Information Compliance Case Study

HIM Personnel play an important role in the Medicare system. Medicare has transitioned from “fee for service” to providing incentive payments for providers that issue high quality care at affordable prices. In order to achieve the “pay-for-quality” incentives hospitals and health care officials must improve their documentation processes. “If it isn’t documented, it wasn’t done” is more important than ever. It is the responsibility of the HIM professional to ensure the integrity of the patient chart. HIM professionals monitor the quality of documentation and ensure all clinical documentation is complete and accurate. HIM professionals are the key to identifying process problems while keeping in mind patient safety, quality of care, and revenue integrity. Medicare requires that hospitals report quality improvement measures in order to receive payments; HIM professionals can directly impact Medicare incentive payments. HIM professionals are directly involved with the Medicare Audit Improvement Act. The HIM professional collects health data that is subject to the audits; HIM professionals are the point of contact for responding to Medicare audit requests.

Regulation placed upon the healthcare system only seek to improve safety and security of the patients we care for. The enactment of the Health Insurance Portability and Accountability Act (HIPPA) and the enactment of Meaningful Use Act the United States government has set strict regulations on the security of health information and has allotted for stricter penalties for non-compliance. The advancement of electronic health record (EHR) systems has brought greater fluidity and compliance with healthcare but has also brought greater security risk of protected information. In order to ensure compliance with government standards organizations must adapt

The high cost of healthcare continues to rise and many in the United States are optimistic for health information technology to reduce and improve our current situation. Health IT encompasses a broad array of new technologies designed to manage and share health-related information. When properly implemented, these systems can help coordinate patient care, reduce medical errors, and improve administrative efficiency. Therefore, implementing a Regional Health Information Organization (RHIO) will help the National Health Information Network (NHIN) achieve their goals in improving quality of care for the citizens of the United States. Thus, in order for the health IT to deliver on its promise, several obstacles must be overcome.

The American Health Information Management Association (AHIMA) is a recognized, respected association of health information management (HIM) professionals worldwide. Founded in 1928, AHIMA has become a respected authority for professional education and training in the effective management of health data and medical records needed to deliver quality healthcare to the public. Throughout AHIMA’s history back to 1928, the American College of Surgeons established the Association of Record Librarians of North America (ARNLA) to “elevate the standards of clinical records in hospitals and other medical institutions” (www.ahima.org, 2015). Since its formation, the Association has undergone several name changes in its evolution of the profession. In 1938 the Association changed its name to the American Association of Medical Record Librarians (AAMRL) for a more concise representation. When the Association became the American Medical Record Association in 1970, health information professionals had increased their involvement in hospitals, community health centers, and other health service facilities. As the health industry continues to evolve, the Association changed its name in 1991 to American Health Information Management Association to capture the expanded scope of clinical data beyond medical records to health information comprising the entire continuum of care.

The hospital’s plan for information management encompasses the full spectrum of data generated and used by the organization in all various departments from housekeeping, laundry services, imaging, and pharmacy through to nursing. In order to provide cost-effective quality services, information must be accurate and communication of the information should be securely transmitted in a timely manner to the appropriate individuals on a need to know basis.

There are various legal and ethical aspects of Health Information Management. Government regulations in healthcare continue to make drastic changes. In Healthcare, lawsuits become more and more complex and issues increase. It is important for Health Information managers to have knowledge of healthcare laws.

There are many challenges associated with HHR. For example, there must be additional instructions to find the storage locations of patients’ health information. The instructions must show whether the documents are in electronic, paper, or scanned format. An additional process to link all of documentation formats needs to be deployed so that patients’ data can be collected and saved accurately. Not all the time those extra helps are available. Therefore, composing and organizing a completed HHR take a significant amount of time for health information management (HIM) professionals to gather all paper records and retrieve digital documents. The functions of HIM professionals encounter many challenges when working with HHR. The privacy and security policies for different types of records must be fully reinforced. Moreover, the updated data for each HHR have to be kept in detail for accuracy of information and easy accessing. In case of disclosing information requests, HIM professionals face a big burden of locating and verifying the information that is needed to fulfill the reasonable demand while limiting the release of information to the minimum. HIM professionals sometimes have to search through multiple systems to find the requested documents. According to Dimick, another disadvantage of the HHR system is when healthcare organizations participate in quality

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).

It has only been within the last five years that health information management (HIM) has experienced exponential changes, due to the healthcare reform. The electronic health record (EHR) is connected to health information exchanges and other systems of interoperability. The timely completion of charts, coding and release of information (ROI) has become much more efficient with the electronic record. Traditional HIM functions will just be transformed and will always be an integral part of successful patient care. Professionals must be flexible and willing to adapt and even generate change. As Health Information Technology continues to evolve, so will the roles

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

Health information technology (HIT) involves trading of health information in an electronic format to advance health care, reduce health expenditures, improve work efficiency, decrease medication errors, and make health care more accessible. Maintaining privacy and security of health information is crucial when technology is involved. Health information exchange plays an important role in improving the quality and delivery of health care and cost-effectiveness. “There is very little electronic information sharing among clinicians, hospitals, and other providers, despite considerable investments in health information technology (IT) over the past five years” (Robert Wood Johnson Foundation, 2014, p. 1).

The job titles associated with Lexington Medical Center’s Health Information Management Department are the Assistant Vice President of HIM, Operations Manager, Coding Manager, CDI Manager, Coding Quality Manager, three HIM Coordinators, Nine Coding Specialists, one Medical Coding Assistant, eight CDI Specialists, four Medical Record Associate III’s, five Medical Record Associate II’s, two Medical Record Associate I’s, nine Medical Language Specialists (Transcriptionists), one Administrative Assistant, one Data Integrity Specialist, and three contracted Release of Information Specialists. Dr. Hess also works with the AVP and the CDI Manager to act as the voice of the doctors to the HIM department and the voice of the HIM department to the doctors.

If I were given the authority to create a Health Information Organization (HIO) for my local area I would desire the support of important stakeholders in my community that would be able to quickly and securely exchange health information (Florida Health Information Exchange a.k.a HIE) to increase efficiency of sharing and meaningfully using Electronic Health Records (HER) technology that allow for physicians to share patient medical records faster and with more accuracy. In my area participating health care providers of medical facilities including, radiology centers, diagnostic laboratories, and public health departments are important contributors in governing the health information exchange for the purpose of improving health and care in my community.

The purpose of this office is to promote and oversee the development of a national health information technology infrastructure within the United States. It fulfills this purpose through the functions of policy coordination and strategic planning for the implementation of

The department of Health and Human Services protects and guides the health and well being of individuals here in America (Thacker, 2014). They fulfill these duties providing Americans with adequate and efficient health and human services and monitoring services designed to increase the efficiency of care in the health system (Thacker, 2014). One of the services being monitored by the department of Health and Human Services is the electronic health record system, which carries private and vital information of patient’s health record enabling all eligible participating health workers access to these records (Thacker, 2014). A breach of the protective health information of patients in a health organization creates chaos as these are against the health insurance portability and accountability (HIPAA) law (Thacker, 2014). Hence, measure will have to be put in place to determine what caused the breach and how to rectify it to ensure the breach never happens again (Thacker, 2014).