Unit 2 Health Data Management Research Paper

Health information management, also known as HIM, has been acknowledged as an allied health profession since 1928. HIM is a profession dedicated to the effective management of patient information and healthcare data needed to deliver quality treatment and care to the public. The original objective was to elevate the standards of clinical recordkeeping in hospitals, dispensaries, and other healthcare facilities (Sayles, 2014). Today HIM is known as the American Health Information Management Association or AHIMA. It still holds similar underlying purposes: to ensure the quality, confidentiality, and availability of health information across diverse organizations, settings, and disciplines (Sayles, 2014). HIM plays a critical role in the successful implementation of electronic health records and ensures that providers, healthcare organizations, and patients have access to the right health information when and where it is needed while maintaining the highest standards of data integrity, confidentiality, and security. It ensures compliance with legal mandates, but it has proven to be a challenge with the constant change in legislation and regulatory environment. Past surveys suggest that HIM plays some type of importance in accordance to HIPAA privacy and security compliance. In a 2006 AHIMA survey, members were asked about the progress of their organizations’ privacy and security compliance efforts. Margret Amatayakul & Mitch Work discuss those results in a 2007 journal article

Implementation of the electronic health records (EHRs) has been a growing trend in the healthcare field from fear of the unknown to the acceptance of the reality of the EHRs and the actually utilizing the system. The struggle to go live with the EHR was a challenge because change is always a difficult implementation. According to Fickenscher & Bakerman, (2011) Change is a process that is individualized base on one's ability to adopt and the interest on the change. Some people may take longer to understand a process while others will grab the skill within a short time. However, some few setbacks slow down the adoption of the EHRs when it was first implemented, Culture, communication and training and time. Despite

Patients are taking an aggressive role in their healthcare needs. Patients desire to in touch with their medical records. Medical professionals are utilizing the Electronic Health Records to implement current data into information necessary to provide quality care for the patient. Thereby, managing patients’ current, and past histories. To understand what is occurring today, one must recognize why patients are taking an active approach to their healthcare.

Health Information Exchange (HIE) supports both transferring and sharing of health related information that is usually stored in multiple organizations, while maintaining the context and integrity of the information being exchanged (HIE, 2014). The goal of health information exchange is to expedite access to and retrieve clinical data to provide safe efficient, effective, equitable, timelier patient-centered care (HIE, 2014). HIE “provides access and retrieval of patient information to authorized users in order to provide safe, efficient, effective, and timely patient care” (HIE, 2014).

An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient

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

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).

Muhammed H. (2015) conducted a study to determine the relationship between EHRs and patient safety. According to the researcher, EHRs are healthcare applications that digitize patient information and clinical workflows. It may be considered as a data repository that stores patient data, and assists providers by providing reference information and recommendations for care. Furthermore it enables providers to electronically place orders and consolidate clinical notes across hospital departments. The results showed that about 70% of hospitals in PA adopted advanced EHRs since 2012 and there has been a 27% decline in patient safety events

In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as part of the American Recovery and Reinvestment Act (ARRA). The HITECH Act supports the concept of Electronic Health Records and Meaningful Use. Meaningful Use is an effort led by the Centers for Medicare & Medicaid Services (CMS). According to the Centers for Disease Control and Prevention, "Meaningful Use is defined; using certified Electronic Health Record Technology in a meaningful manner; ensuring that the certified EHR technology is connected in a manner provides the electronic exchange of health information to improve the quality of care; and that providers must submit information on quality of care and other measures

“… longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting”. Included in this information are patient demographics… reports. The EHR automates and streamlines the clinician 's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, and related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting.”(GAO, 2010)

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

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Electronic Health Record (EHR) standards refer to the agreed format that is applied to support the definition, use and exchange of data that is related to all the aspects of Health care Information and Technology (HIT). The standards should ensure that there is accurate, comprehensive and secure health information of an individual patient in digital format. Being HIT building blocks, they should provide a common framework of promoting uniformity in defining and identifying the components of a health system. The standards should provide consistent collection and exchange of patient’s information, enhance data quality and ensure reduction of medical errors. Some of the standards include: HL7 EHR Functional Model, CCHIT certification criteria and incentive programs (Amatayakul & American Health

“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an

Electronic health records (EHR’s) have many advantages, but there are plenty of disadvantages. EHR’s were created to manage the many aspects of healthcare information. Medical professionals use them daily and most would feel lost without it. Healthcare organizations were encouraged to adopt EHR’s in 2009 due to the fact that a bill passed known as The Health Information Technology for Economic and Clinical Health Act (HITECH Act). “The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice”, (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012).