Columbus State Community College Allied Health Professions Department Health Information Management Technology

Transcription

1 COURSE: HIMT 1135 B Health Data Management- EHR Columbus State Community College Allied Health Professions Department Health Information Management Technology CREDITS: 1.5 CLASS HOURS PER WEEK: 2 PREREQUISITES: None COREQUISITE: HIMT 1111 DESCRIPTION OF COURSE This course provides hands-on experience with the electronic health record (EHR). Health record content is reviewed and data flow as it relates to navigation and use of the EHR. STUDENT LEARNING OUTCOMES At the conclusion of this course the student shall be able to: 1. Navigate the health record (paper-based, hybrid and electronic health record formats to locate data necessary for abstracting data and documenting used for billing, reporting, and audits. 2. Describe the functionality of the electronic health record (EHR). 3. Identify privacy and security issues with the EHR. 4. Differentiate between clinical information systems, administrative information systems and other support systems. 5. Identify best practice to assure the quality of documentation and HIM services. 6. Discuss the current state of meaningful use and health information exchange. 7. Cite the benefits of consumer health informatics and the personal health record. 8. Describe HIT systems used in healthcare facilities and the HIM department. GENERAL EDUCATION OUTCOMES Columbus State Community College's general education outcomes are an integral part of the curriculum and central to the mission of the college. The faculty at Columbus State has determined that these outcomes include the following competencies: Critical Thinking Scientific and Technological Effectiveness COURSE MATERIALS REQUIRED 1. Headset and microphone for attendance at online meetings TEXTBOOK, MANUALS, REFERENCES, AND OTHER READINGS Documentation for Medical Records (Barbara Odom-Wesley, Diann Brown, and Chris Myers) Introduction to Computer Systems for Health Information Technology by Sayles and Trawick (Also used in HIMT 2870)

2 Open source material from the ONC HIT curriculum GENERAL INSTRUCTIONAL METHODS 1.Guided study through required textbook. 2. Online lectures 3. Reinforcement exercises/lab Assignments 4. Online resources may be used to supplement material. ASSESSMENT Columbus State Community College is committed to assessment (measurement) of student achievement of academic outcomes. This process addresses the issues of what you need to learn in your program of study and if you are learning what you need to learn. The assessment program at Columbus State has four specific and interrelated purposes: (1) to improve student academic achievements; (2) to improve teaching strategies; (3) to document successes and identify opportunities for program improvement; (4) to provide evidence for institutional effectiveness. In class you are assessed and graded on your achievement of the outcomes for this course. You may also be required to participate in broader assessment activities. STANDARDS AND METHODS FOR EVALUATION Quizzes: There will be weekly quizzes given to assess achievement of course content. Quizzes will be taken at home. Quizzes are closed book assessments. Therefore, the student may not use there textbook, notes or any other reference material during the quiz. The quizzes will be timed for 20 minutes. If a student exceeds the 20 minute time limit, 2 points will be deducted from the student s quiz score for each minute the time limit was exceeded. Quizzes are to be done independently. Discussing or sharing the contents of quizzes and tests with classmates is prohibited and is considered academic misconduct. Quizzes not submitted by the due date and time will earn a score of zero points. Assignments/Lab Assignment: Assignments measure student observations, experiences, and thought processes. Completion of various assignments and lab assignment will be required. Details regarding assignments will be posted on Blackboard. If a student misses an assignment due date, a score of zero (0) will be recorded for the assignment. Final Exam: A final exam (Covering material covered weeks 9-15 of the semester) will be given on the date specified on the course schedule. Students enrolled at in web-based courses must take exams at the Columbus State testing center (main campus, Dublin, Westerville, Delaware and Gahana) Testing availability dates will be posted on the announcement page of Blackboard. If the midterm exam is not completed within the posted testing window, a score of zero (0) will be earned. It is the student s responsibility to follow the testing center policies (e.g. no children in testing center, turn off cell phones, present student id card, etc.) and to be at the testing center at least one hour prior to closing. Information regarding the testing center policies can be found on their web site at

3 GRADING SCALE Final grades will be determined as follows: Quizzes 25% Assignments/Laboratory Assignments 35% Final Exam 40% 100% % =A % =B 79-70% =C % =D 59%-Below =E SPECIAL COURSE REQUIREMENTS To access the material for this on-line course, you must Have Internet Access Provider and headset with microphone to attend online meetings. Use your CSCC Account Take Tests at Columbus State testing centers. ATTENDANCE POLICY Web-based course: Students enrolled in web-based course should plan to spend a minimum of 2-3 hours per credit hour each week on their studies for this course. Attendance Reporting: A student will be reported as not attending for financial aid reporting if the student has missed more than one posted assignment, quiz due date or test. See Financial Aid Reporting information provided below in this syllabus. STUDENT CODE OF CONDUCT As an enrolled student at Columbus State Community College, you have agreed to abide by the Student Code of Conduct as outlined in the Student Handbook. You should familiarize yourself with the student code. The Columbus State Community College expects you to exhibit high standards of academic integrity, respect and responsibility. Any confirmed incidence of misconduct, including plagiarism and other forms of cheating, will be treated seriously and in accordance with College Policy and Procedure AMERICANS WITH DISABILITIES ACT (ADA) POLICY

4 It is Columbus State policy to provide reasonable accommodations to students with documented disabilities. If you would like to request such accommodations because of physical, mental or learning disability, please contact the Department of Disability Services, 101 Eibling Hall, (V/TTY). Delaware Campus students may also contact an advisor in the Student Services Center, first floor Moeller Hall, Ask for Delaware Campus advising, or for assistance. INCLEMENT WEATHER OR OTHER EMERGENCIES (optional wording) In the event of severe weather or other emergencies that could force the college to close or to cancel classes, such information will be broadcast on radio stations and television stations. Students who reside in areas that fall under a Level III emergency should not attempt to drive to the college even if the college remains open. Assignments due on a day the college is closed will be due the next scheduled class period. If an examination is scheduled for a day the campus is closed, the examination will be given on the next class day. If a laboratory is scheduled on the day the campus is closed, it will be made up at the next scheduled laboratory class. If necessary, laboratory make-up may be held on a Saturday. If a clinical is missed because of weather conditions: (insert department policy). Students who miss a class because of weather-related problems with the class is held as scheduled are responsible for reading and other assignments as indicated in the syllabus. If a laboratory or examination is missed, contact me as soon as possible to determine how to make up the missed exam or lab. Remember! It is the student s responsibility to keep up with reading and other assignments when a scheduled class does not meet, whatever the reason. In the event the college is forced to close during Final Examination Week, exams scheduled for the first missed date will be rescheduled for (date), in the same location at the same time scheduled. Exams scheduled for a second missed date will be rescheduled for. Thus, our final exam is scheduled for (date) at o clock. If the college is closed that day, the exam will be held on (date) at o clock. If our exam is the second day the college has been closed, the exam will be held on (date) at o clock. FINANCIAL AID ATTENDANCE REPORTING Columbus State is required by federal law to verify the enrollment of students who participate in Federal Title IV student aid programs and/or who receive educational benefits through the Department of Veterans Affairs. It is the responsibility of the College to identify students who do not commence attendance or who stop attendance in any course for which they are registered and paid. Non-attendance is reported quarterly by each instructor, and results in a student being administratively withdrawn from the class section. Please contact the Financial Aid Office for information regarding the impact of course withdrawals on financial aid eligibility.

5 UNITS OF INSTRUCTION/SCHEDULE Week 1 - Unit of Instruction: Content (Data Elements of health record components) - Learning Objectives/Goals: Chapter 5 List the types of demographic data, administrative information, clinical information collected in health records; explain the purpose of each element. List the data elements collected in the: o History and physical examination o laboratory reports. o imaging reports. o anesthesia assessments and reports. o operative reports. o pathology reports. o implant and transplantation records. Explain the function and content of discharge summaries. Explain the function and content of patient instructions. List the various types of specialty documentation maintained in acute-care records. List the data elements that must be collected in emergency and trauma records. List and describe the standard clinical data sets that are collected for hospital patients. Identify the types of clinical information collected in health records; explain the pupose of each element. Describe the types of services covered in physicians' orders. List the various types of documentation authored by physicians and explain their content and functions. Explain the conditions under which medical consultations should be ordered. List the various types of documentation authored by nurses; explain their content and function. Explain the functions of general and specific consents. Appendices Describe a complete medical record in a hybrid environment. Describe a legally sound health record. Describe standards for the content of the EHR. Recognize the principles of sound form and screen design. Describe the EDMS as a component of the EHR. - Assignment: Read chapter 5 and appendices Odom-Wesley Chapter 5 Clinical Information and Observation Appendices: A, D, F, G, and H

6 Lab Assignment: Abstracting - Assessment Methods: Quiz Abstracting Assignment Week 2 Unit of Instruction: Format of the Health Record Best Practices - Learning Objectives/Goals: Chapter 6 Compare the format, functionality, and features of three different paper-based health record formats. Describe the format, function, and features of electronic health records. Explain the types of technological systems that support EHRs. Explain the functions of clinical decision support systems included in medical records. Explain the importance of the standardization of forms and views to improve the functionality of health records. Describe the value of standardization for acronyms, abbreviations, and symbols to improve the functionality of health records. Link specified components of the health record system as improvements for users of the health records. Describe the challenges of the hybrid health record. Describe how paper-based, hybrid, and electronic health record formats affect HIM functions. Chapter 7 Explain the concept and importance of document improvement. Identify four guidelines for a successful document improvement program. Explain the purpose of health record analysis. Explain the difference between quantitative and qualitative analysis. Discuss the importance of ongoing record review and data quality analysis. Describe the steps involved in creating a data dictionary. Define the term authentication within the context of health records. Describe tools used to achieve authentication of health records. Explain the process for correcting errors in paper-based and electronic health records. Identify four areas of concern when working to prevent fraud in the electronic health record environment. Discuss the importance of data quality in electronic health records; discuss ways in which it can be achieved. Identify three concepts important to developing a litigation response plan for e-discovery.

7 Outline the points that need to be addressed in a disaster-recovery plan. - Assignment: Read chapter 6 and 7 Odom-Wesley Chapter 6 Format of the Health Record Chapter 7 Best Practices in Health Record Documentation - Assessment Methods: Quiz Week 3 - Unit of Instruction: An overview of the HIT and the EHR - Learning Objectives/Goals: C7 U1 Define a system and relate systems concepts to HIT Discuss specific examples of settings where Health IT is used (acute, rural, public health, clinic, office, patient home, etc.) Identify common components of a clinical HIT system Demonstrate beginning level competency in maneuvering the demonstration EHRS C6 U3.1 State the similarities and differences between an electronic medical record (EMR) and electronic health record (EHR). Identify the attributes and functions of an EHR Describe the perspectives of health care providers and the public regarding acceptance of or issues with an EHR, which can serve as facilitators of or major barriers to its adoption. Explain how the use of an EHR can affect patient care safety, efficiency of care practices, and patient outcomes. Discuss how health information exchange (HIE) and Nationwide Health Information Network (NHIN) impact health care delivery and the practice of health care providers. Outline issues regarding governmental regulation of EHR systems such as meaningful use of interoperable health information technology and a qualified EHR Identify how ongoing developments in biomedical informatics can affect future uses and challenges related to health information systems. Chapter 1 Introduction to Computers

8 Describe the functions of the basic components of the personal computer to include hardware, software, networks, and internet technologies. Identify and discuss the impact of computers in healthcare in all areas within a facility. Discuss the history of computers in healthcare. Compare and contrast the similarities and differences between the Internet, Intranet and the Extranet as used in Healthcare. Introduce the electronic health record and the benefits of its use over the paper record in acute care. Chapter 7 Computers in HIM Identify the systems need to support efficient operations in the HIM department. Differentiate between the various software products used in the HIM department. Improve the quality of data within the health information management systems. - Assignment: Listen to HIT lectures (ONC lectures) Introduction & Overview: Components of HIT Systems (C7 U1) Introduction to Electronic Health Records (C6 U3-1) Read chapter 1 and 7 Sayles and Trawick textbook. Chapter 1 Introduction to Computers Chapter 7 Computers in HIM Lab Assignment: VistA (CPRS) C7 Unit 1 Activity Scavenger Hunt - Assessment Methods: Quiz C7 Unit 1 VistA Scavenger Hunt Week 4 - Unit of Instruction: EHR Functionality - Learning Objectives/Goals: C6

9 Describe the purpose, attributes and functions of CPOE, clinical decision support systems, patient monitoring systems, and imaging systems. Explain ways in which CPOE, clinical decision support systems, patient monitoring systems, and imaging systems are currently being used in health care Discuss the major values to CPOE, clinical decision support systems, patient monitoring systems, and imaging systems adoption Identify common barriers to CPOE, clinical decision support systems, patient monitoring systems, and imaging systems adoption Identify how CPOE, clinical decision support systems, patient monitoring systems, and imaging systems can affect patient care safety, quality and efficiency, as well as patient outcomes Chapter 9 Clinical Information Systems Differentiate between the various clinical information systems Define clinical information system. Determine what clinical information system is needed to meet the needs of the facility. Determine what clinical information system is needed to meet the needs of the enterprise wide organization. Chapter 10 Electronic Health Record Explain the role of the clinical vocabularies in the EHR. Support the need for the EHR. Address issues related to the EHR. Describe what the EHR is and what it is not. Educate the provider on benefits of the EHR. Identify the need for the multiple systems required to support the EHR. -Assignment: Listen to HIT lectures (ONC lectures) Electronic Health Record Functionality C14 u 4 Introduction to CPOE (c6 U 4-1) Aspects of CPOE (C6 U4-2) Clinical Decision Support Systems (C6 U5-1) Clinical Decision Support Systems (C6 U 5-2) Assessing decision support capabilities of commercial EHRs (C14 U7) Patient Monitoring Systems (C6 U6-1) Patient Monitoring Systems (Telehealth) C6U6-2 Medical Imaging Systems (C6 U7) Read chapters 9 and 10 Sayles and Trawick textbook Chapter 9 Clinical Information Systems Chapter 10 Electronic Health Record Lab Assignment:

10 VistA (CPRS) C7Unit 2 Activity - Complete assessment and complete documentation required. - Assessment Methods: Quiz C7 U 2 Activity Week 5 - Unit of Instruction: Functions of HIT Systems and support of the process HIE - Learning Objectives/Goals: ONC Lectures 6.9: Explain applications that need to be integrated in health care information systems Describe the strategies used by health care organizations to ensure integration of functions. Discuss the critical elements needed to integrate billing, financial, and clinical systems. Discuss the core elements of a Master Patient Index (MPI) Describe the components integral to a Unique Patient Identifier (UPI) C7 U3: Identify common elements of the HIT system. Explain the need for standards and why they exist. Define and differentiate between messaging standards and terminology standards. (transmission VS meaning very basic) Compare current efforts to facilitate health information exchange between providers, communities, regions, & nation. (basic level definitions/descriptions NHIN, HIEs, etc.) Chapter 8 Administrative Information Systems Determine what administrative information system is needed for a particular task. Differentiate between administrative information systems Differentiate between a decision support system and an executive information system. Describe how administrative systems impact health information management practices. - Assignment: Listen to HIT lectures (ONC lectures) Administrative, Billing, and Financial Systems (C6 U9 1) Administrative, Billing, and Financial Systems (C6 U9 2) Understanding Information Exchange in HIT Systems (C7 u 3) External Influences (C6 U3-2)

11 Vendor strategies for terminology, knowledge management, and data exchange C14 U6 Read chapter 8 Sayles and Trawick textbook Chapter 8 Administrative Information Systems Activity: Activity (C7 U3 ):Interview with a health or healthcare staff member who has had a bad experience with health data sharing, systems interoperability, or exchange. (Assignment instructions on Blackboard) - Assessment Methods: Quiz Activity (C7 U3 ):Interview Week 6 - Unit of Instruction: Patient centered care Privacy and security - Learning Objectives/Goals: C7 U10/C6U8: C7u7 Define patient-centered care. Assess the effectiveness of HIT systems in supporting patient-centered care. Explain how current and emerging technologies including the Internet have impacted and may continue to affect consumer health informatics. Describe the role of genomics in consumer health informatics. Describe the emergence of Personal Health Records and their implications for patients, health care providers, and health systems. Discuss how consumerism influences the ongoing development and use of health information systems. Explain and illustrate privacy, security, and confidentiality in HIT settings. Identify common threats encountered when using HIT. Formulate strategies to minimize threats to privacy, security, and confidentiality in HIT systems Chapter 12 Privacy and Security Develop policies and procedures related to privacy. Describe the control access to protected health information. Identify the need and process of risk analysis.

12 Develop password management plan. - Assignment: Listen to HIT lectures (ONC lectures) HIT and Aspects of Patient Centered Care C7 U10a) HIT and Aspects of Patient Centered Care C7 U10b Consumer Health Informatics (c6 U8-1) Consumer Health Informatics (C6 Unit 8-2) Protecting Privacy, Security, and Confidentiality in HIT Systems C7 U7a Protecting Privacy, Security, and Confidentiality in HIT Systems C7 U7 b Read chapter 12 Sayles and Trawick textbook Chapter 12 Privacy and Security Lab Assignment: VistA (CPRS) activity C7 Unit 7 System safeguards - Assessment Methods: Quiz Activity C7 Unit 7 Week 7 - Unit of Instruction: Future of Computers in Healthcare - Learning Objectives/Goals: Chapter 14 The Future of Computers in Healthcare Differentiate between the two types of computer assisted coding. Discuss the evolution of the personal health record. Identify the current and future state of health information exchange. Describe emerging role associated with the electronic health record. - Assignment: Read chapter 14 Sayles and Trawick textbook Chapter 14 The Future of Computers in Healthcare - Assessment Methods: Quiz

13 Week 8 Final exam (Comprehensive) available at testing center starting The last day to complete the exam is.

14 Policies/Procedures Help Technical Issues (e.g. login issues, password, downtime, computer settings, etc) call the help desk at (614) Students will receive at their CSCC address. If you need assistance setting up your Columbus State contact the help desk at Content of the course (e.g. testing, questions about lessons, locked out of an quiz/test, questions about course structure, etc.) contact your instructor via or voice mail. Blackboard, cougar web and more: Click on the HELP tab at the top of Blackboard. There are many how to and help topics listed under this tab. There are also links to many of the common sites that student need to visit, such as the testing center web site. Communicating With the Instructor: Your instructor is available through to answer your questions regarding the content of the material and the structure of the course. The instructor contact information is posted under the faculty information button on Blackboard. is a wonderful communication tool that is a vital part of your learning process. However, there are some general policies that must be considered when communication through . Check frequently: Typically, students enrolled in web-based program check their 5 days per week. Use your Columbus State Instructors will reply to s from the address the student used to send the message. If the instructor initiates the original , the student s Columbus State will be used. If you need assistance activating you CSCC or routing your Columbus State to your personal account contact the Student Help Desk at (614) Subject line: The subject line must include the course number. For example, HIMT 121. Using the course number in the subject line will assist the instructor in addressing your questions. Cougar Id: Students must include their cougar id in the communication. Asking Questions: If the student has several questions, it is best to number the questions. Numbering the questions will help the instructor clearly identify the question(s), so that all question(s) are answered. If the contains a question that refers to a particular assignment question or quiz question, it is best to repeat the question text in the or include the page number and question number. Be specific when asking your questions.

15 The student should explain how he/she worked through the problem(s) in question. This will help the instructor better answer the question. Etiquette: Students should be professional in their communication. Remember there is a person on the receiving end of the . Using all capital letters is considered the same as yelling in an and also makes the more difficult to read. Use of profanity is never acceptable.