Research Paper on Health Information Management

Introduction

Courtesy of technological advancement, modernization and industrialization, there has been a need to improve and come up with modernized and efficient ways of making hospital activities successful. This shift in technology has led to changes in policies, procedures and operations across the hospital. As a director of health information in a hospital, various issues may cause a proposal to change policies, procedures and operations across a hospital. With the expansive technological advancements, it is paramount for a hospital to conform to the changes within the technology sector. There are many proposals to be discussed below made to the CEO and board of directors. The recommendations were made in unison with the committee teams to ensure that every system within the hospital is up-to-date and to ensure that the hospital can flow with the current technology in addition to ensuring that the personnel working finds it easier to use the various technological equipment.

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Systems for Clinical Classification and Coding

For the hospital to be able to meet the technological changes, it is paramount for them to have current applications or systems for clinical classification and coding which include the encoder and computer-assisted coding. The computer-assisted coding (CAC), is a software used in hospital inserted in the desktop that helps to analyze healthcare documents and produces appropriate medical codes for specific phrases and terms within the document presented to the software (Garvi, Watzlaf & Moeini, 2005). It has a high capacity to evaluate quality coding practices since it has multiplied efficiency and productivity. An American Health Information Management Association study found out that coders that used CACS spent less than 22% less time coding a record than coders that did not consult a CACS (American Health Information Management Association, 2012)

Additionally, helps to speed the initial steps that are needed to translate the medical records into codes. (Benson, 2012) The possible implement considerations to be put in place include the following in that because the systems rely heavily on IT efficiency, computer systems networks and interfacing capacity should be assessed. It is good and appropriate for one to ensure that there is understanding on how to structure workflow. Depending on how the CAC engine is implemented, it may affect physician workflow (Benson, 2006). Since this software is among the resent and upcoming software it is good for the company to provide training for its personnel to maximize the benefits of using it. It is important for the organization to keep in mind that professionals within the coding field require skills in critical thinking due to the nature of their jobs. Notably, this means that focus should not be put solely on technology.

On the other hand, encoders are essential too since they enable the medical personnel to stay in touch with the shifting policies and regulations within the coding industry. It helps in making the most appropriate and best medical decision based on the patient's complete history. Through the system, one can know and get a better understanding the medical wellbeing of the patient. However, due to the changing world of technology and IT, it is good for the hospital to adapt the software method.

Evaluation Accuracy of Diagnostic and Procedural Coding

When evaluating and going through the patient's records, it is good and appropriate to make sure the accuracy of diagnostic and procedural coding is met (Garvi, Watzlaf & Moeini, 2005). Notably, this means that catch-all terms for codes used to identify what was done to a certain patient such as surgery, durable medical equipment and medications are up-to-date and the records well stored. On the other side, the individual's disease or medication conditions should be well documented to ensure accurate diagnostic coding.

The Challenges with the CDI Process

To ensure proper diagnostic and procedural coding, there is the use of CDI process which however is facing quite some challenges. First, the process began with a focus on reimbursement but quickly shifted to concentrate on quality outcomes. Staffing is an issue since there has been a shortage of CDI specialists. Also, the ongoing budget limitation has limited program expansion into outpatient and other settings. CDI directors are in need of stronger reporting and data analytics support. To ensure that there are good connections between auditing, accurate diagnostic and procedural coding it is good for the company to ensure that the challenges facing CDI program are looked into and that the IT system is up-to-date to ensure there is efficient accountability.

Information Operability and Exchange

HIE involves the sharing of electronic clinical data across organizations within a region, community or even a hospital system (Garvi, Watzlaf & Moeini, 2005). Interoperability is the accessing and sharing of health information securely, consistently and appropriately which is done especially using technology. One among the many interoperability issues is patient identity matching. Names are subject to periodic changes by a person throughout their life.

One of the most common solutions for this has been to create a unique patient identifier. This identifier could consist of a single identity element or use multiple standardized elements that could take single form for all patients. A fundamental and critical success factor for HIE is the ability to accurately link multiple records for the same patient across the overworked system in an organization. Algorithms can unify the various functions that are coded in the HIE. Common data capture of demographic elements through uniform policies that are widely shared will help to overcome the policy variations across organizations and appropriately manage the free-text component of data entry for names ( US Department of Human and Health Services, 2015).

Health Information Systems and Data Storage Designs

Health information system is a system that captures, stores and controls the various information of patients in addition to controlling the operations within the hospital set-up (US Department of Health and Human Services, 2015).

They include:

The District level routine information system which generates information in support of planning and management of quality health care services which mostly helps the management to be able to cater for any emergencies in case they occur. Disease surveillance system that assists in the generation of information from interpretation, collection and storage of a huge chunk of information that stems from different media.

Hospital patient administration system that manages the business process of patient registration and appointment scheduling that caters for the admission and accommodation of the patient.

The data storage designs include:

Removable data storage which involves devices that can be used for data storage and are removable away from the main computer hardware which includes the CDCs and USB. Off-site storage is where the actual data is stored in a remote location and usually is easily accessed through the internet. Notably, this would help save anything that could happen to data that is stored in the on-site hardware.

Lastly is the on-site data that is designed not to be removed from the computer and stores data. The best HIS in a hospital setting is the district level routine information system that helps the hospital to plan for any emergency that might occur within the hospital and the best storage design is the off-site data storage which in-spite of any destruction or emergency in the hospital, data stored on the internet can hardly get distorted or destroyed physically.

Managerial Challenges Related to Clinical Indices, Database and Registries from HIM

There are often difficulties in tracking patients' records across multiple systems. This is because there are many patients in the hospital and that the system at some point may fail and thus will be unable to recover all the information for all patients. Additionally, there is often an integration gap between patient care and administration in that it has been hard most of the time for the management to ensure that treatment codes match and care given accurately tracked for both administrative purposes and analytics of which at some point this may be hard to be done.

There is also lack of analytics talent. Healthcare providers are struggling to find the right analytics experts to help them get the most out of their databases. In ensuring proper management of secondary data sources, it is advisable to have a solid understanding of the original purposes of the secondary data collection, including processes for collection and submission, and verification and validation practices. It is important to ensure that the primary data of the patient is well recorded to avoid accessing the wrong data for the wrong patient. Amounts paid by insurers are often considered proprietary and unavailable.

Approaches to Data Warehousing

The approaches to data warehousing include Bill Inman's enterprise data warehouse approach that is the top-down design. In this approach, a normalized data model is designed first, then the dimension data marts which contain data required for specific departments, are created from the data warehouse (Benson, 2006).

The other approach is in the Ralph Kimball's dimensional design approach that is the bottom-up design. The data marts facilitating reports and analysis are created first; these are then combined to create a broad data warehouse.

In conclusion, it is important for the hospital always to use, and it is recommended to be at the forefront to uphold the most modern methods of recording in hospital. There is need to change a lot of policies and practices to make sure that the patients are catered for and taken good care of.

Summary of the Recommendations

The HIE should be updated with the current IT to ensure that the patient identity is correct and to ensure that the information present in the system of the hospital is placed on the correct patient (Benson, 2006). All systems in the hospital should be in harmony. The most recommended information system is the district level routine information system and the best data storage being the on-site storage which would help the hospital to be able to cater for all records even to plan for emergencies. It is also excellent for the hospital setting to the latest software that is Computer Assisted coding for accuracy purposes and appropriate medical codes. This is to help make the coder's job easier.

It is recommendable for the hospital to adapt and use the CDI program to help in having accurate diagnostic and procedural coding. All the records in the hospital should be updated and necessary follow-ups made to ensure that the gap between the patient and the administration is bridged. The bottom-up design is the best to help ensure the data and reports about the patients and their analysis are created first and then combined to create a broad data warehouse to ensure that there is efficient and proper running of the hospital.

References

American Hospital Association. (2012). AHA guide to the health care field. American Hospital Association.

Benson, S. (2006). Computer-assisted coding software improves documentation, coding, compliance and revenue. Perspectives in Health Information Management, CAC Proceedings, Fall.

Garvin, J. H., Watzlaf, V. J., & Moeini, S. (2005). Development and Use of Automated Coding Software to Enhance Antifraud Activities. Perspectives in Health Information Management.

US Department of Health and Human Services. (2015). Health Resources and Services Administration. Area Health Resource File.