Discussion: Evolution Of Electronic Medical Records And Information Management

Discussion: Evolution Of Electronic Medical Records And Information Management ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Evolution Of Electronic Medical Records And Information Management I’m studying for my Computer Science class and need an explanation. Discussion: Evolution Of Electronic Medical Records And Information Management See attachments of assignment and a sample paper topic_task_2_evolution_of_emr.docx bshi_task_2_lindacolton_secure_.pdf Topic “The Evolution of Electronic Medical Records” Key words: Health Information Management (HIM) Running head: CAPSTONE TASK 2 1 C506 Task 2: Health Informatics and Information Management in Home Health Linda S. Colton Western Governors University CAPSTONE TASK 2 2 Abstract Modern healthcare organizations including home health agencies rely on the accuracy, integrity, reliability, and accessibility of health information for a multitude of functions in addition to providing quality patient care, including quality initiatives and reimbursement. Payment methodology changes, adoption of electronic health records (EHRs), and the other technological advancements have altered the work of healthcare professionals, including those in health informatics and information management (HIIM). Attempts to control healthcare costs have increasingly propelled patient care to settings non-hospital settings. This report examines the role of health informatics and information management (HIIM) professionals in home health care, describes the integral challenges they encounter in this unique setting, and recommends possible solutions. CAPSTONE TASK 2 3 C506 Task 2: Health Informatics and Information Management in Home Health Health Information and Information Management in Home Health Residents of the United States age 65 and older grew from 35 million in 2000, to 49.2 million in 2016 (U.S. Census Bureau, 2017). Technology is keeping preterm infants alive at much earlier gestations and lower weights. Healthcare is being pushed to less costly settings by government programs and other reimburses. Discussion: Evolution Of Electronic Medical Records And Information Management All these changes are causing home health to broaden its role in the healthcare spectrum. Health Informatics and Information Management (HIIM) practitioners can benefit from these developments, and contribute to the advancement of home health with their existing experience and knowledge. HIIM authorities need to comprehend home health and its information requirements to assist those already working in this setting, and educate home health administrators on the benefits of employing HIIM professionals within their agency Home Health: No Place Like Home For centuries, ill and injured people received care in their homes, but medical and technological advancements plus financial incentives caused healthcare to become an official industry and moved care to formal settings. Nowadays, economics and technology are reversing the trend. Healthcare has increased in the home, “where health care began, and where patient satisfaction and quality of life are greatest” (Fusco, 1994). When you are acutely sick or injured, you want to receive the best care possible in a state of art facility. When one is less severely ill or injured, recuperating, or managing a chronic illness, it is often preferable to receive care in the home. Sleeping in your own bed and having your family, friends, and pets nearby is preferable to a clinical setting for most people. A comfortable, familiar setting can be less stressful for a patient than having to be transported to and from a healthcare facility, or having to be inpatient. CAPSTONE TASK 2 Yet, it is the cost containment efforts of insurance companies and government programs which have encouraged hospitals to discharge patients earlier with home health care. Home health began as a business in America during the late 19th century, but it was not commonly utilized until Medicare was made available to the elderly in 1965, and to some disabled younger citizens in 1973. Home health agency (HHA) services are predominantly provided to the elderly, and as life expectancy has increased, this population has grown in America. Discussion: Evolution Of Electronic Medical Records And Information Management Medical, technological, and pharmaceutical advancements have also increased the survival rate of infants born prematurely or with congenital anomalies. These and other immunity compromised patients can require care at home to prevent unnecessary exposure to communicable diseases. Patients who are non-compliant with care or medications including at risk obstetrical patients, uncontrolled diabetics, and asthmatics can benefit from home assessments and educational visits. Home health services include: • Intermittent skilled nursing • Private duty nursing • Physical therapy • Speech therapy • Occupational therapy • Intermittent home health aide • Durable medical equipment and medical supplies These home health services are provided according to a plan of care that is certified and periodically recertified by a physician (“Medicare and Medicaid Program”, 2017). Home health services allows individuals to remain in their homes while receiving care that would otherwise need to be provided in a hospital or other healthcare facility. Patients 4 CAPSTONE TASK 2 5 receive care based on orders by a physician from the clinicians working for the home health agency. The physician certifying a patient’s need for home health does not work for the agency, and the clinician who provides the care does not work for the physician. Additionally, the physician requesting home health services upon discharge from an inpatient hospital stay, frequently is not the physician who will be following the patient. The services provided by home health agencies vary based on their structure and the patient they serve. Home health organizations may be official agencies operated by a county public health department, nonprofit agencies (independent or hospital affiliated), proprietary or for-profit agencies, corporate chains, and hospital based agencies. Discussion: Evolution Of Electronic Medical Records And Information Management The majority of agencies are accredited by either The Joint Commission (TJC) or the Community Health Accreditation Program (CHAP). Most home health agencies are Medicare-certified having proved that they meet federal standards and consequently are eligible to receive payment for Medicare patients. Some HHAs may choose to be non-certified if they do not provide skilled nursing or other services covered by Medicare (Nies & McEwen, 2011, p. 652). Roles of Participants/Key People Health informatics and information management (HIIM). This department oversees the storage and retrieval of patient information while ensuring compliance with state and federal regulations, and accreditation standards. Even if a HHA is affiliated with a hospital, they still often have separate health records (Butler, 2017b, p. 16). Home health medical records are frequently hybrid, maintained in paper and electronic formats. HIIM responsibilities include processing health records which may involve assembling paper charts, scanning and indexing documents in to an electronic document management system (EDMS), and/or working queues in in and electronic health record (EHR). They typically also handle release of patient information, CAPSTONE TASK 2 6 and following up on plans of care and other documentation which may need physician signature or revision made by the HHA clinician. Most HHAs have centralized certified coding professionals (Butler, 2017b, p. 17), but some still rely on their clinicians to do coding as part of their patient assessments. Depending on the size of an agency and its resources, traditional HIIM functions may be the responsibility of a dedicated department, may be an individual, or may be the divided between clinical, support, and IT staff. Senior management. Discussion: Evolution Of Electronic Medical Records And Information Management A governing body and an administrator, who is often a physician or registered nurse, typically lead the HHA. They are responsible for ensuring the organization is providing quality care, fiscally responsible, and compliant with federal, state, and local laws. Management. A nursing manager usually oversees clinical operations within a HHA. They are ultimately responsible for patient care policies and procedures, as well as clinical staffing and training. Depending on the size and type of care offered, the HHA agency may have additional clinical supervisors over different branches, regions, or category of clinical therapies. Clinicians. The type of healthcare practitioners HHAs employee varies, but frequently includes registered nurses (RN), home health aides, occupational therapists, physical therapists, physicians, practical nurses, social workers, and speech therapists. They are trained and licensed professionals who provide direct care to patients. They also act as a liaison between the patient, family, other caregivers, and the agency. HHA clinicians communicate with their patients’ physicians by phone, fax, email, or secure messaging systems. They are responsible for carrying out the physician’s orders and documenting it in the patient’s home health record. Their documentation is necessary for reimbursement, to document quality of care, and to comply with regulations and standards. CAPSTONE TASK 2 7 Intake/Referral Coordinators. HHAs receive referrals for services from a variety of sources including hospital discharge planners, physician offices, and the potential patient or family member. The HHA intake/referral coordinators are counterparts to hospitals’ registration staff. Discussion: Evolution Of Electronic Medical Records And Information Management They start or update the patient’s health record documenting information such as the patient’s demographic information, therapies being requested, physician who will certify patient’s need for services, date of the physicians’ last face-to-face encounter with the patient, and the patient’s insurance or government program information. The intake/referral staff is the frontline for the agency’s patient health information. Accurate patient and provider information can prevent HIPAA breaches. Obtaining precise and timely documentation prior to initiating care ensures that the patient will receive appropriate, medically necessary care from the agency, and the HHA will be reimbursed for their services. Reimbursement/Finance. One of the primary purpose of patient health records if to document the information needed to substantiate the medical necessity home health services and document the services provided for reimbursement (Johns, 2011, p.31). Reimbursement is dependent on the health information captured during the intake/referral, prior authorization, clinical documentation, and coding processes. Equally, these areas are reliant on of education and feedback from the Reimbursement professionals if claims are denied because of issues related to their responsibilities. Furthermore, inappropriate and fraudulent billing by some HHAs has caused additional payer review of supporting documentation and increased the importance of accurate and timely documentation of patient services. Information Technology (IT). As with any industry today, home health relies on various software and hardware to conduct its business. Point of care charting on mobile devices, electronic health records, clinical decision support systems, reporting, and record retrieval are CAPSTONE TASK 2 8 just a few health information functions which require the support of IT professionals. Discussion: Evolution Of Electronic Medical Records And Information Management HIIM must depend on the IT department to perform necessary installations and upgrades to the EHR, especially those required by regulators. They also must be able to keep all the equipment functioning and available to those in the HHA offices and the mobile devices being utilized in patient homes. Quality Improvement (QI)/Compliance. Oversight of Medicare and Medicaid HHAs is conducted by county health departments, federal agencies, and their contractors, including the Centers for Medicare and Medicaid, the Office of Inspector General, and the Department of Justice. Patients, commercial payers, affiliated hospital, and physician referral sources all are interested in substantiating that the HHA is providing quality patient care that is compliant with regulations and standards. Effective health information management not only supports patient care, it also produces data that evaluates the effectiveness and quality of the care provided, as necessary for regulatory and accreditation agencies. Data from the HHA’s patient health records are used in quality improvement activities and for strategic planning (Gregg Fahrenholz & Russo, 2013, p. 551). Home health QI, Compliance, and HIIM responsibilities may or may not be within the same department, but they will undoubtedly need to work together closely to support the HHAs quality initiatives. Evolution Within Field of HIIM The American College of Surgeons established the Hospital Standardization Program in 1918 which required medical records to be written precisely and completely on all patients. Prior to this time, charts were kept informally and sporadically unless they were being used for research (Johns, 2011, pp. 6-7). Discussion: Evolution Of Electronic Medical Records And Information Management These standards progressed into other healthcare settings including home health as healthcare professionals recognized the value of keeping a record of the CAPSTONE TASK 2 9 care received, any complications, and the outcomes of the care they and others have provided to a patent. Home health clinicians had to go to the HHA’s office to get their schedules, and to review previous nursing notes, medication profiles, or physician orders which were maintained in paper patient charts by medical records staff. This process continues to be utilized by some home health agencies for all or some of their disciplines, but most have implemented point of care systems with allow the clinician to document into the patient’s chart and review their health record during the visit. Home health utilization increased in the U.S. significantly after Medicare was made available to the elderly in 1965. Home health continues to be predominately provided to the elderly and disabled with Medicare and Medicaid as their primary payers; and therefore, federal regulations have had the primary impact on the content and format of HHA health information. Home health agencies become Medicare-certified after they have proven that they meet federal standards and consequently are eligible to receive payment for Medicare patients. Some HHA may select to be non-certified if they do not provide skilled nursing or other services covered by Medicare. The Centers for Medicare and Medicaid’s (CMS) Home Health Initiative endorsed in 1994 that conditions of participation for home health agencies include “a core standard assessment data set and patient-centered, outcome-oriented performance expectations that stimulate continuous quality improvement” (Gregg Fahrenholz & Russo, 2013, p. 588). The Outcome and Assessment Information Set (OASIS) is a data set to monitor outcome quality improvement measures on adult home health patients. The OASIS data elements are the basis of the comprehensive assessment that HHAs complete on all patients at the start of care, every sixty days thereafter, with a notable change in conditions, transfer, and discharge. These assessments CAPSTONE TASK 2 10 are completed by the clinician, and form the basis for the patient’s Plan of Care. HHAs must submit OASIS data on all adult Medicare and Medicaid patient electronically to the Quality Improvement and Evaluation System (QIES) with thirty days of its completion. Discussion: Evolution Of Electronic Medical Records And Information Management HHAs may use the CMS Home Assessment Validation Entry (HAVEN) software or their EHR vendor supplied application. This mandate compelled many HHAs who had not already done so to adopt EHRs. The OASIS data elements have been revised periodically, and the submission and reporting requires specific software and internet service provider version. Therefore, HIIM frequently works with IT to facilitate the OASIS submission. The Health Insurance Portability and Accountability Act (HIPAA) law of 1996 was enacted primarily to streamline the transfer of health information with the creation of a uniform set of electronic healthcare transaction codes. It required the Department of Health and Human Services to implement national standards for electronic healthcare transactions, code sets, because of technological advancements and subsequent potential threats to the security of health information. The HIPPA Privacy Rule addresses the use and disclosure of protected health information. It balances the need to share patient information in some essential instances, while defending patient’s privacy from malicious or unnecessary use. The HIPAA Security Rule create national standards to protect electronic personal health information (ePHI). As healthcare has become more complex with the growth of managed-care, home health agencies have had to increase their attention to their health information. HHAs should be able to store patient information securely, and retrieve it when necessary to maintain licensure, certification, and accreditation. With the adoption of EHR expanding, it has become increasingly obvious that home health providers should have EHRs with interoperability requirements to achieve optimal care coordination and quality outcomes with hospitals, physicians, and other CAPSTONE TASK 2 11 providers (Office of the National Coordinator [ONC], 2013). Consequently, it has become more vital for home health agencies to employ HIIM professionals to prevent problems related to the availability, quality, and security of their health information.Discussion: Evolution Of Electronic Medical Records And Information Management Topic’s Influences on The Workplace A longstanding adage in healthcare states that “if it isn’t documented, it didn’t happen.” More accurately, a home health visit “has not been completed until it has been documented and incorporated into the patient’s clinical record” (Follman, 2015). Home health operations depend on a variety of information being captured and maintained in patient records including: • Patient demographics and service agreement • Certification and plan of treatment • Physician’s orders • Physician documentation of face-to-face encounter • Progress notes for each discipline involved the patient’s care • Comprehensive assessment/OASIS • Consents and other legal documents • Referral and transfer information • Discharge summaries (Johns, 2011, pp. 100-101). HIIM supports the home health agency by ensuring that all health information related to a patient is merged into their health record that is accessible for care, reimbursement, quality improvement, educational, research, and regulatory functions. Without experienced HIIM practitioners HHAs may not be able to adequately perform these functions. Many HHAs recognize the benefit of employing professionals who have the expertise to address the unique difficulties of health information in their setting. HIIM practitioners are familiar with working CAPSTONE TASK 2 12 with a variety of clients and can collaborate with clinician and IT professionals on technological and workflow issues. However, HIIM is dependent on the support of management, the clinical disciplines, IT, and other departments to successfully apply its expertise and best practices within the agency, while tackling the inherent challenges of home health HIIM. Discussion: Evolution Of Electronic Medical Records And Information Management Inherent Challenges Probable causes. Documenting in a non-traditional setting. Most home health services are provided in the residence of the patient or a family member. Occasionally they may receive services in a hotel, school, daycare, or other settings if necessary. This fundamental characteristic of home health is the basis of many of challenges faced by home health HIIM professionals. Home health is unlike other healthcare settings because the patient or family oversees the facility where care is being provided. It is more difficult for health information to be captured easily, comprehensively, and then incorporated in to patient health records timely when documentation is being done by clinicians in “an environment over which they have little control” (Butler, 2017b, p. 17). Furthermore, the clinicians may do their charting on paper or be responsible for completing other forms with the patient, such as consents and service agreements. The HHA relies on them to make sure that necessary paper documentation makes i … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10