State of Information Governance in Healthcare
Case Study – Four Hospital Integrated Delivery System
By: Lesley Kadlec MA RHIA
In an effort to begin to answer basic questions related to the state of information governance (IG) in healthcare, and to showcase some existing information governance models in practice, several organizations across the country were invited to participate in case studies. An analysis of the results of the IG case study from a four hospital integrated delivery system is the basis for this document.
Executive Sponsor
President/CEO.
Program Managers
CIO and Chief Quality Officer
Organizational Description
This organization an integrated health care system and the region’s largest health care provider. As a
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HIM staff had participated in the implementation of the electronic health record, but they did not have a voice in how the data was being used. HIM leadership recognized that a framework was needed.
Physicians were complaining of there being too much clutter in the EHR. They wanted to have a mechanism to understand the patient’s story. There were complaints of too much “garbage” in the record and physicians could not get to the heart of the patient’s complaints. Some physicians wanted to use “progress notes” for everything without entering any discreet data. There was a dependence on scanned documentation, both clinical notes as well as business documents. Scanned documents could not be found in the “notes activity” within the electronic record, meaning physicians had to search multiple tabs to find information while providing patient care. Information Governance Drivers
The program was started to meet reporting requirements for core measures and quality initiatives. The data that was being pulled was felt to be inaccurate or incomplete, and the lack of data integrity was leading to concerns for patient safety.
Physicians could not tell the patient’s story with the amount of clutter in the EHR. Filters were not usable and problem lists were not being maintained. After 8-9 years post implementation, HIM was being bombarded with scanned documents, both
In a healthcare world that operates on stringent budgets and margins, we begin to see the need for a higher capacity healthcare delivery system. This in turn puts pressure on the healthcare organizations to ensure higher standards of patient care, and compliance with the reform provisions. However, these are the harsh realities of today’s healthcare environment, a setting in which value does not always equal quality. The use of technology can help to amend some of this by providing higher capacity care without compromising quality; this can be done with the use of such technology as electronic health records (EHRs). This paper will aim to address how EHRs influence healthcare today by expanding upon topics such as funding sources, reimbursement methods, economic factors, socioeconomic factors, business influences, and cost containment.
The electronic health record (EHR) is a digital record of a patient’s health history that may be made up of records from many locations and/or sources, such as hospitals, providers, clinics, and public health agencies. The EHR is available 24 hours a day, 7 days a week and has built-in safeguards to assure patient health information confidentiality and security. (Huston, 2013)
Since the establishment of Intermountain Health Care, they have grown to become an internationally recognized system of 22 hospitals, a medical group with more than 185 physician clinics, and an affiliated health insurance company. They have been recognized for their achievements and innovations in the development of systems and management, in order to produce effectiveness and efficiency within the processes of healthcare through high quality services and minimisation of costs. Intermountain Health Care’s performance has proved to be advancing exponentially as of the mid 90s, due to clinical-improvement projects routinely showing significant cost savings.
After decades of paper based medical records, a new type of record keeping has surfaced - the Electronic Health Record (EHR). EHR is an electronic or digital format concept of an individual’s past and present medical history. It is the principle storage place for data and information about the health care services provided to an individual patient. It is maintained by a provider over time and capable of being shared across different healthcare settings by network-connected information systems. Such records may include key administrative and clinical data relevant to that persons care under a particular provider. Examples of such records may include: demographics, physician notes, problems or injuries, medications and allergies, vital
The purpose of this paper is to discuss the electronic health record mandate. Who started it and when? I will discuss the goals of the mandate. I will discussion will how the Affordable Care Act ties into the mandate of Electronic Health Record. It will describe my own facility’s EHR and what steps are been taken to implement it. I will describe the term “meaningful use,” and it will discuss possible threats to patient confidentiality and the what’s being done by my facility to prevent Health Information and Portability Accountability Act or HIPAA violations.
The purpose of this discussion board is to describe the Electronic Health Record (EHR), the six steps of an EHR and how my facility implements them, describe “meaningful use” and how my facility status is in obtaining it, and to further discuss the EHR’s and patient confidentiality.
Several years ago, a mandate was ordered requiring all healthcare facilities to progress from paper charting and record keeping to electronic health record (EHR). This transition to electronic formatting has pros and cons associated with it. I will be describing the EHR mandate, including who initiated it, when it was initiated, the goals of the EHR, and how the Affordable Care Act and the Obama administration are tied into it. Then I will show evidence of research and discuss the six steps of this process as well as my facilities progress with EHR. Then I will describe meaningful use and how my facility attained it. Finally, I will define HIPAA law, the possible threats to patient confidentiality relating to EHR, and how what my facility
In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.
As the national health care system transitions to the electronic health record (EHR), it is important to recall the impetus to this reform. Prior to the implementation of the electronic health record, the national health care system encountered many problems that impeded quality patient care. There was not a standardized formal structure with the process. Consequently, it lacked communication across disciplines and among providers and
It has only been within the last five years that health information management (HIM) has experienced exponential changes, due to the healthcare reform. The electronic health record (EHR) is connected to health information exchanges and other systems of interoperability. The timely completion of charts, coding and release of information (ROI) has become much more efficient with the electronic record. Traditional HIM functions will just be transformed and will always be an integral part of successful patient care. Professionals must be flexible and willing to adapt and even generate change. As Health Information Technology continues to evolve, so will the roles
A wave of medical errors and patient deaths caused by healthcare providers renewed the search for a viable EHR system in 2000. Electronic health records would allow "providers to make better decisions and provide better
Although the general population has concerns about who has the ability to access their medical records, data has been put into place showed that the general population knows that having an EHR would be beneficial (Thede, 2010). Research has suggested that patients, providers and insurance companies have benefited from EHRs because insurance companies do not have to pay for duplicate testing as well as patients and providers having the ability to increase the quality of care that is provider (Thede, 2010). Not to mention, the patients aren’t pained to have to remember every detail of the history when visiting various specialist (Thede, 2010). Moreover, EHR can increase medical staff efficiency and reduce errors, and keeping adverse drug events from happening (Bill to promote electronic health records proposed, 2008).
An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.” (healthit.gov) The EHR mandate was created “to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.” ("Providers & Professionals | HealthIT.gov", n.d., p. 1) The process has proved to be quite challenging for providers. As an
Electronic health records (EHR’s) have many advantages, but there are plenty of disadvantages. EHR’s were created to manage the many aspects of healthcare information. Medical professionals use them daily and most would feel lost without it. Healthcare organizations were encouraged to adopt EHR’s in 2009 due to the fact that a bill passed known as The Health Information Technology for Economic and Clinical Health Act (HITECH Act). “The HITECH Act outlines criteria to achieve “meaningful use” of certified electronic records. These criteria must be met in order for providers to receive financial incentives to promote adoption of EHRs as an integral part of their daily practice”, (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012).