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Ch2 Hlth Info Mngmt

Health Informantics & Information Hlth Mngmt Career

QuestionAnswer
accredited record technician credential offered early 1950' after completion 9-12month tech program & successful completion certification exam
replaced by RHIT Registered Health Information Technician accredited record technician
certification process by which gov & nongov organizations evaluate ed programs, health care facilities, & individuals having met predetermined standards
certified coding associate (CCA) entry-level coding credential implemented by AHIMA in 2002
recomended experience for credential is 6months or completion of AHIMA-approved coding certificate program/other formal training certified coding associate (CCA)
certified coding specialist (CCS) advanced coding crendential implemented by AHIMA in 1992
must pass CCS exam, focusing on inpatient coding systems; recommended exp. 3+ years certified coding specialist (CCS)
certified coding specialist-physician based (CCS-P) adv coding credential implemented by AHIMA in 1997
must pass CCS-P exam, focusing on ambulatory care coding; recommended exp. 3+ yrs certified coding specialist-physician based (CCS-P)
code of ethics guides practice of people who choose given profession & sets forth values & principles defined by profession as acceptable behavior within practice setting
Commission on Accreditation of Health Informatics and Information Management CAHIIM accrediting body est. by AHIMA 2004 for undergraduate HIM programs prev. accredited by CAAHEP Council on Accreditation of Allied Health Educational Programs
CAHIIM also offers accreditation program for master's degree programs in HIM which will convert to accreditation process in future
Communities of Practice (CoP) on-line communication tool offered by AHIMA for connecting association members
provides up-to-date news & links to resources, helps keep mbrs informed on latest HIM trends, solve problems, network & career build Communities of Practice (CoP)
credential denotes that individuals have met specific standards & demostrated level of competence in field of practice
required to maintain over time by meetins CE requirements as defined by agency/association supporting such credentials
electronic health information management use of emerging info & communications tech to manage health info systems
hybrid record record including both paper & electronic documents & uses both manual & electronic processes to store/review docs
information data organized & processed into meaningful form, either manually/by computer to make valuable to user
adds to representation & tells recipient something not known before information
knowledge derived from information once information is organized, analyzed, & synthesized by user
licensure legal approval for facility to operate/person to practice within his/her profession
individual must meet eligibility requirements defined by state before granted to practice licensure
licensure occurs at ___ level & is overseen by ___ state; state licensing board/agency
National health information infrastructure
Office of the National Coordinator for Health Information Technology role within HHS charged with providing national leadership in support of gov & priv efforts to develop standards & infrastructure to more effectively use info tech to acheive quality hlth care & reduce hlth care costs
position created by Pres. Bush 2004 & reports to Secretary of HHS Office of the National Coordinator for Health Information Technology
profession occupation requiring extensive training & study/mastery of specialized knowledge & skill
usually has a professional association, ethical code, & process of certification/licensing profession
Regional health information organizations (RHIOs) organizations working together develop means of sharing hlth info for patient care & other uses, typically within geographical area
various models exist incl models where info stays with originators & accessed as auth, & models centralize data & control of access as auth Regional health information organizations (RHIOs)
RHIOs are part of the development of a national hlth info infrastructure
Registered health information administrator (RHIA) offered by AHIMA for those passing cert. exam & meet ed. req. CAHIIM-accredited HIM program-baccalaureate dgree lvl, or cert. of completion CAHIIM-accr. HIM program plus baccalaureate degree from regionally accredited college/univ.
credential offered by AHIMA, that functions in managerial lvls of health services & info sys & uses of health-related data for planning, delivering, & evaluating healthcare Registered health information administrator (RHIA)
Registered health information technician (RHIT) AHIMA credential for those who pass cert. exam & meet academic req. of CAHIIM-accredited HIM prog. at assoc. degree lvl
functions in technical areas of hlth data collection, analysis, & monitoring, often specializing in coding diagnoses/procedures for reimb. & research purposes Registered health information technician (RHIT)
data facts, ideas, concepts that can be captured, communicated & processes manually/electronically
record body of known/recorded facts regarding someone/thing.
when patient seeks care/treatment from HCP a ___ of care/treatment is generated record
primary professional association for HIM professionals, in US American Health Information Management Association (AHIMA)
as a result of advances in information & communication technology HIM profession is undergoing fundamental changes in way hlth care data/info collected, processed, communicated & managed
for the inception, HIM profession's focus has been improving patient care through better documentation & ensuring privacy, confidentiality & securtiy of patient info
primary source of health data & info for the health care industry patient record
a record can also be referred to with the following words in front of it patient, medical, health, clinical, resident, client, etc.
patient records is created as a direct result of health care delivered in that setting
data, information, or record may have "clinical" preceeding it to denote that it relates specifically to care & treatment of a patient
heightened reliance by providers on patient record for source of data or decision making when health care providers are working collaboratively to provide most effective treatment/care for patient
basis for health care billing reimbursement documentation within patient record
use data in record as proof of care delivered to patient third-party payers
health care setting/provider will not be reimbursed for services rendered without proper documentation
efforts to control spiraling health care costs has placed extra importance on the patient record
patient record also functions as a legal document that confirms whether treatment was delivered in manner appropriate for given hlth problem
record can serve as proof in a court of law as to what transpired during patient's course of treatment
as a legal document the patient record is defined as record "generated at/for HCO as its business record & record that would be released upon request"
patient record can serve as a source of data for research, programs, evaluation, education & public health studies
"report cards" performance reports of HCOs
help consumer evaluate & select health plan "report cards"
in order to record minimum info about a patient, early institutions used ledgers
NY Hopsital was established in 1771, but only began recording patient information around 1790
Penn. Hosptial est. 1792 in Philadephia with leadership of Ben Franklin
Charity Hosp. in New Orleans entered 1st medical records in large ledgers
when hospitals moved from ledgers to individual patient records they were organized into systems that allowed easier retrieval of patient's record & data within document
early hospital records were brief & contained carefully handwritten entries
some early hosptials filed the records according to diseases or treatments, & some indexes to identify diseases & associate w/particular patient records
1874 upon invention of typewritter, some lengthly handwritten docs were typed operative reports & history/physical exams
ACS established minimum standards including specifications for content of patient record & required certain activities to be documented in record within specific time frame
ACS helped form the professional organization AHIMA
one chapter in within the Joint Commission accreditatio manuals is devoted to information management
state licensing boards require HCF accredited by Joint Commission as well as meet state licensing requirements to be authorized to provide health care services
voluntary Joint Commission accreditation review involved standards at level/step up from state-mandated minimum requirements
at times state licensing requirements are more specific that the Joint Commission standards
heavily influenced methods for documenting record & fast/accurate retrieval of doc for reimbursement private health insurance & fenderal programs for insuring
insurance companies & MCO have increased quantity & specificity of documentation from patient record in order to support each claim for hlth care services that is submitted for payment
due to 1965 added provisions to Social Security Act, instead of voluntary standards, regulations were part of the federal Conditions for Participation
Conditions for Participation regulations providers must follow for reimbursement of care given to patients using Medicare/Medicaid
ACS established minimum standards including specifications for content of patient record & required certain activities to be documented in record within specific time frame
ACS helped form the professional organization AHIMA
one chapter in within the Joint Commission accreditatio manuals is devoted to information management
state licensing boards require HCF accredited by Joint Commission as well as meet state licensing requirements to be authorized to provide health care services
voluntary Joint Commission accreditation review involved standards at level/step up from state-mandated minimum requirements
at times state licensing requirements are more specific that the Joint Commission standards
heavily influenced methods for documenting record & fast/accurate retrieval of doc for reimbursement private health insurance & fenderal programs for insuring
insurance companies & MCO have increased quantity & specificity of documentation from patient record in order to support each claim for hlth care services that is submitted for payment
due to 1965 added provisions to Social Security Act, instead of voluntary standards, regulations were part of the federal Conditions for Participation
Conditions for Participation regulations providers must follow for reimbursement of care given to patients using Medicare/Medicaid
"if it isn't documented, it wasn't done" mantra to attempt to communicate importance of proper documentation in record under Medicare review program
one solution for attempting to control health care costs was to move from fee-for-service to prospective payment method
prospective payment method payment rate established in advance & reflect average of what service should cost
btwn 1980-2002 Congress moved to prospective payment method for ambulatory surgery cntrs, inpatient ACH, skilled nursing facilities, home hlth agencies, outpatient hostpial services, inpatient rehab factilities & long-term care hospitals
primary patient record applied changing technology, however scans/images were stored in separate area
increased reliance on HIT as means of staying competitive in information-intensive industry personal computers & data communication tech entered marketplace
paper-based patient record converted into electronic format would be composed of electronic databases containing hlth care info generated of patient while treated in given hlth care facility
IOM defined patient record of future as on that "will reside in system significantly designed to support users by providing accessibility to complete & accurate, data, alerts, reminders, clinical support systems, links to medical knowldege & other aids"
if record computerized, researchers could access data in aggregate form when looking for a certain treatment but no need to identify an individual patient
"public & private sectors join in establishing Computer-based Patient Record Institute to promote & facilitate development, implementation, & dissemination of CPR" recomendation of 1989 IOM study to inprove patient records through use of information tech
to reduce hlth care costs, control medical/medication errors, reduce needless duplication of diagnostic tests, monitor public hlth & bioterroism concerns government should enable ways to develop 21st century EHR system June 2004 President's Information Technology Advisory Committee(PITAC) published report
PITAC proposed framework for hlth care info infrastructure would be composed of EHRs for all americans; computer-assisted clinical decision support; computerized provider order entry & secure private, interoperable, electronic hlth exchange
progress report from Office of National Coordinator for Health Information Technology (ONC) laid out stratigic action to achieve vision of consumer-centric & information-rich health care
support efforts to implement EHRs & regional hlth information organizations to support an overall national hlth info infrastructure ONC
has taken action-oriented role in facillitating adoption of HIT & EHR systems federal goverment, in response to PITAC report & ONC progress report
evolved from need for accurate/complete records rgding care/treatment of patient as one means of improving/standarizing health care HIM profession
ACS's standardization prorgam was catalyst for organizing & educating group of people who could assist hospitals in meeting informational needs of accrediting bodies & medical educators
director of hospital activiteds at ACS & important leaders in hospital standardization movement Dr Malcolm MacEachern
in 1928 Dr Malcolm MacEachern invited medical records workers to attend meeting of Clincal Congress of the ACS which resulted in medical records workers organizing to form Association of Record Librarians of N. America (ARLNA)
first president of (ARLNA) Grace Whiting Myers, Librarian Emeritus of Massachusetts General Hospital
(ARLNA) formed Board of Registration in 1933 which developed rules & regulations which "certified" that an individual met certain criteria/standards entitling them to bear credential, registered record librarian (RRL)
AHIMA e-health Task Force, 2002 determined that skills HIM professionals could easily transfer to e-health enviroment & they were suited to perform as profession transitions into e-HIM enviroment
the future state of hlth info is electronic, consumer-cenetered, comprehensive, longitudinal, eccessible, credible, & secure. ownership of hlth info is shared responsibility btwn consumer & provider update to 2010 vision statement AHIMA e-HIM task for from Bloomrosen 2005
body of knowledge & practice that ensires availability of hlth info to facilitate real-time hlth care delivery & critical hlth-related decision making for mutliple purposes across diverse org, settings & disciplines practice of HIM in 2010 defined as
moving towards virtual department; functions re-engineered/eliminated as processes for EHRs change HIM department changes
HIM professionals work wherever hlth data collected, organized, & analyzed
AHIMA advances role of HIM professionals through support cutting-edge academic programs, offer certification/professional development opportunities, & engaging in key initiatives supporting HIM practice
1932 cirriculum for medical record librarians was finalized
early medical record librarian programs were in hostpials & required 2-4 yrs college, some req graduation from approved nursing school
developed by ARLNA 1943 Essentials of an Acceptable School for Medical Record Librarians
Essentials of an Acceptable School for Medical Record Librarians is uniform standard for all medical record programs
ART programs transitioned to 2 & 4 yr college/univeristy settings in 1960's & 70's due to profession's body of knowledge grew & expanded skills in work setting were required of program graduates
when AHIMA changed its name in 1991 college programs changed their program names to HIM
standards that are basis for HIM program accreditation Standards for Health Information Management Education
expertise hlth data calloction, analysis, monitoring, maintenance & reporting activites in accordance w/established data quality principles, legal/regulatory standards & professional best practices guidelines Asoociates Degree HIM
expertise to develop, implement/manage individual, aggregate, & public hlth care data collection & reporting systems Baaclaureate Degree HIM
executive level, enterprise-wide, administrative, research or applied health informantics activities Master's Degree HIM
accreditation is defined as voluntary, nongovernmental process that educational programs elect to participate in as a means of demostrating to public that program meets/exceeds stated standards of educational quality
Standards for Health Information Management Education was previously Essentials of an Acceptable School for Medical Record Librarians
program accreditation standards of AHIMA represent minimum requirements an education program must follow to acheive program accreditation
2004 AHIMA established its own accrediting body Commission on Accreditation for Health Informantics & Information Management Education (CAHIIM)
approval programs offered by AHIMA but not fall under responsibility of CAHIIM Coding & Transcription
Coding & Transcription administered by AHIMA Approval Committee for Certificate Programs
demostrating to public that program/orgranization meets/exceeds stated standards of quality focus of accreditation
means of protectin public from individuals who haven't met standards of practice prescribed by given state or profession licensure, certification, registration
credentialed individuals req to maintain credential over time by meeting CEUs as defined by agency/organization that supports credential
licensure occurs at state level & overseen seen by state licensing board/agency
most hlth professionals who treat/touch patients in some way are required to be licensed by state in which they practice
HIM professional certification begain in 1933 when AHIMA formed Board of Registration to set standards for its members
constructed from detailed job analysis studies of individuals working in the field certification examinations
AHIMA's certifying body is Council on Certification (COC)
COC is responsible for creating/maintaing certification & recertification process
Created by: lfrancois