College of Public Health and Health Informatics Health Informatics Department !""#$%&'! !()*+,$"-./01)2/-$345+(15!

!()*+,$"-./01)2/-$ 60/.(557/-)*5$ !
)*+,!-.!/012&3*,'*45!6/5!6-$5!738! 9&3*,'*4:;<=*&13=.#+&.=*!

"#$%&'#!(!

! !

8()0-7-9$:;<(=2>(5$
! 8#=$',9#!%3#!3,=%>'?!>:!3#*0%3!,4:>'@*A>4! @*4*B#@#4%!*4+!>'B*4,C*A>4=.! ! 8,D#'#4A*%#!%3#!'>0#=!>:!3#*0%3!,4:>'@*A>4! E'>:#==,>4*0=.! ! 8#=$',9#!%3#!>'B*4,C*A>4*0!3,#'*'$3?!>:!FG6!*4+!GH! +#E*'%@#4%=.! ! I>@E*'#!J*',>&=!4>4$0,4,$*0!*00,#+!3#*0%3$*'#! >$$&E*A>4=.! ! KLE0*,4!%3#!'>0#!>:!*!E'>M#$%!@*4*B#'.! ! N4+#'=%*4+!3>O!=<,00!=#%=!:'>@!@&0AE0#!+,=$,E0,4#=!$*4! 3#0E!?>&!,4!?>&'!$*'##'.!!
Second Semester 2013-2014 Health Information Systems 2

History of HIM Organizations

! 1918: American College of Surgeons Hospital Standardization Program requires hospitals to keep accurate and complete medical records for all patients, filed in an accessible manner ! 1928: medical records clerks form the Association of Record Librarians of North America
Second Semester 2013-2014 Health Information Systems 3

History of HIM Organizations (continued)

! 1941: name changes to American Association of Record Librarians ! 1970: name changes to American Medical Record Association ! 1991: name changes to American Health Information Management Association (AHIMA)

Second Semester 2013-2014

Health Information Systems

Patient Records: Processing and Handling

! Efforts improved over time
! Early efforts included:
! Analyzing patient charts for deficiencies and obtaining missing items ! Tracking, storing, retrieving, and indexing charts ! Creating forms committees to standardize what appeared on specific forms (now called forms control)

Second Semester 2013-2014

Health Information Systems

Figure 2-1 Flow of inpatient information using a paper chart. Second Semester 2013-2014

Health Information Systems

Evolution of HIM
! Caused by:
! Regulatory reporting, billing, accreditation requirements made abstracting, aggregating, and reporting information collected from patient charts HIM functions ! Computerization of health information ! IOM mandate for creation of an electronic patient record

Second Semester 2013-2014

Health Information Systems

Overview of Health Information Field

! Some health information jobs are more prevalent in inpatient acute care facilities than outpatient settings
! Example: large hospital may have a number of coding specialists

! Some jobs are outsourced to companies specializing in a particular service

! Examples: medical transcription, computer security, system trainers
Second Semester 2013-2014 Health Information Systems 8

Figure 2-3 Abridged organizational chart for an acute care HIM department. Second Semester 2013-2014

Health Information Systems

HIM Department Professionals (continued)

! Health information manager:
! Manages HIM department ! Implements and monitors HIM systems, policies, procedures ! Educates employees ! Enforces policies ! Requires bachelors or masters degree and AHIMA certification exam to be RHIA
Second Semester 2013-2014

Health Information Systems

10

HIM Department Professionals (continued)

! Health information technician:
! Enters medical records data into computer systems ! Validates accuracy and completeness of records ! Performs other tasks as determined by needs and training ! Requires associate degree and AHIMA certification to become RHIT
Second Semester 2013-2014 Health Information Systems 11

HIM Department Professionals (continued)

! Coding specialists:
! Clinical data specialists ! Clinical coding and reimbursement specialists

! Reimbursement specialists:
! DRG coordinators ! APC coordinators

Second Semester 2013-2014

Health Information Systems

12

HIM Department Professionals (continued)

! Other HIM professionals:
! Medical transcriptionists ! Cancer or tumor registrars ! HIM compliance specialists ! Optical imaging coordinators

Second Semester 2013-2014

Health Information Systems

13

HIM and IT Comparison

! HIM: concerned with security, accuracy, and completeness of health records and the information reported in them ! IT: concerned with operation of HIS computers as well as phone systems and other computers ! Both: managed by CIO

Second Semester 2013-2014

Health Information Systems

14

Figure 2-4 Abridged organizational chart for a hospital IT department. Second Semester 2013-2014

Health Information Systems

15

IT Department Organization
! Information services (IT) director or manager:
! Oversees hospital computer systems, infrastructure of health information system ! Supervises computer network, databases, applications, network security, administration, database administration, strategic planning, telecom system ! Works closely with HIM director
Second Semester 2013-2014 Health Information Systems 16

IT Department Organization (continued)

! Other IT personnel include:
! Clinical project managers ! IT project managers ! Clinical analysts ! Clinical vocabulary managers ! Clinical applications coordinators ! Data quality managers ! Data resource administrator
Second Semester 2013-2014 Health Information Systems 17

IT Department Organization (continued)

! Other IT personnel include:
! Decision support analyst ! HIS department technicians ! Enterprise applications specialists ! Integration architects ! Health systems specialists ! Solution analysts ! Solution consultants
Second Semester 2013-2014 Health Information Systems 18

IT Department Organization (continued)

! Other IT personnel include:
! Systems analysts ! Information security managers ! Records and information coordinators

Second Semester 2013-2014

Health Information Systems

19

Nonclinical Allied Health Professions

! Do not involve medical or diagnostic services to the patient ! Handle and safeguard medical information vital to those who provide direct services

Second Semester 2013-2014

Health Information Systems

20

Nonclinical Allied Health Professions (continued)

! Includes all HIS, IT, HIM, and HIT professions
! Examples: medical office managers, registration and scheduling clerks, medical transcriptionists, computer system analysts, billing and coding specialists

Second Semester 2013-2014

Health Information Systems

21

Skill Set Requires Attention to Detail

! Ensure successful operation of healthcare delivery system ! HIM functions include compiling, storing, retrieving, controlling access to patients records

Second Semester 2013-2014

Health Information Systems

22

Skill Set Requires Attention to Detail (continued)

! Other HIM functions include coding, abstracting, aggregating health information for billing, reporting, research ! HIS/IT functions involve computerization of records, developing and maintaining systems that deliver them

Second Semester 2013-2014

Health Information Systems

23

Clinical Project Managers, IT Project Managers

! Help organizations determine scope of work, objectives, budget, schedule, responsibilities ! Track progress of each component, advise management when projects are off budget or schedule ! Positions involve attention to detail, planning, risk analysis, and communication skills
Second Semester 2013-2014 Health Information Systems 24

Clinical Project Managers, IT Project Managers (continued)

! Both clinical project managers and IT project managers do the same work, within their respective areas of the organization ! They communicate with each other frequently when two areas overlap

Second Semester 2013-2014

Health Information Systems

25

Importance of Multiple Skill Sets

! Development of computerized patient health records and delivery systems are continuing to create merger between HIM and HIS/IT departments ! Todays students should become acquainted with multiple skill sets regardless of career choices

Second Semester 2013-2014

Health Information Systems

26

Skills to Learn
! Medical terminology, computer technology, health information management, workflow, project management, accounting principles ! Time management and budgeting principles

Second Semester 2013-2014

Health Information Systems

27

Figure 2-5 Overlapping skill sets of the HIM or IT worker. Second Semester 2013-2014

Health Information Systems

28

Tips From the Field

! ! ! ! Learn medical vocabulary Embrace technology Learn about what physicians do Think big picture; how does your profession fit within all of the processes at your facility? ! Understand workflow; what is being done and how?
Second Semester 2013-2014 Health Information Systems 29

Tips From the Field (continued)

! Learn a little project management; how do you break down a project into tasks or estimate a timeline? ! Learn a little accounting because it will be helpful across disciplines

Second Semester 2013-2014

Health Information Systems

30

Pretest (True/False)
! The American Health Information Management Association was originally called the Association of Record Librarians of North America. ! In many healthcare facilities, the CIO manages both the HIM and IT departments. ! In hospital settings, Registered Health Information Technicians (RHITs) supervise Registered Health Information Administrators (RHIAs).
Second Semester 2013-2014 Health Information Systems 31

Pretest (True/False) (continued)

! A DRG coordinator facilitates reimbursements from Medicare. ! One of the jobs of the APC coordinator is to verify that the correct ICD-9-CM and HCPCS codes have been used on an outpatient claim.

Second Semester 2013-2014

Health Information Systems

32

I(N+$8(=+O0($

?@A?$BCD!E6?@F$&&G$:FHEI"J"IH$ "IK:F#E?":I$?@D!I:8:HL$ F@3:MFD@3$

Second Semester 2013-2014 Health Information Systems 33