2. Cristian Lieneck and Eric Weaver

4.  By the end of this class, the student should be able to:  Examine the data reporting advantages of electronic medical records over paper-based charting systems.  Illustrate the necessity of Healthcare IT for use in quality reporting and P4P reimbursement methodologies.  Compare the healthcare industry’s use of information technology to a non-healthcare industry’s use of IT.  Assess the role of interoperability of EMR data to enhance information exchange and quality of care.

5.  The healthcare industry maintains medical records for several key purposes. Patient Care Communication Legal Documentation Billing and Reimbursement Research and Quality Management

6.  Documentation of all healthcare services provided by a healthcare organization.  Individually identifiable data, in any format (paper, electronic, or hybrid).  Any records of care in any health-related setting. (AHIMA, 2012)

7.  Excludes any data that is not representative of official business records from the healthcare institution. Copies of personal health records (PHRs) may be considered part of the legal record. Must be used in the provision of patient care.

8.  Medical record data examples: Legal health record Patient-identifiable source data Administrative data Derived data

9.  Early Accomplishments Legibility of healthcare data and information. Improved accessibility to health care data and information

10.  Ongoing Challenge Unstructured formats within certain EMR systems For reporting standardization, data fields must be discrete instead of in a free-formed narrative format Lack of structure limits the ability of an EMR to be used as a quality reporting tool With structured data input and sophisticated error prevention, healthcare organizations can reduce medical errors

11.  Slow technology adoption rate attributable to the following causes: Healthcare data is more complex than other industries (more complex systems needed) Healthcare information is highly sensitive and personal (concerns for privacy heightened with technology) Healthcare IT is expensive (business case and ROI have been elusive before “meaningful use” incentives and P4P initiatives)

12.  Integration of heterogeneous EMR systems is an immense challenge  Central component of the US HIT strategy is to further the: adoption of interoperable systems exchange of health care information across multiple organizations

13.  Health Information Exchanges (HIEs) Mobilize ehealthcare information electronically across organizations within a region, community or hospital system Provide the capability to electronically move clinical information among disparate health care information systems while maintaining the integrity of the data

14.  In order to achieve interoperability, portability, and data exchange, health care information standards must employ standards.  Most Common Data Interchange Standards: Health Level Seven Standards (HL7) Digital Imaging and Communications in Medicine (DICOM) National Council for Prescription Drug Programs (NCPDP) ANSI X12N standards

15.  That brings us to the close of this lecture. In it, we discussed:  The data reporting advantages of electronic medical records over paper-based charting systems.  The necessity of Healthcare IT for use in quality reporting and P4P reimbursement methodologies.  The reasons why the healthcare industry lags in information technology.  The role of interoperability of EMR systems to enhance information exchange and quality of care.  The major types of health care information standards

16. Article review  Hall, M. & Schulman, K. (2011). Ownership of medical information. The Journal of the American Medical Association, 301(12): 1282-1284.

17. PRESENTATION REFERENCES American Health Information Management Association. (2012). Practice brief: Definition of the health record for legal purposes. Retrieved from the AHIMA website on 5/07/2012: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_009223.hcsp?dDocName=bok1_009223 http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_009223.hcsp?dDocName=bok1_009223