AHIMA-IHE White Paper HIT Standards for HIM Practices 2015 Figures

Figure 1 #=8 IHE ITI White Paper, 2015 IG Principles HIM Business Requirements by Principle HIM Practice Checklist Use Cases HIT Standards #=8 Availability #=10 Integrity #=13 Protection #=9 Availability #=9 Integrity #=5 Protection #=6 Availability #=5 Integrity TBD Protection TBD Availability TBD Integrity TBD Protection TBD AHIMA, 2014 AHIMA, 2015 IHE ITI White Paper, 2015

Figure 2 Develop and defend Proposal to IHE ITI Committee for 2014-15 development cycle Develop Project Infrastructure Call for Participation to form AHIMA HIM Task Force Develop Project Methodology Develop Business Requirements and Checklist of HIM Best Practices by IG Principle: Information Availability, Integrity and Protection Develop Use Cases under Information Availability Conduct standards gap analysis Develop Recommendations for HIM Professionals and SDOs on standardization of HIM practices, gaps in existing HIT standards and needs for new standards Publish White Paper with the Roadmap for standardization of HIM practices and HIT products Develop publication in JAHIMA and presentation at 2015 AHIMA Convention Develop new Proposal for IHE 2015-16 development cycle

Figure 3 Capture Process Use Store Dispose Share

Level 1 Level 2 Level 3 Level 4 Record Content Hierarchy CDA FHIR Lifetime Record Lifetime Record (Prenatal Care – Birth – Life – 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 Level 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

Clinical Episode of Care: Functions and Records Flow Figure 5a Clinical Episode of Care: Functions and Records Flow Patient Registration Assessment Testing Diagnosis &Care Plan Prescription Discharge Functions Records Records Records Records Records Records Records

Episode of Care Functions Episode of Care Record Components Figure 5b 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 Test Diagnosis & Care Plan Prescription Discharge/ Transfer Episode of Care Record Components Patient, 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

Information Governance Principles: Figure 6 Information Governance Principles: Accountability—Transparency—Integrity Protection—Compliance—Availability Retention - Disposition Metrics Policies Procedures Rules Roles Information Lifecycle Capture Process Store Dispose Share / Exchange Use Controls AHIMA.ORG/INFOGOV

Figure 7 Health Information Systems should support HIM practices HIM practices should inform IHE Profile Specifiers Health Information Systems built based on the IHE Profiles should support HIM practices

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 Patient, 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 System Clinical Testing Episode Record Lifecycle Record Is Open Record is Closed Record Entry Clin Test Order Registration Clin Testing Procedure Clin Test Result Report ClinTest Order Test Demogr. Clin Testing Documentation Clin Test Result Report Record Verification Record Verification APP2-Record Receiver and Record Component Originator (Ancillary System) Pharmacy Episode Record Lifecycle Record Is Open Record is Closed Record Protection Record Protection Record Entry Med Order Registration Med Proceessing Med Dispensing Med Order Med Demogr. Medication Documentation Med Dispense Report Record Verification Record Verification APP3-Record Receiver and Record Component Originator (Ancillary System) APP - Application Record Protection Record Protection