Information Technology

The management structure of Information Departments varies depending on the healthcare organization. Some have a management level officer who reports directly to the Chief Executive Officer; in others, the managers of individual ancillary departments have a department director who report to the Chief Operating Officer or designate. Admitting is responsible for obtaining initial information from the patient including demographic data, payer information, and reason for admission. They will obtain general consent for admission to the hospital and agreement to pay services not covered by the payer and will acknowledge receiving information about the Health Insurance and Portability and Accountability Act (HIPAA) [hip-pa]. Admitting may also ask patients if they have or would like to complete an advanced directive for care. Medical records traditionally were kept on paper; with the growing shift to electronic records, many medical record departments are transitioning their responsibilities to include some aspects of EHRs. The primary responsibility is to ensure that the medical records meet legal and regulatory requirements.

Information technology departments have always had the responsibility to maintain infrastructure including hardware and software and the security of the data. With implementation of EHRs and greater linkage to data from medical equipment, it has evolved into Health Information Technology. Now, in addition to the use of information technology for administrative and financial functions, it has been expanded to include many clinical functions. This has led to the addition of Chief Information Officers and Chief Medical Information Officers as part of the administrative team.

Electronic Health Records (EHRs)

Patients seem to be responding positively to the enhanced communication among health organizations as a result of the implementation of Electronic Health Records, especially the elimination of having to provide duplicate information for every visit to a new department or when receiving a new service. The amount of data is difficult for patients to keep track of and understand as it may include demographic information, health insurance, current medications, allergies, and details of the current and past illnesses. Patients were also confused, for example, when a test or x-ray was repeated when they visited a new department or received a new service, despite the fact that the same test or x-ray was performed just weeks earlier. Electronic Health Records have enabled all departments within a healthcare institution or system access to the results of every test or visit that has occurred with each patient, significantly decreasing the need for patients to attempt to repeatedly explain their interpretation of previous visits or services as well as eliminating the process of requesting records from other departments to assess the patient’s status.

Several types of data are used to gather and record information. Much of the observational data such as the history, results of the physical examination, procedure, and surgery reports are recorded as narrative data. Numerical measures include weight, vital signs, and volumes. Recorded signals are increasingly digital and can be transferred directly to EHRs. This includes electrical activity (electrocardiograms [ĭ-lĕktrō-kär-dē-ə-grăm’]) and pressures generated from a variety of monitoring devices like blood pressure and other measures of cardiac pressures. Many devices like intravenous fluid administration devices or ventilators now have the ability to directly input data into EHRs. Drawings, either produced by hand or with software, provide a record of an observation made to aid in documenting or following the progress of a wound, surgery, injury, etc. Photographs and images are becoming more common in digital format and allow one to record an abnormal finding or wound at admission to better follow the progress. Many healthcare organizations now record all X-rays and imaging in digital format.

Data can be transmitted verbally face to face or by phone. This has the advantage of direct communication but usually has no permanent record. Even audio recordings may be less satisfactory because they require the user to listen to the entire recording. Paper medical records have been the mainstay of communication. There are problems with legibility and organization, and the record can usually only be one place at one time. Frequently, this means that many units keep their own version of the medical record and only inpatient records are uniform. In the past, many results of tests or images were recorded on film or in an analog format. While these could be added to the chart (electrocardiograms or laboratory results) or stored in a central location (X-rays), this method has the same availability problems as paper records. Digital records have the potential to replace permanent records across the institution, avoid duplicate entry of information like demographics, and allow access to view and enter data at multiple locations. Increasing use of digital imaging also allows any user with authorization to view images including real-time images like ultrasounds.

Differences between Electronic Medical Records and Electronic Health Records

An EMR contains the standard medical and clinical data gathered in one provider’s office. Electronic health records (EHRs) go beyond the data collected in the provider’s office and include a more comprehensive patient history.

For example, EHRs are designed to contain and share information from all providers involved in a patient’s care. EHR data can be created, managed, and consulted by authorized providers and staff from across more than one health care organization.

Unlike EMRs, EHRs also allow a patient’s health record to move with them—to other health care providers, specialists, hospitals, nursing homes, and even across states. .

An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment.

Benefits of Electronic Medical Records

An EMR is more beneficial than paper records because it allows providers to:

Track data over time
Identify patients who are due for preventive visits and screenings
Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings
Improve overall quality of care in a practice

The information stored in EMRs is not easily shared with providers outside of a practice. A patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team.

https://www.healthit.gov/providers-professionals/electronic-medical-records-emr

HIPAA

What is HIPAA?

HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following:

Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
Reduces health care fraud and abuse;
Mandates industry-wide standards for health care information on electronic billing and other processes; and
Requires the protection and confidential handling of protected health information

Protection and Confidential Handling of Health Information

The HIPAA Privacy regulations require health care providers and organizations, as well as their business associates, develop and follow procedures that ensure the confidentiality and security of protected health information (PHI) when it is transferred, received, handled, or shared. This applies to all forms of PHI, including paper, oral, and electronic, etc. Furthermore, only the minimum health information necessary to conduct business is to be used or shared.

READ: HIPAA

Patient Health Information Rights

Patient’s Bill of Rights

On June 22, 2010, President Obama announced new interim final regulations, the Patient’s Bill of Rights, that include a set of protections that apply to health coverage starting on or after September 23, 2010, six months after the enactment of the Affordable Care Act.

The Departments of Health and Human Services, Labor and Treasury collaborated on the Patient’s Bill of Rights – which will help children (and eventually all Americans) with pre-existing conditions gain coverage and keep it, protect all Americans’ choice of doctors, and end lifetime limits on the care consumers may receive. These new protections create an important foundation of patients’ rights in the private health insurance market that puts Americans in charge of their own health.

New York State Patient Bill of Rights

As a patient in a hospital in New York State, you have the right, consistent with law, to:

Understand and use these rights. If for any reason you do not understand or you need help, the hospital MUST provide assistance, including an interpreter.
Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, source of payment, or age.
Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.
Receive emergency care if you need it.
Be informed of the name and position of the doctor who will be in charge of your care in the hospital.
Know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation.
A no smoking room.
Receive complete information about your diagnosis, treatment and prognosis.
Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.
Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet “Deciding About Health Care — A Guide for Patients and Families.”
Refuse treatment and be told what effect this may have on your health.
Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation.
Privacy while in the hospital and confidentiality of all information and records regarding your care.
Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge.
Review your medical record without charge. Obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay.
Receive an itemized bill and explanation of all charges.
Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital’s response, you can complain to the New York State Health Department. The hospital must provide you with the State Health Department telephone number.
Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.
Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the hospital.
Effective pain management.

Public Health Law(PHL)2803 (1)(g)Patient’s Rights, 10NYCRR, 405.7,405.7(a)(1),405.7(c)

Quality Assurance

In 2001, the Institute of Medicine published a report called, “Crossing the Quality Chasm: A New Health System for the 21st Century.” We know that populations and the individuals that make up these populations want excellent health outcomes. We also know that outcomes need to be improved by healthcare services until they reach the point of excellence.

This improvement in health outcomes needs to be consistent with the professional knowledge of medicine and practices, as it exists in a scientific and rational fashion.

Quality, then, is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes, in a manner that is consistent with current professional knowledge.

So, what does “quality” mean? When we speak of “quality” we speak of better patient outcomes or improvements in patient health. We speak of better system performance or improvement in patient care. We also think of better professional development or improvements in the way that clinicians learn and improve their knowledge.

In order to achieve this, we need a body of scientific evidence. We need a methodology that is rigorous, scientific, and able to produce conclusions which we can then distill in particular contexts. We need to be able to take these recommendations, or these inferences, and apply them to the practice of healthcare. And not only just apply them, in terms of improving patient health, but also try to measure an improvement in performance of the system itself.

We can also measure if the professional development by clinicians has improved and we can use the data that has been collected on patient outcomes, to bolster and improve the scientific literature – to indeed, demonstrate if quality of care has been improved.

An important organization that is improving the quality of healthcare in the United States is the Agency for Healthcare Research and Quality, also known as AHRQ [A-H-R-Q] or “arc” [ark]. AHRQ [ark] is a part of the Department of Health and Human Services and its mission is to improve quality, safety, efficiency, and effectiveness of healthcare for all Americans. It attempts to improve healthcare outcomes by emphasizing the use of evidence to reduce risk of harm and to improve healthcare outcomes.

AHRQ attempts to transform health research into practice in order to facilitate a wider access to effective healthcare services; there is also a mission to reduce unnecessary costs.

In order to demonstrate that quality has been improved, we need to define a set of measurements that quantify results. These metrics for measuring quality may look at processes or outcomes. The electronic health record is important in improving quality, not just acting as a vehicle for data collection, but also providing the data required for analysis in a sophisticated fashion.

Health Information & Quality Assurance