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1. DeVry Memorial Hospital Practicum Presentation HIT170 By:
Daryle A. Cook DeVry University Professor: Michelle Levack June 27,
2015
2. Healthcare Data Management Healthcare Data Management
consists of Data and information that are provided in most every
healthcare setting to deliver the common facts of magnitudes. These
facts are called data elements describing the patients age, gender,
health conditions, procedures, and the health insurance company
which they may or may not have. They may be disabled, retired, or
still working; however, speaking they still must be registered into
the healthcare system. This information must then be stored in a
database for a common purpose to show the diagnosis of patients
that are required for treatment and care in a healthcare
organization. The information is used to determine what method of
billing are required for payment of services. The information given
are necessary for the HIM professionals to understand what may have
or had transpired between patients and physicians. The content will
support the interoperability and connectivity of healthcare
information of EHRs extensive. The guidelines are used by AHIMA ,
and e-HIM Workgroup on a EHR database. Also with the information
given will help develop a data dictionary implementing the new EHR
system. The data will assist in the design plan, development of an
enterprise data dictionary, to ensure collaborative involvement and
buy-in, as well as the flexibility of growth, design, expansion of
field values. The adoption of a nationally recognized standard, and
normalize field of definitions across the board with data sets etc.
Healthcare Data Sets and Standards describes the initial efforts at
developing standardized data sets for use in different types of
healthcare settings. This includes acute care, ambulatory care,
long-term care, and home care. Typical health information functions
are record processing, monitoring of record completion,
transcription, release of patient information, clinical coding,
abstracting, and clinical data analysis. However there are more HIM
functions in some departments like research and statistics, cancer
and/or trauma registries, and birth certificate completion.
Secondary Data Sources are contained in registries and similar
databases; unlike, Primary data sources are considered the health
record because the patient is documented by professionals who
provided care of service. Ethical issues in the health information
management are to maintain such activities like research, clinical
trials, reimbursement, also the accreditations, and exchanging of
information for the safety of patients rights.
3. Health Data Structure Clinical Quality Performance
Improvement and Management - The purposes of quality performance
are patient safety research, administration, population of health
reporting and evaluation. The most important concept discussed in
quality is that of measurement, dealing with issues that involved
in healthcare quality, healthcare professionals that have struggled
with where to put their focus and resources. The key to improvement
lay in the measurement of the characteristics of their practices.
Performance improvement (PI) in healthcare is the process for
involving personnel in planning and executing a continuous flow of
improvements to provide quality health care that meets or exceeds
expectations. Performance monitoring is data driven base on
internal and external data is the foundation of all PI activities.
Important areas must be monitor for high-risk, high- volume, or
problem-prone. What is at stake is the outcome of care, customer
feedback, and the requirements of regulatory agencies in which
consider prioritizing performance measures. Example for
organization-wide performance improvement process are identify
performance measures, measure performance, analyze and compare
internal/external data, identify improvement opportunity, and
perform ongoing monitoring.
4. Healthcare Information Requirements, and Standards Health
Information Functions and Secondary Data Sources First HIM
functions are information-centered, the means are ensuring
information quality, security, and availability. The medium in
which the information is stored will dictate how specific functions
are carried out. The goal of the health record system is to ensure
that accurate information is available to authorized users to
support quality patient care. Example is storage of information in
paper-based records involves different types of tasks than does
storage of information in electronic records. The requirements are
to record processing (concurrent and retrospective analysis and
monitoring of health record content, Record completion, Storage and
retrieval of health records (including monitoring and tracking of
health records location), Release of patient information, Clinical
coding of diagnoses and procedures, Transcription of medical
reports (excluding pathology and radiology reports), Statistical
and internal report generation, and Cancer and trauma registry.
Standards are fixed rules that must be followed for every form (for
example, where the form title should be located). Guidelines
provides general direction about the design of a form (for example,
usual size of the font used), number tracking, testing and
evaluation plan, checking the quality of new forms, systematizing
storage, inventory, and distribution, and establishing a forms
database.
5. Data Storage and Retrieval Fundamentals of Electronic
Information Systems are discussing the major components of an
information system, identifying principal activities of information
systems, describing major types of information systems with example
of each, identifying between the purposes and functions of MIS,
DSS, ES, and KMS. There are different types of computers, steps in
the systems development life cycle, learning the vendor selection
process, and learning to identify the main three types of system
software and providing examples of each. It entails learning the
purpose of electronic database and describing the purpose of a
database.
6. Health Record Documentation Requirements Purpose and
Function of the Health Record - Primary purposes are patient care
delivery, the health record documents the services provided by
clinical professional and allied health professionals working
together in a variety of settings, and patient care management, in
which patient care management refers to all the activities related
to managing the healthcare services provided to patients. The
health record assists providers in analyzing various illnesses,
formulating practice guidelines, and evaluating the quality of
care. There is patient care support processes, financial and other
administrative processes, and patient self-management, in which
individual have become more actively involved in managing their own
health and healthcare to become a primary user of the health
record. Content and Structure of the Health Record are determined
by primarily practice needs and significant standards. Standard
statements are the expected behavior or reference points against
which structures, processes, or outcomes can be measured.
Therefore, the main four sources are Facility-specific standards
found in a facility policies and procedures organization. Licensure
requirements that provide services, in most healthcare
organizations must be licensed by government entities such as the
stat or country in which they are located and must maintain a
license as long as care is provided. Certification standards
government reimbursement program standards are applied to
facilities that choose to participate in federal programs such as
Medicare and Medicaid. These standards are titled conditions of
participation or condition for coverage that certifies standard
services are met. Accreditation standards is the end result of an
intensive external review process that indicates a facility has
voluntarily met the standards of the independent accrediting
organization.
7. Information and Communication Technologies Introduction
Electronic to Health Information Systems are the healthcare
information systems (ISs) running the gamut from patient-specific
clinical ISs to administrative or financial systems to fully
integrated systems that combine clinical and
administrative/financial information. Such systems can exist within
a single institution or across organizations. The development and
use of healthcare information systems is not new. The enormously
complex, both in their organization structure, and in terms of the
information they manage can be difficult to implement healthcare
information systems effectively. The cost of support and to
maintain are at the national level, and has been directed toward
the expanded use of information technology (IT). Electronic Health
Records related information on a individual that conforms to
nationally recognized interoperability standards and that can be
created, managed, and consulted by authorized clinicians and staff
across more than one healthcare organization. Principles of
Organization and Work Planning are critical elements in
implementing the mission of an organization and achieving its
long-term strategic goals and short-term operational goal. The
goals are achieved through application of the organizations
resources, including its human, financial, and physical assets
ensuring that the organization perform the right activities in the
best ways possible to achieve its mission.
8. Health Organization Structure Healthcare Delivery Systems
are complex and at times can be stressful. Evidence-based
guidelines suggest diagnostic or therapeutic interventions would
improve the patient health by regularly monitoring and giving
therapies in managing pain. The quality of healthcare, the chance
of patients getting well, proven effectiveness in managing pain.
The excellence in performing quality care to patients are
recommendations for treatment by health professionals, developing
standards to assess the clinical practice of individual health
professional, education and training of health professionals,
assisting patients to make informed decisions and improving
communication between patient and health professionals. The
development of integrated healthcare delivery systems (IDS) also
referred to as Integrated Delivery Network or IDN are made up with
a number of associated medical facilities that furnish coordination
in healthcare services. Some examples are ambulatory surgery
centers, physician office practices, outpatient clinics, acute care
hospitals, and skilled nursing facilities (SNFs), MCOs, and etc.
The main purpose are to integrate delivery systems for a continuing
of care, maximize effectiveness, and reduce costs. Focusing on
holistic care rather than fragmented care among specialists.
Examples are different levels of care.
9. DeVry Memorial Hospital Overview Over the 21st century HIM
profession in the healthcare industry has embarked on some of the
greatest transformation in the history of the U.S. healthcare
system. Shifting into a fast pace challenge expanding the
traditional HIM role as medical record custodian and keeper of
clinical information. The transformation in the HIM profession is
necessary to cease tangible product or tool as it becomes
electronic. Information accuracy and content will continue to be
critical; however, clinical information will become intellectual
property, organizational capital, and competitive intelligence.
Payers, providers, researchers, lawyers, and regulators will
require credible information to create knowledge that provides
sustainable competitive advantages for their organizations. The
changes will have directly impacted health information practice and
cannot be done successfully without HIM best practices and
leadership. Building the best practices and influence policy, the
HIM profession is called upon to articulate lessons learned from
the implementation of electronic medical records, ICD-10-CM/PCS
planning and training to achieve meaningful use of
computer-assisted coding initiatives, advances in health
information exchanges, and the introduction of patient- centered
care models such as the medical (healthcare) home and accountable
care organizations (ACOs). The health information management (HIM)
profession continue to grow and change, becoming highly visible in
the national arena as federal laws have evolved to protect patient
privacy, to advance technologies, collect and maintain patient data
accurately and securely. The adoption classification systems
increases the quality of data in clinical documentation, and to
encourage the use of electronic health records as the primary
source for monitoring quality of care.
10. Mission, Value, and Vision My mission is the same as AHIMAs
mission to be professional at all times, and increase healthcare by
advancing with the best of practices. I would follow the health
information management guidelines, stay trusted with the education,
research, and professions of a license healthcare organization. The
record department values are to show accurate and confidential
personal health information. HIMs provide leadership in the areas
required by HIM practices with standards universal, I will also
adhere to the AHIMA Code of Ethics, promote disciplinary
cooperation with other professionals in a healthcare organization.
The Vision is to remain focused at all times, and show quality
performance that would enhance healthcare with valued
information.
11. Management of Information Technology The potential and
appropriate information of technology can be accomplish by
organizational and management goal setting. In a formal
organization the structure of planning and management is critical
for HITs, and they must be careful for finance purposes where they
get their information resources from. High quality, cost- effective
healthcare services depend on the availability of accurate
information. The structure of administration and function criterias
must be organized and executed, to ensure information means be
managed. Calculated planning and operations with a broad oversight
organizations infrastructure systems in place. Many of the
organization matters will require the support of a chief
information officer (CIO), HIM, chief security officer (CSO), or a
chief privacy officer (CPO).
12. The Preparation The Course preparation consisted of knowing
how the healthcare data sets and standards relate to medical
records. The functions of health information shows how secondary
data sources are used, ethical behavior patterns and problem
solving issues are handled, acknowledging clinical quality
performance improvements, and giving management protocols. I
watched short movies and was given short quizzes, also working with
digital filing terminal systems, and retrieving incorrect medical
records from the medical charts. I was also given assignments for
moving to an EHR System, learning data integrity deficiencies
slips, and on organizational charts. I worked in the Quadramed and
made journal entries weekly, also learned about positions in a
hospital with assignments etc.
13. Summary Considering my new occupation as a health
information technician, I have learned a great deal about how the
healthcare organization works. I acknowledged my goal to be the one
of the best HIT as possible, I look back at what I have learned and
am still learning from my experience in the HIT170 practicum
course. First I can start by thanking my Professor Levack and DeVry
University for allowing me to be an participant in this prestigious
course. By being determined to finish the course I must think about
the beginning where I started from, reading, studying and
researching about the course of studies. I looked at the short
movies, answered questions on quizzes, participated in discussions
panels, asked the professor about things I was not sure of,
learning about the purpose and functions of HIM, content and
structure, clinical vocabularies and classifications, the digital
filing systems, master index, registries indexes, and ethical
standards of the healthcare organization. I studied the positions
in a hospital, healthcare delivery in the U.S., moving to an EHR
system along with transcripts. It was a pleasure learning about
deficiency slips, retrieving medical records, and about
duplications. There are so much more to talk about, but I would be
sharing this information all day. The organizational chart I find
very meaningful, the discharge-planning, and writing in a journal.
What I acknowledged from all of this course, I have been
enlightened to adapt in my next conquest of being a good HIT. I
thank all those who inspired me to be the best I can in achieving
my degree.