1 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Health Information Management Chapter 16

2 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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.

3 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. This chapter will examine:  How health information is used  Characteristics of high-quality data  Concerns of quality assurance  Importance of HIPAA  Functions of the NCHS  Types of healthcare statistics kept  Total quality management  Acknowledging and handling medical errors

4 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Evolution of the Profession: AHIMA  Began as the Association of Record Librarians of North America  Changed its name to the American Medical Record Association in 1970  Evolved into AHIMA in 1991  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.

5 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Health Information Management Professions  Registered Health Information Administrator (RHIA)  Registered Health Information Technician (RHIT)

6 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding Professions  Certified Coding Assistant (CCA)  Certified Coding Specialist (CCS)  Certified Coding Specialist (CCS-P)

7 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Health Care Privacy and Security  Certified in Health Care Privacy and Security (CHPS)

8 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Move toward Computer-Based Records In 2005, 25% of the nation’s physicians used some form of computer-based medical records.

9 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Federal Register  Provides daily access to rules, proposed rules, changes, and notices of federal agencies and organizations  Published by Office of Federal Register, National Archives and Records Administration  Excellent source of health data  Can sign up for daily s with a table of contents that connects to the Federal Register website

10 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. How Use of Electronic Records Reduces Medical Errors  Keeps prescriptions organized  Notes allergies clearly  Reduces costs by avoiding duplicate tests  Can reduce staffing needs Note: Information entered into the computer is only as reliable as the person who entered the data.

11 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Characteristics of High-Quality Health Data Experts agree on nine characteristics of high-quality health data:  Validity  Reliability  Completeness  Recognizability  Timeliness  Relevance  Accessibility  Security  Legality

12 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Characteristics of High-Quality Health Data Validity: synonymous with accuracy. Healthcare information must be accurate to be usable. Reliability: Healthcare professionals must be able to rely on the information presented.

13 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Characteristics of High-Quality Health Data Completeness: Incomplete records may lack vital information needed to care for the patient. Recognizability: All users of health information must be able to interpret the data that are presented in the health record.

14 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Characteristics of High-Quality Health Data 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. Relevance: Information in the record must be relevant to be useful.

15 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Characteristics of High-Quality Health Data Accessibility: Healthcare data must be accessible to multiple users at one time. Security: Precautions must be taken to prohibit intruders from accessing medical records. Legality: The record must be completely legible and properly authenticated.

16 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Quality Assurance  Activities designed to increase the quality of a product or service through process or system changes that increase efficiency or effectiveness.  Many people assume that quality is a result only of patient satisfaction surveys. This is actually only a small part of the quality-assurance process.

17 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Challenges of Quality-Assurance Problems Quality assurance is concerned with issues revolving around healthcare services, such as:  Overuse  Underuse  Misuse

18 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Some Overused Treatments  Hysterectomies  Tympanostomy tubes  Antibiotics

19 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Some Underused Treatments  Mammograms  Cervical cancer screenings  Beta-blockers for heart patients  Eye examinations for diabetic patients

20 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Misuses of Healthcare Services  Laboratory tests that provide erroneous results  Medication errors  Hospital injuries to patients  Nosocomial infections

21 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

22 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. HIPAA Regulation HIPAA is regulated by the Office of Civil Rights (OCR), which is a division of the Department of Health and Human Services.

23 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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.

24 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Provisions of HIPAA’s Privacy Rule  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.

25 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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 accounting of nonroutine uses and disclosures of their personal health information.

26 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Confidentiality Patients have the right to expect patient confidentiality with regard to their health records.

27 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. National Center for Health Statistics (NCHS)  Division of the Centers for Disease Control and Prevention (CDC)  Primary provider of health information statistics

28 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

29 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. NCHS Functions  Monitoring of trends in health status and healthcare delivery  Identification of health problems  Support for biomedical and health services research  Provision of information for making changes in public policies and programs

30 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

31 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Total Quality Management (TQM) TQM consists of management and control activities designed to enhance the quality of services provided to patients.

32 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. TQM Concept  Much of today’s TQM concepts originated with W. Edwards Deming.  Deming stressed an emphasis on quality rather than quantity, applying his principles to various types of businesses and managers.

33 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Deming’s 14 Points for Management  Create constancy of purpose toward improvement of product and service.  Adopt the new philosophy.  Cease dependence on inspection to achieve quality.  End the practice of awarding business on the basis of price tag.

34 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Deming’s 14 Points for Management  Constantly improve the system of production and service.  Institute training on the job.  Institute leadership.  Drive out fear so that everyone can work effectively for the company.  Break down barriers between departments.

35 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Deming’s 14 Points for Management  Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity.  Remove barriers that rob the hourly worker of his or her right to pride of workmanship.  Remove barriers that rob people in management and in engineering of their right to pride of workmanship.

36 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Deming’s 14 Points for Management  Institute a vigorous program of education and self-improvement.  Make the company transformation everyone’s job.

37 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Joint Commission  Nonprofit organization  Provides accreditation services to healthcare facilities  Voluntary process, but vital to healthcare organizations  Many ambulatory outpatient facilities are accredited by the Joint Commission

38 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

39 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sentinel Event  Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

40 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Reporting Sentinel Events  Do so immediately  Investigate thoroughly  Rectify contributing factors  Keep records documenting the incident

41 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Incidents Possible in Ambulatory Care  Medication errors  Delay in treatment  Medical equipment failure  Patient falls  Fire  Wrong-site surgery  Unintended retention of foreign objects

42 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

43 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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

44 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Disclosing Errors  89% of patients want physicians to disclose errors concerning their care.  77% of physicians agree that errors should be disclosed to patients.

45 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Obstacles to Disclosure of Errors  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

46 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Expectations  Forthcoming information  Sympathy  Apology  No financial obligation for treatment as a result of the error  Opportunity to ask questions

47 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Summary of Scenario  Read lengthy, complicated documents carefully and determine what is being communicated.  Maintain a good relationship with health professionals.  Be flexible and open to changing regulations in the healthcare industry.  Records must be accurate, complete, and reliable for medical professionals who use them.

48 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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.