Health information: management of a strategic resource
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
St. Louis, MO
Elsevier Saunders
2016
|
| Ausgabe: | 5. ed. |
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | Includes bibliographical references and index |
| Beschreibung: | XXVI, 771 S. Ill. |
| ISBN: | 9780323263481 |
Internformat
MARC
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| 245 | 1 | 0 | |a Health information |b management of a strategic resource |c Mervat Abdelhak ; Mary Alice Hanken |
| 250 | |a 5. ed. | ||
| 264 | 1 | |a St. Louis, MO |b Elsevier Saunders |c 2016 | |
| 300 | |a XXVI, 771 S. |b Ill. | ||
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| 338 | |b nc |2 rdacarrier | ||
| 500 | |a Includes bibliographical references and index | ||
| 650 | 4 | |a Medical informatics | |
| 650 | 4 | |a Information resources management | |
| 650 | 4 | |a Medical Informatics |x organization & administration | |
| 650 | 4 | |a Information Services |x organization & administration | |
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| 700 | 1 | |a Hanken, Mary Alice |e Sonstige |4 oth | |
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Datensatz im Suchindex
| _version_ | 1804153301266071552 |
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| adam_text | Titel: Health information
Autor: Abdelhak, Mervat
Jahr: 2016
CONTENTS
I t ; Î M i
Foundations of Health Information Management
1 HEALTH CARE SYSTEMS, 1
Abbreviations, 3
Evolution of Health Care Systems in the United States, 4
Health Care in the Nineteenth Century, 4
Twentieth-Century Reforms, 4
Health Care in the Twenty-First Century, 7
Healthy People, 7
Regulatory Agencies and Organizations, 8
Federal Government as Regulator, 8
Department of Health and Human Services, 8
Social Security Administration, 10
Occupational Safety and Health
Administration, 11
The Role of States, 11
State Health Departments, 11
Licensure of Health Care Facilities, 11
Legislation, 12
Accreditation, 13
The Joint Commission, 13
American Osteopathic Association, 13
Commission on Accreditation of Rehabilitation
Facilities, 13
Community Health Accreditation Program, 13
National Committee for Quality Assurance, 13
Regulatory Mechanisms of Health Occupations, 13
American Medical Association, 14
American Osteopathic Association s Commission
on Osteopathic College Accreditation, 14
Commission on Accreditation of Allied Health
Education Programs, 14
Commission on Accreditation for Health
Informatics and Information Management
Education, 14
Accreditation Commission for Education in
Nursing, 14
State Licensure of Practitioners, 14
Health Care Delivery Systems, 14
Continuum of Care, 14
Ambulatory Care, 15
Physician Practices, 16
Community Health Centers, 16
Community-Based Care, 16
Surgicenters and Urgent Care Centers, 16
Hospital Ambulatory Care, 17
Hospitals, 17
Ownership, 18
Bed Size (Bed Count), 18
Length of Stay, 18
Clinical Classification, 18
Hospital Patients, 19
Organization, 19
Governance Structure, 20
Leadership, 20
Medical Staff (Professional Staff
Organization), 21
Essential Services, 23
Health Information Management, 25
Subacute Care, 25
Home Care (Home Health Care), 25
Long-Term Care Facilities, 26
Assisted Living, 26
Domiciliary or Custodial (Residential), 26
Independent Living Facility, 26
Life Care Centers, 26
Hospice Care, 27
Respite Care, 27
Complementary and Alternative Medicine, 27
E-Health, 27
Adult Day Care Services, 28
Mobile Diagnostic Services, 28
Contract Services, 28
Health Care Delivery Systems, 28
Health Care Professionals, 28
Health Care Team, 29
Physicians, 29
Physician Assistant, 30
Nursing, 30
Nursing Care Models, 30
Allied Health Professionals, 31
Financing Health Care, 31
Reimbursement, 32
Managed Care, 33
Health Maintenance Organizations, 33
Preferred Provider Organizations, 33
Case Management, 33
Point-of-Service Plan, 34
Utilization Management, 34
Government s Role as Payer, 34
Medicare, 34
Medicaid, 35
State Children s Health Insurance Program, 35
TRICARE, 35
Workers Compensation, 35
Technology in Health Information, 36
Point-of-Care Clinical Information Systems, 36
Electronic Data Exchange, 36
Decision Support Systems, 36
Electronic Health Record, 36
National Health Information Infrastructure, 36
National Call for EHRs, 36
Future Issues, 37
Chapter Review, 37
References, 38
Contents
2 THE HEALTH INFORMATICS AND INFORMATION
MANAGEMENT PROFESSION, 39
Abbreviations, 40
Health Information Management—a Profession in
Transition, 41
The Patient Record—Source of Health Data and
Information, 41
Evolution of the Patient Record, 42
Early History, 42
Influential Forces, 43
Accreditation, 43
Licensing of Health Care Facilities, 44
Paying for Health Care, 44
Technology, 45
Evolution of the Health Information Management
Profession, 46
Early History, 46
1990s, 47
2000s Forward, 47
Formation of Education Programs, 49
Accreditation of Educational Programs, 51
Professional Certification, 51
Registered Health Information Administrator
and Registered Health Information
Technician, 52
Certified Coding Associate, Certified Coding
Specialist, Certified Coding Specialist—
Physician Based, 52
Certified Health Data Analyst, 52
Certified in Healthcare Privacy and Security, 53
Clinical Documentation Improvement
Practitioner, 53
Certified Healthcare Technology Specialist, 53
Importance of Professional Certification, 53
Other HIM-Related Professional Organizations
and Relevant Credentials, 53
Maintenance of Certification and Lifelong Learning, 54
Fellowship Program, 55
American Health Information Management Association
Today, 55
American Health Information Management
Association Communications, 57
Ahima Foundation: Research and Education in Health
Information Management, 57
The Professional Code of Ethics, 58
Looking to the Future, 58
Chapter Review, 58
References, 58
Health Care Data and Information Systems
3 HEALTH INFORMATION INFRASTRUCTURE
AND SYSTEMS, 61
Abbreviations, 62
Health Information Technology in Health Care, 62
Background, 64
Federal Involvement in Health Information
Technology, 65
State Health Information Exchange Cooperative
Agreement Program, 69
Congress, 71
Role of the Private Sector, 72
Compelling Reasons to Implement Health Information
Technology, 74
Obstacles to Health Information Technology
Adoption, 76
Health Information Networks, 78
Role of Health Information Management and Health
Informatics, 81
Key Concepts, 82
Chapter Review, 83
References, 83
4 HEALTH DATA CONCEPTS AND INFORMATION
GOVERNANCE, 88
Abbreviations, 90
Health Data Users and Uses, 91
Users and Uses of Health Data, 91
Patients, 91
Health Care Practitioners, 91
Health Care Providers and Administrators, 91
Third-Party Payers, 91
Utilization and Case Managers, 92
Quality of Care Committees, 92
Accrediting, Licensing, and Certifying Agencies, 92
Governmental Agencies and Public Health, 92
Health Information Exchanges, 92
Employers, 92
Attorneys and the Courts in the Judicial
Process, 93
Planners and Policy Developers, 93
Educators and Trainers, 93
Researchers and Epidemiologists, 93
Media Reporters, 93
Decision Making, 93
Knowledge Hierarchy, 93
Definitions, 94
Decision-Making Process, 94
Overview of the Patient Record, 94
The Unique Roles of the Patient Health Record, 94
Patient Health Record, 94
Data Collection Standards, 95
Governmental, 95
Department of Health and Human Services, 95
Overview of Information and Data Sets, 97
Core Health Data Elements, 97
Centers for Disease Control and Prevention, 98
Nongovernmental, 98
Accrediting Organizations, 98
Standards-Setting Bodies, 99
Professional Organizations, 99
Researchers and Other Groups, 100
Basic Principles of Data Collection, 100
Contents
Documentation Responsibilities, 100
User Needs, 100
General Documentation Forms and Views, 100
Patient Identification, 101
Administrative Forms, 101
Clinical Forms, 102
Operative Forms, 107
Obstetrical Data, 108
Neonatal Data, 108
Nursing Forms, 109
Ancillary Forms, 109
Discharge Forms, 110
Documentation Guidelines, 110
General, 111
Abbreviations and Symbols, 111
Authentication, 112
Paper-Based Records, 112
Format Types, 112
Source-Oriented Medical Record, 112
Problem-Oriented Medical Record, 112
Integrated Medical Record, 113
Design and Control of Paper Forms and Computer
Views and Templates, 113
Forms or Views Team, 114
General Design Principles, 114
Needs of Users, 114
Purpose of the Form or View, 114
Selection and Sequencing of Items, 114
Standard Terminology, Abbreviations, and
Format, 114
Instructions, 115
Simplification, 115
Paper Forms Design and Production, 115
Computer View/Screen Format Design, 117
Online System Interface, 118
Other Display Features, 119
General Control Principles, 120
Forms and Views Summary, 120
Health Record Flow and Processing, 120
Medical Transcription, 120
Methods to Ensure Data Quality, 122
Record Content Review and Retrospective
Completion, 122
Data Quality Monitoring Methods and
Solutions, 123
Quality Assessment and Improvement Study of
Patient Record Documentation, 123
Quantitative Analysis, 125
Qualitative Analysis, 125
Legal Analysis, 125
Special Concerns of Alternative Care
Settings, 126
Clinical Staff Activities Related to Data
Quality, 126
Medical Record Committee, 126
Continuing Record Reviews, 126
Clinical Documentation Improvement, 127
Organization Structure That Encourages Data
Quality, 127
The Joint Commission Information Management
Standards, 127
Information Resources Management
Committee, 127
Information Governance, 127
Characteristics of Data Quality, 128
Definitions, 128
Accessibility, 129
Accuracy, 129
Comprehensiveness, 129
Consistency, 129
Currency, 129
Data Definition, 129
Granularity, 130
Precision, 130
Relevance, 130
Timeliness, 130
Data Integrity, 130
Data Needs Across the Health Care Continuum, 130
Minimum Data Sets, 130
Acute Care, 130
Data Needs, 131
Uniform Hospital Discharge Data Set, 131
Special Forms and Views, 131
Issues in Data Collection and Quality, 132
Ambulatory Care, 132
Data Needs, 132
Uniform Ambulatory Care Data Set, 132
Data Elements for Emergency Department
Systems, 134
Special Forms and Views, 134
Issues in Data Collection and Quality, 135
Long-Term Care, 135
Data Needs, 135
MDS 3.0: Minimum Data Set for Long-Term
Care Facility Resident Assessment
Instrument, 135
Special Forms and Views, 136
Issues in Data Collection and Quality, 136
Long-Term Subacute Care, 136
Rehabilitation, 136
Inpatient Rehabilitation Facility Patient
Assessment Instrument, 137
Issues in Data Collection and Quality, 137
Home Health Care, 137
Data Needs, 137
Outcome and Assessment Information
Set, 137
Special Forms and Views, 138
Issues in Data Collection and Quality, 138
Continuity Assessment Record Evaluation, 140
Hospice, 140
Special Forms, 140
Issues in Data Collection and Quality, 141
Behavioral Health, 141
Contents
Data Needs, 141
Special Forms and Views, 141
Issues in Data Collection and Quality, 142
Personal Health Record, 142
Data Needs, 142
Special Forms and Views, 142
Issues in Data Collection and Quality, 142
Patient-Centered Care, 143
Patient-Centered Medical Home, 143
Patient Portal, 143
Electronic Health Record Initiatives, 143
Summary and Management Issues, 143
Chapter Review, 143
References, 144
5 DATA ACCESS AND RETENTION, 145
Abbreviations, 146
Access and Retention of Health Information, 146
Access and Retention of Paper-Based Records, 147
Record Identification, 147
Alphabetical Identification, 147
Numerical Identification, 147
Filing Equipment, 148
Filing Cabinets, 149
Open-Shelf Files, 150
Motorized Revolving Units, 150
Compressible Units, 150
Space Management, 150
Centralized and Decentralized Files, 150
Filing Methods, 151
A Iphabetical Filing, 151
Straight Numerical Filing, 151
Terminal Digit Filing, 152
Master Patient Index, 153
Content, 153
Creation of the Index, 155
Records Management Issues, 156
File Folders, 156
Color Coding, 158
Record Security, 160
Storage of Inactive Records, 160
File Conversion to Terminal Digit System, 160
Record Tracking, 162
Manual Record-Tracking Systems, 162
Automated Record-Tracking Systems, 163
Record Retention, 164
Federal Statutes and Regulations, 164
State Statutes and Regulations, 164
Organizational Needs, 165
Retention Schedule, 165
Destruction, 165
Facility Closure, 166
The Legal Health Record Definition, 166
Disaster Planning, 166
Disaster Recovery, 166
Technology in Access and Retention, 169
Input, Output, and Storage Devices, 169
Radiofrequency Identification, 169
Document Imaging Devices, 169
Voice Recognition, 169
Computer-Assisted Coding Tools, 170
Automated Access and Retention of Records, 170
Electronic Document Management, 170
Electronic Health Records and Electronic
Document Management, 170
EDM System Components, 171
System Benefits and Advantages, 172
Evaluating EDM System Requirements, 174
EDM Implementation Strategies, 174
Legal Considerations, 174
Key Concepts, 174
References, 175
6 ELECTRONIC HEALTH RECORD SYSTEMS, 176
Abbreviations, 178
Electronic Health Records: The Case for Quality and
Change, 178
Evolving Patient Records, 180
Questions as Guides to the Chapter, 182
The Paper Patient Record Drawbacks, 182
Electronic Health Records Today, 184
Patient Safety and Data, 184
National Progress on Health Information
Technology, 185
Emerging Models and Alliances, 185
Enterprise Systems and Electronic Health Records, 186
Viewing the Health Information Flow throughout
Enterprise Systems, 186
Understanding the Role of Systems Migrations, 187
Enterprise Systems Links to Electronic Health
Records, 188
Integrating Medical Devices into the Electronic
Health Record, 188
Definitions Framework, 189
Health Information Technology, 189
Legal Health Record, 190
Electronic Health Records, 192
Personal Health Record, 194
Designated Record Set, 195
How Health Care Standards Guide Electronic Health
Records, 195
Standards Development and the Electronic Health
Record, 195
Commission on Certification of Health Information
Technology, 196
Health Insurance Portability and Accountability
Act, 196
Key Health Care Standards Organizations, 197
American Society of Testing and Materials, 197
Health Level 7, 198
ASTM and HL7 Collaborative Work, 198
Logical Observation Identifiers Names and
Codes, 200
RxNorm, 200
What are Electronic Health Record Systems and How do
they Work?, 202
Contents
Electronic Health Record Systems and Their
Functions, 202
How Health Data is Entered, Accessed, and
Retrieved for Care, 204
Patient Registration, Identity Management, and
Admission, 204
Ordering and Documentation at Admission to
Hospitals and Residential Settings, 204
Results Management—Diagnostic Tests to
Transcribed Documents, 204
Communication Links, 205
Online Documentation, 205
Clinical Decision Support Systems, 207
System Capabilities, 208
How do Technical Infrastructure, Data Requirements,
and Operations Workflow Fit in EHR Systems?, 209
Technical Infrastructure and Data Requirements, 209
Data Requirements for the Electronic Health
Record, 209
Terminologies and the Electronic Health Record, 210
Clinical Data Repositories, 212
How Health Data Are Extracted for Analysis, 212
The Role of Patient Data, Public Health, and
Research, 212
How are Electronic Health Record Systems
Evaluated?, 213
Health Care and Health Services Evaluation
Overview, 213
Cost Savings, Cost Avoidance, and Return on
Investment, 213
Improved Staff and Processes Productivity, 214
Clinical Quality Improvement and Medical Outcome
Improvement, 214
Improved Customer Satisfaction: Providers, Patients,
Employees, 215
Electronic Health Records Progress: Unintended
Consequences, 215
Vendor Collaboration, 215
Industry-Wide Goals to Use Electronic Health Records
Effectively, 216
What Are Meaningful Use Requirements and How
Do They Work?, 216
Incentive Program for Meaningful Use, 216
What are the Requirements and Challenges of Health
Information Exchange, 218
Securing National Goals for Health Information
Exchange, 218
Health Information Exchange Model Profiles, 218
Making and Maintaining the Business Case, 218
Changing Electronic Health Record Technology, 219
Changes in the Role and Scope of the Health
Information Management Professional, 219
Management Questions and Moving to the Virtual
Department, 219
Documentation Principles, 219
Unique Patient Identification, 219
Legibility, 219
Accuracy, 220
Completeness, 220
Timeliness, 220
Integrity, 220
Authentication, 220
Privacy, Confidentiality, and Security, 220
The Physical Past, 221
The Emerging Present, 221
Patient Identity Management, 222
Providing Prior Information, 222
Who Is Authorized to Make Entries in the Health
Record?, 222
Documenting Care, 222
Handwriting, 223
Speech, 223
Direct Input, 223
Document Imaging, 224
Device Capture, 224
Clinical Imaging, 224
Copying and Pasting, 224
Storage and Retention, 225
Thinning Records, 225
Coding, 225
Health Record Review, 225
Reporting Structure, 226
Data Presentation, 226
Types of Review, 226
Record Completion Process, 226
Performance Improvement Plans, 226
Reports, 226
Release of Information, 227
The Future Now, 228
Needed Changes in Organization Policies and Business
Rules Regarding Electronic Health Record Users and
Systems, 229
Policies, 229
Business Rules, 231
Versioning, 231
Templates, 231
Titles, 232
Electronic Record Maintenance, 232
Completion and Authentication, 233
Printing, 233
Virtual Health Information Management
Department, 237
How do Industry Challenges Affect Electronic Health
Record Planning, Implementation, and Benefits
Realization?, 237
Selected Milestones, 237
Cost Issues, 238
Infrastructure Requirements, 238
Laws and Progress, 238
Privacy and Security, 239
Health Care Information Standards and
Interoperability, 239
Challenge to Health Information Professionals, 240
Summary, 242
Chapter Review, 243
References, 243
Contents
Health Care Informatics
7 CLASSIFICATION SYSTEMS, CLINICAL
VOCABULARIES, AND TERMINOLOGY, 247
Abbreviations, 248
The Challenge of Clinical Communications and
Information Exchange, 249
Interoperability and Shared Terminologies, 249
Putting Terminologies in a Framework, 250
Structured versus Unstructured Text, 250
Standardized Terminology, 251
eHealth: Standardized Terminology, 252
Basic Understanding of Terms, 252
Vocabulary, 253
Terminology, 254
Classification System, 255
Nomenclature, 256
Codes, 256
Administrative Terminologies, 257
Clinical Terminologies, 257
Clinical Terminologies, 258
Desirable Characteristics of Clinical
Terminologies, 258
Content, 258
Concept Orientation, 258
Concept Permanence, 258
Nonsemantic Concept Identifier, 258
Polyhierarchy, 258
Formal Definitions, 258
Reject Not Elsewhere Classified , 259
Multiple Granularities, 259
Multiple Consistent Views, 259
Context Representation, 259
Graceful Evolution, 259
Recognized Redundancy, 260
Copyrighted and Licensed, 260
Commercial Information System Vendor-
Neutral, 260
Scientifically Valid, 260
Well Maintained, 260
Self-Sustaining, 260
Scalable Infrastructure and Process Control, 260
Interface Terminologies, 260
Mapping, 262
General Equivalence Mappings, 262
The Role of the Unified Medical Language System
and Mapping, 263
Understanding Terminologies, 264
Exploring the Core Set of Terminologies, 264
The Role of IHTSDO and SNOMED-CT, 265
Logical Observation Identifiers Names and
Codes, 268
RxNorm, 271
National Drug Code, RxNorm, and UMLS
Metathesaurus, 271
Drug Coding Systems Working Together, 272
RxNorm and the UMLS Metathesaurus, 273
The National Drug File-Reference Terminology, 273
Federal Medication Terminologies, 273
Universal Medical Device Nomenclature System, 275
Nursing Terminologies, 276
Differences in NIC and NOC, 277
Omaha System, 277
International Classification for Nursing
Practice, 277
Terminologies Used at Point of Care, 277
Transaction and Code Set Standards, 278
The Final Rules, 278
HIM and Commonly Used Terminologies, 279
International Classification of Diseases, 279
International Classification of Diseases, Ninth
Revision, 279
International Classification of Diseases, Tenth
Revision, 280
International Classification of Diseases, Tenth
Revision, Procedural Coding System, 280
Derivations of the International Classification of
Diseases, 281
Diagnostic and Statistical Manual of Mental
Disorders, 281
International Classification of Diseases for
Oncology, 282
Current Procedural Terminology, 283
Healthcare Common Procedure Coding
System, 283
Diagnosis-Related Groups and MS-DRGs, 283
Adaptation of Administrative Terminologies, 284
Going Forward, 285
Chapter Review, 286
References, 286
8 TECHNOLOGY, APPLICATIONS, AND SECURITY, 289
Abbreviations, 291
Health Information Infrastructure, Technology, and
Applications, 291
Scope of Health Information Systems, 292
Components, 292
Computers in Health Care—Past and Present, 294
Early Efforts: 1960s to 1980s, 294
Evolution of Hospital Information Systems: 1980s
to Late 1990s, 294
Late 1990s to 2010, 294
2010 to Present, 294
Health Information Systems as a Critical
Discipline, 295
Computer Fundamentals, 295
Hardware, 295
Personal Computers, 296
Smartphones and Mobile Devices, 296
Storage, 296
Virtualization, 296
Voice Recognition, 297
Contents
Software, 297
Programming Languages, 297
Databases, 298
Database Models, 298
Network Technology, 300
Wired Versus Wireless Comparison, 301
Client-Server Platforms, 301
Interface Engine, 302
Designing the User Interface, 303
User Interface Team, 303
General Design Principles, 304
Needs of Users, 304
Selection and Sequencing of Items, 304
Instructions, 304
Guidelines for Designing Web Pages, 304
Screen Space, 304
Computer Applications, 305
Administrative Applications, 305
Admission, Discharge, and Transfer
System, 305
Decision Support Systems, 306
Clinical Applications, 306
Results Reporting, 306
Order Entry, 307
Computerized Provider Order Entry, 307
Clinical Decision Support Systems, 308
Point-of-Care Systems, 308
Emerging Technologies, 309
Bar Coding, 309
Radio Frequency Identification Device, 310
Internet and Web Services, 310
Fundamentals, 310
Internet Tools, 311
JAVA, 312
Intranet, 313
Virtual Private Network, 313
Web 2.0, 313
Telemedicine and Telehealth, 313
Fundamentals, 314
Implementation, 314
Computer Security, 315
Authentication Tools, 316
Passwords, 316
Single Sign-On, 317
Tokens or Cards, 317
Biometrie Devices, 317
Access Controls, 317
Reporting Capabilities, 318
Examples of Security Reports, 318
Physical Security, 318
External Controls, 318
Firewalls, 318
Encryption, 319
Internet Security, 319
Malicious Software Protection, 319
Remote Hosting Models, 320
Data Management Technology, 321
Data Mart, 321
Creating a Data Mart, 321
Data Modeling, 323
Chapter Review, 324
References, 324
9 HEALTH INFORMATION SYSTEMS:
COLLABORATION, ANALYSIS, DESIGN,
IMPLEMENTATION, OPERATION, 326
Abbreviations, 328
Collaboration Essential to Health Information
Systems, 328
Value of User Perspective, 328
A Natural Dependence, 329
Collaboration Principle, 329
Environmental Basics (Required for True
Collaboration), 329
Four Shared Environmental Basics, 329
Personal Commitment, 330
Trust, 331
Respect, 332
Policy Setting, 332
Five Unshared Environmental Basics, 333
Expectations, 333
Vocabulary, 334
Understanding, 334
Process, 335
Knowledge, 336
The Tide Turns, 336
Information Systems Analysis Phases, 337
Initiation Phase, 337
Analysis Phase, 337
Design Phase, 338
Implementation Phase, 338
Operations/Maturity Phase, 339
Evaluation Phase, 339
The Players, 339
Role of the HIM Professional, 340
Project Management, 340
System Life Cycles, 341
General System Life Cycle, 341
Information System Life Cycle, 341
Information System Life Cycles in the
Organization, 341
Aggregate Information Life Cycle of the
Organization, 342
Principles of Systems Development, 343
Business Process Redesign, 343
Analysis, 344
Tools and Aids for System Analysis, 344
Process Modeling, 344
Analysis Document, 345
Investigative Strategies for Analysis of
Requirements, 346
Ways of Gathering Information, 346
Ways of Presenting Information, 351
Data Dictionary, 353
Contents
Design, 355
Logical and Physical Design, 356
Output Design, 356
Input Design, 356
Processing Design, 356
File and Database Design, 356
Controls and Security Design, 356
Design Principles, 356
Input and Output, 356
Screen Design, 357
General Design, 357
System Performance, 358
Database Design, 359
Entity-Relationship Diagrams, 359
Computer-Aided Systems Engineering Tools
(CASE), 361
System Implementation, 361
User Preparation, 361
Site Preparation, 362
System Testing and Conversion, 362
Test Phases, 362
System Conversion, 362
Startup, 362
Abrupt Changeover, 362
Gradual Phase-In, 362
Implementation Readiness, 363
User Plans for Updated Processes and
Procedures, 363
Transition Plan, 363
Training, 364
Preparation of User Manuals, 365
Data Migration, 365
User Acceptance Testing, 366
Go Live , 366
System and Project Evaluation, 366
Evaluation Methods, 369
Benefits Realization, 369
Cost-Benefit Analysis, 369
Break-Even Analysis, 370
Cost-Effectiveness Analysis, 370
Other Evaluation Approaches and
Methods, 370
Purchasing Process: Request for Proposal, 372
Request for Information, 372
Planning Steps Before Request for Proposal
Preparation, 372
Analysis of System Requirements, 372
Development of System Specifications, 373
Development and Distribution of the Request for
Proposal, 373
Disclaimer and Table of Contents, 373
Proposal Overview, 373
Enterprise Profile, 373
Conditions of Response, 374
Functional Specifications, 374
Example of a Point-of-Care Request for
Proposal, 374
Technical Requirements, 374
Installation and Training Requirements, 374
Vendor Profile, 376
System Costs and Financing Arrangements, 377
Contractual Information, References, and Other
Materials, 377
Distribution of the Request for
Proposal, 377
Evaluation Criteria, 377
Demonstrations and Site Visits, 379
Demonstrations, 379
Site Visits, 379
System Selection and Contract
Negotiation, 379
Operation/Maturity Phase, 380
Chapter Review, 380
References, 380
Data Management and Use
10 STATISTICS AND DATA PRESENTATION, 381
Abbreviations, 382
OVERVIEW OF STATISTICS AND DATA
PRESENTATION, 382
Role of the Health Information Management
Professional, 382
Health Care Statistics, 383
Vital Statistics, 383
Rates, Ratios, Proportions, and Percentages, 383
Mortality Rates, 384
Gross Death Rate, 384
Net Death Rate, 385
Anesthesia Death Rate, 386
Postoperative Death Rate, 386
Maternal Death Rate, 386
Neonatal, Infant, and Fetal Death
Rates, 386
Using and Examining Mortality
Rates, 387
Autopsy Rates, 388
Morbidity Rates, 389
Census Statistics, 391
Organizing and Displaying the Data, 393
Types of Data, 393
Nominal Data, 393
Ordinal or Ranked Data, 394
Interval Data, 394
Ratio Data, 394
Discrete Data, 394
Continuous Data, 395
Types of Data Display, 395
Frequency Distribution, 395
Bar Graph, 395
Pie Chart, 396
Histogram, 396
Frequency Polygon, 397
Contents
Statistical Measures and Tests, 399
Descriptive Statistics, 399
Measures of Central Tendency, 399
Measures of Dispersion, 400
Inferential Statistics, 402
Tests of Significance, 402
Interval Estimation, 408
Sampling and Sample Size, 409
Summary, 410
Chapter Review, 410
References, 411
11 RESEARCH AND EPIDEMIOLOGY, 412
Abbreviations, 413
Overview of Research and Epidemiology, 414
Role of the Health Information Management
Professional, 414
Designing the Research Proposal, 415
Hypothesis and Research Questions, 415
Review of Literature, 416
Methodology (Draft), 417
Research Plan, 417
Specific Aims, 417
Significance (Review of Literature and Preliminary
Research), 417
Methodology, 418
Human Subjects, 419
Literature Referenced, 420
Budget Development, 420
Appendix Design, 420
Additional Considerations, 420
Validity and Reliability, 421
Validity, 421
Sensitivity and Specificity, 421
Analysis and Discussion, 421
Reliability, 421
Biases, 423
Confounding Variables, 423
Sampling Variability, 423
Ascertainment or Selection Bias, 423
Diagnosis Bias, 423
Nonresponse Bias, 423
Survival Bias, 423
Recall Bias, 423
Interviewer Bias, 424
Prevarication Bias, 424
Epidemiologic/Research Study Designs, 424
Descriptive Study, 424
Cross-Sectional or Prevalence Study, 424
Survey Research, 426
Qualitative Research, 428
Analytic Study Design, 430
Case-Control or Retrospective Study
Design, 430
Prospective, Cohort, or Incidence Study
Design, 432
Historical Prospective Study Design, 433
Experimental Epidemiology, 435
Clinical and Community Trials, 435
Life-Table Analysis, 435
Comparison, 436
Use of Computer Software in Research, 438
Outcome Studies and Epidemiology, 438
Study Procedures, 439
Data Analysis, 439
Summary, 442
Chapter Review, 443
References, 443
12 PERFORMANCE MANAGEMENT AND PATIENT
SAFETY, 445
Abbreviations, 446
The Big Picture and Key Players, 447
Federal Oversight Agencies, 447
Accrediting Bodies, 448
The Joint Commission, 448
National Committee for Quality Assurance, 448
National Quality Awards, 448
Purchasers, 449
Consumers, 449
National Health Care Quality Measurement
Priorities, 450
Performance Measurement, 450
Structure, Process, and Outcome Measures, 451
Structure Measures, 451
Process Measures, 452
Outcome Measures, 452
Developing Performance Measures, 452
Collecting Measurement Data, 453
E-Measures, 454
Data Quality, 454
Performance Assessment, 455
Reports for Analysis, 455
Performance Goals and Targets, 455
Performance Improvement, 456
Performance Improvement Models, 456
Rapid Cycle Improvement, 457
Six Sigma, 457
Lean, 458
Benchmarking, 458
Process Improvement Tools, 459
Idea Generation, 459
Information Organization, 460
Data Presentation and Analysis, 462
Patient Safety, 465
Safety Measurement, 465
Patient Safety Databases, 467
Safety Improvement, 468
Root Cause Analysis, 468
Proactive Risk Assessment, 469
Risk Management, 470
Loss Prevention and Reduction, 470
Claims Management, 470
Utilization Management, 471
External Requirements, 471
Program Components, 471
Contents
Prospective Review, 471
Concurrent Review, 472
Discharge Planning/Case Management, 472
Retrospective Review, 472
Plan and Program Structure, 473
Medical Staff Credentialing and Privileging, 474
Credential Verification, 475
Privilege Delineation, 476
Ongoing Evaluation, 476
Role of Managers in Quality and Patient Safety, 477
Chapter Review, 479
References, 480
13 DATA ANALYTICS: REPORTING,
INTERPRETATION, AND USE, 482
Abbreviations, 483
Data, 484
Health Care Data, 484
Health Care Data Users, 485
Health Care Data Quality, Reporting, and Uses, 485
Benchmarking, 488
Clinical Decision Support, 488
Consumer Education, 488
Performance Management, 488
Planning and Assessment, 488
Regulatory Reporting, 489
Registries Overview, 489
Case Definition and Eligibility, 489
Case Finding, 490
Electronic Abstracting, 490
Follow-Up, 490
Registry Data Quality Integrity, 490
Confidentiality and Release of Registry
Information, 490
Cancer Registries, 490
Hospital Cancer Registries, 491
Accessioning, 491
Population-Based/State Cancer Registries, 491
Cancer Registry Abstracting, 491
Cancer Registry Coding, 491
Cancer Registry Staging, 491
Quality Management of the Cancer Program and
Registry Data, 492
The Cancer Registrar Profession, 492
Birth Defects Registries, 492
Birth Defects Case Definition and Coding, 493
Quality Control of Birth Defects Registry
Data, 493
Use of Birth Defects Registry Data, 493
Death Registries, 494
Diabetes Registries, 494
Diabetes Registry Case Finding, 494
Implant Registries, 495
Immunization Registries, 495
Immunization Registry Case Finding and Data
Use, 495
Organ Transplant Registries, 496
Transplant Case Registration and Data Use, 496
Trauma Registries, 496
Trauma Registry Case Finding and Data Use, 497
Traumatic Brain Injury Registry, 497
Traumatic Brain Injury Case Finding and Data Use
Case Definition and Coding, 497
Traumatic Brain Injury Registry Abstracting, 497
Data Use—National Level (Reporting), 497
Data Use—State Level (Reporting), 497
Research and Use of Data, 498
Public Health Research, 498
Public Health Informatics, 498
Use of Population-Based Data, 498
Health Services Research, 499
Medical Research, 500
Certified Health Data Analyst, 500
Data Dictionary, 501
Data Dictionary Definitions, 501
Purpose of the Data Dictionary, 502
Scope of the Data Dictionary, 503
Meta-Content of the Data Dictionary, 503
Building the Data Dictionary, 503
Step 1: Inventory of an Existing Enterprise, 503
Step 2: Identifying New Data Content Needs, 503
Step 3: Consensus Development, 504
Criteria for Data Element Inclusion, 505
Cataloging Standards, 505
Data Interpretation and Outcomes, 505
Outcomes Data and Information Systems, 506
Outcomes Data Use, 506
Outcomes and the Electronic Health Record, 506
Outcome Indicators, 508
Outcomes and Coding Issues, 508
Desirable Outcome Systems, 509
Chapter Review, 512
References, 513
14 PUBLIC HEALTH INFORMATICS, 515
Abbreviations, 516
Public Health and Medical Care, 516
Healthy People 2020, 516
Immunizations and Infectious Diseases, 516
Injury and Violence: Public Health Impact, 518
Meaningful Use and Public Health Reporting, 523
Health Information Exchange and Public Health, 523
Population-Based Data, 524
Information Needs and Core Public Health
Functions, 524
Public Health Information Network, 527
National Electronic Disease Surveillance System and
NEDSS Base System, 527
Institute of Medicine Committee on Health
Threats Resilience and Work Force
Resilience, 528
Public Health Programs, 528
National Initiatives, 529
Public Health Information Network, 529
National Vaccine Program, 529
State Initiatives, 529
Contents
Birth Defects Registry, 529
Immunization Information, 529
Focused Health Problem: Asthma in Washington
State, 529
Environmental Public Health Data, 530
Health Problems and Costs, 530
Improving Health, 530
Integrating the Information System, 531
Legal Context, 533
Federal Laws, 533
State Laws, 533
What Public Health Does with Data, 534
Analysis and Use of Data and Information, 534
Chapter Review, 537
References, 537
Management
PRIVACY AND HEALTH LAW, 539
Abbreviations, 540
Why are Legal Issues Important to Health Information
Management Professionals?, 541
Fundamentals of the Legal System, 541
Sources of Law, 541
Constitutional Law, 541
Federal and State Statutes, 542
Rules and Regulations of Administrative
Agencies, 542
Court Decisions (Case Law), 543
The Legal System, 543
The Court System, 543
Federal Courts, 543
State and Territory Courts, 544
Roles of the Key Players: Court Procedures, 544
Cases That Involve Health Care Facilities and
Providers, 545
Malpractice and Negligence, 545
Intentional Torts, 545
Products Liability, 547
Contractual Disputes, 547
Antitrust Claims, 547
Crimes and Corporate Compliance, 547
Noncompliance with Statutes, Rules, and
Regulations, 548
Legal Obligations and Risks of Health Care Facilities and
Individual Health Care Providers, 548
Duties to Patients, in General, 548
Duty to Maintain Health Information, 548
Duty to Retain Health Information and
Other Key Documents and to Keep Them
Secure, 549
Error Correction, 550
Addenda, 551
Authentication and Authorship Issues, 551
Validity of Health Information as Evidence, 552
Retention of Other Records and Information, 552
Duty to Maintain Confidentiality, 552
Privacy Act of 1974, 554
Freedom of Information Act, 554
Regulations on Confidentiality of Alcohol and
Drug Abuse Patient Records, 554
Internal Uses and External Disclosures of Health
Information, 554
General Principles Regarding Access and Disclosure
Policies, 555
Health Information Ownership, 555
Resources on Releasing Patient Information, 555
Authorizations for Disclosure of Patient
Information, 555
Disclosure for Direct Patient Care, 557
Disclosure for Performance Management and
Patient Safety, 558
Disclosure for Educational Purposes, 559
Disclosure for Research, 559
Uses for Administrative Purposes, 559
Disclosure for Payment Purposes, 560
Disclosure to Attorneys, 560
Disclosure to Law Enforcement Personnel and
Agencies, 560
Disclosure to Family Members When the Patient Is
a Minor, 561
Disclosure to Family Members When the
Patient Is an Emancipated Minor or an
Adult, 561
Disclosure to Family Members in Cases of
Incompetence or Incapacity, 561
Patient Access to Personal Health
Information, 562
Other Patient-Directed Disclosures, 562
Redisclosure Issues, 563
Disclosure to Outsourcing Firms Handling Health
Information Functions, 563
Disclosure to the News Media, 563
Disclosure Pursuant to Legal Process, 564
Health Information Management Department
Security Measures to Prevent Unauthorized
Access, 565
Duty to Provide Care That Meets Professional
Standards, 566
Duty to Obtain Informed Consent to Treatment, 567
Duty to Provide a Safe Environment for Patients and
Visitors, 569
Duty to Supervise the Actions of Employees and the
Professional Staff, 569
Medical Staff Credentialing Process, 570
Accessibility of Credentials Files and Quality
Profiles, 571
Legal Risks, 571
Contract Liability Issues and the Health Information
Management Department, 572
Legal Resources for Health Information
Management Professionals, 573
Chapter Review, 573
References, 574
Contents
HUMAN RESOURCE MANAGEMENT, 576
Abbreviations, 577
Human Resource Management, 578
Navigating Through Turbulent Times, 578
Broad Environmental Forces, 578
Continuing Challenges in the 21st Century, 578
The Federal Regulatory Context, 579
The Demographic Imperative, 579
Forces Transforming Health Care, 580
Challenges for Health Information Management
Professionals, 580
Leadership and Human Resources
Management, 580
Overview of Leadership Theory, 581
Relationships and Leadership Style, 581
Transformational Leadership, 583
Leadership Development, 583
The Ethics of Leadership, 583
Other Core Values in Health Care
Management, 585
Ethics of the Ordinary, 585
Power and Ethical Decision Making, 585
Values Clarification, 586
Servant Leadership, 586
Applications to Human Resources
Management, 585
Codes of Ethics, 586
Organizational Human Resources Management:
A Systems Perspective, 587
Health Information Management: A Systems
Viewpoint, 587
Systems Perspective Applied to Human Resources
Management, 588
Environmental Influences and Human Resources
Management, 589
Women s Participation in the Workforce, 589
Technological Change, 591
Economy Forces and Trends, 591
Demographic Changes in the Workforce, 592
Legal, Regulatory, and Accreditation
Requirements Affecting Human Resources
Management, 594
Institutional Accreditation, 594
Civil Rights and Equal Employment Opportunity
Legislation, 595
Gender Discrimination and Sexual
Harassment, 596
Protecting the Rights of Persons with
Disabilities, 597
Age Discrimination, 598
Immigration Control and Employment, 598
Employee Health and Workplace Safety, 598
Security and Privacy of Information, 599
Employee Compensation, 599
Labor-Management Relations and Collective
Bargaining Legislation, 600
Managing Human Resources Within the
Unionized Environment, 601
The Changing Work Environment and Employee
Expectations, 602
Internal Environment of the Health Care
Organization, 603
Organizational Culture, 603
Information Systems, 603
Role of Human Resources Management System in
Health Care Organization, 604
The Employee as Client of the Human Resources
Management System, 604
Employee Assistance Programs, 605
Strategic HIM Workforce Planning, 605
Performance Appraisal Systems, 616
Adverse Outcomes of Employee Performance, 622
Employee Counseling and Discipline, 624
Grievance Process, 626
Compensation Management, 627
Training and Development, 630
Employee Health, Safety, and Weil-Being, 632
Future Issues, 632
Chapter Review, 633
References, 633
OPERATIONAL MANAGEMENT, 635
Abbreviations, 636
Introduction, 636
Individual Work Processes (Micro Level), 637
Organizing Work, 637
Serial Work Division, 637
Parallel Work Division, 637
Unit Assembly Work Division, 637
Work Distribution Chart, 637
Productivity, 641
Productivity Standards, 641
Work Simplification or Methods Improvement, 645
Identifying a Problem Area or Selecting a Work
Process or Function to Improve, 645
Gathering Data About the Problem, 646
Organizing and Analyzing Data Gathered on the
Problem, 648
Formulating Alternative Solutions and
Improvements, 649
Selecting the Improved Method, 649
Implementing the Improved Method and
Evaluating the Effectiveness of the
Improvement, 652
Systems and Organizational Level (Midlevel), 652
Systems Analysis and Design, 652
Systems Model Concept, 653
Input-Output Cycle, 653
Goals of Systems Analysis and Design Process, 654
Components of Systems Analysis and Design, 654
Designing the System, 655
Evaluating the Proposed System, 655
Implementing the System, 655
Contents
xxv
Organizational Structure, 655
Formal Organizational Infrastructure, 655
Informal Organization, 655
Organization-Wide Level, 656
Change Management, 656
Strategic Management, 656
Situational Analysis, 656
External Environmental Analysis, 656
Internal Environmental Analysis, 657
Mission, Vision, and Values, 657
Strategy Formulation, 657
Strategic Implementation, 658
Strategic Control, 658
Project Management, 659
Characteristics of a Project, 659
Characteristics of Project Management, 659
Project Planning, 659
Information Technology Applications, 663
Reengineering, 665
Objectives, 665
Use of Policies and Procedures in the Reengineering
Process, 665
Relationship to Quality Improvement, 666
Applications to Health Information
Management, 666
Design and Management of Space in Health
Information Services, 667
Work-Space Design, 667
Work Flow, 667
Traffic Patterns, 667
Functions Performed in the Work
Space, 668
Need for Confidentiality of Work
Performed, 669
Shift Workers—Sharing Work Space, 669
Flexibility for Future Needs, 669
Employees Personal Needs, 669
Design of the Workstation, 670
Ergonomics, 670
Components of the Workstation, 671
Environmental Considerations, 673
Chapter Review, 676
References, 676
REVENUE CYCLE AND FINANCIAL
MANAGEMENT, 677
Abbreviations, 678
Historical Perspective, 679
Payment for Health Care Services, 679
Managing the Revenue Cycle, 682
Front-End Activities, 683
Contracting, 683
Licensure and Provider Enrollment, 684
Charge Master—Fee Schedule, 684
Registration and Admitting—Access
Management, 685
Utilization Management—Case
Management, 685
Patient Encounter, 685
Coding-Charge Capture, 685
Back-End Activities, 686
Patient Accounting, 686
Claims Processing, 686
Collection Follow-up and Claim Denial
Management, 687
Payment Processing, 687
Reimbursement Analysis, 690
Case Mix Analysis, 691
Financial Aspects of Fraud and Abuse
Compliance, 691
Setting Priorities for Financial Decisions, 692
Management Accounting, 692
Mission, 693
Goals, 693
Objectives, 693
The Budget and Business Plan, 693
Budgets, 693
Statistics Budget, 693
Operating Budgets, 694
Master Budget, 694
Who Participates in Budget Development?, 694
Budget Periods and Types, 694
Flexible Budget, 694
Zero-Based Budget, 694
Budgeting for Staff, 695
Using the Budget As a Control, 695
Variance Reports, 695
Preparing a Business Plan, 695
Identifying Trends, 696
Staffing Information, 696
Program and Automation Assessments, 697
The Four Ms, 697
Developing the Business Plan and Budget, 697
Cost Allocations, 697
Why Does Allocation Occur?, 697
Allocation Methods, 698
Step-Down Method, 698
Double-Distribution Method, 698
Simultaneous-Equations Method, 699
Why Is Cost Allocation Methodology Important for
the HIM Professional?, 699
Financial Accounting, 700
Fundamental Accounting Principles and
Concepts, 700
Entity, 700
Going Concern, 700
Stable Monetary Unit, 700
Matching Concept, 700
Objectivity, 701
Disclosure, 701
Financial Management Duties, 701
Cash and Accrual Systems, 701
Fiscal Periods, 702
Contents
Using Financial Reports to Provide Management
Information, 702
Using Ratios to Evaluate Financial Data, 703
Liquidity Ratio, 704
Turnover Ratio or Activity Ratio, 704
Performance Ratio, 705
Capitalization Ratio, 705
Capital Expense and Investment Decisions, 705
Capital Expenditures, 706
Capital Request Evaluation Process, 706
Time Value of Money, 706
Compounding, 706
Discounting, 706
Net Present Value, 708
Accounting Rate of Return, 709
Payback Method, 710
Arguments Pro and Con for Evaluation Methods, 710
Other Phases of Financial Management, 710
Implementing, 710
Seeking Alternatives, 710
Role of the HIM Professional in Financial
Management, 710
Chapter Review, 711
References, 711
Additional Resources, 712
GLOSSARY, 713
INDEX, 743
|
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| id | DE-604.BV042538593 |
| illustrated | Illustrated |
| indexdate | 2024-07-10T01:24:26Z |
| institution | BVB |
| isbn | 9780323263481 |
| language | English |
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| spelling | Health information management of a strategic resource Mervat Abdelhak ; Mary Alice Hanken 5. ed. St. Louis, MO Elsevier Saunders 2016 XXVI, 771 S. Ill. txt rdacontent n rdamedia nc rdacarrier Includes bibliographical references and index Medical informatics Information resources management Medical Informatics organization & administration Information Services organization & administration Medizinische Informatik (DE-588)4038261-8 gnd rswk-swf Medizinische Informatik (DE-588)4038261-8 s DE-604 Abdelhak, Mervat Sonstige oth Hanken, Mary Alice Sonstige oth HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=027972697&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Health information management of a strategic resource Medical informatics Information resources management Medical Informatics organization & administration Information Services organization & administration Medizinische Informatik (DE-588)4038261-8 gnd |
| subject_GND | (DE-588)4038261-8 |
| title | Health information management of a strategic resource |
| title_auth | Health information management of a strategic resource |
| title_exact_search | Health information management of a strategic resource |
| title_full | Health information management of a strategic resource Mervat Abdelhak ; Mary Alice Hanken |
| title_fullStr | Health information management of a strategic resource Mervat Abdelhak ; Mary Alice Hanken |
| title_full_unstemmed | Health information management of a strategic resource Mervat Abdelhak ; Mary Alice Hanken |
| title_short | Health information |
| title_sort | health information management of a strategic resource |
| title_sub | management of a strategic resource |
| topic | Medical informatics Information resources management Medical Informatics organization & administration Information Services organization & administration Medizinische Informatik (DE-588)4038261-8 gnd |
| topic_facet | Medical informatics Information resources management Medical Informatics organization & administration Information Services organization & administration Medizinische Informatik |
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