HIM 500 9-2 FINAL GRADED Final Project Submission Health Information Technology Recommendations.doc

HIM 500 9-2 FINAL GRADED Final Project Submission Health Information Technology Recommendations.doc

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Unformatted text preview: HIM 500 9-2 Final Project Submission: Health Information Technology Recommendations Augustin Muhizi Professor: Terry Brandes Southern New Hampshire University June 30, 2018 Abstract Featherfall Medical Center is currently struggling a lot with its use of health care information technology. Problems range from outdated technological systems, regulations violations, record-keeping issues, lack of communication and training, and overall ineffective use of technology. Resulting from these issues are staff complaints and operational and ethical problems which are beginning to negatively affect the organization’s bottom-line. For these very same reasons, the facility has begun to look for outside help to restructure its technological infrastructure through upgrades in technology, clearly defined employee roles as they relate to technology, and provide appropriate, and proper needed training for all staff members. 1). Preparation for Consult: Key Historical Events Back in the early 1900’s, Ernest A. Codman of Boston, Massachusetts commented on the appalling condition of hospital records and the resulting issues that they contributed to, including those related to patient safety and care lapses (FACS, n.d.). Codman’s findings led him to convey to the Clinical Congress of Surgeons in North America, that the efficiency of hospitals could be measured on the adequacy level of their records (Lee, 2013). As a result of Codman’s findings, the American College of Surgeons (ACS) created a document that provided hospitals and medical professionals alike a mold for which they could follow and a level of conformity or standardization. On December 20, 1919, such a document was created and was called “The Minimum Standard” (Wright, 2017). Written within “The Minimum Standard” document, one can find the following in relation to medical record keeping: That accurate and complete records be written for all patients and filed in an accessible manner in the hospital- a complete case record being one which includes identification data; complaint; personal and family history; history of present illness; physical examination; special examinations, such as consultations, clinical laboratory, X-ray and other examinations; provisional or working diagnosis; medical or surgical treatment; gross and microscopical pathological findings; progress notes; final diagnosis; condition on discharge; follow-up; in case of death, autopsy findings (Wright, 2017). Shortly after the movement towards hospital standardization, the Association of Record Librarians of North America (ARLNA) was created by the ACS, and their target goal was to enhance the standards of clinical records in hospitals and other medical institutions (Johns, 2002). Health information management's standards can be traced back to the 1920’s with the introduction of what is now known as the American Health Information Management Association (AHIMA) (AHIMA, n.d.). Founded in 1928, the AHIMA has gone through many name changes, but its main focus was to improve the quality of medical records, the management of these records, even though the technology in which these records are kept has basically remained the same throughout the years. With the arrival of the computer age, medical records began to transform from hand written paper documents to electronic medical records (EMR). One of the best known early experiments in relation to computer systems supporting the management of healthcare information can be traced back to Lockheed/Technicon system in El Camino Hospital in Mountain View, California. Their creation of a “hospital information system” (HIS), allowed clinicians to input and collect data on their patient data base via a full-range of electronic medical record (EMR) (Shortliffe, 2005). During the 1970’s and 1980’s, universities began to develop the computerized medical records (CMRs). The primary focus of these records was related to patient medical alerts, provider notes, medication records, and order entry communications, and were geared towards such departments and systems as registration, radiology, pharmacy, laboratory, and nursing (Bowie & Green, 2015). It was not until the 1990’s, that the more contemporary version of today’s record format could be found. With the help of the Institute of Medicine (IOM), the development moved to a patient record which would contain different patient encounters, among different providers and facilities, back then known as a computer-based patient record (CBPR) or what we would call today’s early electronic medical records (EMR) (Bowie & Green, 2015). 2). Preparation for Consult: Guidelines Healthcare information technology (HIT) is a large investment for any healthcare facility. As such, guidelines or technology architecture ought to be incorporative into the workflows of those facilities. Technology architecture (TA) is a series of guidelines for the integration of a new technology within an organization (Jones, Duncan, Langberg, & Shabot, 2000). The ultimate goal of a well-thought-out technology architecture plan would be to aid large growing health care facilities with controlling costs, and promoting integration of applications, data stores, and networks. Besides to integration guidelines, use guidelines need to be established among each healthcare facility. Given the nature of information contained in an electronic medical record (EMR), medical privacy guidelines needed to be established on a universal basis. Among the contained information one could find in these confidential records are such items as personal identification, demographics, and otherwise considered private and sensitive medical related information. The US Department of Health and Human Services (DHHS) realized a need for laws to be put in place on the best secure way in which patient related medical information could be reviewed, used, transmitted, and released. With that need, under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Privacy Rule, officially known as Standards for Privacy of Individually Identifiable Health Information was born (SPIIHI) (Kulynych, & Korn, 2003). Therefore, HIPAA was passed by Congress in 1996 as a way of regulating a number of healthcare concerns that can affect each citizen who seeks medical attention including transmission and invasion of what is considered private health information (PHI) (Kulynych, & Korn, 2003). The Privacy Rule can be summarized by examining its main goal; assurance that an individual’s medical information is properly protected while ensuring the flow of records to enable a best high quality of healthcare to those who need it. The Privacy Rule depicts a few stipulations. Most importantly, the information passed is based on a minimum necessary to accomplish the proposed objective (Kulynych, & Korn, 2003). The Privacy Rule creates a new level of protection and barriers to the use or transmission of what is considered identifiable health information by imposing not only a series of guidelines on clinical personnel, but administrative and support staff as well. Hence, clerical staff such as medical billers, data processors, and filing personnel, all are granted access to electronic medical records (EMR) on a daily basis. Some gaps in the HIPAA limit the functions of the law in relationship to covered entities and their employees, including HMOs, health insurance companies, and providers who practice particular financial and administrative transactions (Meingast, Roosta, & Sasry, 2006). Other occurrences of disclosure with consent can be found in relationship to public health issues, judicial proceedings, and law enforcement investigations, including abuse and neglect (Meingast, Roosta, & Sasry, 2006). In these particular cases, the patient neither needs to grant consent nor is given the opportunity to deny access to the records. In an age dominated by computer-based knowledge, it is much easier than ever to collect, analyze, and share any transmitted medical data. Therefore, many physicians have become increasingly dependent on the ease of availability of such information. For this same reason, a number of controls and safeguards have been put in place to ensure patients’ information privacy and confidentiality, while providing security and protection. Hence, passwords, limited personnel access, federal regulations, and specially organized filing systems have been tried in large part to secure the public from invasion of their records. 3). Preparation for Consult: Standard Technologies Currently, basic healthcare information systems are comprised of four components, data, process, information technology, and users (Zeng, Reynolds, & Sharp, 2009). A standard healthcare information system (HIS) is comprised of an ongoing and continual set of interactive software applications including those related to patient information databases with corresponding input from outside organizational systems such as laboratories, electronic communications among clinicians and patients, order management systems, digital imaging software, coding and billing applications, registration software, and materials/supply management (Walker, Carayon, Leveson, Paulus, Tooker, Chin,... & Stewart, 2008). Moreover, some healthcare information systems contain data bases related to clinical research including outcomes analysis, quality assurance, clinical trials, implementation of pathways and protocols, and scholarly information such as digital libraries, bibliographic searches, and drug information databases (Shortliffe, 1999). Finally, basic office needs are found in most healthcare information systems including those related to office automation such as spreadsheets, word processors, and PowerPoint presentations capabilities. 4). Preparation for Consult: Roles Although they all work within the same healthcare organization, the roles played by each of the Featherfall Medical Center employees can be quite different depending on one’s work environment and will directly impact their needs for an EMR/EHR system. These interactions with the system will require different levels of proper training, management, supervision, and assigned user controls. a). Clinical Staff From a clinical professional standpoint, the physician, nursing, and technologist staff are responsible for such tasks as monitoring, recording and reporting symptoms and/or changes in a patient’s condition, including those related to vital signs, and physical appearance, order and delivery of mediations; modifying patient treatment plans and care paths, consulting and coordinating with other physicians and departments, order, interpret, and evaluate diagnostic tests to identify and asses patient conditions; provide instructions to patient, family, and care givers. Most importantly, clinical staff members, both physicians, nursing, and technologists alike, need to maintain accurate, detailed reports and medical records for which any other provider, nurse, physician, or technician, can pick up and continue on care for that patient. This information in these reports is individual and personalized to that specific patient and their care, making each record and report extremely complex and extraordinary detailed. b). Administrative/Support Staff From an administrative/support staff standpoint, uses for Featherfall’s EMR/EHR system would include scheduling, coding and billings, transcription, registration, and material/ supply management. Although the uses of these user roles are generally related to basic data entry or updating already transcribed or recorded information, adequate, proper training, and user assignment is imperative in coordinating accurate records, proper facility reimbursement, patient follow up, and patient retention. c). Health Information Management One of the most important user roles in any EMR/EHR system is that of the Health Information Management (HIM) team. Since EMR/EHR systems provide users with easy access to patient data proper management is required. A core challenge for any HIM team would be addressing security and limiting access to those who truly need it. Primary strategies the Featherfall HIM team will address relates to Role Based Access Control (RBAC), which assigns collections of privileges called roles to users, and Experience Based Access Management (EBAM), which analyzes audit logs to determine access rights (Zhang, Gunter, Liebovitz, Tian, & Malin, 2011). This task would be accomplished by reviewing job positions in the organization, in comparison with the daily workflows the employees in these positions need to perform, then assigning privileges to positions, or variants of them, to enable the employees to accomplish their assigned tasks, while emphasizing accountability and security by auditing the access and use of patient data to discourage/punish any forms of misuse, mishandling, and abuse (Zhang, Gunter, Liebovitz, Tian, & Malin, 2011). 5). Preparation for Consult: Evaluation The processes by which evaluation of the newly implemented healthcare technology systems will be conducted would include hospital role classification, intelligent role abstraction, empirical training evaluations, and staff questionnaires, and surveys. First, hospital role classification needs to be determined to the extent where and expertly defined job description are created, reviewed and assigned. By using a technologically based learning classifier, it would be possible to review users as they access patient records to classify specific needs and requirements (Zhang, Gunter, Liebovitz, Tian, & Malin, 2011). Secondly, some role hierarchies would be developed to determine the correct level of access and the proper required training needed. Third, proper, thorough staff training would be completed through the use of simulation records and possible use scenarios as designated by the role in which each staff member plays in the organization. Also, audit record access and usage against federally mandated regulations will be implemented to ensure proper usage and unmask any possible issues which may result in regulation violations. Finally, upon completion of training, implementation of the new technology, and a designated period of use, anonymous staff surveys and questionnaires through the use of web survey technology would be thoroughly conducted, emails, and suggestions boxes used to determine if any additional training or system updates are required. Hopefully, by following through these straightforward steps, it would be possible to help create and implement a healthcare technology system which will allow Featherfall Medical Center to move into a new and prosperous direction in the future while striving to provide best patient quality care. 6). Health Regulations and Laws Ramifications: Finances Usually, during the auditing process, the OIG will determine discrepancies and how to correct these discrepancies. Specifically, SNHU Medical clinic would be granted with the opportunity to address the issues in a timely manner prior to the allocated/fixed deadline. If, for some reasons, deadline is not met or respected as expected, the clinic might face a significant financial fine as applicable. Consequently, implementing compliance plans should be thoroughly and fully discussed in meetings as it can be very viable for the clinic success. Specifically, “to ensure members are all aware of compliance plan, they should be provided with the necessary documents and should be allowed to provide feasible and constructive feedback (Fox, 2013).” The plan would be fully enforced to ensure staff members are familiar with new information as well as how to interact appropriately in a given clinical setting. There are many various ideas as far as disseminating information goes. It is critically important to ensure that members are getting the correct information and are able to be understanding it clearly. Clear understanding would be established by a return demonstration or a repeat back. As discussed previously, up coding is a well-known fraud form and if ever convicted, healthcare professionals and their employing facility may face up to a 250,000-dollar fine or a five-year firm prison sentence. A quite often example of up coding would be for instance, a patient who would come for a scheduled visit to see her/his Dr. Echo for just a regular and routine checkup. Per error or unwillingly, Dr. Echo bills for extended checkup which normally would be reimbursed US 150 dollars rate instead of the routine reimbursement rate coted at 80 US dollars. In this example, Dr. Echo inadvertently/willingly submitted the incorrect code in order to receive a higher reimbursement, a fact which is usually considered insurance fraud. Therefore, Dr. Echo’s clinic would become liable for any false claims made within this healthcare facility entity. Moreover, similar such examples quite often had occurred in the recent past where physicians were being used to doing unnecessary procedures on patients in vue to collect higher payments. Very recently, the sad case for a well-known pediatric dentist from Florida who was jailed for committing significant fraud cases in his practice. Hence, he was performing unnecessary dental extraction procedures on very young children to collect more money from insurance companies. For instance, a young child needed just one tooth extraction, but instead, the dentist extracted seven teeth. Later on, the same dentist was sued by many more patients in successive lawsuits. Therefore, insurance fraud cases do occur quite frequently and can happen in many various ways. 7). Health Regulations and Laws Ramifications: Daily Operations Per laws/regulations, when filing an insurance claim, one would ensure that the documentation and code are thoroughly accurate to prevent any frustration down the road. Specifically, in order for SNHU Medical clinic to receive insurance reimbursement, they ought to file a correct and complete claim, and in a timely manner. To make it better, for any over recovered funds, SNHU Medical Clinic would consider sending out a check to the payer for any overpaid funds. When it enters into effect, an order must follow and comply with all laws and regulations to avoid any undue consequences. Therefore, all staff should be aware and mindful of any type of regulatory compliances implemented by any given business at a particular time period. Hence, SNHU Medical Clinic would guarantee their standards and set objectives that should be recognized and adhered to by each staff member. Similarly, staff members/employees should always be willing to comply with any requirements or laws that are being implemented by the national administrations (state or local levels). Whenever staff members are not compliant with set laws and set regulations, it can ultimately lead to hindering the success and growth for any particular given organization and employees collectively. Therefore, a rather strict, but formal compliance plan has been established by SNHU Medical Clinic and ought to be followed thoroughly by each and every one. SNHU Medical Clinic would strive to ensure that their staff can easily identify internal compliance and all the regulatory guidelines implemented. SNHU Medical Clinic staff members should moreover be able to identify their individual training needs, risks, roles and procedures. Specifically, staff would also be able define clearly objectives while following procedures being implemented. To be safe, a thorough employee evaluation and a careful employee background check would be highly required. Also, a careful SNHU Medical Clinic employee’s behavior monitoring would be highly recommended and mandatory in order to avoid and prevent any potential problems. On the other hand, “Meaningful” use does reflect clearly the provider’s patient population. Thus, family practice has enough patients that visit r...
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  • Summer '17
  • electronic medical record, Electronic health record, health information, SNHU Medical Clinic

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