend • Backend • Medical language editor

29. Quality of Medical Transcription • Check reports for errors • Turnaround time

30. HIM Interdepartmental Relationships • Patient registration • Information • Identifying • Treatment • Payment • Health record number assigned • May be part of HIM or separate department • Centralized or decentralized location

31. Billing Department • Uses codes and other information from HIM to create bill • Insurer may require patient information

32. Patient Care Departments • Provides information to patient care areas

33. Information Systems • HIM must work with IS • HIM skills are needed for • Federal, state and accreditation standards • Privacy and security • IS skills need for • Hardware and software • Infrastructure

34. Management and Supervisory Processes • Policy and procedure development • Organization • Departmental • Content of policy • Policy title • Description of scope of policy • Expected standard • Guidelines to achieve expected standard

35. Policies and Procedures • Policies are broad statements. • Procedures are specific requirements. • Step-by-step instructions

36. Management and Supervisory Processes

37. Policies and Procedures

38. References • Health Information Management Technology: An Applied Approach. American Health Information Management Association