Computer Assisted Coding

Healthcare providers and patients have since been allowed to securely access and share medical information electronically using the electronic health information exchange (HIE) system, thus improving quality care, safety, cost and swiftness.

Due to the growing inpatient/outpatient requirements, as well as the impending update to the ICD-10 codes; the spearfish regional hospital is in dire need of a new Computer assisted coding system (CACS) with ICD-10 code language. This technologies will assist the coding department with their day to day processes, as well as allow the hospital to continue with its growth to meet the higher demands of our growing community. Included in this report will be a detailed report of the technologies being requested, as well as information on these vendors 3M, Nuance, and Optum who can supply these

With the introduction of information technology advancement into the hospital health care system, we must embrace in this technology and must ensure that we have a more efficient and secure system. This will allow us to create measures that will allow us to protect electronic protected health information (ePHI). All data that is being transmitted on any open networks will be protected from any cyber attackers or unauthorized personnel. In order to protect this data, any ePHI data will be sent by encrypting the data to ensure that in the event that it is intercepted it

Computer assisted coding has been adopted by most healthcare organizations in order for their overall applications to have enhanced production. This would improve the coding accuracy, Consistency, Transparency, and Compliance to create a smoother transition towards using CAC technology on a regular basis. Computer assisted coding provides a natural-language processing (NLP) that is used as a software scan towards medical documentation in the electronic health record (EHR) system. This can become an identifying key terminology that suggests certain codes for that particular treatment or service. The natural-language processing focuses on interpreting unstructured records by using special algorithms to support the codes. These unstructured applications

The Health Information Exchange has proven to be convenient and beneficial in essence of improving patient and health professionals’ ability to access patient medical histories and records by providing quicker, more reliable access. There have been some challenges recognized with the implementation of the health information exchange. While speeding up the process of retrieval of sensitive medical records has been a blessing, the process of electronic delivery of medical records has also been seen by some as risky. The electronic health information exchange allows health care providers to release vital private patient healthcare information via

One of the challenges of health information exchange is privacy and security. Even though having electronic health information exchange reduces a lot of privacy and security issues, it raises new issues as well. A breach that formerly affected a single paper record now can expose an entire database of patient records. At the same time, health information exchange presents powerful new ways to improve the privacy and security of patients ' data, including encryption, authentication and authorization controls, and electronic audit trails. Two of the biggest challenges we’ve encountered are patient matching/master patient index synchronization issues and the vendors’ variable use of interoperability standards. The biggest issues we’ve experienced, so far are relate to the MPI synchronization of patients across all the entities. Public HIEs, as well as the private HIE vendors, should focus on this challenge. Technically, interoperable platforms, EHR’s, are often hindered by the inability to determine an exact patient match, because the eMPI solutions aren’t robust enough. This also potentially creates data integrity and patient safety issues, if the clinical data goes across multiple records. There also some struggles with the variable use of the interoperability standards between the EHR vendors. One of

With the enthusiasm for health information technology, potential risks and problems associated with electronic health records have received far less attention. Three fundamental security goals are essential to EHR systems: confidentiality, integrity and availability (Haas e26). Patients lose the protection of implied trust domain of medical institutions due to their medical record maintenance performed by non-medical enterprises (e27). Depending on the paradigm, enabling access to an increased number of users poses threats to security and privacy.

A Health Information Exchange, or HIE, is technology that enables the electronic movement of health-related information among health care providers and others. HIEs are an

Health Information Exchange is the electronic movement of healthcare information amongst organizations according to the national standards. HIE as it is widely known, serves the purpose of providing a safe, timely, and efficient way of accessing or retrieving patient clinical data. Health Information Exchange allows for doctors, nurses, pharmacists, and other vital healthcare professionals to have appropriate access and securely share vital medical information regarding patient care. Health Information Exchange has been in efforts of developing for over 20 years in the United States. In 1990 the Community Health Management Information Systems (CHMIS) program was formed by the Hartford Foundation to foster a development of a centralized data repository in seven different geographically defined communities. Many of the communities struggled in securing a cost-effective technology with interoperable data sources and gaining political support. In the mid-1990s a similar initiative began known as the Community Health Information Networks (CHINs) with the intention of sharing data between providers in a more cost-effective manner. In 2004, the Agency for Healthcare Quality and Research Health Information Technology Portfolio was funded $166 million in grants and contracts to improve the quality and safety to support more patient-centered care. This was the beginning of the progress we have seen in HIE today. Health Information Exchange devolvement serves the purpose of improving

As viewed by many HIM professionals Computer-assisted coding is a valuable tool for enhancing the effectiveness of coding and billing. CAC software scans medical documentation in the electronic health record (EHRs) using a natural language processing (NLP) engine, identifying key terminology and proposing codes for that specific treatment or service. Human coder then revised these codes. CAC can also investigate the background of key words to conclude whether they need coding.

Computer-assisted coding is defined as the “use of computer software that automatically generates a set of medical codes for review, validation, and use based upon clinical documentation provided by healthcare practitioners”

The Health information exchange or also known as HIE is the sending of healthcare-related data electronically to facilities, health information organizations and government agencies according to national standards. The goal is to be able to access and retrieve data more efficient, safer, and to improve the quality of care and patient safety and reduce healthcare costs.

In today’s society, medical records becomes a huge issue. In many organizations such as healthcare, patient confidentiality becomes a high concern. Having internet health services, creates a challenge for compliance in healthcare. Providers have treated application security and infrastructure security independently until now. Access must be secured for clinical applications to alleviate the concern from providers in healthcare. Therefore, IT infrastructure must be protected from hackers, misusing information as well as thieves. (FairWarning, n.d.)

Information security and privacy is occupying a most important role in the healthcare territory in order to deliver protected information process to their patients (Appari, & Johnson, 2010). As healthcare department is the organization with vast data and essential information the hospitals has to keep a useful information security technique in their enterprise process (Mishra et al., 2011). Information security is one such phase in the healthcare sphere which is extremely problematic to describe and evaluate even to the individuals who are working on the process. In the healthcare organization, information is of many types which required for the work and even the security is a main control for almost all the practices which are transmitted out in the healthcare field (Appari, & Johnson, 2010). Hospitals, in specific, have been instructed to create a new set of security specialists to protect healthcare data tools techniques upon which exists may rely. Healthcare data is very critical for patients because it is very confidential records. If a medical apparatus is filled with a computer virus it can even exemplify a possibility to patients ' lives. Hence, hospitals should design alertness of the risk, to defend against concerns to healthcare databanks and be concerned about the high risk of infected computers or medical tools being connected to their networks (Mishra et al., 2011).

In light of available security measures and their widespread acceptance within the information security community, there is no excuse for healthcare organizations to fail in fulfilling their duty to protect personal patient information. Guaranteeing the confidentiality and privacy of data in healthcare information is crucial in safeguarding the data of patients as there should be a legal responsibility to protect medical records from unauthorized access.