Healthcare Technologies Essay Discussion Paper

Healthcare Technologies Essay Discussion Paper

M05_GART2674_01_SE_C05.QXD 5 8/10/09 9:52 AM Page 98 Healthcare Records LEARNING OUTCOMES After completing this chapter, you should be able to: 䊏 Discuss the functions that healthcare records serve H primary and secondary health records 䊏 Explain the difference between 䊏 Identify different forms used I to record patient information 䊏 Discuss standard data elements and standard data sets G 䊏 Explain how health records assist in the continuity of care G 䊏 Define a RHIO 䊏 Describe the various formsSof telemedicine 䊏 Explain an E-visit , ACRONYMS USED IN CHAPTER 5 S H Acronyms are used extensively in both medicine and computers. The following A acronyms are used in this chapter. ALOS Average Length of Stay N NCVHS CDC Centers for Disease Control I and Prevention National Committee on Vital Health Statistics NHIN National Health Information Network OASIS Outcome and Assessment Information Set CMS CPR CT Centers for MedicareC and Medicaid Services Q Cardiopulmonary Resuscitation U Computed Tomography (also A CAT, Computerized Axial PACS OR PAC SYSTEM Picture Archiving and Communication System Tomography) Healthcare Technologies Essay Discussion Paper

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PET Positron Emission Tomography DEEDS Data Elements for Emergency Department Systems 1 PHI Protected Health Information PHR Personal Health Record DNR Do Not Resuscitate RAI Resident Assessment Instrument RHIO Regional Health Information Organization SNF Skilled Nursing Facility SOAP Subjective, Objective, Assessment, Plan UACDS Uniform Ambulatory Care Data Set ECG EEG EHR EKG HEDIS 1 Electrocardiogram (also EKG) 0 Electroencephalogram 5 Electronic Health Record T ECG) Electrocardiogram (also Health Plan EmployerS Data and Information System HPI History of Present Illness IDN Integrated Delivery Network LOS Length of Stay MDS Minimum Data Set MPI Master Patient Index MRI Magnetic Resonance Imaging NCDB National Cancer Data Base UAMCMDS Uniform Ambulatory Medical Care Minimum Data Set UCDS Uniform Clinical Data Set UHDDS Uniform Hospital Discharge Data Set 98 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 99 HEALTHCARE RECORDS 99 Understanding Healthcare Records Healthcare records have many purposes, the most important of which is to help healthcare providers with patient care. The patient health record is the repository of data and information about the patient, the condition of the patient’s health, the care and treatments the patient received, and the outcome of that care. This chapter will familiarize you with some of the contents of health records and how they are used. The term patient health record has replaced the term patient medical record because it encompasses a holistic view of patient care.

Though the terms are used almost interchangeably, an acute care patient record is usually concerned with one stay or episode, whereas an outpatient medical record is usually limited to one group or clinic. Later in this chapter we will discuss efforts to overcome these limitations by regional providers sharing records electronically and the growing interest by patients in maintaining lifelong personal health records. In Chapter 4 the term data was used to differentiate the H information the computer processes from the software application. In this and future chapters theIword data does not just mean computer information, but rather the information in a health record. Additionally, the term health data G is sometimes used herein for what is technically health information. In a more precise definition, data and information are not the same thing. Data are records G of facts. Information is data in a useful form that conveys meaning. For example, the numeric values 68, 70, 72 are data. S 䊏 䊏 If the data represent height in inches, they may be used to plot an adolescent’s growth rate. , If the data represent a patient’s pulse, they are used to provide information about the patient’s heart rate measured at different intervals. Health information, therefore, is not just the patient dataS but the presentation of this data in a useful form and the association of other relevant details with H it Healthcare Technologies Essay Discussion Paper.

Figure 5-1 shows a standard form used in pediatric practices. When patient height is recorded on this form, the doctor can easily see A a boy’s height to the general popthe rate of growth over time. Curved lines on the form compare ulation at the same age. In this chapter we will examine some N typical health information forms and further explore the concepts of data elements and data sets introduced in the previous chapter. I C Functions of Healthcare Records Q U A patient’s health record provides accurate information not only about the patient’s treatment, but also about the patient’s health history and previous treatments. A As such, it serves as the primary communication document among various providers who might care for the patient at different times in different departments. The patient record also provides the basis for all billing 1 and reimbursement. Coding professionals review the record of the patient visit and determine 1 what codes to put on the insurance claim. CMS and other health insurance auditors follow the dictum that “if it isn’t documented, it wasn’t done,” meaning that medical claims will not be paid0if the patient record does not have enough detail about the encounter or treatment to support the5claim. The health record is a legal document. Should a question arise as to the cause of a disease or injury, or to determine if a medical error was made, relevant T portions of the patient’s record may become evidence in a court of law. S Healthcare records provide the basis for improvements in health. Individually, a patient’s record is evaluated and used to develop care plans for the patient.

Collectively, health records can be used by the healthcare facility to improve the quality and processes of healthcare delivery. Public health departments, Homeland Security, and law enforcement officials use information from health records to track births, deaths, communicable diseases, effects of exposure to hazardous materials, bioterrorism threats, gunshot wounds, child abuse, and other crimes. Researchers use patient records from clinical trials to monitor the effectiveness and safety of new drugs. De-identified health records are analyzed by researchers to find health trends in our society and measure which treatments seem to have the best outcomes. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 100 8/10/09 9:52 AM Page 100 CHAPTER 5 2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles Mother’s Stature Date Father’s Stature Age Weight Stature BMI* NAME RECORD # 12 13 14 15 16 17 18 19 20 cm AGE (YEARS) 95 90 75 50 25 in 62 S T A T U R E 60 58 56 54 52 50 48 46 44 42 40 38 cm 3 4 5 6 7 8 9 H I G G S , 160 155 150 145 140 135 130 125 S H A N I C Q U A 120 115 110 105 100 95 36 90 34 85 32 80 30 80 W E I G H T 70 60 50 40 30 lb 10 5 10 11 35 30 25 20 15 10 kg 2 3 4 5 6 7 8 9 1 1 0 5 T AGE (YEARS) 10 11 S12 13 190 185 180 175 170 165 160 155 150 in 76 74 S T A T U R E 72 70 68 66 64 62 60 105 230 100 220 95 90 95 210 90 200 85 75 80 75 50 25 10 5 190 180 170 160 70 150 W 65 140 E I 60 130 G 55 120 50 110 H T 45 100 40 90 35 30 25 20 15 10 kg 14 15 16 17 18 19 20 80 70 60 50 40 30 lb Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts FIGURE 5-1 Pediatric Growth Chart of Boys’ Stature for Age and Weight for Age Healthcare Technologies Essay Discussion Paper.

Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 101 HEALTHCARE RECORDS 101 Primary and Secondary Records Health information professionals classify health records as primary or secondary records: 䊏 䊏 Primary records are those that are gathered directly from the patient and his or her providers, as well as records obtained from devices and diagnostic tests performed on the patient. Primary records are used for patient care and as legal documents. Secondary records are those that are created later, by analyzing, summarizing, or abstracting from the primary records. Secondary records are used in billing, research, and quality improvement. Types of Primary Health Records Primary records may be electronic medical records or paper forms, but what they have in comH mon is that they document the patient’s history and state of health, the clinician’s observations and actions, and all tests, treatments, and outcomes. As such,Ithe patient’s health record at a given facility is actually a collection of documents or computer records, G descriptions of which are provided later in this chapter. G As you have learned in previous chapters, there are differences between inpatient and outpatient facilities. The type and quantity of information they keep also varies by the type of facility. S For example, primary health records are generated and maintained by patients, doctors, nurses, , chiropractors, and others. home health providers, hospitals, rehabilitation facilities, dentists, The following examples illustrate some of the differences between health records at different providers’ locations: S 䊏 䊏 䊏 䊏 Acute care hospital charts contain admission and discharge reports, nursing notes, physician examination notes, all orders, test results, operativeHreports, pathology and radiology reports, and administrative and demographic forms.

However, A in nearly all cases these are concerned with the current stay. N Ambulatory care facilities (physician offices) tend to keep a single chart per patient, combinI ing documents from all previous visits, medical history, consults, lab results, and reports from other providers. The principal document is the physician’sCnote, which details the observation and findings, but often includes the physician’s orders and plan of treatment. In addition to demographic and social history information, many officesQkeep records of communications with the patient and their insurance plans in the chart as well. U Home care agency records are uniquely centered on a physician’s orders for treatment at A home. CMS has standardized the details that are required about a patient’s home care. The nurses or therapists visiting the patient at home keep notes from each visit concerning the services performed and the patient’s progress. These are1updated in records maintained by the home care agency. 1 Dental records generally contain very abbreviated notes about the treatments and proce0 ever had with the practice includdures performed, but usually cover all visits the patient has ing dental hygienists and other dentists Healthcare Technologies Essay Discussion Paper.

Also, because dental 5 x-rays are small, most offices store them in the patient’s chart. This is different from medical facilities where x-rays and other diagnostic images are typically stored in a separateTlocation or computer system. S Types of Secondary Health Records Secondary health records are those that are created by abstracting relevant details from the primary records. These secondary records are used for reimbursement (insurance claims), quality improvement at the facility, reporting to accreditation and government agencies, and research. The following are some examples of secondary health records: 䊏 Health insurance claims are created by selecting information from the patient record, such as procedures and diagnoses, assigning codes to them, and assembling them with information from the patient’s demographic and insurance information. These are then submitted to the insurance plan for payment. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 102 8/10/09 9:52 AM Page 102 CHAPTER 5 䊏 䊏 The master patient index (MPI) is typically a computerized system intended to prevent duplicate registrations for the same patient. By taking key identifying facts from patient demographic information such as full name, date of birth, gender, and sometimes Social Security number, a list is created of all the patients registered anywhere in the healthcare facility. By checking the MPI first, registration clerks can see if the patient is already registered and thereby avoid creating duplicate records in the system. Aggregate data is collected by gathering selected items of information from many patients’ charts and then analyzing it. For example, in Chapter 1 we discussed ALOS or average length of stay. By extracting the LOS of all of the patients in the hospital last month, the hospital can calculate the average. Similarly, aggregate data can be analyzed to determine the case mix or for quality improvement purposes. Case mix will be described further in Chapter 9. Healthcare Technologies Essay Discussion Paper

Transition from Paper to Electronic H Records Many social forces and practical reasons I are causing healthcare providers to change from paper health records to electronic health records (EHRs). Social reasons include an increasingly mobile G doctors more frequently. Additionally, many patients society where patients move and change today see multiple specialists for theirG care. This means their medical record no longer resides with a single general practitioner who provides their total care. Thus, the ability to share examination records and test results is increasinglySimportant to the patient’s continuity of care (discussed later in this chapter). , Practical reasons for the move to EHRs include the fact that paper records cannot be easily accessed or shared, the charts must be copied and faxed or transported from one office to another, and handwritten portions of the record S are often abbreviated, cryptic, or illegible. Finally, searching the contents of paper charts requires manually opening every chart and reading it. H Chapter 7 will cover ways EHR systems can be used to help improve patient health, the quality of care, and patient safety by Aproviding access to complete, up-to-date records of past and present conditions. Though many facilities are moving toward electronic health records, the N transition will take several years. I C Contents of Health Records Q Although the types of documents or data contained in medical records differ between inpatient U and outpatient facilities, many of them serve a similar purpose. However, clinical records are not the only items stored in a patient’s chart. A For example, many ambulatory offices store nearly any document concerning a patient in the patient’s chart. Figure 5-2 compares a list of some typical records in an inpatient and outpatient chart. Additional information and samples of many of the 1 forms are provided later in this chapter. 1 Data Administrative and Demographic Whether health records are paper or0electronic, certain administrative documents tend to originate as paper forms Healthcare Technologies Essay Discussion Paper.

Generally this5is the registration information provided by the patient or relative and certain legal documents that the patient must sign. In an all-digital facility these T paper documents are subsequently scanned as images and stored in the electronic record. When a patient is first registered, demographic data such as name, address, phone numbers, S next of kin, and emergency contact information is recorded. Registration will also record information used for billing such as account guarantor and insurance plans. Though some facilities allow the patient to enter this information directly using a web page, most facilities employ a registrar to enter the data into a computer. In a paper-based facility the patient demographics form is called the face sheet. In facilities that are still transitioning from paper to electronic records, the information may be entered into the computer then printed out to create a face sheet for the paper chart. Demographic and billing information is verified and updated if necessary for each return visit. Patients’ insurance cards may also be photocopied or scanned into the computer during registration. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 103 HEALTHCARE RECORDS Comparison of Contents of Patient’s Chart Acute Care Hospital Registration Record Consent Forms, Authorizations, Property list, Advance Directives Medical History (Admitting Doctor) Physical Examination (Admitting Doctor) Doctor’s Office 103 FIGURE 5-2 Contents typical of acute care versus ambulatory patient charts Healthcare Technologies Essay Discussion Paper.

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H RegistrationIForm G Authorizations, Advance Consent Forms, Directives G Medical History (From Patient) S Doctor’s Notes , from each visit. (Complaint, Symptoms, History, Review of Systems, Vital Signs, Physical Exam, Assessment, Plan of Care) Physician Orders S orders and Test Results Diagnostic Test Clinical Observations: Doctors’ notes, Nurses’ notes, Therapy notes Flow sheetsH (specialty specific—pediatric, obstetric, etc.) Surgery Report/Anesthesia Record Medical Records from other providers Consultation Reports Test Results Discharge Summary Patient Discharge Instructions A N ConsultationI Reports Problem List C Medication Q List Immunization U Record Correspondence A Authorization forms to Disclose PHI Copies of Insurance Cards 1 1 Consent and Directives 0 A number of legal documents signed by the patient are included in the medical record. In some 5 cases these are simple permission statements included on the patient information form; in other T filed in the chart or scanned into facilities the patient signs many individual forms, which are then the computer. Some typical examples include the following. S The patient acknowledges receipt of the Notice of Privacy Practices discussed in Chapter 3. This consent or acknowledgment may be included on the registration form or combined with another consent form. HIPAA CONSENT TO USE AND DISCLOSE PHI CONSENT TO TREATMENT A general consent to be treated by the healthcare practice or facility is usually included in the registration form. Additional informed consent forms are required for each operation or special procedure (discussed below). CMS requires that patients be given a statement of their rights under Medicare. Patients will sign an acknowledgment that they have received the statement and their rights have been explained Healthcare Technologies Essay Discussion Paper