HEALTH INFORMATION TECHNOLOGY PROGRAM HITT 1301 HEALTH DATA CONTENT AND STRUCTURE/CRN: Fall 2015/6161/RT

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1 HEALTH INFORMATION TECHNOLOGY PROGRAM HITT 1301 HEALTH DATA CONTENT AND STRUCTURE/CRN: Fall 2015/6161/RT Syllabus is subject to change at the discretion of the instructor. Carolyn Stariha, MS, RHIA Office: Suite 533, Room 532 (5 th floor) Telephone: Office Hours: Student Conferences by appointment. This is an online class except the Midterm Exam, Final Exam, and Individual Projects are completed at the Coleman College. The class will meet at the Coleman College on Mondays (4:30pm) for the Midterm Exam, the Final Exam, and to present Individual Projects. Also, the GoToMeetings will be on Mondays from 6:30pm-7:30pm (CST). The syllabus review will be online on a gotomeeting (August 26, 2015-Wednesday) from 4:00pm-5:00pm (CST). Gotomeeting information will be provided in Eagle 2 online (Quick mail). Course Description: Introduction to system and processes for collecting maintaining and disseminating primary and secondary health related information. Introduction in delivery and organizational structure to include content of health record, documentation requirements, registries, indices, licensing, regulatory agencies forms, and screens. Course Objectives: AHIMA DOMAINS, SUBTASKS, AND TASKS for the Registered Health Information Technician I. Domain: Healthcare Data A. Subdomain: Data Structure, Content and Use 1. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources 2. Conduct qualitative analysis to assure that documentation in the health record supports the diagnosis and reflects the progress, clinical findings, and discharge status II. Domain: Health Information Analysis 1.Abstract records for department 5. Present data in verbal and written forms III. Domain: Healthcare Environment Healthcare Information Requirements and Standards Assist in developing health record documentation Perform quantitative analysis of health records to evaluate compliance with regulations and standards Perform qualitative analysis of health records to evaluate compliance 1

2 Assist in preparing the facility for an accreditation, licensing, and/or certification survey Ensure facility-wide adherence to health information services compliance with regulatory requirements Domain: Information Technology & Systems Subdomain: Health Information Systems Collect and report data on incomplete records and Timeliness of record completion 1. Maintain filing and retrieval systems for paper-based patient records Maintain integrity of master patient/client index Maintain integrity of patient numbering and filing systems Design forms, computer input screens & other health record documentation tools Course Goals: *US Department of Labor, Secretary s Commission on Achieving Necessary Skills 1. Trace the history of medical record management and describe the evolution of healthcare. 2. Discuss the health information profession, code of ethics, and organizational structure. 3. Define the term (health record), understand its purpose, uses, and the content therein. 4. Identify regulatory bodies that impact health record documentation. 5. Analyze health records qualitatively and quantitatively. 6. Describe advantages and disadvantages of the filing, storage, and retention methods. Describe the filing systems. 7. Collect data on the quality of documentation in the health record. 8. Collect data on the status of incomplete records. 9. Identify design rules for data collection forms. 10. Describe construction considerations that must be made for paper forms. 11. Describe the function of indexes and registries, the way in which data is collected, and the types which must be maintained. Scans Competencies: 1. F1 Reading, F2 Writing, F3 Listening, F10 Seeing things in the minds eye, C5 Acquires and Evaluates Information. 2. F1 Reading, F2 Writing, C9 Participates as a member of a team, F12 Reasoning. 3. F12 Reasoning, F1 Reading, F2 Writing, C5 Acquires and Evaluate. 4. F12 Reasoning. 5. C7 Interprets and communicates information. 6. F12 Reasoning, Acquires and Evaluates Information, F9 Problem Solving. 7. C7 Interprets and communicates information. 8. F8 Decision Making, C7 Interprets and Communicates. 9. F12 Reasoning, F9 Problems Solving. 10. C5 Acquires and Evaluates Reasoning. 2

3 Textbook Reference: -Health Information Management Technology, 4th Edition-Nanette Sayles, ISBN: Health Information: Management of a Strategic Resource, 4th Edition-Abdelhak, Grostick, Hankens, & Jacobs. -Healthcare Information Technology Exam Guide for CompTIA-MCCormick & Gugerty, ISBN: Professional Review Guide, PRG, 2014 Edition (Latest Edition) -Comprehensive Review Guide for Health Information RHIA & RHIT Exam Prep-Tyson- Howard & Thomas Class Time: Distance Education Students will meet on Mondays at the Coleman College to take the Midterm, Final exam, and for Individual Projects. The exams and projects will be scheduled for 4:30pm in Room 538 on the 5th floor. The individual presentations will take two (2) class sessions to complete and all students are required to be in attendance for both sessions. This is mandatory and if a student is absent for one (1) of the sessions then points will be deducted from their grade. If the student does not present their project then they will lose points for the presentation portion of their project. Class Requirements: 1. Read the assignments outlined on the attached schedule. 2. Turn in assignments in a timely manner. 3. Have necessary materials to complete assignments. 4. Participate actively in class discussions. 5. Conduct research. Course Methodology: Distance Learning/Powerpoints Classroom Participation Student Research Videos Exams: Exams are multiple choice, true and false, fill in the blank, matching and essay ( questions). There will be approximately 5 exams including the mid-term and the final. Exams need to be taken on the date assigned. Make-up exams may not be taken for the Mid-term or Final Exams. All make-up exams must be approved by the instructor and 20 points will be deducted from each make-up exam. Mid-term and Final exam must be taken at the Coleman College from (4:30 pm until 7:00 pm). ****Please Note: All assignments are due on the dates stated. No late assignments accepted. Any assignment which is submitted late will not be graded. If you do not turn in your assignments, group project assignments, and homework on time then you will receive an automatic F. Do not submit any assignment via Eagle online or instructor s HCC . Once again, please do not any assignments in because they will not be graded. Do not ask if a late assignment can be 3

4 submitted. Students need to use time management and complete their assignments in a timely fashion. Houston Community College System seeks to provide equal education opportunities without regard to race, color, religion, national origin, sex, age, or handicap. This policy extends to employment, admission, and all programs and activities supported by the college." ADA STATEMENT: Any student with a documented disability (e.g. physical, learning, psychiatric, vision, hearing, etc.) who needs to arrange reasonable accommodations must contact Disability Services Office at (713) at the beginning of each semester. Faculty is authorized to provide only the accommodations requested by the Disability support services office. NOTICE: Students who repeat a course for a third or more time may soon face significant tuition/see increases at HCC and other Texas public colleges and universities. Please ask your instructor/counselor about opportunities for tutoring/other assistance prior to considering course withdrawal or if you are not receiving passing grades. Early Alert Syllabus Statement: The Houston Community College Early Alert program has been established to assist in the overall effort to retain students who are at risk of failing, withdrawing, or dropping a course. This process requires instructional faculty and student support staff to identify students who are performing poorly as early as possible and provide relevant support services to help students overcome their deficiencies. A student is identified when an instructor notices academic or personal difficulties that affect student s academic performance. The possible problem (s) could be tardiness, missed/failed test scores, excessive absences, or a number of other circumstances. Once a referral is made counselors will then contact students to discuss the issues and possible solutions to their academic difficulties. Tutor- Mr. John Davis (Hours are listed outside of the HITT Lab on the 5th floor, Room 538). See Student Success Center for further details. Academic Success Center-( ) Academic Dishonesty will not be tolerated. Exams and assignments are individual assignments. Plagiarized and copied papers will be handled in accordance with established HCCS college policy. Do not copy the work of other professionals. Attendance Policy: Students who are absent more than three class sessions may be administratively dropped from the course without notification. Exceptions to this policy will be up to the discretion of the instructor. The instructor checks attendance weekly. The instructor is required to report all absences for all students receiving financial aid (grants, VA, Social Security, etc.) Distance education student need to send the instructor a weekly stating how they are doing in the class. 4

5 It is the responsibility of the student to formally withdraw from a class not the instructor. Students must actively participate in Eagle online. If the student does not participate then they will be considered an absent student. EGLS3 -- Evaluation for Greater Learning Student Survey System At Houston Community College, professors believe that thoughtful student feedback is necessary to improve teaching and learning. During a designated time, you will be asked to answer a short online survey of research-based questions related to instruction. The anonymous results of the survey will be made available to your professors and division chairs for continual improvement of instruction. Look for the survey as part of the Houston Community College Student System online near the end of the term Grading Policy: Homework Assignments (Discussion Postings, Video Assignments)- 9% Journal Assignment- 3% HIM Interviews- 4% Quizzes- 14% Individual Projects-5% (All of the above assignments are worth 35% of your grade) Tests (including Mid-term) 40% Final Exam 25% NO Make-Up Examinations for the Midterm and/or Final Grading Scale A B C Below F The letter grade of D cannot be earned in the Health Information Technology Program Test Scores: Students in the Health Information Technology Program may not keep test, nor test results that have been taken within the program. Upon receiving test outcomes, students must record their test scores so they are able to remember their grades. Also, students will not be able to review the results of tests taken online. Students will be able to review the midterm exam and final only at the Coleman College. 5

6 Cover Sheet: All assignments must have a coversheet. Assignments turned in without a coversheet will result in points being deducted. The cover sheet must be centered on the sheet of paper and must include the following: Student s Name Student s ID # Class Name and Class CRN # Assignment Title Date Due Instructor s Name JOURNAL ASSIGNMENT: Students are to prepare at least a two (2) page, doubled spaced typed journal summary. One of the following Health Information Journals must be utilized The American Health Information Management Association Journal, Advance, or For the Record. A copy of the article must be attached to the summary. The student must include a Cover Sheet & a Works Cited Page. References need to be cited according to APA guidelines. Students will need to answer the questions listed on the assignment. Be sure the article pertains to the Electronic Record. Submit assignment via Eagle online. Date Due: September 27, 2015 HOMEWORK: Assignments are listed under the objectives. Students must answer all questions fully in order to receive credit. The questions should be answered to assist the student with learning and being successful within the classroom. Homework is due as assigned (Sunday 11:30pm-CST). Also, students will be watching video throughout the semester and answer the questions provided with the assignment. Due: As Assigned HIM INTERVIEWS: Each student will interview a credentialed Health Information practitioner (RHIA, RHIT, CCS) of the students choice. Students must notify practitioners to schedule the interview. Interviews need to be done in person not by phone, faxes, or . Students will be given 5 questions to ask at their interview. The student will need to make-up 5 questions of their own to ask at the interview. The interview is 4% of your grade. Interview questions and answers must be submitted to the instructor on the date they are due. Be sure to include the practitioner s name, title, place of business, and phone number. Students are not allowed to interview practitioners at the same time. This is an individual project and should be treated as such. Students will present questions to the class. Practitioners should be someone other than the student's preceptor for the Practicum I. Submit assignment via Eagle online. Student needs to follow the guidelines of this assignment in order to receive the proper credit. Date Due: November 16, 2015 QUIZZES: Students will be quizzed weekly over the assigned readings. 6

7 INDIVIDUAL PROJECTS: Each student will be assigned a Health Information topic. Students are at liberty to research any related journals, books, the internet, magazines, etc. Students may also interview professionals in the field. Creativity is strongly encouraged. Please include a bibliography or works cited page with your report. Students will present their topic in class. The student needs to have a powerpoint to present the information or another form of visual aid. The presentations should be 10 to 15 minutes in length. The report should have a cover sheet, 5 pages of information discussing the topic, and a bibliography or works cited page. The work cited page needs to be referenced according to APA (American Psychological Association). The student must have at least four references with only 2 from the internet. Student must be present on in order to get full credit for attendance. Plan to be in attendance on both dates. Due Date: October 26, 2015 Presentations Due: October 26, 2015 & November 2, 2015 DISCUSSION POSTINGS: Students will do research on 6 topics and post on the course board. The discussions must consist of at least one page of research and references must be cited according to APA. The topics include: Discussion 1: The evolution, from the medical records to health information. Be sure to include information regarding HIPAA and the electronic medical record. Discussion 2: Ethics in Health Information Technology Discussion 3: The evolving job functions of the Health Information Professional. Be sure to include past job functions and present job functions such as the Privacy Officer. Also, review all of the credentials which AHIMA offers. Discussion 4: The future of the Health Information Profession. How is the electronic record changing Health Information Technology? Where is the future of HIM going? How will the electronic record affect the future? How will Universal Health Care affect health care in general and the HIM profession?. Pros and Cons of an Electronic Health Record. Discussion 5: The importance of Health Information. The importance of Privacy and Security of Health Records. Be sure to include legal information, HIPAA, and information related to confidentiality. Also, include information about Health Care Reform, HI-Tech Act, and Stimulus Act. Discussion 6: Ethical Issues Related to Documentation and privacy, Ethical Issues related to the Electronic Record, and HIPAA. Information you have learned about the Electronic Health Record. Due: As Assigned HAHIMA Meetings-Attendance will give students 3 points overall on their final grade. The student must be a member in good standing and pay all fees related to the meeting. Also, student will need to prepare a 2 page typed summary of the information that was learned 7

8 at the meeting. The original CE Form needs to be turned into the instructor prior to the end of the semester. HITT 1301 Health Data Content and Structure\CRN: Fall 2015/RT SCHEDULE Please note: Quizzes and Exams are posted on Mondays (4:00pm) and close on Sundays (11:30pm). Lesson 1: August 24, 2015-August 30, 2015 Introduction to Course-August 26, 2015 (Wednesday) at 4:00pm-5:00pm (CST) gotomeeting online. Information for the gotomeeting will be available in Eagle 2 (Quick Mail). Lesson 2: August 31, 2015-September 6, 2015 Evolution of Health Care and Health Information/An Overview of Healthcare in the U.S./An Overview of How Healthcare is Paid for in the US/Health Care Policy/Regulatory Aspects of Healthcare IT: Legal Best Practices and Requirements/Reporting Requirements and Regulatory and External Factors Affecting Healthcare IT. Quiz 1 Discussion Posting 1 Homework Assignment September 7, Labor Day Holiday Lesson 3: September 8, 2015-September 14, 2015 Forms Design/Computer Hardware and Architecture for Healthcare IT/Core HIT Functionality/Human Factors in Healthcare IT/Physical Safeguards, Facility Security, Secure Systems, and Networks, and Securing Electronic Media Quiz-2 Discussion Posting 2 Homework Assignment Video Assignment Lesson 4: September 14, 2015-September 20, 2015 Exam I (Covers information from Lesson 2. The exam will cover the Evolution of Health Care and Health Information/An Overview of Healthcare in the U.S./An Overview of How Healthcare is Paid for in the US. Ethics in Health Care/Ethics and Healthcare Focus on Information Technology Quiz 3 8

9 Lesson 5: September 21, 2015-September 27, 2015 Journal Assignment Due: September 27, 2015 (Flow of the Health Record /Health Record Content/Format Types/Management of Health Record Documentation/The role of Information Technology in Healthcare/An Overview of Processes Associated with Healthcare Delivery Within Provider Organization/Organizational Success Factors in Healthcare Informatics Implementation/Fundamental of Health Workflow Process Analysis and Redesign) Discussion Posting 3 Homework Assignment Quiz 4 Lesson 6: September 28, 2015-October 4, 2015 HIPAA/Training Essentials for Implementing Healthcare IT/Building Trust/Risk Assessment and Management/Healthcare Information Security: Operational Safeguards Quiz 5 Homework Assignment Video Assignment Lesson 7: October 15, 2015-October 11, 2015 Exam II (Covers Information from Lesson 3)- Forms Design/Computer Hardware and Architecture for Healthcare IT/Core HIT Functionality/Human Factors in Healthcare IT/Physical Safeguards, Facility Security, Secure Systems, and Networks, and Securing Electronic Media Filing and Numbering Systems/Record Storage and Retention/Record Problems/Unique Operational Safeguards in an Electronic Health Record and a Healthcare Information Exchange/Architectural Safeguards/Healthcare Cybersecurity Technology. Quiz 6 Homework Assignment Video Assigment Final Exam Review Lesson 8: Exam III (MID-TERM) will cover information From Lessons 1-Lesson 5. The exam will be taken on October 12, 2015 at 4:30pm in Room 538, on the 5th floor. Previously taken exam may be reviewed at 3:00pm. 9

10 Lesson 9: October 19, 2015-October 25, 2015 Index and Registries Quiz 7-(March 23-March29) Homework Assignment Discussion Posting 4 Video Assignment Lesson 10: October 26, 2015-November 1, 2015 Individual Projects Presentations will be presented at the Coleman College at 4:30pm in Room 538, 5 th floor on October 26, 2015 & November 2, 2015 All individual assignments are due on October 26, Lesson 11: November 2, 2015-November 8, 2015 Continuation of Individual Projects Presentations will be presented at the Coleman College at 4:00pm in Room 538, 5 th floor on November 2, 2015 Exam 4 will cover information from Lesson 6- HIPAA/Training Essentials for Implementing Healthcare IT/Building Trust/Risk Assessment and Management/Healthcare Information Security: Operational Safeguards Lesson 12: November 9, 2015-November 15, 2015 Regulatory Agencies/Electronic Health Record Homework Assignment Discussion Posting 6 Video Assignment Exam 5 will cover information Lesson 7-(Filing and Numbering Systems/Record Storage And Retention/Record Problems/Indexes and Registries/Unique Operational Safeguards in an Electronic Health Record and a Healthcare Information Exchange/Architectural Safeguards/Healthcare Cybersecurity Technology. Lesson 13: November 16, 2015-November 22, 2015 Electronic Health Record HIM Interviews due on November 16, 2015 Lesson 14: November 26 & 27, 2015-Thanksgiving Day November 23, 2015-November 29, 2015 Electronic Health Record Exam 6 will cover information from Lesson 13 & Lesson 14 (Electronic Health Record). Lesson 15: November 30, 2015-December 6, 2015 Final Exam Review 10

11 Lesson 15: Final Exam (Comprehensive) The Final Exam will be taken at the ColemanCollege on December 7, 2015 at 4:30pm in Room 538. Previously taken exams may be reviewed at 3:00pm. 11

12 Health Information Technology HITT 1301 Health Data Content and Structure Objectives Mastery of all objectives will be demonstrated by student obtaining at least 75% accuracy rate on written exams. Lesson 1: No Reading Assignment. Lesson 2- Evolution of Health Care and Health Information/An Overview of Healthcare in the U.S./An Overview of How Healthcare is Paid for in the US/Health Care Policy READING ASSIGNMENT Abdelhak Ch. 1, 2, 3 Sayles- Ch. 1, 2, 11, & 19 McCormick & Gugerty-Ch. 1, 2, 11 Homework Assignment: Answer the following questions. The student will: Trace evolution of the following: Health care in the United States, Joint Commission, and the American Health Information Management Association (AHIMA). Know the essential characteristics of a hospital. Discuss the health care consumer. Know regulatory agencies and Department of Health and Human Services. Know the purpose, value, uses, and responsibility of the health record. Know the educational requirements for the RHIA and RHIT. Know the continuing education requirements for the RHIA and RHIT. Understand the Health Information practitioner roles in the work place. Explain the institutions and individuals that makeup the healthcare setting. What is the role of the government in healthcare? What is the objective of health insurance? Explain Medicare and Medicaid. Explain the trends in Payment reform. Explain concerns for PHI. How is healthcare IT helping to reform healthcare? What is interoperability? 12

13 Lesson 3: Fundamentals of Electronic Information Systems/Introduction to Electronic Health Information Systems/Electronic Health Records/Computer Hardware and Architecture for Healthcare IT/Core HIT Functionality/Human Factors in Healthcare IT/Physical Safeguards, Facility Security, Secure Systems, and Networks, and Securing Electronic Media READING ASSIGNMENT Abdelhak- Ch. Sayles- Ch. 14, 15, & 16 McCormick Ch. 15, 16, 26 Homework Assignment: The student will answer the following questions. The student will: State the major components of an information system. State the principal activities of information systems. Explain the purpose of an electronic database. What is the purpose and benefits of a data warehouse? Compare and contrast clients and servers. Explain the evolution of information systems in healthcare. Explain and identify the three major types of information system applications and their general functions used in healthcare organization. Explain the difference between unstructured and structured data entry. Define and explain data warehouses, data mart, and data mining. Explain the roles of the HIM professional in Electronic Health Information Systems. Define the electronic health record and describe its various components. Explain the challenges to developing an electronic health record. What are some of the various initiatives to promote adoption of EHR and health information technology (HIT)? Describe the functionality of an EMR. How do various healthcare information systems interact with the EMRs? Describe what usability is and why it is important in healthcare IT. Differentiate human factors from human-computer interaction. What are the necessary physical safeguards for your system, including location, access, and access control devices? What are the guidelines for security and preservation of electronic media for storage devices and secure disposal of electronic media? 13

14 Lesson 4: Ethics in Health Care/Ethics and Healthcare Focus on Information Technology READING ASSIGNMENT ABDELHAK- Ch. 3 & 4 Sayles-Ch. 12 McCormick & Gugerty-Ch. 3 Homework Assignment: The student will answer the following questions. Student Will: Know and understand the professional code of ethics. What is ethic? What is ethical and what is not ethical? Know and Understand AHIMA s Code of Ethics and Bylaws. Name some unethical things that a health information professional can do. What is the difference between law and ethics? What are appropriate uses and users when deal with health records whether paper based or electronic. Lesson 5: (Flow of the Health Record /Health Record Content/Format Types/Management of Health Record Documentation/The role of Information Technology in Healthcare/An Overview of Processes Associated with Healthcare Delivery Within Provider Organization/Organizational Success Factors in Healthcare Informatics Implementation/Fundamental of Health Workflow Process Analysis and Redesign) READING ASSIGNMENTS ABDELHAK Ch. 4 Styles-Ch. 3 McCormick & Gugerty-Ch. 4, 5, 12, 17, 20, 21 Homework Assignment: The student will answer the following questions. Health Record Flow Student Will: Trace the flow of the medical record. Know documents generated by the medical service, nursing service, and ancillary services. List, understand, and know administrative data. List, understand, and know clinical data. Know report guidelines and time limits. Define, understand, and know problem oriented, source oriented, and integrated medical record. Know the advantage and disadvantage of each. Define SOAP. Management of Health Information READING ASSIGNMENT Homework: The student will answer the following questions. The student will know: Know documentation requirements. 14

15 Understand the different types of analysis. Understand documentation requirements by Joint Commission. Know the components of Quantitative and Qualitative Analysis. Know and understand potentially compensable events. Know and understand incomplete and delinquent medical records. Describe the key components of the electronic health record. Discuss barriers to HER adoption for both physicians and hospitals. Discuss the barriers of health information exchange. Explain the workflow associated with scheduling a patient for a visit to an ambulatory healthcare facility. Explain the need for health data standards. Explain meaningful use. Lesson 6: HIPAA/Training Essentials for Implementing Healthcare IT/Building Trust/Risk Assessment and Management/Healthcare Information Security: Operational Safeguards Sayles-Ch. 13 McCormick & Gugerty-Ch. 23, 24, 25, 27 Additional reading materials will be provided by Ms. Stariha The student will answer the following questions. The student will know: What is HIPAA? Why is HIPAA important? What is the privacy rule? Explain the relationship between dependability and healthcare quality and safety. Explain five guidelines for building dependable systems. Identify the differences between security, privacy, and other healthcare risks. Explain the different threats and associated mitigation strategies. Define operational safeguards. Lesson 7: Filing and Numbering Systems/Record Storage and Retention/Record Problems/Unique Operational Safeguards in an Electronic Health Record and a Healthcare Information Exchange/Architectural Safeguards/Healthcare Cybersecurity Technology. READING ASSIGNMENT Sayles-Ch. 7 McCormick Ch. 28, 29, 30 Homework Assignment- The student will answer the following questions. The student will know: Know and understand the different filing systems. Know and understand the different Numbering Systems. Know and understand the advantages and disadvantages of each. Know Centralization and Decentralization. Understand the elements of Record Control. 15

16 Understand the elements of Record Retention. Explain the relationship between identity, access, control, authorization, authentication, and role assignment. Explain access control to data from the perspective of patient, user, and resource, as well as in the context of information use. Explain how to apply security concepts to a healthcare information exchange (HIE). Explain the importance of architectural safeguards for designing, building, purchasing, and implementing safe and secure IT systems and medical devices. What is the balance between usability and security? Define usability safeguards including encryption. Lesson 10: Indexes and Registers READING ASSIGNMENT Abdelhak Ch. 13 Sayles-Ch. 8 Homework: The student will answer the following questions: Student will know: Define Index. Define Register. Understand and know the Master Patient Index. What is the content and arrangement? Understand and know the Number Index. What is the content and arrangement? Understand and know the Disease and Operation Index. What is the content and arrangement? Know uses of Indexes. Know the uses of automated and manual indexes. Know the different types of indexes and their uses. Know the different types of registers and their uses. Know and Understand Database Management, Case Eligibility, Case-finding, Abstracting, Coding, Staging, automation, and uses of the discussed registries. i.e., AIDS, Diabetes, Birth Defects etc. Lesson 11: Electronic Medical Record READING ASSIGNMENT Abdelhak -Ch. 5, 7, 8, 9 Sayles-Ch. 7, 14, 15, 16, 17, McCormick & Gugerty-Ch. 6, 7, 8, 10, 17, 18, 19 Homework: The student will answer the following questions: Student will know: -Understand the concept and evolution of the electronic health record (EHR). -Identify and define terms associated with EHRs. -Relate the various initiatives local, regional, and national adoption of the EHR and health information technology. 16

17 -Discuss the EHR challenges and the supporting roles of health information management professionals in addressing them, especially with respect to privacy, security, and legal aspects. -Develop an appreciation for the planning and implementation aspects of EHRs. -Provide examples of EHR systems as they may be implemented in various types of care settings. -Discuss clinician and other user needs in an electronic health record environment. -Identify common health information management operational issues in a hybrid and electronic health record environment. -Identify resources and strategies needed by health information management professionals to lead and participate in electronic health record projects. -Discuss the role of social medial and mobile devices in relation to the Electronic Health Record. Define the terms clinical data repository, clinical decision support, computerized provider order entry, workflow analysis, health information exchange, and continuity of care document. Explain the key elements of a clinical decision support system. Compare decision support capabilities and customizability. Lesson 12: Regulatory Agencies/Regulatory Aspects of Healthcare IT: Legal Best Practices and Requirements/Reporting Requirements and Regulatory and External Factors Affecting Healthcare IT READING ASSIGNMENT: McCormick Ch. 13 & 22 Homework: The student needs to answer the following questions. Define business associate, covered entity, privacy, security, and protected health information. What are the legal documentation requirements-what needs to be baked in or included in application development to meet legal requirements? Explain the implications for healthcare IT on the necessary requirements to assure privacy and security for electronic healthcare information. Name and explain external agencies and regulatory bodies that have an effect on healthcare information technology. Explain how healthcare reform (including both legislative and payment reform) is influencing the development and use of HIT systems. Name key areas of risk and benefit within EMR systems as they relate to regulations and reimbursement. Lesson 13: Electronic Health Record READING ASSIGNMENT: McCormick Ch. 31, 32, 33, 34, 35, 36 Homework: The student needs to answer the following questions. What are key certification programs and process? Describe multiple ways of assessing HIT. Compare and contrast electronic health record/electronic medical record technologies and how each is implemented. Explain different server types, environments, features, and limitations. What are some ways to troubleshoot and solve common PC problems. 17

18 Explain the importance of programming for healthcare information technology. What are operating systems and their functions? Explain what a database is and why it is important in healthcare information technology. Explain what data warehousing and data mining are. Describe key data networking concepts. Describe how data flows in a wired or wireless network. Describe HL7 and its use in transmitting healthcare data. Describe trends in systems analysis and design in healthcare. 18

19 Please Note: Only one person per topic Health Information Technology HITT 1301 Data Content and Structure Individual Projects 1. HIM Department (Organizational Charts) 2. Administrative & Clinical Records 3. AHIMA Professional Code of Ethics 4. Proper Documentation Guidelines 5. Chart Assembly (Types of Record Design) 6. Quantitative & Qualitative Analysis 7. Forms Design 8. Straight Numeric & Terminal Digit Filing 9. Case Abstracting (Indexes & Registries) 10. Health Information Management Professionals: Credentials, HIM Career Opportunities, Professional Organizations 11. Electronic Record (Advantages & Disadvantages) 12. Record Storage Methods including Filing equipment 13. Electronic Health Record 14. Electronic Health Record 19

20 15. Numbering Systems 16. Traditional Paper-Based Record vs. Electronic Health Record 17. HIPAA 18. Professionalism 20