AHIMA-IHE White Paper HIT Standards for HIM Practices Figures

Level 1 Level 2 Level 3 Level 4 Record Hierarchy Lifetime Record Lifetime Record (-9mos – Birth – Death) Level 2 Episode of Care Record Episode of Care (EOC) Record Episode of Care (EOC) Record Episode of Care (EOC) Record Level 3 Record at Function’s Level/ Record Entry EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Com-ponent EOC Record Compo-nent EOC Record Compo-nent EOC Record Compo-nent Level 4 Record at Data Entry Level Com-ponent Sections Com-ponent Sections Compo-nent’s Resources Com-ponent Sections Compo-nent’s Resources Compo-nent’s Sections Compo-nent’s Resources Compo-nent’s Resources CDA FHIR Section Templates Section Templates Section Templates Section’s Templates FHIR Attributes FHIR Attributes FHIR Attributes Template’s Data Fields FHIR Attributes Template’s Data Fields FHIR Attributes Template’s Data Fields

Information Governance Principle: Record Availability HIM Practice A1. All documents are accounted for Use Case A1.1: All documents are accounted for in a specific timeframe after discharge Clinical Episode of Care: Functions and Records/Documents Flow Patient Registration Assessment Testing Diagnosis &Care Plan Prescription Discharge Functions Records Records Records Records Records Records Records Clinical workflow needs to be supported by the source systems. This is the XDW – make sure to align this

Episode of Care (EOC) Record Lifecycle Record is Open Record is Closed Record Entry Record Entry Record Entry Record Entry Record Entry Episode of Care Functions Registration/ Admission Triage Assessment Lab/Diagnostic Testing Diagnosis & Care Plan Prescription Discharge/ Transfer Episode of Care Record Components Pt, Facility demographics, Consent for HIE Triage Notes, Vital Signs Medical Summary; Prelim Diagnosis and Care Plan Consent for Test, Test Order Test Result Report Confirmed Diagnosis and Updated Care Plan Meds Order Dispense Report ADT Record Record Verification Record Verification Record Verification Record Verification Record Verification Record Verification Record Verification Record Protection Record Protection Record Protection Record Protection Record Protection Record Protection Record Protection APP 1: Record Originator: EHR-S AHIMA – ISO - HL7 Record Lifecycle Modeling Tasks Julie/Deb – Mike G., AO, DW, HR - Gary D.

Episode of Care (EOC) Record Lifecycle Record is Open Record is Closed Record Entry Record Entry Record Entry Record Entry Record Entry Episode of Care Functions Registration/ Admission Triage Assessment Lab/Diagnostic Testing Diagnosis & Care Plan Prescription Discharge/ Transfer Episode of Care Record Components Pt, Facility demographics, Consent for HIE Triage Notes, Vital Signs Medical Summary; Prelim Diagnosis and Care Plan Consent for Test, Test Order Test Result Report Confirmed Diagnosis and Updated Care Plan Meds Order Dispense Report ADT Record Record Verification Record Verification Record Verification Record Verification Record Verification Record Verification Record Verification Record Protection Record Protection Record Protection Record Protection Record Protection Record Protection Record Protection APP 1: Record Originator: EHR-S Testing Episode Record Lifecycle Record Is Open Record is Closed Record Entry Test Order Registration Testing Procedure Test Result Reporting Test Order Test Demogr. Testing Documentation Test Result Report AHIMA – ISO - HL7 Record Lifecycle Modeling Tasks Julie/Deb – Mike G., AO, DW, HR - Gary D. Record Verification Record Verification APP2-Record Receiver and Record Component Originator (Ancillary System) Pharmacy Episode Record Lifecycle Record Protection Record Protection Record Is Open Record is Closed Record Entry Med Order Registration Med Proceessing Med Dispensing Med Order Med Demogr. Medication Documentation Med Dispense Report APP - Application Record Verification Record Verification APP3-Record Receiver and Record Component Originator (Ancillary System) Record Protection Record Protection

Information Governance Principle: Record Availability HIM Practice A1. All documents are accounted for Use Case A1.1: All documents are accounted for in a specific timeframe after discharge Clinical Encounter Functions and Records/Documents Flow Clinical Encounter’s Functions Patient Registration Assessment Testing Diagnosis &Care Plan Prescription Discharge Records Records Records Records Records Records Records Clinical workflow needs to be supported by the source systems. This is the XDW – make sure to align this

Information Governance Principle: Record Availability HIM Practice A1. All documents are accounted for Use Case A1.1: All documents are accounted for in a specific timeframe after discharge Clinical Episode of Care/Encounter’s Functions and Records/Documents Flow Patient Registration Assessment Testing Diagnosis &Care Plan Prescription Discharge Functions Records Records Records Records Records Records Records Technical Actors Participating Systems: 1 – Administrative System (Source System) 2 – EHR System 3 – Ancillary Systems (Laboratory, Radiology, etc.) 4 – Pharmacy System Clinical workflow needs to be supported by the source systems. This is the XDW – make sure to align this *HL7 EHR Lifecycle Model Release 1, Draft Standard for Trial Use. 27 January 2008

Document Creation/Sharing/Exchange

Audit? – revision History USE CASES A1, 2, 3, X USE CASES A4, X USE CASES A 5, X Record Retraction Record Entry Indivi- dual docu- ment Record Protection Audit? Audit Audit Audit Record Integrity Audit Audit Audit= Validation Audit? – revision History APP2-Record Receiver and Record Component Originator (Ancillary System) AHIMA – ISO - HL7 Record Lifecycle Modeling Tasks Julie/Deb – Mike G., AO, DW, HR - Gary D. Record Verification Record Verification APP3-Record Receiver and Record Component Originator (Ancillary System) ISO TS 21089: 2004 Trusted end-to-end information flows

More robust then AHIMA, though process still minimal AHIMA – ISO - HL7 Record Lifecycle Modeling Tasks Julie/Deb – Mike G., AO, DW, HR - Gary D. More robust then AHIMA, though process still minimal EHRS-FM R2 (Used for Record Infrastructure Record Entry Lifecycle Event Metadata on FHIR) 2014

Systems: Document Sharing/Exchange HIE

Information Lifecycle Time Information Access and Use Level 4 Level 2 Level 1 Level 5 Share Accountability Transparency Integrity Protection Compliance Availability Capture Process Use Store Dispose AHIMA.ORG/INFOGOV

Forms Committee Tools and Resources EXAMPLES: Charters Org Charts Sample Plans Role Definitions Practice Guidelines Sample Procedures Articles Case Studies Tools for: ROI, Classification, Valuation, Defining Data & Info Uses IG Toolkit Toolkit www.arma.org