Health Information Management

1Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Health Information ManagementHealth Information Management

Chapter 16


IntroductionIntroduction

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

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


This chapter will examine:This chapter will examine:

How health information is usedHow health information is used Characteristics of high-quality dataCharacteristics of high-quality data Concerns of quality assuranceConcerns of quality assurance Importance of HIPAAImportance of HIPAA Functions of the NCHSFunctions of the NCHS Types of healthcare statistics keptTypes of healthcare statistics kept Total quality managementTotal quality management Acknowledging and handling medical errorsAcknowledging and handling medical errors


Evolution of the Profession: AHIMAEvolution of the Profession: AHIMA

Began as the Association of Record Librarians of Began as the Association of Record Librarians of North AmericaNorth America

Changed its name to the American Medical Record Changed its name to the American Medical Record Association in 1970Association in 1970

Evolved into AHIMA in 1991Evolved into AHIMA in 1991

Advances in technology have brought healthcare services 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.


Health Information Management Health Information Management ProfessionsProfessions

Registered Health Information Administrator Registered Health Information Administrator (RHIA)(RHIA)

Registered Health Information Technician (RHIT)Registered Health Information Technician (RHIT)


Coding ProfessionsCoding Professions

Certified Coding Assistant (CCA)Certified Coding Assistant (CCA) Certified Coding Specialist (CCS)Certified Coding Specialist (CCS) Certified Coding Specialist (CCS-P)Certified Coding Specialist (CCS-P)


Health Care Privacy and SecurityHealth Care Privacy and Security

Certified in Health Care Privacy and Security Certified in Health Care Privacy and Security (CHPS)(CHPS)


Move toward Computer-Based RecordsMove toward Computer-Based Records

In 2005, 25% of the nation’s physicians used In 2005, 25% of the nation’s physicians used some form of computer-based medical records.some form of computer-based medical records.


Federal RegisterFederal Register

Provides daily access to rules, proposed Provides daily access to rules, proposed rules, changes, and notices of federal rules, changes, and notices of federal agencies and organizationsagencies and organizations

Published by Office of Federal Register, Published by Office of Federal Register, National Archives and Records AdministrationNational Archives and Records Administration

Excellent source of health data Excellent source of health data Can sign up for daily emails with a table of Can sign up for daily emails with a table of

contents that connects to the contents that connects to the Federal Federal RegisterRegister website website


How Use of Electronic Records How Use of Electronic Records Reduces Medical ErrorsReduces Medical Errors

Keeps prescriptions organizedKeeps prescriptions organized Notes allergies clearlyNotes allergies clearly Reduces costs by avoiding duplicate testsReduces costs by avoiding duplicate tests Can reduce staffing needsCan reduce staffing needs

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


Characteristics of High-Quality Characteristics of High-Quality Health DataHealth Data

Experts agree on nine characteristics of Experts agree on nine characteristics of high-quality health data:high-quality health data: Validity Reliability Completeness Recognizability Timeliness

Relevance Accessibility Security Legality



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

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



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

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



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

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



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

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

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


Quality AssuranceQuality Assurance

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

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


Challenges of Quality-Assurance Challenges of Quality-Assurance ProblemsProblems

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


Some Overused TreatmentsSome Overused Treatments

HysterectomiesHysterectomies Tympanostomy tubesTympanostomy tubes AntibioticsAntibiotics


Some Underused TreatmentsSome Underused Treatments

MammogramsMammograms Cervical cancer screeningsCervical cancer screenings Beta-blockers for heart patientsBeta-blockers for heart patients Eye examinations for diabetic patientsEye examinations for diabetic patients


Misuses of Healthcare ServicesMisuses of Healthcare Services

Laboratory tests that provide erroneous resultsLaboratory tests that provide erroneous results Medication errorsMedication errors Hospital injuries to patientsHospital injuries to patients Nosocomial infectionsNosocomial infections


HIPAAHIPAA

Health Insurance Portability and Accountability Health Insurance Portability and Accountability Act (HIPAA)Act (HIPAA) Became law in 1996Became law in 1996 Became effective April 14, 2003Became effective April 14, 2003 Applies to records that are created orApplies to records that are created or maintained by healthcare providers, health maintained by healthcare providers, health plans, and healthcare clearinghouses that plans, and healthcare clearinghouses that engage in electronic transactions engage in electronic transactions


HIPAA Regulation HIPAA Regulation

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


Provisions of HIPAA’s Privacy RuleProvisions of HIPAA’s Privacy Rule

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

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



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

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



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

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


Patient ConfidentialityPatient Confidentiality

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


National Center for Health National Center for Health Statistics (NCHS)Statistics (NCHS)

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

Primary provider of health information statisticsPrimary provider of health information statistics


NCHS FunctionsNCHS Functions

Documentation of health status of the Documentation of health status of the population and its subgroupspopulation and its subgroups

Identification of disparities in health status and Identification of disparities in health status and use of healthcare services by socioeconomic use of healthcare services by socioeconomic factorsfactors

Description of experiences with the healthcare Description of experiences with the healthcare systemsystem

Evaluation of the impact of health policies and Evaluation of the impact of health policies and programsprograms


NCHS FunctionsNCHS Functions

Monitoring of trends in health status and Monitoring of trends in health status and healthcare deliveryhealthcare delivery

Identification of health problemsIdentification of health problems Support for biomedical and health services Support for biomedical and health services

researchresearch Provision of information for making changes in Provision of information for making changes in

public policies and programspublic policies and programs


Types of NCHS Statistics Types of NCHS Statistics

Teenage pregnancyTeenage pregnancy Incidence of HIV Incidence of HIV

infectioninfection Alcohol and drug Alcohol and drug

useuse BirthsBirths DeathsDeaths Communicable Communicable

diseasesdiseases

Infant health and Infant health and mortalitymortality

Leading causes of Leading causes of deathdeath

Life expectancyLife expectancy Sexually transmitted Sexually transmitted

diseasesdiseases SuicideSuicide


Total Quality Management (TQM)Total Quality Management (TQM)

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


TQM ConceptTQM Concept

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

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


Deming’s 14 Points for ManagementDeming’s 14 Points for Management

Create constancy of purpose toward Create constancy of purpose toward improvement of product and service.improvement of product and service.

Adopt the new philosophy.Adopt the new philosophy. Cease dependence on inspection to achieve Cease dependence on inspection to achieve

quality.quality. End the practice of awarding business on the End the practice of awarding business on the

basis of price tag.basis of price tag.



Constantly improve the system of production Constantly improve the system of production and service.and service.

Institute training on the job.Institute training on the job. Institute leadership.Institute leadership. Drive out fear so that everyone can work Drive out fear so that everyone can work

effectively for the company.effectively for the company. Break down barriers between departments.Break down barriers between departments.



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

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

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



Institute a vigorous program of education and Institute a vigorous program of education and self-improvement.self-improvement.

Make the company transformation everyone’s Make the company transformation everyone’s job.job.


Joint CommissionJoint Commission

Nonprofit organization Nonprofit organization Provides accreditation services to healthcare Provides accreditation services to healthcare

facilitiesfacilities Voluntary process, but vital to healthcare Voluntary process, but vital to healthcare

organizationsorganizations Many ambulatory outpatient facilities are Many ambulatory outpatient facilities are

accredited by the Joint Commissionaccredited by the Joint Commission


Risk Management Risk Management

Any occurrence that could result in patient injury Any occurrence that could result in patient injury or any type of financial loss to the facility is called or any type of financial loss to the facility is called a a risk. risk. Risk management efforts focus on:Risk management efforts focus on: Loss preventionLoss prevention Avoiding patient injuryAvoiding patient injury Avoiding any financial loss resulting fromAvoiding any financial loss resulting from liability liability Avoidance of negative publicity resulting fromAvoidance of negative publicity resulting from sentinel events sentinel events


Sentinel EventSentinel Event

Unexpected occurrence involving death or Unexpected occurrence involving death or serious physical or psychological injury, or serious physical or psychological injury, or the risk thereof.the risk thereof.


Reporting Sentinel EventsReporting Sentinel Events

Do so immediatelyDo so immediately Investigate thoroughlyInvestigate thoroughly Rectify contributing factorsRectify contributing factors Keep records documenting the incidentKeep records documenting the incident


Incidents Possible in Ambulatory CareIncidents Possible in Ambulatory Care

Medication errorsMedication errors Delay in treatmentDelay in treatment Medical equipment failureMedical equipment failure Patient fallsPatient falls FireFire Wrong-site surgeryWrong-site surgery Unintended retention of foreign objectsUnintended retention of foreign objects


Acknowledging and Disclosing Acknowledging and Disclosing Medical ErrorsMedical Errors

Most medical professionals would never Most medical professionals would never intentionally make an errorintentionally make an error

Most errors are minor without serious Most errors are minor without serious consequencesconsequences

Some will lead to medical professional liability Some will lead to medical professional liability litigationlitigation


DefinitionsDefinitions

Sentinel eventSentinel event: unexpected occurrence : unexpected occurrence involving death or serious physical or involving death or serious physical or psychological injurypsychological injury

Adverse eventAdverse event: an injury caused by medical : an injury caused by medical management rather than the underlying management rather than the underlying condition of the patientcondition of the patient

Near MissNear Miss: an error that is caught or : an error that is caught or corrected before it affects the patientcorrected before it affects the patient


Disclosing ErrorsDisclosing Errors

89% of patients want physicians to disclose 89% of patients want physicians to disclose errors concerning their care.errors concerning their care.

77% of physicians agree that errors should 77% of physicians agree that errors should be disclosed to patients.be disclosed to patients.


Obstacles to Disclosure of ErrorsObstacles to Disclosure of Errors

Fear of litigationFear of litigation Patient-physician relationship prior to incidentPatient-physician relationship prior to incident Characteristics of the injuryCharacteristics of the injury Physician’s communications skillsPhysician’s communications skills Patient’s financial statusPatient’s financial status Patient distressPatient distress Patient attritionPatient attrition Damage to reputationDamage to reputation License revocationLicense revocation Loss of staff privilegesLoss of staff privileges


Patient ExpectationsPatient Expectations

Forthcoming informationForthcoming information SympathySympathy ApologyApology No financial obligation for treatment as a No financial obligation for treatment as a

result of the errorresult of the error Opportunity to ask questionsOpportunity to ask questions


Summary of ScenarioSummary of Scenario

Read lengthy, complicated documents Read lengthy, complicated documents carefully and determine what is being carefully and determine what is being communicated.communicated.

Maintain a good relationship with health Maintain a good relationship with health professionals.professionals.

Be flexible and open to changing regulations Be flexible and open to changing regulations in the healthcare industry.in the healthcare industry.

Records must be accurate, complete, and Records must be accurate, complete, and reliable for medical professionals who use reliable for medical professionals who use them.them.


Closing CommentsClosing Comments

Patients want health information to be kept Patients want health information to be kept confidential.confidential.

Patients expect healthcare professionals to Patients expect healthcare professionals to show concern and warmth and to listen to and show concern and warmth and to listen to and answer questions.answer questions.

Lack of trust is the root of many medical Lack of trust is the root of many medical professional liability lawsuits.professional liability lawsuits.

Documents

Health Information Management