AHIMA Data Quality Model

Apply accurate, complete, and consistent coding practices for the production of high-quality of healthcare data.

The Clinical Documentation Improvement (CDI) has emerged as the most vital drive for overcoming the issues associated with maintaining a complete and good sound medical record in the U.S healthcare system. The main focus of CDI is to enhance clinical clarity of the health records which usually involves the process of improving the medical/health records documentation in order to promote effective patient outcome, data quality measures and accurate reimbursement for services and care rendered. For a medical record to be meaningful and mirror the scope of treatment and services provided, it must be accurate and meet the established guidelines set forth by the governing bodies such as the Centers for Medicare and Medicare.

Utilize health information professionals and practice to ensure compliance with health data structures, standards and content.

The passage of the American Recovery and Reinvestment Act encouraged and mandated the use of health information exchange (HIE) technology in the healthcare industry. The time had finally come to enter into the electronic age, and learn how to integrate electronic health records (EHRs) into their environment. Evolution and revolution are never easy, and several issues will arise during the transition. As EHR utilization spread through healthcare organizations, problems with interoperability became evident. How could healthcare organizations successfully achieve interoperability, and collect consistent patient data? A data dictionary may be the key to unlocking an accurate and efficient HIE.

 Maintenance of complete and accurate medical records for each patient as described in RC.01.01.01. This standard was also identified by JACHO as top compliance issue for the industry.

Precisely some of the characteristics are generally based on the main levels of quality assurance such as with accuracy, accessibility, comprehensiveness, consistency.

As the national health care system transitions to the electronic health record (EHR), it is important to recall the impetus to this reform. Prior to the implementation of the electronic health record, the national health care system encountered many problems that impeded quality patient care. There was not a standardized formal structure with the process. Consequently, it lacked communication across disciplines and among providers and

But as noted previously, more is needed than standardizing these processes. Health care providers (physicians and hospitals) should embrace electronic health records (EHRs) and should integrate appropriate information from billing systems with clinical information (the recording and analysis of clinical services) from EHRs (Wikler et al., 2012; Cutler et al., 2012). To address concerns that occur due to accessing medical records, the secretary of health and human services could expand criteria under the Health information Technology for Economic and Clinical

It also helps them avoid errors by providing a standardized form, applicable in all health care settings.

AHIMA recognizes that superior quality health care and clinical data are critical resources needed for effective healthcare, and works to assure that the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely. This group is concerned about the effective management of health information from all sources and its application in all forms of healthcare and wellness preservation. Health issues, disease, and care quality also transcend across national borders. AHIMA’s professional interest is in the application of best health information management practices when and wherever they are needed. (The American Health Information Management Association, 2010).

The use of health information standards is vital the delivery of care. These standards help physicians to have access to accurate information. As a result, this information would help healthcare professionals to provide the conventional treatment to their patient. In case of the patient described in my scenario, if he moves to another state or city he can be treated. This is achievable because of the use of these standards. Using health information standards would also contribute to eliminate medical errors. This

“Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance” (The Joint Commission, 2015).

Being able to access information from multiple healthcare facilities on patients helps doctors become better at treatment. It has the possibility to making them make safer decisions, more efficient and provide a higher level of quality care. In order for this to be successful nationwide, there needs to be a set of standards that all the players must agree to. The eHealth collaboration is leasing the way in the creation of these standards but it is very obvious that more work needs to be done. What is important to note however, is that the ground work has been started and we are moving towards that

There is an accentuation on the need for quality of coded data with the use of computer-assisted coding in healthcare organizations to assure compliance is being met with regards to the increasingly multifaceted quality reporting requirements.

The first quality initiative that could increase patient satisfaction and potentially reduce healthcare cost is the national data warehouse. According to Brennan, Cafarella, Kocot, McKethan, Morrison, Nguyen, Shepard & Williams II (2009), “this type of quality analysis needs to be valuable to both payers and consumers. For payers, quality analysis helps them potentially understand payment mechanisms, quality providers, regional differences and medical management techniques. For consumers, there is a better understanding of practice and potentially cost differences of providers. So, the primary purpose for creating a national data warehouse will be to develop key quality measures that all parties can agree on.” The second quality initiative that could increase patient satisfaction and potentially reduce healthcare cost is creating one common contract between all health plans and providers (Brennan et al., 2009). According to Brennan et al., (2009), “to accomplish this, a national group comprised of government personnel and knowledgeable provider contractors from the health plans will set national guidelines. Regional contracting groups will be entirely made up of current health plan contractors and will do the local contracting under