I am writing to present a compelling case for including a HIM professional on the CPOE (Computerized Provider Order Entry) project team at Happytown General Hospital. As an HIM professional myself, I strongly believe that our department possesses unique insights, skills, and knowledge that can significantly contribute to the successful implementation and optimization of the CPOE system. In this proposal, I will outline the benefits and value that a HIM professional can bring to the project team.
Expertise in Health Information Management: HIM professionals possess specialized knowledge in managing health information throughout its lifecycle. We have a deep understanding of the information needs of various healthcare stakeholders, including physicians, nurses, pharmacists, and administrators. Our expertise in data standards, clinical terminology, documentation practices, and privacy regulations enables us to bridge the gap between technical requirements and clinical workflows. By including a HIM professional on the CPOE project team, we can ensure that the system is designed and implemented in a manner that aligns with best practices and regulatory requirements.
Clinical Documentation Improvement (CDI) and Coding: Accurate and comprehensive clinical documentation is crucial for the success of the CPOE system. HIM
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HIM professionals have a strong foundation in data governance principles, data integrity, and data quality management. By having a HIM professional on the CPOE project team, we can ensure the development and implementation of robust data governance policies, data standards, and data validation processes. Our involvement will contribute to the accuracy, completeness, and reliability of data captured within the CPOE system, enabling informed clinical decision-making, research, and
They should be hold accountable for any breach in protocols. • Present format for electronic documentation does not allow for comprehensive clinical documentation during follow-up visit. Efforts should be made to upgrade the electronic medical record system to the standard of that expected for a medical center and research institute. This is to allow for proper documentation according to the industrial standard, and easy retrieval of patient’s information for clinical research. There is a need to employ a clinical documentation improvement specialist (CDIS) in this
In Medical Records the Health Information Management Specialist (HIMS) will search labs for a patient’s lipid results and diabetes to enter data in the system. Another part of statistics gathered by the HIMS is after sending outgoing referrals to another physician outside of the facility, a PHI Log is made on the patient (Appendix H-Sleep study referral because SCHC no longer provides those). The PHI Log contains information about the referral: the date requested, who requested (usually the name of SCHC physician), name of the organization that it will be sent to, fax number and what part of the chart did the HIMS send. What job title is responsible for generating statistical data? What job title from the health information department involved with this process?
CPOE systems with clinical decision support systems can improve
Many healthcare organizations had to implement an electronic health records system (EHR) to meet certain guidelines set forth by the government. This was a technology that the clinic implemented years ago to meet the needs of the patient, the requirements of the insurance companies, lean processes, and government regulations. This software helped also look for opportunities to treat our patients better and track data for population health. HG Clinic is investing in a new billing system that will allow them to track patient data better and improved billing process. These are just examples of opportunities that the clinic implemented and are continuously evaluating their current software and equipment and looking for opportunities for
A core element of confidence building is showing the professionals how to value and use information adopted for coded data. This type of information has the power to describe medical necessity in support of admissions, readmission’s and continued stays. An example I would like to give is, by pinpointing
Health Information Exchange Providers across the U.S. are turning to the Health Information Exchange also known as HIE. HIE provides secure online access to patients charts among a network of providers, hospitals, clinics, doctor’s offices, and pharmacies who join in the exchange, so they can have timely electronic access to records their patients will allow them to share. For patients this means having their medical records available no matter where they go and for providers it means having instant access to life saving information when seconds count
Para. 2) The Omaha System remains statistically superior to other interface terminologies of the electronic health record. The efficacy of the Omaha system has been heavily researched and covers numerous types of patients in various types of settings. The authors, well credentialed and academic, thoroughly describe the Omaha system and its benefits for meaningful use achievement.
This includes but is not limited to consulting with managers to determine the role of information technology (IT), modifying and designing systems to ensure efficient workflow, overseeing installation of new systems, troubleshooting and correcting system malfunctions, educating staff on proper procedures and use of new systems as well as analyzing collected data and integrating systems across various units (Western Governors University, 2021). Employment within this field can be found in a hospital position, as a role in reducing hospital costs and patient care, as well as in private practices as a role in improving patient care at a more personal level (Western Governors University, 2021). There is no separate licensing needed, but a background in healthcare and data (bachelor’s degree) as well as a master’s in clinical informatics (Western Governors University,
Confidentiality and data breaches are a few of the main concerns, as many providers become neglectful when sharing patient electronic health information. Current use of Electronic Health Records (EHR) has proven to be helpful for hospitals and independent medical practice to provide efficient care for patients. Balestra reports that using computers to maintain patient health records and care reduces errors, and advances in health information technology are saving lives and reducing cost (Balestra, 2017). As technology advances EHR are going to continue to be the main method of record keeping among medical providers. Therefore, staff and medical providers need to be trained on how to properly share patients EHR safely and in a secure form in order to maintain patient confidentiality.
This includes creating, managing and following patient data. The American Health Information Management Association (AHIMA) defines information governance as “an organization wide framework for managing information throughout its lifecycle and for supporting the organization’s strategy, operations, regulatory, legal, risk, and environmental requirements.” In today’s healthcare system, it is more important than ever to know and understand how healthcare information is created, transferred and used. Due to the development of systems such as electronic health records and clinical decision support systems it is important that health information maintains its reliability and validity throughout its
Most people don’t think to worry or wonder where all of their information goes when they visit the doctor’s office, or how the doctor knew things about them from several years ago. They don’t ask the question especially when they go to a new doctor who knows the same thing about them that they’ve never talked about. Electronic Health Records, also known as EHR’s, are becoming some of the most important parts of medical offices around the country and are advancing more and more each day. Ever since the 80’s, EHR’s were being designed and formed, but not until 2009, when the HITECH Act came out, did they start becoming of key importance to the health care market. As they keep growing more and more each day, EHR’s are becoming vital to patient health.
The authors also showed how HCPCS codes are used when healthcare providers provides education to the patient and/or their family. Gatlin, Mburu, Jackson, and Hunt briefly discuss International Classification of Disease 10th edition (ICD-10) and how healthcare providers have to adopt to a completely new alphanumeric language. In conclusion, Gaitlin, Mburu, Jackson, and Hunt has thoroughly discuss HCPCS and how important it is in healthcare billing. The authors provided two examples on HCPCS and CPT codes are used to help ensure accurate documentation for billing.
Documenting the patient's medical information, reduces medical errors that can become a life or death
The policies and procedures should address the following areas that include, effective communication among various entities in the organization, education and training program for the every department, and most especially the HIM department, implementation of communication channel within the HIM department and other department in the organization, procedures for appropriate disciplinary action/corrective measures, and auditing/monitoring system. Furthermore, the policies and procedures should outline specific action plans that should be followed in the HIM department; the policies and procedures will be fashioned to adhere the guidelines and recommendations of major accrediting and professional organizations such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and National Center for Health Statistics. The issue of medical record availability should be addressed to specify the document requirements necessary for effective coding practice, and also the establishment of the role of physician advisor should be considered in order provide guidance on coding issue and to act as liaison between medical staff and the HIM department. Additionally, as part of the effort to address the coding issues, the HIM coordinator should set goals that will guarantee 100% coding accuracy report and less
Based on this case the cost driver is to properly distribute the direct cost among the different divisions. Dr. Julian would like to control her departments costs by having them distributed fairly among the divisions without affecting the hospital’s reimbursement/revenue. Carroll University Hospital is currently using the standard costing unit, which is based on the cost of bed/day for inpatients. Currently the present cost accounting system that is being used at CUH takes the total direct cost of the departments, then allocates the indirect costs and distributes it among the departments evenly regardless of the actual resources being used in those departments, and without considering that there may be some patients in these divisions that may require more resources than others, this method does not seem to recognize the different activities,