1. Describe the purpose of the Institute of Medicine and its role in the development of the electronic health record.
The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.
2. Describe the purpose of the Office of the National Coordinator for Health
Jan 2004 – President George Bush issued a plan to achieve EHR’s by 2014
• Created office of National Coordinator for Health Information Technology (ONCHIT) to coordinate the effort.
Outlined a strategic national agenda for health information exchange (HIE)
• Laid foundation for creation of Regional Health Information Organizations (RHIO’s)
3. Describe the projected impact of ARRA on electronic record implementation.
American Recovery and Reinvestment Act (ARRA)
• Provides financial assistance to colleges and universities to expand medical informatics
• Major changes to the privacy and security rules
• Establishes additional gov’t and agency involvement in setting HIT and EHR
4. Name and describe the purpose of HL-7.
Health level 7 Aids the exchange of data among hospital systems, physician practices and other types of provider systems
Computerized Physician / Provider Order Entry Systems (CPOE)
• Provider enters orders directly into the computer system
• Includes prompts, reminders, alerts
• Enhanced legibilty to reduce errors
• Decision support
1991 – IOM created the Computer-based Patient Record Institute (CPRI)
AHIMA’s name for electronic systems to manage all aspects of an individual’s primary and secondary health information
5d. EHR (Electronic Health Record)
A complete electronic health record, generated and stored electronically
• Selected by IOM and submitted to DHHS in 2003
• Term was used by President Bush in the
HIT Initiative, 2003
5e. EMR (Electronic Medical Record)
Describes systems based on document imaging
The nationwide health information network is a set of standards, services and policies that enable secure health information exchange over the Internet.
5g. PHR (personal health record)
A personal health record, or PHR, is a health record where health data and information related to the care of a patient is maintained by the patient.
The ultimate objective is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology.
Health information exchange (HIE) is the mobilization of healthcare information electronically across organizations within a region, community or hospital system.
5j. POC documentation
Electronic medical record (EMR) point-of care (POC) documentation in patients' rooms is a recent shift in technology use in hospitals. POC documentation reduces inefficiencies, decreases the probability of errors, promotes information transfer, and encourages the nurse to be at the bedside.
5k. POS system
A point of service plan, or POS plan, is a type of managed care health insurance system. It combines characteristics of both the HMO and the PPO. Members of a POS plan do not make a choice about which system to use until the point at which the service is being used.
The POS is based on the basic managed care foundation: lower medical costs in exchange for more limited choice. But POS health insurance does differ from other managed care plans.
Institute of Medicine (IOM) initiated a study on improving the patient record in light of new technology.
The Systematized Nomenclature of Medicine (SNOMED) is a multiaxial, hierarchical classification system. As in any such system, a disease may be located in a body organ which results in a code in a topography axis and may lead to morphological alterations represented by a morphology code.
The Recovery Audit Contractor, or RAC, program was created through the Medicare Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid to healthcare providers under fee-for-service (FFS) Medicare plans.
The Public Health Information Network (PHIN) is a national initiative, developed by the Centers for Disease Control and Prevention (CDC), for advancing fully capable and interoperable information systems in public health organizations. The initiative involves establishing and implementing a framework for public health information systems.
6. Describe the role of ASTM and ANSI in the standardization of data for health information exchange.
American National Standards Institute (ANSI)
• Provides standards for hospital, professional, and dental claims, eligibility
inquiries, electronic remittance advice, and
other billing issues
American Society for Testing and Materials (ASTM) • Standards for Demographics
• Legal elements
• Financial elements
• Provider data
• Problem list
• Immunization record
• Patient medical or dental history
• Orders and treatment plans
• Diagnostic tests
• Medication profile
• Scheduled appointments
7. Describe the potential impacts electronic health records may have on the
HIM profession and HIM functions.
8. Describe each of these characteristics of data quality, and explain why data quality is an essential component of primary and secondary health data.
a. accuracy and consistency
e. data definition
a. accuracy and consistency
b. accessibility -the degree to which a product, device, service, or environment is available to as many people as possible.
c. comprehensiveness -a measurement of the understanding of a passage of text
d. currency -accepted as a medium of exchange
e. data- individual facts, statistics, or items of information
f. integrity - concept of consistency of actions, values, methods, measures, principles, expectations, and outcomes.
g. precision -a measure of the detail in which a quantity is expressed
h. relevance -having any tendency to make the existence of any fact that is of consequence to the determination of the action more probable or less probable than it would be without the evidence
i. timeliness- Occurring at a suitable or opportune time
DATA RENTENTION AND ACESS
DATA RENTENTION AND ACESS
3a. Retention period for medical records
Adult: 10 years after the most recent encounter
Minor: Age of majority + 10 years
3c. Retention period for diagnostic images
3d. Retention period(years) for fetal heart monitor records
age of majority +10 years
3e. Retention period(years) for narcotic records
2 years from dispensing date
3f. Retention period(years) for birth and death records
3g. Retention period(years) for daily analysis of hospital records
3h. Retention period(years) for monhtly analysis for hopsital services
3i. Retention period(years) for annual reports of hospital services
3j. Retention period(years) for master patient index
3k. Retention period(years) for disease and operation index
10 or 25 years, if studies are performed
3l. Retention period(years) for physicians index
10 or 25 years if studies are performed
3m. Retention period(years) for birth and death registers
4.Texas statue of limitations for filing medical malpractice cases involving the care of: adults , minors
adult: 2 years from date of discovery
minor: age of majority + 2 years
inactive record: record of patients who have not been treated at the facility for 2-5 years
active record: pateint records recently being used, less than 2 years
purging record: removing inactive records from paper or electronic files
scanning record: converting paper material to electronic files
7. Describe factors to consider when destroying paper pateint records
A. Retain certain information: admit & d/c dates, physician names, dx, H&P reports, Op & patho reports, D/C summary
B. Directr must obtain approval from facility authority (CEO, COO..)
C. Schredding (secure dox until shred), shred & recycle or Incineration (EPA compliant)
D. Commercial service follow steps of compliance
Manifest must show list of MR#, patient names & dates of service
E. Two witnesses present and sign destruction letter
8. Describe factors to consider when contracting with a service company for off-site storage of inactive paper health records.
Cost, security & accessibility
9. Compute LFI
10. Discuss factors to consider regarding file room accessibillity.
Space & accessibility
11. Describe the purpose and content of each of the following:
a. master patient index
b. physician index
c. operation index
d. disease index
a. master patient index - Locates patient record in system
b. physician index - to gather , track and trend data by physician--MR#, Dx, ICD codes, LOS, outcomes
c. operation index - to gather , track and trend stats on coditions treated & procedures of admin purposes--MR#, Dx, ICD codes, LOS, outcomes
d. disease index -to gather , track and trend stats on coditions treated & procedures of admin purposes--MR#, Dx, ICD codes, LOS, outcomes
DOCUMENTATION REQUIRMENTS IN NON-ACUTE FACILITIES
DOCUMENTATION REQUIRMENTS IN NON-ACUTE FACILITIES
1. Describe general NON-ACUTE long term care patient record documentation requirements.
H&P exam w/in 24 hrs of admit
2. State Medicare and Medicaid time frames for completion of the H&P in LTC facilities
Medicare H&P report w/in 36 hrs of admit
Medicaid H&P report w/in 72 hrs of admit
3. State purposes of:
a. transfer or referal statement
b. comprehesive care plan
c. pharmacy consultatin review
a. transfer or referal statement - reason for transfer; Dx; current status; rehab potential
b. comprehesive care plan - goals, plans prepared by interedisciplinary team (RN, Drs, Soc Serv, Case mgr etc...)
c. pharmacy consultation review - drug regimen for each patient
4. Define "interdisciplinary progress notes"
Combination of RN, Drs, Soc Serv, Case mgr notes etc...
5. Describe general rehabilitation facility patient record documentation requirements.
CARF = Commission on Accredidation of Rehabilitation Facilities
6. State purpose of :
memorandum of transfer (MOT)
interdisciplinary treatment plan
memorandum of transfer: condition at time of treatment
interdisciplinary treatment plan: including documentation of patient, family comments, progress notes of ALL services
7. Describe general behavioral health facility patient record documentation requirements:
Initail assessment 60-72 hours after admit
Physical exam done
8. Describe time frames for :
a. psychiatirc evaluation (Abdulheck p.148
b. problem list
c. psychological assessment
d. nursing assessment
a. psychiatirc evaluation - done by Dr. w/in 60hrs of admit
b. problem list - initial list of problems, w/in 24 hrs of admit
c. psychological assessment - Hx & Dx, initialized at admit
d. nursing assessment - RN does w/in 8 hrs of admit
9. State purpose of the various required assessments
Initail - reason for visit
H&D report - Hx and diagnosis
Chemical assessment - drugs and usage
Activity assessment - Drug, med sheet results
10. State the legal and documnetation requirements for:
a. initaiting use of restraints/seclusion
b. physician evaluation
c. time frames for monitoring
d. alloawable time frames in which pateints may be restrained/seclusion
a. initaiting use of restraints/seclusion: requires Dr orders
b. physician evaluation: Dr eval w/in ONE hr after appying restraints
c. time frames for monitoring: every 15 mintues
d. alloawable time frames in which pateints may be restrained/seclusion: Adults up to 4 hrs; minor up to 2 hrs
11. Describe general home health care patient record documentation requirements. (Abdulheck p.144
Clinician discharge plan
12. Describe the purpose of patient summaries.
review of services and care
13. Describe the general hospice care patient record documentation requirements.
Emergency contact person
Psychsocio and grief assessment
14. State purpose of:
a. grief assessment
b. bereavement follow-up
a. grief assessment: family's coping/acceptance, assessment of spiritual needs of patient and family
b. bereavement follow-up: follow up with family ONE year post death of patient
15. State required tiem frame for the bereavement follow up
ONE YEAR post death
16.Describe general ambulatory care patient record documentation requirements:
a. Organized outpatient departments
b. ancillary departments
c. free-standing ambulatory care faciltiies
d. emergency departments
a. organized outpatient departments: H&P, Problem list, treatment results, tests,
b. ancillary departments: Dr orders tests results
c. free-standing ambulatory care faciltiies: Summary of past surgeries, Dx, treatments, dispensation
d. emergency departments: Pt ID#, ETA, H&P, results, vitals, disposition of Pt.
17. Explain why the following items are critical documentation elements in ED documentation?
a. time and means of arrival
b. disposition and time of discharge
c. documentation if patient left AMA
a. time and means of arrival: determine priority care and gain additional information
b. disposition and time of discharge: A person's inherent qualities of mind and character
c. documentation if patient left AMA: type of treatment in progress
18. Define and state the purpose of the Personal Health Record
A combination of copies of documents generated by providers, patients and others...to facilitate coordination of the health information generated among various health care providers
19. Recomended contents of Personal Health Reacord (PHR)
Personal info, Hx, past treamtns, allergies, medications, family Hx, education, test results etc...
a. Patient receiving dialysis
b. medication adminstration in correctional facility
a. Patient receiving dialysis: vitals, assess site, response to treatment, Pt education
b. medication adminstration in correctional facility: All personnel should possess the education and training needed to carry out their responsibilities.