Module 2 Health Information Services Flashcards
HIM vs Health Informatics
HIM - data entry/retrieval/analysis
HI - database management/creation/mining, more technical
What are the four domains of practice in HIM?
- Data Quality
- Privacy
- e-HIM
- HIM Standards
Design, development, adoption, application of IT based innovations in health care services delivery, management, and planning.
Health Informatics
HIMs are responsible for management of health information through:
- Collection
- Organization
- Storage and retention
- Access
- Dissemination
- Analysis and interpretation
- Destruction
Key concepts for HIM
- Privacy
- Security
- Confidentiality
– Records Management – Access and Disclosure – Coding Specialist (HIM I) – Data Analysis – HI Manager (HIM II)
Traditional HIM Roles
– Deals with paper and electronic format (currently hybrid)
– form creation/management, documentation standards
– assembly and quantitative/qualitative analysis
– chart tracking
– storage, retrieval, protection, retention, and destruction of health info
Records Management ($19)
– May also be called Release of Information (ROI)
– Responsible for analyzing requests for patient information from various sources and responding appropriately
– Must be experts in all privacy laws, not just health privacy laws
Access and Disclosure ($28)
– Use software to classify patient information
– In some large facilities, coders will “specialize” in certain areas, but the move is away from this and towards “cross training”
Coding Specialist ($35)
Search ____ in job postings for HIM careers
HLTH
– Not an entry to practice position, but a career transition with experience
– Analyze patient information to answer questions posed by doctors, researchers, government, management, etc. regarding health trends, quality of care, patient outcomes, resource utilization statistics, wait times, and so on
Data Analysis (competitive)
– Often posted as HIM II
– May include regular HIM duties, but also includes managing staff and processes in an HI department
HI Manager ($32)
Most important stage as it provides direction for all HIM activities
Information Management Planning
Articulating a HIM strategy that links to the organization’s strategic plan and IT plan
First step in information management planning
What are the 7 phases of the health information cycle?
information management planning capture and collection preservation access, use, and dissemination maintenance and protection disposition evaluation
What 8 factors should a HIM strategy address?
- security, access and privacy of HI
- legislations and regulations
- disaster recovery plans
- information sharing
- documentation and data collection requirements
- migration plan to EHR
- IT infrastructure requirements
- staff competencies and training needs
8 types of data collected in the capture and collection phase:
- clinical data
- administrative data
- research
- education
- risk management
- professional practice assessments
- legal events
- legislative data
Involves data integrity and data quality
the preservation phase
T or F. Data quality = accuracy of content, while data integrity = accuracy of chart context; right patient, right location, etc
True
One way to ensure preservation of data
data quality audits
Sharing of information that involves granting authorization to retrieve or receive data and then act on it
access in the access, use, and dissemination phase
Phase that ensures HI is kept current and secure
maintenance and protection phase
_______ have forced hospitals to take careful inventory of all the physical locations and HI systems where health information is stored
hybrid records
Involves setting retention schedules compliant with legislation, as well as setting physical and technical safeguards
maintenance and protection phase
The destruction phase of a health record
disposition
Disposition must include policies for ______ information stored electronically in medical equipment
resetting
Permanent and ongoing phase
evaluation
Phase that looks at the effectiveness of IM strategies, and incorporates changes in standards or legislation and IT
evaluation
Became an emerging field with computing advances where early applications were put into use in the 60s
Health Informatics
What are the goals of HI?
The well being of patients and efficiency in health care
HI may also be called MI, BMI, BMHI. Expand.
Medical Informatics (MI), Biomedical Informatics (BMI), and Biomedical and Health Informatics (BMHI)
What are the three domains and disciplines of HI?
- Biomedical Science
- Computer Science
- Behavioral Science
What are the four fundamental concepts of HI?
- data
- knowledge
- information
- modelling complex realities
observations and measurements
data
the relationships between data
knowledge
the result of interpreting data using knowledge
information
T or F. HI deals with direct and indirect data collection
true
information you may not get from the patient themselves; family, third party, etc
indirect data
machine acquired data (biosignal acquisition)
direct data
human acquired data
indirect data
Processing of health data can be divided into which 2 parts:
- applications designed to create knowledge
2. applications capable of degrees of use knowledge in decision-making processes
Application that analyzes data in data warehouses
clinical data mining
Applications like the Human Genome Project
bioinformatics
Applications that increase the efficiency and quality of care
intelligent systems
Applications with an “intelligent” approach to decision support in medicine
knowledge-based systems
Applications that automate planning tasks
case-based reasoning
Application that uses natural language processing to code from documents
automated coding
Application that is more effective than human monitoring of repetitive tasks
monitoring and control system
Study of the standards of right and wrong in human behavior
ethics
The criteria we use to determine which actions are right and wrong
ethics
What a person believes to be right or wrong
morals
Beliefs important to an individual that guide their conduct and decisions
values
May be external or internal
duties
Duties where others depend on you to fulfil your responsibilities in your profession
external duties
Duties based on your values and dictates the way you do something; accomplishing duties in a way that makes you proud or in the best way you can
internal duties
Showing kindness to or doing good for others
beneficence
Causing no harm
nonmaleficence
Honoring an individual’s right to autonomy, being truthful, not withholding information from a patient about their own health (unless legally required), and honoring an individual’s decisions
respect
What are the ethical principles of healthcare?
- beneficence and nonmalificence
- respect
- autonomy
- truthfulness
- fidelity
- justice
A person’s right to self-determination (provided they are mentally competent and have all the facts)
autonomy
Contributes to trust
truthfulness
Withholding the truth works against ____.
autonomy
Faithfulness or loyalty and adherence to your professional code of ethics
fidelity
Proper and equitable distribution of healthcare resources
distributive justice
Paying of compensation for wrongdoings
compensatory justice
Acting in a fair and impartial manner
procedural justice
What are three boundaries for health professionals?
patients, colleagues and hospital setting
bonus: gifts
List the 6 ethical issues related to HIM Professionals.
- protection of confientiality and privacy
- documentation
- access and disclosure
- coding
- quality management
- EHR
What is the standard used for concepts of privacy and confidentiality?
CSA Model Code for the Protection of Personal Information
What are the principles of the CSA Model Code?
- accountability
- identifying purposes
- consent
- limiting collection
- limiting use, disclosure, and retention
- accuracy
- safeguards
- openness
- individual access
- challenging compliance
Health Canada has developed the _______ to help guide organizations that manage personal health information as a guide for good practice
Pan-Canadian Health Information Privacy and Confidentiality Framework
manipulating data that is reported in health indicators (ie wait lists)
performance data
What is the full name of CHIMA?
Canadian Health Information Management Association
What is the full name of AHIMA?
American Health Information Management Association
What is the full name of HIMAA?
Health Information Management Association of Alberta
What is the full name of IFHIMA?
International Federation of Health Information Management
What is the full name of AMIA?
American Medical Informatics Association
What is the full name of CAHIIM?
Commission on Accreditation for Health Informatics and Information Maanagement Education
What is the full name of HIMSS?
Health Information Management Systems Society
What is the full name of CNIA?
Canadian Nursing Informatics Association
What is the full name of IMIA?
International Medical Informatics Association
How many phases are there in the health infomation life cycle?
7 phases
Involves data quality and integrity; may use audit to ensure this phase
preservation
Ensures health information is current and secure; involves setting retention periods that are compliant with legislation, as well as setting safeguards
maintenance and protection
Most important stage as it provides direction for all HIM activities; must articulate a HIM strategy that links to the strategic plan and IT plan of the organization
information management planning
Granting authorization to retrieve or receive data and act on it
access, use and dissemination
Includes retrieval of types of health data, including clinical, administrative, research, education, risk management, professional practice assessments, legal events and legislative
capture and collection
Evaluates the effectiveness of HIM strategies; permanent and ongoing phase
evaluation
Destruction phase
disposition
List the four components of the HI pyramid.
data > integrity > knowledge > wisdom
Which organization developed the Code of Ethics for HIM professionals?
CHIMA
Provide an example of applications designed to create knowledge.
eCPS, textbook
Provide examples of applications capable of degrees of use knowledge in decision making processes
decision making software that can help clinician consider next steps; an extra level of information application
T or F. You may be morally opposed to the idea of a DNR note, but are ethically required to abide by the patient’s decision.
True.
How are ethics and morals different?
Ethics refer to rules provided by an external source (codes of conduct; principles in religion) while morals refer to an individual’s own principles regarding right and wrong
Provide other examples where ethics and morals may not agree.
Contraception, abortion, assisted suicide, etc.
In what ways can documentation be an ethical issue?
- backdating progress notes
2. changing documentation to reflect outcomes of care vs what was actually done at the time
In what ways can access and disclosure be an ethical issue?
- violation of the “need-to-know” principle
- secondary release of information
- storage of and access to charts with sensitive information
In what ways can coding be an ethical issue?
- upcoding
- cherry picking easy charts
- workload expectations
In what ways can quality management be an ethical issue?
- manipulating data that is reported on health indicatiors
- misrepresenting negative outcomes
- incomplete health records hidden in preparation for accreditation visits
In what ways can EHR be an ethical issue?
protection of electronic data
