Health Information Management 1
Introduction Health information management is a relatively new field that continues to grow in popularity among students of the health professions. The advent of computer-based medical records makes this a high-demand career opportunity. 2
This chapter will examine: What kind of certifications are involved in Health Information Management How health information is used Concerns of quality assurance Importance of HIPAA Functions of the National Center for Health Statistics (NCHS) Types of healthcare statistics kept Total quality management Acknowledging and handling medical errors 3
Evolution of the Profession: HIM Changed its name to the American Medical Record Association in 1970 Evolved into HIM in 1991 HIM takes care of all medical information, errors, and statistical information that involves the patient. 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. 4
What Certifications are offered in Health Information Management Registered Health Information Administrator (RHIA) Registered Health Information Technician (RHIT) Certified Coding Assistant (CCA) Certified Coding Specialist (CCS) Certified Coding Specialist (CCS-P) 5
9 Characteristics of Data entered in Health Information (Medical Records) What should the records reveal? Experts agree on nine characteristics of high-quality health information: Validity Reliability Completeness Recognizability Timeliness Relevance Accessibility Security Legality 6
9 Characteristics of High-Quality Health information 1. Validity: synonymous with accuracy. Healthcare information must be accurate to be usable. 2. Reliability: Healthcare professionals must be able to rely on the information presented. 3. Completeness: Incomplete records may lack vital information needed to care for the patient. 4. Recognizability: All users of health information must be able to interpret the data that are presented in the health record. 7
9 Characteristics of High-Quality Health information 5. Accessibility: Healthcare data must be accessible to multiple users at one time. 6. Security: Precautions must be taken to prohibit intruders from accessing medical records. 7. Legality: The record must be completely legible and properly authenticated. 8
9 Characteristics of High-Quality Health information 8. Timeliness: Health information must be entered into the record as soon as it becomes available so that decisions made are supported by the latest information about the patient s condition. 9. Relevance: Information in the record must be relevant to be useful. 9
The Role of Quality Assurance Occasionally you will need a person or group to oversee the quality of patient care There is also a need to oversee the practice of care in the medical office or hospital There are several areas that the Quality Assurance team observe and corrects the medical offices and their practices. 10
Quality Assurance Many people assume that quality is a result only of patient satisfaction surveys. In other words what can be make the quality of patient or services more efficient? Surveys are actually only a small part of the quality-assurance process. Definition of Quality Assurance: Activities designed to increase the quality of a product or service through process or system changes that increase efficiency or effectiveness. 11
Quality-Assurance Problems Found Quality assurance is concerned with issues revolving around healthcare services, such as: Overuse Underuse Misuse 12
Some Overused Treatments Hysterectomies Tympanostomy tubes Antibiotics 13
Some Underused Treatments Mammograms Cervical cancer screenings Beta-blockers for heart patients Eye examinations for diabetic patients 14
Misuses of Healthcare Services Laboratory tests that provide erroneous results Medication errors Hospital injuries to patients Nosocomial infections Quality Assurance teams are always monitoring ways to improve the efficiency of the facility or to prevent reoccurring events. 15
HIPAA Health Insurance Portability and Accountability Act (HIPAA) Became law in 1996 Became effective April 14, 2003 Applies to records that are created or maintained by healthcare providers, health plans, and healthcare clearinghouses that engage in electronic transactions 16
HIPAA Regulation HIPAA is regulated by the Office of Civil Rights (OCR), which is a division of the Department of Health and Human Services. 17
Provisions of HIPAA s Privacy Rule Patients must give specific authorization before protected information can be disclosed. Covered entities must provide patients with a copy of their privacy practices. Pharmacies, health plans, and other covered entities must have specific patient permission before sending marketing materials. Covered entities cannot use business associate agreements to circumvent the rule s marketing provisions. 18
Provisions of HIPAA s Privacy Rule Patients generally can access their personal medical records and request changes to correct any errors. Patients can request an account of nonroutine uses and disclosures of their personal health information. 19
Patient Confidentiality Patients have the right to expect patient confidentiality with regard to their health records. 20
What Department holds the Statistics for Health Information? National Center for Health Statistics (NCHS) It is a division of the Centers for Disease Control and Prevention (CDC) Primary provider of health information statistics 21
NCHS Functions Documentation of health status of the population and its subgroups Identification of disparities in health status and use of healthcare services by socioeconomic factors Description of experiences with the healthcare system Evaluation of the impact of health policies and programs Monitoring of trends in health status and healthcare delivery Identification of health problems Provision of information for making changes in public policies and programs 22
Types of NCHS Statistics Teenage pregnancy Incidence of HIV infection Alcohol and drug use Births Deaths Communicable diseases Infant health and mortality Leading causes of death Life expectancy Sexually transmitted diseases Suicide 23
Joint Commission Nonprofit organization involved in maintaining the organization and corrections of medical facilities. Provides accreditation services to healthcare facilities Voluntary process, but vital to healthcare organizations Many ambulatory outpatient facilities are accredited by the Joint Commission 24
Risk Management Any occurrence that could result in patient injury or any type of financial loss to the facility is called a risk. Risk management efforts focus on: Loss prevention Avoiding patient injury Avoiding any financial loss resulting from liability Avoidance of negative publicity resulting from sentinel events 25
What is a Sentinel Event? Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. 26
Reporting Sentinel Events Do so immediately Investigate thoroughly Rectify contributing factors Keep records documenting the incident 27
Incidents Possible in Ambulatory Care Medication errors Delay in treatment Medical equipment failure Patient falls Fire Wrong-site surgery Unintended retention of foreign objects 28
Acknowledging and Disclosing Medical Errors Most medical professionals would never intentionally make an error Most errors are minor without serious consequences Some will lead to medical professional liability litigation 29
Definitions Sentinel event: unexpected occurrence involving death or serious physical or psychological injury Adverse event: an injury caused by medical management rather than the underlying condition of the patient Near Miss: an error that is caught or corrected before it affects the patient 30
Why would Errors go Unreported? Fear of litigation Patient-physician relationship prior to incident Characteristics of the injury Physician s communications skills Patient s financial status Patient distress Patient attrition Damage to reputation License revocation Loss of staff privileges 31
What the Patient Expects After an Error Forthcoming information Sympathy Apology No financial obligation for treatment as a result of the error Opportunity to ask questions 32
Closing Comments Patients want health information to be kept confidential. Patients expect healthcare professionals to show concern and warmth and to listen to and answer questions. Lack of trust is the root of many medical professional liability lawsuits. 33