Based on extensive experience in the field, this book will introduce readers to the principles and practices of Health Information Management through understanding of Health Information Technology and its application today. Topics covered in the book are based on the core competencies defined by AHIMA as well as HIPAA regulations and JACHO recommendations. To prepare for twenty-first century healthcare occupations, the reader needs to understand the connectivity and applications that make up Health Information Systems of today. The book will provide readers with a thorough understanding of both the terminology of Health Information Technology and the practical use of Information Systems in actual medical facilities. Ample illustrations make it easy to visualize workflow scenarios and technical concepts. Photographs of healthcare providers using various HIT systems and medical devices make it easy to see the practical applicability in a medical office.

Table of Contents

Table of Contents Preface Introduction Learning Made Easy (walk through) Organization of The Text A Few Words of Advice About The Author Acknowledgements Chapter 1 Health Care Delivery Fundamentals Healthcare Settings Ambulatory Care Facilities Acute Care Facilities Long Term Care Facilities Rehab Facilities Home Care Comparison of Inpatient versus Outpatient Admission and Discharge Health Care Providers and Professions Direct Care Providers Doctors Nurses Licensed Practical Nurse Registered Nurse Physician Assistant Allied Health Care Professions Clinical Allied Health Professions Non-Clinical Allied Health Professions Chapter One Summary Testing Your Knowledge of Chapter 1 Chapter 2 Health Information Professionals History of Health Information Management HIT and HIM professions List of job descriptions and organizational structures HIM manager or director Registered Health Information Administrator Clinical Data Specialist DRG Coordinator APC Coordinator Clinical Coding Specialist Coding Associate Medical Transcriber Cancer Registrar HIM compliance specialist Optical Imaging Coordinator Registered Health Information Technicians Real Life Story: Building An All Digital Hospital Clinical Project Manager, IT Project Manager Clinical Analyst Clinical Vocabulary Manager Clinical Applications Coordinator Data Quality Manager Data Resource Administrator Decision Support Analyst Health Information Systems Department Technician Enterprise Application Specialist Integration Architect Health Systems Specialist Solution Analyst Solution Consultant Systems Analyst Information Security Manager Records and Information Coordinator Officers and Other Positions Compliance Officer Privacy Officer Information Privacy Coordinator Security Officer Risk Management Specialist Utilization Manager Quality Improvement Director Senior Document Coordinator Health Services Manager Patient Information Coordinator Clinical Research Associate Medical Office Manager Health Insurance Specialist Real Life Story: Examples of Project Management Organizations of Importance to HIM or HIT Professionals AHIMA HIMSS AMIA MGMA ACMPE ANSI HL7 AAMT NCRA AAPC Skills For Success Chapter Two Summary Testing Your Knowledge of Chapter 2 Chapter 3 Accreditation, Regulation and HIPAA Accreditation and Regulation CMS State and Local Laws The Joint Commission (JCAHO) CAP CARF HIPAA Administrative Subsection HIPAA Transactions and Code Sets HIPAA Uniform Identifiers Privacy and Security of Patient Records HIPAA Privacy Rule Privacy Policy Consent Modifying HIPAA Consent Authorization Research Research Exceptions Marketing Government Agencies Minimum Necessary Incidental Disclosures A Patient's Right to Know About Disclosures Patient Access to Medical Records Health Information Management Responsibilities Personal Representatives Minor Children Business Associates Civil and Criminal Penalties Real Life Story: The First HIPAA Privacy Case HIPAA Security Rule The Privacy Rule and Security Rule Compared Security Standards Implementation Specifications Administrative Safeguards Security Management Process Assign Security Responsibility Workforce Security Information Access Management Security Awareness and Training Security Incident Procedures Contingency Plan Real Life Story: Contingency Plans Ensure Continued Ability to Deliver Care Evaluation Business Associate Contracts and Other Arrangements Physical Safeguards Facility Access Controls Workstation Use Workstation Security Device and Media Controls Technical Safeguards Access Control Audit Controls Integrity Person or Entity Authorization Transmission Security Organizational, Policies and Procedures Documentation Requirements Organizational Requirements Policies and Procedures Documentation Chapter Three Summary Testing Your Knowledge of Chapter 3 Chapter 4 Fundamentals of Computer Systems The Technology Behind Health Systems Hardware CPU Memory and Storage Random Access Memory Hard Drives Optical Disks Read Only Memory Magnetic Tape Input and Output Devices Ergonomics Software Operating Systems Application Software Bits and Bytes How a Computer Works Extending Functionality Databases Characters Fields Records Files and Tables Data Dictionary Relational Data Images Image Storage: File or BLOB Networks Network Hardware Clients and Servers Local Area Networks Wide Area Networks Internet Protocols (TCP/IP) Secure Remote Access Wireless Networks Printers and Reports Report Server COLD Interoperability standards Data Elements Data Sets HL7 Maintaining Interoperability CCOW Communication Systems E-Mail systems Telecommunications Real Life Story: A Look Behind The Hospital Network Chapter Four Summary Testing Your Knowledge of Chapter 4 Chapter 5 Health Care Records Understanding Health Care Records Functions of Health Care Records Primary and Secondary Uses of Records Types and Structure of Health Records Transition From Paper To Electronic Records Health Record contents Administrative and Demographic Data Consent and Directives HIPAA Consent to Use and Disclose PHI Consent to Treatment Informed Consent Refusal of Treatment Medicare Patient Rights Statement Assignment of Benefits Advance Directives Organ Donor Personal Property List Disclosure Records Clinical Documents Medical History Physical Exam Diagnostic and Therapeutic Orders Diagnostic and Therapeutic Reports Diagnostic Images Operative Records Nursing Notes Referral Consults Case Management Discharge Summary Obstetrical Records Pediatric Records Public Health Records Continuity of Care Record RHIO Who Owns The Record? The Personal Health Record Telemedicine Teleradiology Reporting Home Nursing Visits Patient Reporting And Telemonitors E-Visits Chapter Five Summary Testing Your Knowledge of Chapter 5 Chapter 6 Organization, Storage and Management of Health Records How Paper Charts Are Organized Source Oriented Record Problem Oriented Record Integrated Record Electronic Views Filing Paper Records Paper Chart Numbering Systems Paper Chart Filing Systems Terminal Digits Filing Color Coding Record Storage and Circulation Calculating Storage Chart Locator Systems Legal and Ethical Management of Health Records Record Retention Real Life Story: You Never Know What You Don't Know Destruction of Health Records Release of Information HIM and HIT Ethics AHIMA Code of Ethics Chapter Six Summary Testing Your Knowledge of Chapter 6 Chapter 7 Electronic Health Records Electronic Medical Records IOM CPRI HIPAA EHR Defined Social Forces Driving Adoption Health Safety Health Costs Government Response Functional Benefits of an EHR Health Maintenance Trend Analysis Alerts Decision Support Prescriptions Medical References Protocols Form Affects Functionality Standard EHR Coding Systems SNOMED MEDCIN LOINC Advantages of Codified Records Health Maintenance Trend Analysis Alerts Decision Support Documenting At The Point of Care Benefits of Real Time Documentation Document storage and image retrieval systems Quality Control Real Life Story: Where's My Chart? Flow of An Office Fully Using EHR Electronic Signatures How Digital Signatures Work Methods of Capturing and Recording Data Clinician Entered Data Saving Clinicians Time Nomenclature Lists Forms Search Prompt Flow Sheets Orders Protocol Patient Entered Data Workflow Using Patient Entered Data Preventive Health Screening Alternative Workflow E-Visits Workflow of An E-Visit Health Maintenance Immunizations Preventative Care Screening Using EHR Data For Alerts Reactions to Drugs or Other Treatments Other Types Of Alerts Decision Support Chapter Seven Summary Testing Your Knowledge of Chapter 7 Chapter 8 Additional Health Information Systems Departmental Systems LIS and device systems Radiology department Cat, CT, PET, MRI etc. Digital images Voice recognition Pharmacy systems Dispensing Systems Drug Trials ER systems Scheduling Systems Surgery Appointments Staff Implant Records Chapter Eight Summary Testing Your Knowledge of Chapter 8 Chapter 9 Health Care Business Systems Administration and Business Systems Registration Master Patient Indexes Insurance Eligibility Episode vs. continuing care Admission/Discharge Coding, Billing and Reimbursement Batch and Real-time posting Transaction Standards Electronic Claims Paper Claims UB-92 CMS 1500 Electronic Remittance Prospective Payment System DRG Accounting and Tax Records Payroll Purchasing and Supplies Inventory Control Chapter Nine Summary Testing Your Knowledge of Chapter 9 Chapter 10 Health Statistics, Research and Quality Improvement Secondary Health Records Using Data Analysis and Research Health Care Statistics Using codified data Coding and abstracting reports Registries Cancer Tumor Immunization CDC Text analysis processing Chapter Ten Summary Testing Your Knowledge of Chapter 10 Chapter 11 Information Systems for Managerial Support Administrative Records Maintenance Records Personnel Records Training Evaluations Accreditation Continuing Education Unit records Incident Records Chapter Eleven Summary Testing Your Knowledge of Chapter 11 Chapter 12 Principles of Management Workflow and Design Project Management Change Management Training and Education Systems Upgrades and Test environments Chapter Twelve Summary Testing Your Knowledge of Chapter 12

Author Biography

About the Author Richard Gartee is the author of four college textbooks on health information technology, computerized medical systems, managed care, and electronic health records. Prior to becoming a full time author and consultant, Richard spent 20 years in the design, development and implementation of leading medical practice and electronic health records systems. Richard served as Vice-President of Product Development and subsequently as Director of Design Strategy at Medical Manager Research & Development, Inc. He also served as a liaison to other companies in the medical computer industry as well as Blue Cross/Blue Shield, a U.S. Department of Commerce International Trade Mission and various universities. Richard is a current or past member of many of the professional organizations and national standards groups recommended in this book: w American Health Information Management Association (AHIMA) w Healthcare Information Management Systems Society (HIMSS) w American National Standards Institute (ANSI) X-12n committee for development of electronic claims standards w Health Level Seven (HL7) committee for development of claims attachment standards w Workgroup for Electronic Data Interchange (WEDI) taskforce for development of electronic remittance guidelines w A faculty member/speaker at the Medical Records Institute international Electronic Health Records conference (TEPR) for twelve years.