Health Information Management Technology: An Applied Approach

Health Information Management Technology: An Applied Approach free pdf ebook was written by CarolB on February 27, 2002 consist of 28 page(s). The pdf file is provided by library.ahima.org and available on pdfpedia since December 04, 2011.

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Health Information Management Technology: An Applied Approach pdf




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Health Information Management Technology: An Applied Approach - page 1
Health Information Management Technology An Applied Approach Edited by Merida L. Johns, PhD, RHIA AMERICAN HEALTH INFORMATION® MANAGEMENT ASSOCIATION
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Health Information Management Technology: An Applied Approach - page 2
Contents About the Editor and Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv Part I Foundations of Health Information Technology Chapter 1 Chapter 2 Chapter 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Merida L. Johns, PhD, RHIA Functions of the Health Record . . . . . . . . . . . . . . . . . . . . . . . . .21 Cheryl V. Homan, MBA, RHIA Content and Structure of the Health Record . . . . . . . . . . . . . . .45 Harry B. Rhodes, MBA, RHIA, Beth M. Hjort, RHIA, and Michelle L. Dougherty, RHIA Healthcare Data Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 Kathleen LaTour, MA, RHIA Secondary Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 Elizabeth Bowman, MPHA, RHIA Ethical Issues in Health Information Technology . . . . . . . . . .167 Laurinda B. Harman, PhD, RHIA Legal Issues in Health Information Technology . . . . . . . . . . . .193 Merida L. Johns, PhD, RHIA Chapter 4 Chapter 5 Chapter 6 Chapter 7 Part II Health Information in the Healthcare Delivery System Chapter 8 Healthcare Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . .241 Bonnie S. Cassidy, MPA, RHIA, FHIMSS iii
Health Information Management Technology: An Applied Approach - page 3
iv Contents Chapter 9 Clinical Vocabularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .291 Mary Jo Bowie, MS, RHIA, RHIT Chapter 10 Reimbursement Methodologies . . . . . . . . . . . . . . . . . . . . . . . .327 Michelle A. Green, MPS, RHIA, CMA Part III Health Information in the Evaluation of Healthcare Services Chapter 11 Healthcare Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .415 Carol E. Osborn, PhD, RHIA Chapter 12 Clinical Quality Management . . . . . . . . . . . . . . . . . . . . . . . . .477 Cathleen A. Barnes, RHIA, RHIT, CCS Chapter 13 Performance Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . .521 Andrea Weatherby White, PhD, RHIA Part IV Information Systems and Technology Chapter 14 Introduction to Healthcare Information Systems . . . . . . . . . . .557 Karen A. Wager, DBA, RHIA, and Frances Wickham Lee, DBA Chapter 15 Fundamentals of Information Systems . . . . . . . . . . . . . . . . . .591 Sandra Bailey, RHIA, and Keith Morneau, MS Chapter 16 Information Systems for Managerial and Clinical Support . . . .647 Merida L. Johns, PhD, RHIA Chapter 17 Information Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .661 Merida L. Johns, PhD, RHIA Chapter 18 Applications of Emerging Information Technologies . . . . . . . .685 Terrell Herzig, MS, and Joan C. Hicks, MS, RHIA Part V Principles of Organization and Supervision Chapter 19 Introduction to Organization and Supervision . . . . . . . . . . . . .713 Sandra Fuller, MA, RHIA Chapter 20 Supervision of Health Information Technology Functions . . . .763 Merida L. Johns, PhD, RHIA, and Joan Ludwig, RHIA Appendix A Sample HIM Position Descriptions . . . . . . . . . . . . . . . . . . . . .805 Appendix B Standards for the Form and Content of the Health Record . . . .829 Appendix C Sample Notice of Health Information Practices . . . . . . . . . . . .837 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .841 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .883
Health Information Management Technology: An Applied Approach - page 4
About the Editor and Authors Merida L. Johns, PhD, RHIA, was the founding director of the HIT program at San Diego Mesa College and later served as the director of the HIT program at Alfred State College. Dr. Johns was also a faculty member in the HIM program at The Ohio State University and served as the program director for the nontraditional HIT-HIM progression program at Ohio State. She was the founding director of the master’s program in health informatics at the University of Alabama at Birmingham. She served as president of the American Health Information Management Association (AHIMA) in 1997 and as vice-president for educa- tion and accreditation for AHIMA until 2000. She currently is the director of the master’s program in information systems management at Loyola University in Chicago. Sandra Bailey, RHIA, is an independent consultant based in Virginia. She was an assis- tant professor in health information technology (HIT) at Northern Virginia Community College from 1970–1999. She has been active in the AHIMA since 1983, as a speaker, member, and chairman of the Education and Registration Committee in 1978, and was president of the Washington, D.C., Health Information Management Association in 1975. Cathleen A. Barnes, RHIA, RHIT, CCS, is a research manager at the Medstat Group in Santa Barbara, California, and is an HIT instructor at Santa Barbara City College. Ms. Barnes has been an HIM professional since 1974. She has published articles in various publications including the Journal of AHIMA, and is a frequent presenter at conferences throughout the United States and Italy. She would like to thank Judy Cordeniz, RHIA, the Holy Rosary Medical Center in Ontario, Oregon, and Sue Watkins for their encouragement and examples. Mary Jo Bowie, MS, RHIA, RHIT, is an independent health information consultant based in Binghamton, New York. She received her master of science degree in Health Ser- vice Management from the New School for Research in Binghamton, and her bachelor of science degree in Medical Record Administration from Ithaca College in Ithaca, New York. She currently serves on the Ambulatory Care Coding Guidelines Committee and is v
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vi About the Editor and Authors an active member of the Long-Term Care Section for the New York Health Information Management Association (NYHIMA). Elizabeth Bowman, MPHA, RHIA, is a professor in the health information management program at the University of Tennessee—Memphis Health Science Center. Elizabeth has been an HIM educator for more than twenty-five years. She received her bachelor’s degree from Millsaps College and her master’s degree in public administration with a concentra- tion on healthcare administration from the University of Memphis. She has served as the chair of the AHIMA Assembly on Education, and she received the AHIMA Educator Award in 1999. She was also awarded the Tennessee Health Information Management Associa- tion Distinguished Member Award in 1998. Bonnie S. Cassidy, MPA, RHIA, FHIMSS, is a principal consultant with the North High- land Company in Atlanta, Georgia. Previously she was a senior manager in the healthcare consulting practice of Ernst & Young, LLP. She received her bachelor of science degree in medical record administration from Daemen College in Amherst, New York. Her achieve- ments include the AHIMA 2000 Legacy Award, AHIMA 1995 Professional Achievement Award, and a Distinguished Member Award from the Ohio Health Information Manage- ment Association in 1991. Michelle L. Dougherty, RHIA, is a health information management practice manager at AHIMA. She received a bachelor’s degree in health information administration from the College of St. Scholastica. Prior to her time at AHIMA, Ms. Dougherty worked as a con- sultant on postacute, long-term, and home health care. She has been a board member and chair of the Long Term Care Section as well as a member of the AHIMA Program Com- mittee, Triumph Awards Committee, and Organizational Structure Taskforce. Sandra Fuller, MA, RHIA, is the senior vice-president of professional development ser- vices at AHIMA. She was the director of patient data services at the University of Wash- ington and served on AHIMA’s Board of Directors through 1996. She received both her bachelor’s degree in health information management and her master’s degree in manage- ment from the College of St. Scholastica. Michelle A. Green, MPS, RHIA, CMA, is a professor at Alfred State College in Alfred, New York. She received the State University of New York Chancellor’s Award for Excel- lence in Teaching in 2000 and was included on the 1994, 1998, and 2000 lists of Who’s Who among American Teachers. Ms. Green would like to thank her husband and son “for understanding that being a teacher is what I am, not what I do.” Laurinda B. Harman, PhD, RHIA, is associate professor and chair of the department of health information in the College of Allied Health Professions at Temple University in Philadelphia. Laurinda has been an HIM professional and educator for over thirty years. Prior to joining the faculty at Temple University, she directed HIM baccalaureate programs at both George Washington University in Washington, D.C., and The Ohio State Univer- sity in Columbus, Ohio. She also served as director of education and human resource
Health Information Management Technology: An Applied Approach - page 6
About the Editor and Authors vii development at George Washington University and as a faculty member in the health infor- mation technology program at Northern Virginia Community College. She served as the editor of Ethical Challenges in the Management of Health Information. Terrell Herzig, MS, received his master of science degree in health information at the University of Alabama at Birmingham, where he is currently on the faculty of the School of Health Related Professions. He has led AHIMA tutorials in networking and data com- munications and has been a consultant on HIPAA security, security planning, and config- uration management. Joan C. Hicks, MS, RHIA, is the director of health system information services for the University of Alabama Health System. Her accomplishments include an AHIMA Best Prac- tices Award in 2000 and an AHIMA Motivator Award in 1999. She is a distinguished mem- ber of the Alabama Association of Health Information Management and a faculty member of the Alpha Eta Society. Ms. Hicks would like to acknowledge Merida Johns and Terrell Herzig for their work on this book. Beth M. Hjort, RHIA, is a professional practice manager for AHIMA. Ms. Hjort has also worked in acute care hospitals in Illinois and New York and served on the start-up team for the first open magnetic resonance imaging center in Madison, Wisconsin. Cheryl V. Homan, MBA, RHIA, is the director of information management for the ProMedica Health System in Toledo, Ohio. She has been an HIM professional for over twenty years, served on AHIMA’s Board of Directors from 1997 to 1999, and is a former president of the Ohio Health Information Management Association. Kathleen LaTour, MA, RHIA, is an assistant professor and chair of the department of health information management at the College of St. Scholastica in Duluth, Minnesota. She is an active member of the Minnesota Health Information Management Association and has served as chair and member of many AHIMA councils and as a member of AHIMA’s Board of Directors from 1993 to 1997. Ms. LaTour is one of the editors of AHIMA’s forthcoming health information administration textbook. Frances Wickham Lee, DBA, is an associate professor in the department of health infor- mation administration and policy at the Medical University of South Carolina. She received her master of business administration degree from Western Carolina University and her doctor of business administration degree from the University of Sarasota. She is an active member of AHIMA and won a Distinguished Member Award from the Mental Health Section of AHIMA in 1995. Joan Ludwig, RHIA, received her certificate in health information systems from Seattle University. She has been the director of HIM departments in large teaching hospitals and has been responsible for clinic, inpatient, and outpatient health record systems. Her back- ground also includes employment with an EMR vendor, where she worked as project man- ager in the installation of outpatient EMR systems. Currently, she is a partner with Wind Rose Consultants, Eden Prairie, Minnesota.
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viii About the Editor and Authors Keith Morneau, MS, is an assistant professor in information systems technology at Northern Virginia Community College in Annandale, Virginia. He received a bachelor of science degree in computer engineering from the Florida Institute of Technology and a master of science degree in electrical engineering from George Mason University. He is the author of MCSD Guide to Solution Architectures and Active Server Pages. Carol E. Osborn, PhD, RHIA, is the assistant director of coding and compliance at the Ohio State University Medical Center. She is the author of Statistical Applications for Health Information Management as well as many articles that have appeared in the Jour- nal of AHIMA and Topics in Health Information Management. She is a former president of the AHIMA Assembly on Education. Harry B. Rhodes, MBA, RHIA, has been working in health information management since 1980. He currently serves as the director of HIM products and services for AHIMA. He is also co-chair to the HL-7 Medical Records/Information Management Technical Committee. He was director of medical information services at Columbia/HCA Presby- terian Hospital in Oklahoma City and served as president of the Oklahoma Health Infor- mation Management Association. Currently, he is president of the Chicago Area Health Information Management Association. Karen A. Wager, DBA, RHIA, is an associate professor in the department of health admin- istration and policy at the Medical University of South Carolina, where she received her mas- ter’s degree in health information administration and finance. In 1998, she received a doctorate of business administration from the University of Sarasota. She is a member and has served on various committees of AHIMA. She was president of the South Carolina Health Information Management Association from 1991 to 1992. Andrea Weatherby White, PhD, RHIA, is an associate professor and MHA program director in the department of health information administration and policy at the Medical University of South Carolina. She was named Teacher of the Year by the university in 1995 and won an Excellence in Service award in 2000. She would like to thank Mary Connolly for her assistance in preparing the chapter she authored.
Health Information Management Technology: An Applied Approach - page 8
Preface Health information management professionals are an integral part of the healthcare team. They serve the healthcare industry and the public by managing, analyzing, and utilizing data vital for patient care and making them accessible to healthcare providers when they are needed most. Whether stored on paper or computer files, reliable health information is critical to high-quality healthcare. Enhancing individual patient care through timely and relevant information is one of the primary goals for the health information management profession. The American Health Information Management Association (AHIMA) is the profes- sional association that represents more than 40,000 specially educated health information management professionals who work throughout the healthcare industry. AHIMA has had a long history of commitment to health information management education. Among other contributions, AHIMA has developed and maintained a rigorous accreditation process for academic programs, continuously developed up-to-date curriculum models, supported fac- ulty development, and continued to research and study the needs and future directions of HIM education. This text, specifically directed toward associate degree programs in health information technology (HIT), is an outgrowth of AHIMA’s ongoing effort to provide rich resources for the education and training of new HIM professionals. In addition, it offers a ready resource for current practitioners. Its subject matter is based on the outline of curricular content from AHIMA’s Model Curriculum for Associate Degree Programs in Health Infor- mation Technology. The arrangement of information in the text provides a logical flow for skill and knowledge building of the new HIT professional. Following the prescribed cur- ricular content found in the Model Curriculum, the text ensures coverage of information and topics considered essential for any entry-level HIT practitioner. Although the text is directed primarily at students enrolled in two-year HIT programs, students in other HIM disciplines and allied health programs will find its content highly useful in this increasing information age. ix
Health Information Management Technology: An Applied Approach - page 9
x Preface The book’s underlying metaphor is translating basic theory into practice. A review of the cognitive and competency levels of the model curriculum reveals that HIT programs are applied in nature. Outcome expectations are that students understand theory at a basic level with a major emphasis on skill building to perform day-to-day operational tasks in health information management. The features used throughout the book focus, therefore, on translating basic theory into practice. To accomplish this, each chapter contains the following sections: Theory into Practice: Located at the beginning of the chapter, this section pre- sents a case study with one or two questions that serve as an organizing frame- work for the chapter as theory is presented. This instructional design strategy “sets the stage” and “gains the learner’s attention,” two of the first and most basic steps in instructional design. Real-World Case: Located near the end of the chapter, this section presents an actual situation faced by healthcare enterprises as reported in current literature and periodicals. The story supports the preceding events of instruction (that is, introducing the theory) and moves to the next event: selective perception. Check Your Understanding: This section is essentially a review exercise. These exercises are positioned throughout each chapter so that students can reinforce their understanding of the concepts they have just read. Application Exercises: The purpose of these exercises is to give students the opportunity to put theory into practice. Because skill building is an important part of the expected outcomes for the HIT student, these exercises will bring the real world into his or her sphere. Review Quizzes: These quizzes appear at the end of each chapter. Their format is matched to the cognitive/competency levels identified in the Model Curriculum. The fundamental organization of the book is built on the curricular content of the HIT Model Curriculum. Each of the content areas is represented in the book, except those relat- ing to the biomedical sciences and to technical aspects of classification systems such as ICD. Because this is a technical-level textbook, it is designed to proceed from the specific to the global as an instructional design delivery method. This strategy is used because the book’s intended audience will likely not have a previous background in healthcare deliv- ery or, specifically, in health information management. The text is segmented into five parts. Part I concentrates on explaining the elements of health information management and its related important concepts and ethical issues. Chapter 1 introduces the concept of health information management. The discussion focuses on the history of the health information management profession and the evolution of the roles and functions of HIM professionals over the years. Particular emphasis is placed on introducing elements of the AHIMA Model Curriculum and how they connect with the real world and emerging roles for health information technicians.
Health Information Management Technology: An Applied Approach - page 10
Preface xi Chapters 2 and 3 discuss the generic components of the content use and structure of healthcare data. Content of the health record and documentation requirements are covered. The format of paper and electronic record systems is investigated in chapter 3. Chapter 4 builds on the basic knowledge presented in the previous chapters and discusses the promi- nent healthcare data sets, their purposes and uses, and requiring agencies. Chapter 5 introduces the concept of secondary data sources and reviews various types of secondary data sources such as registries and indexes. Record-keeping practices for both paper and electronic systems are studied. Ethical issues in HIT are discussed in chapter 6, which also presents the introductory concepts of stewardship for health information. Part II builds on the information presented in part I and looks at the environment in which HIT professionals work—essentially, the U.S. healthcare delivery system. Chap- ter 7 covers basic concepts of the legal system as appropriate to the work of the HIT professional. A special emphasis of this chapter is its focus on federal privacy and confi- dentiality rules and regulations applied to health information. Chapter 8 introduces the history, financing, and delivery of health services in the United States. This chapter pro- vides a breadth of information and demonstrates the complexity of the current delivery mechanisms, systems, and regulations involving healthcare. Communication is one of the most important elements in healthcare. Issues relating to nomenclatures and clinical vocabularies are explored in chapter 9. This chapter focuses on reviewing prominent sys- tems and developing an understanding of how they are used throughout the healthcare delivery system. Part II concludes with an introduction to reimbursement methodologies. As discussed in chapter 8, the complexity of healthcare delivery has intensified over the past several decades. Associated with this complexity has been the growth of various reimbursement methods. Chapter 10 introduces students to the uses of coded data and healthcare payment systems. Development of an understanding of reimbursement pro- cesses, billing procedures, chargemaster use, and auditing functions is a major focus of this chapter. Part III introduces the timely topics of healthcare service evaluation. Consisting of three chapters, it looks at the effective use, collection, arrangement, presentation, and ver- ification of healthcare data. Fundamental concepts of descriptive, vital, and facility statis- tics are presented in chapter 11. Chapter 12 discusses quality assessment and performance principles, and chapter 13 describes how the specifics of these methods are applied to clin- ical quality assessment. The roles of clinical quality assessment, risk management, and uti- lization management are thoroughly explored in chapter 13. Part IV is devoted to presenting introductory concepts of information technology (IT) and to providing a broad view of how IT supports the functions of healthcare delivery. Chapter 14 provides an overview of the application of technology to healthcare informa- tion systems and the electronic medical record and ancillary feeder systems. Chapter 15 continues with an introduction to information system concepts, components, and resources such as hardware, software, data, and network resources. Essentially, chapter 15 helps stu- dents to conceptualize the various components necessary for development of a total health information system. Chapters 16, 17, and 18 round out the section on information tech- nology. These chapters review concepts and applications of systems for decision support,
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