Information Systems for HIM Texh

Feasibility Study

Determines whether the information system makes sense for the organization from an economic and operational standpoint and meets their objectives

Disclosure of health information system

Stores and Manages the processing of requests for PHI. Could be part of the ROI system or its own.

Weighted Decision Matrix

A useful method of ascertaining the best electronic health record product and vendor, which can be used to select an information system based on the features that are the most important to the healthcare facility by weighting the importance and adding up

Scope Creep

When the goals of a project grow after the project has already been started

Clinical Information System(CIS)

Frequently a source system for the EHR. Collects and stores medical, nursing, clinical ancillary areas(ie radiology and lab) related to patient care.

Document Management System (DMS)

Electronic method of capturing and managing documents. Different than an EHR because the clinicians do not create the data in the DMS. Think Trace

Optical Character Recognition (OCR)

Technology that can translate a scanned document image into text that can be edited and formatted. This could be done to an entire DMS so it is searchable. Ex Adobe

Charge Description Master (CDM)

A hospital's list of the codes and charges for its services and supplies. Needs to be consistently maintained by a team with reps from the following departments:

-HIM

-Patient Accounts

-Information Systems

-Clinical depts that generate charges(rad)

-Corporate compliance and physicians

Technical interoperability

The degree to which networks, systems, devices, or components are able to exchange and use data in the manner for which they have the basic capability.

Syntactic Interoperability

Message format standards identify how the data should be formatted or structured to allow the exchange. Interface software must be employed for compatibility to enable the exchange. The two systems of two organizations can speak to each other.

Semantic interoperability

Standardized terminologies to provide clarity, consistency, and appropriate meaning in HIE. Still in development.

Process Interoperability

The degree to which the integrity of workflow can be maintained between systems and includes maintaining and conveying information such as user roles, data protection, and system service quality between systems. —coordinating multi-step processes. Training people vs developing software.

Method of HIE: Directed Exchange

"Push exchange" one organization pushes information to another. Secure email files.

Method of HIE: Query-based exchange

"Pull exchange". You create a query of what you're looking for and submit it to the eHealth Exchange where tools are used to automatically respond.

Method of HIE: Consumer Mediated Exchange

Consumers transmitting the data between providers by accessing their own records through a portal

4 steps to Project Planning and what they are….

1. Planning- conducting a feasibility study, setting the budget, setting the goals and objectives, identifying the project manager and team, and obtaining buy in from management and users.

2. Organizing the project- hiring staff, putting teams in place.

3. Defining the scope of the project- defines exactly what is and is not apart the project. Important step to avoid scope creep.

4. Systems Analysis-

Gantt Chart

A time and activity bar chart that is used for planning, managing, and controlling major programs that have a distinct beginning and end. Good for looking at tasks individually.

PERT chart

A management tool that evaluates the tasks, the dependencies on other activities, the activity sequence and the time required to complete the task. It looks more like a mind map than a list. If one thing is late, you will instantly know everything else affected.

Weighted decision matrix vs point system for selection of an Information System(IS)

A point system signs equal points to all the positives of a system and system with the most points wins. A system could be picked which greatly lacks in one area. The weighted decision matrix ensures that a system is picked that aligns with the orgs goals.

Chief Clinical Information Officer

Works with providers to identify needed technology and then ensures the tech is implemented by the providers to improve quality of care, education, and research.

Director of Clinical Informatics

Leads the implementation of the EHR and all post-implementation services.

Mapping Specialist

Creates maps between systems such as vocabularies and classification systems. Helps programs speak to each other by knowing both programs.

Content Analyst

Individual who designs the clinical information system that will be implemented. Their work is directed by the needs of the users. They are also advocates in the usage of health information technology in healthcare.

Chief Technology Officer (CTO)

Assists in developing the business plan for information systems and technology. Ensures the org runs effectively and competitively.

Data Quality Manager

Responsible for the organizations quality management. Works with providers to ensure the org meets the data quality goals for reimbursement and documentation standards.

Chief Security Officer

Protects data from unauthorized access, alteration, and destruction by developing and establishing a compliance program, monitoring regulations, and trends related to security and policy.

Encoder software

a program used by coders to aid in assigning the most appropriate code for a diagnosis or procedure

Rules-based encoder

requires the user to type in the name or portion of the name of the diagnosis or procedure. This entry into the encoder generates a list of suggestions from which the coder selects

Automated codebook encoder

An encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index

Grouper software

Some insurance companies develop their own groupers for facilities to use. It is a computer program that uses specific data elements to assign the diagnosis and procedure codes entered into the encoder into the appropriate MS-DRG(diagnosis related group). The DRG indicates the reimbursement amount from insurer. Connects to billing software.

Chart Deficiency System

A system that track and record documentation omission due to deficiency in the health record that comes to the HIM department. Deficiencies can be in paper, imaged, or electronic records depending on the information system used

Expander

Allows a transcriptionst to type an abbreviation like CHF and it will automatically substitute the whole phrase. Ie. congestive heart failure.

Quality Indicator System

An abstracting system that records information about the patient, the care provided, and the physicians that participated in that care. Used to evaluate the quality of care.

Computer-assisted Coding System

Software that analyzes providers dictated or free text notes and suggests codes to the coder

Clinical Documentation Integrity System

Assists in identifying ways to improve clinical documentation. Helps the HIM professional notify the doctor of missing information

Integrated Delivery System (IDS)

A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced. Often has a central ROI office with an Enterprise Master Patient Index(EMPI) with access to all facilities.

Clinical Decision Support

Provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered and presented at appropriate times, to enhance health and health care.

Longitudinal Health Record

A permanent record of significant information listed in chronological order and maintained across time, ideally from birth to death

Source Systems

Information systems that capture and feed data into the EHR. Ex. Lab/radiology and administration/financial information systems.

Continuity of Care-core data set

The most relevant administrative, demographic, and clinical information about a patients care.

Health Level Seven International (HL7)

A not-for-profit ANSI-accredited SDO dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services. Focuses on data exchange between health information systems.

Personal health record (PHR)

An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care

Fast Healthcare Interoperability Resources (FHIR)

Quality payment program(QPP) under the MIPS, and its 4 criteria

Give monetary rewards to providers for improved value and patient outcomes:

1. Quality: based on specific performance measures; 30%

2. Promoting interoperability: patient engagement and the electronic exchange of health info using CEHRT. 25%

3. Improvement activities- evaluates improvement in care, patient engagement, and access. Providers can choose the activities. 15%

4. Cost: calculated by CMS based on Medicare claims. 30%

Health information blocking

Persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information to save proprietary information

The process to have an EHR certified

1. Developer creates new HIT

2. Developer contacts the ONC-ATL(Authorized testing laboratory) who tests the software.

3. Developer contacts the ONC-ACB(Authorized certification body) who certifies the program.

4. Surveillance by ONC-ACB

Order communication and results retrieval software

Notifies clinical departments, like the lab or radiology, of order the provider inputted.

Computerized Physician Order Entry (CPOE)

Designed for physicians to input orders and receive alerts

Clinical Decision Support System

A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions. Can be connected to knowledge based systems or just be set up to watch for trends in health data and give suggestions.

Natural Language Processing (NLP)

A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; ex. Siri

Template-based data entry

A cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. Customizable to provider or department.

Digitized vs electronic vs digital signatures

Digitized- a scanned image of someone signature. Not secure.

Electronic- requires a password or two factor authentication.

Digital- similar to electronic but it also uses encryption

covered entity (CE)

a health plan, a health care clearinghouse, or a health care provider that transmits any health information in electronic form in connection with a HIPAA transaction

Business associates

Individuals, groups, or organizations, who are not members of a covered entity's workforce, that perform functions or activities on behalf of or for a covered entity. Could release medical records, code,etc.

Security rule of HIPAA

Defines the minimum that a covered entity(CE) must do to protect ePHI. Does not apply to paper, oral communication, or microfilm.

Information access management

Involves implementing policies and procedures to determine which employees have access to what information

Security Incident

The attempted or successful unauthorized access, use, disclosure, modification, or destruction of information in an information system.

Security events

Poor security practices that have not led to harm, whereas security incidents have resulted in harm or a significant risk of harm. Ex leaving computer open

Spoliation

When information is destroyed or hidden when it is needed for court discovery

Mitigation

Attempting to reduce the or eliminate harmful effects of a security breach.

Redundancy

The duplication of data, hardware, or cables so that there is a backup in place in case of failure. Reduces down time

Audit reduction tools

Tools that review the audit trail and compare it to criteria specified by the CE, which eliminates routine entries such as the periodic backups. Also looks for trends and behaviors outside of the norms

Degaussing

The process of removing or rearranging the magnetic field of a disk in order to render the data unrecoverable

3 types of audit

Process Audit- confirms Cars performance of tasks is meeting established standards. Ex. Investigating all triggers.

Product Audit- evaluates a product or service to ensure it meets expectations. Ex that the firewall is blocking spam/malware.

System audit- reviews activities to make sure the system being used is appropriate. F DD MM

Benchmarking

Comparing an organization's practices, processes, and products against those of a similar organization or comparing their outcomes to regional or national standards.

4 types of analytics

Descriptive- looks at the past to see what has already occurred. Uses statistics.

Diagnostic- uses tools such as data mining and dashboards to determine why something happened.

Predictive- analyzes historical data to make predictions such as readmission rates.

Prescriptive- builds upon predictive analysis by suggesting possible courses and what their result may be.

How often should CPT/HCPCs codes in the CDM be updated and reviewed?

Annually

Teleradiology

When a radiology or physician can view radiology images from anywhere.