HITT1401-LectureExam4

EXAM 4

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.

• 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)

• 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

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

• 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

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.

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.

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.

• 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.

• 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

• 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

• Adult: 10 years after the most recent encounter
• Minor: Age of majority + 10 years

5 years

age of majority +10 years

2 years from dispensing date

Permanently

Permanently

Permanently

Permanetly

Permanetly

10 or 25 years, if studies are performed

10 or 25 years if studies are performed

permanetly

• 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

• 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

Cost, security & accessibility

Space & accessibility

• 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

H&P exam w/in 24 hrs of admit

Medicare H&P report w/in 36 hrs of admit

Medicaid H&P report w/in 72 hrs of admit

• 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

Combination of RN, Drs, Soc Serv, Case mgr notes etc...

CARF = Commission on Accredidation of Rehabilitation Facilities

memorandum of transfer: condition at time of treatment

interdisciplinary treatment plan: including documentation of patient, family comments, progress notes of ALL services

• Initail assessment 60-72 hours after admit
• Physical exam done
• progress notes

• 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

• Initail - reason for visit
• H&D report - Hx and diagnosis
• Chemical assessment - drugs and usage
• Activity assessment - Drug, med sheet results

• 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

• Assessments
• Treatment plan
• Progress notes
• Clinician discharge plan

review of services and care

• Indentification
• Dx
• Proress note
• Attedning Dr.
• Emergency contact person
• Psychsocio and grief assessment

• 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

ONE YEAR post death

• 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.

• 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

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

Personal info, Hx, past treamtns, allergies, medications, family Hx, education, test results etc...

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.