HITT Health Information Systems

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1 HITT 1311 Health Information Systems AUSTIN COMMUNITY COLLEGE Semester: FALL 2015: August 25 - December 13, 2015 PROGRAM: COURSE NUMBER: Health Information Technology HITT Health Information Systems COURSE TIME/LOCATION: Saturdays as Scheduled 10:00 a.m. 12:00 p.m., Room 9209 FACULTY NAME: Martha A. Hurtado, RHIA Instructor: Martha A. Hurtado, RHIA Phone: Office Hours: By appointment Location: Room 9215 Website: COURSE DESCRIPTION: Introduction to health IT standards, health-related data structures, software applications and enterprise architecture in health care and public health. COURSE PREREQUISITES: None COURSE RATIONALE: Careers in Health Information Technology (HIT) are among the most varied and rapidly expanding in the health care fields. HIT professionals are an integral part of the healthcare team in managing and processing healthcare records and clinical data. COURSE OBJECTIVES: Upon completion of the course the student will be able to: 1.1 Define the terms electronic medical record (EMR) and electronic health record (EHR). 1.2 Explain the concept of interoperability and its importance in the EHR environment. 1.3 Define the terms syntactic interoperability level and semantic interoperability level. 1.4 Define computer protocol and discuss the most common communication protocol, HL Describe the Health Information Technology for Economic and Clinical Health Act and the federal incentive program for implementing EHRs. 1.6 Understand the concept of meaningful use and identify its three main components. 1.7 List and discuss the benefits and barriers to implementing EHRs. 1.8 List and discuss the evolving roles of the health information manager in the EHR environment. 2.1 Define the term health record and examine it multiple purposes. 2.2 Explain ownership of the health record. 2.3 Describe the requirements and standards for the health record.

2 2.4 Describe the paper health record s purpose, format, and features. 2.5 Differentiate the types of data in the health record. 2.6 Explain the importance of proper documentation in the health record. 2.7 Describe the purpose, format, and features of the electronic health records (EHR). 2.8 Compare and contrast the workflow of the paper health record versus the HER. 3.1 Define the term input, output, processing, storage, and local area network. 3.2 Identify the role of the health information professional in the electronic health record. 3.3 Explain the certification of EHR systems by the Certification Commission for Health Information Technology (CCHIT). 3.4 Demonstrate how to set up and navigate an EHR system. 3.5 Describe the password and security measures of the EHR system. 3.6 Identify menu options in an EHR system. 3.7 Examine charting features in an EHR system. 3.8 Review the various scheduling features of an EHR system. 3.9 Examine secure messaging, document management, laboratory integration, and e- prescribing features of an EHR system Examine mobile features in an EHR system. 4.0 Identify various healthcare settings. 4.1 Understand the difference between an established and a new patient for admission and registration purposes. 4.2 Identify various documents found in an acute care or ambulatory care record. 4.3 Define the term master patient index. 4.4 Explain the registration process for a patient requiring ambulatory care. 4.5 Explain the admission process for a patient requiring acute care. 4.6 Understand the distinction between a subscriber and a guarantor. 4.7 Explain the birthday rule. 5.0 Apply procedures to customize the schedule. 5.1 Demonstrate how to schedule a patient in an acute care setting. 5.2 Demonstrate how to schedule, cancel, and reschedule an established patient in an outpatient setting. 5.3 Illustrate how to generate a provider schedule. 5.4 Apply procedures to check out or discharge a patient. 5.5 Demonstrate how to transfer a patient in an acute care setting. 5.6 Use the Patient Tracker feature of the EHR Navigator to follow the patient from arrival to checkout. 6.0 Define Health Insurance Portability and Accountability Act of 1996 (HIPAA), specifically the Administrative Simplification Provision and the date enacted. 6.1 Define the term covered entity. 6.2 Discuss the main components of the Privacy Rule. 6.3 Define the term protected health information.

3 6.4 Discuss the concept of minimum necessary as it relates to the release of health information. 6.5 Explain the enforcement and penalty process for violations of HIPAA Privacy and Security regulations. 6.6 Demonstrate competency in the use of electronic health record software as it relates to the release of health information. 6.7 Discuss the Breach Notification Rule. 6.8 State the two primary purposes for the development of the Security Standards of HIPAA. 6.9 Discuss the major sections of the standards of the Security Rule Discuss the difference between required and addressable implementation specifications. 7.0 Depict how health information management (HIM) roles and functions are evolving as a result of implementation of electronic health records (EHR). 7.1 Demonstrate use of a master patient index. 7.2 Explain the tracking of paper medical records. 7.3 Discuss the advantages and disadvantages of coding from an EHR. 7.4 Explain how transcribed reports interface and become part of the EHR. 7.5 Discuss the benefits and challenges of using speech recognition technology. 7.6 Demonstrate release of information (ROI) functions carried out by HIM staff in the HER environment. 7.7 Demonstrate how to produce an accounting of disclosures log. 7.8 Demonstrate the monitoring and completion of EHRs. 7.9 Describe the process of scanning paper records, including document identification and preparation, indexing, and quality control. 8.0 Define and discuss structured and unstructured data. 8.1 Define data mining and its relationship to structured and unstructured data. 8.2 Explain manual and automated methods of data collection. 8.3 Identify the elements of a history and physical examination. 8.4 Understand how to enter progress notes into an EHR, as well the role of assessments, orders, test results and other clinical documentation in the EHR system. 8.5 Define cloned notes and their related concerns. 8.6 Define e-prescribing and its benefits and challenges. 8.7 Modify an e-prescription and override a drug allergy notification. 8.8 Understand clinical results reporting and discuss manual and automatic methods of results entry into the EHR. 8.9 Understand how HER systems support public health initiatives Create a Meaningful Use Report via the EHR Navigator Report an immunization. 9.0 Define nomenclature and identify the role of nomenclature in the electronic health record (EHR).

4 9.1 Define classification systems and identify specific classification systems used for coding for each healthcare delivery systems. 9.2 Discuss the purposes of diagnostic and procedural coding. 9.3 Discuss the classification systems used to code diagnoses and procedures, including the International Classification of Diseases, Current Procedural Terminology, Healthcare Common Procedure Coding System, The Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition, and Current Dental Terminology. 9.4 Discuss how EHRs affect coding and billing processes. 9.5 Define and described computer assisting coding. 9.6 Define and discuss important coding and billing terms such as discharged not final billed (DNFB) and present on admission (POA). 9.7 Demonstrate coding and billing processes utilizing EHR software Define clinical decision support system (CDSS) Define the two types of CDSSs Discuss the knowledge-based CDSS Discuss the advantages and disadvantages of using a CDSS List the most common uses of clinical decision support in healthcare Explain the requirements of the Centers for Medicare and Medicaid Services (CMS) for the clinical decision support rule as part of the meaningful use core measures Demonstrate clinical decision support activities in electronic health record (EHR) software and discuss the role of EHRs in clinical decision support Discuss the role of the EHR in quality improvement Examine a personal health record (PHR) Identify the characteristics (or content) of the PHR Compare the differences in the types of PHRs Discuss the multiple purposes of a PHR Explain the various ways PHRs are stored Explain the ownership of the PHR Discuss the advantages of the PHR Identify the challenges to implementing a PHR Explain the connection between the PHR and the electronic health record of (EHR) Identify the components of a patient portal Demonstrate use of the Northstar Patient Portal Define the goals of the Certification Commission for Health Information Technology Explain the incentive criteria for electronic health record (EHR) systems developed by the Centers for Medicare & Medicaid Services Describe how to assess a healthcare facility s readiness for the implementation of an EHR system Evaluate and create a healthcare facility s goals for an EHR system Examine an EHR migration plan Explain the workflow analysis.

5 12.7 Understand the total cost of ownership Describe the evaluation process for HER systems Examine a request for proposal and an implementation plan Assess stages of meaningful use. COURSE STUDENT LEARNING OUTCOMES: The curriculum of the Austin Community College Health Information Technology program is designed to meet or exceed the professional course content as published in the AHIMA Model Curriculum that includes the HIM Entry-Level Competencies and Knowledge Clusters. This course addresses the specific Domains, Subdomains, and Competencies identified below: Domain I: Health Data Management Subdomain A: Health Data Structure, Content, and Standards 1. Collect and maintain health data (such as data elements, data sets, and databases). 2. Conduct analysis to ensure that documentation in the health record supports the diagnosis and reflects the patient s progress, clinical findings, and discharge status. 3. Apply policies and procedures to ensure the accuracy of health data. 4. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases. Subdomain B: Healthcare Information Requirements and Standards 1. Monitor and apply organization-wide health record documentation guidelines. Subdomain C: Clinical Classification Systems 1. Use and maintain electronic applications and work processes to support clinical classification and coding. Domain IV: Information Technology & Systems Subdomain A: Information and Communication Technologies 1. Use technology, including hardware and software, to ensure data collection, storage, analysis, and reporting of information. 2. Use common software applications such as spreadsheets, databases, word processing, graphics presentation, , and so on in the execution of work processes. 3. Use specialized software in the completion of HIM processes such as record tracking, release of information, coding, grouping, registries, billing, quality improvement, and imaging. 4. Apply policies and procedures to the use of networks, including intranet and Internet applications, to facilitate the electronic health record (EHR), personal health record (PHR), public health, and other administrative applications. 5. Participate in the planning, design, selection, implementation, integration, testing, evaluation, and support for EHRs.

6 Subdomain B: Data, Information, and File Structures 1. Apply knowledge of database architecture and design (such as data dictionary) to meet departmental needs. Subdomain D: Data Security 1. Apply confidentiality and security measures to protect electronic health information. 2. Protect data integrity and validity using software or hardware technology. 3. Apply departmental and organizational data and information system security policies. 4. Use and summarize data compiled from audit trails and data quality monitoring programs DISCIPLINE/PROGRAM STUDENT LEARNING OUTCOMES: Upon completion of the Associate of Applied Science Degree in Health Information Technology, the student will be able to: A. Appropriately manage and use health data. B. Collect report and interpret database information and compute related healthcare statistics. C. Apply and participate in the implementation of laws and policies and procedures within healthcare delivery systems as they relate to payment systems, healthcare provider information needs, patient privacy and disclosure and ethical standards of practice. D. Utilize technology, including specialized hardware and software applications to ensure accurate data collection, record tracking, and analysis, reporting and will be able to apply and contribute to the application of electronic health records and to the maintenance and design of patient information retrieval systems, while maintaining confidentiality and security of information. E. Apply the fundamentals of team and financial resource management, including budgeting, teamwork, education, communication and interpersonal skills in order to contribute to work plans, policies and procedures, resource management and others in performance as a member of a team. SCANS Competencies In 1990, the U.S. Department of Labor established the Secretary s Commission on Achieving Necessary Skills (SCANS) to examine the demands of the workplace and whether our nation s students are capable of meeting those demands. The Commission determined that today s jobs generally require competencies in the following areas: Resources: Identifies, organizes, plans and allocates resources Interpersonal: Works with others Information: Acquires and uses information Systems: Understands complex interrelationships Technology: Works with a variety of technologies

7 The Texas Higher Education Coordinating Board requires that all degree plans in institutions of higher education incorporate these competencies and identify to the student how these competencies are achieved in course objectives. HITT 1311 COMPETENCE Resources Interpersonal Information Systems Technology Basic Skills Thinking Skills Personal Qualities EXAMPLE OF LEVEL Identifies resources used in course and allocates time for studying. Shares experiences and knowledge with classmates, works as a member of a team for any assigned activities. Identifies coding and classification system for records. Identifies electronic health record. Identifies systems to use such as encoder, quadramed or AS400. Discusses electronic health record with classmates and instructor. Reads assigned chapter pages or web articles. Identifies and prepares for tests, quizzes and research activities. Works as a team member for any assigned activities. Asserts self and networks with classmates and virtual lab to obtain information on current topics. TEXTBOOKS: (1) Exploring Electronic Health Records 2015 edition, Darline Foltz, RHIA and Karen Lankisch, Ph.D, RHIA, ISBN (2) Health Information Management Technology, 4 th Nanette B. Sayles, EdD, RHIA, CHPS, CCS, CPHIMS, FAMIMA, ISBN:

8 INSTRUCTIONAL METHODOLOGY: Classroom and Online Face to face GRADING SYSTEM: The Health Information Technology courses use the following scale for determination of final grades: A = % B = 80-89% C = 70-79% D= F = below 60 A grade of 70% or above is required for passing any subject area. METHOD OF EVALUATION: Class Attendance/Participation: 10% Blackboard/Course Navigator Assignments: 30% Chapter Exams: 30% Final Exam: 30% All grades will be posted on Blackboard. Late Assignment Policy: Please refer to the Assignment Guidelines posted on Blackboard under Course Information for detailed directions for completing assignments and formatting. Assignments must be turned in by the due date listed on the Course Schedule. Late assignments may be subject to a 5 point penalty if submitted after the posted due date. Exam Policy: All scheduled exams will be taken in class in Blackboard. If a student misses one exam for a documented medical or family emergency, a makeup exam must be scheduled within 7 business day by ing the instructor. ALL EXAMS MUST BE TAKEN NO LATER THAN THE DUE DATE INDICATED ON THE COURSE SCHEDULE.

9 COURSE POLICIES: Attendance/Class Participation Regular and punctual class and laboratory attendance is expected of all students. If attendance or compliance with other course policies is unsatisfactory, the instructor may withdraw students from the class. Cell Phone Use: Students are expected to place their cell phone on mute status at the beginning of each class meeting. If the student receives an emergency call, he or she is asked to quietly leave the classroom to respond to the cell phone call. Withdrawal Policy It is the responsibility of each student to ensure that his or her name is removed from the roll should he or she decides to withdraw from the class. The instructor does, however, reserve the right to drop a student should he or she feel it is necessary. If a student decides to withdraw, he or she should also verify that the withdrawal is submitted before the Final Withdrawal Date. The student is also strongly encouraged to retain their copy of the withdrawal form for their records. The student is required to turn in their program student ID and any equipment or items that belong to the department. Failure to do so may compromise their standing at ACC. Students who enroll for the third or subsequent time in a course taken since fall, 2002, may be charged a higher tuition rate, for that course. State law permits students to withdraw from no more than six courses during their entire undergraduate career at Texas public colleges or universities. With certain exceptions, all course withdrawals automatically count towards this limit. Details regarding this policy can be found in the ACC college catalog. Incompletes An instructor may award a grade of I (Incomplete) if a student was unable to complete all of the objectives for the passing grade in a course. An incomplete grade cannot be carried beyond the established date in the following semester. The completion date is determined by the instructor but may not be later than the final deadline for withdrawal in the subsequent semester. Requests for incompletes must be submitted by the following dates: Deadline for Fall Semester: Second Friday in November November 13 th, 2015 Deadline for Spring Semester: Friday following Spring Break Deadline for Summer Semester: Friday following the 4th of July

10 In all cases an incomplete cannot be requested unless 1/2 of the required coursework has been completed. For HITT 1311, you must have completed the following: Exam 1, Exam #2 (midterm) and assigned class assignments/presentations. Statement on Scholastic Dishonesty A student attending ACC assumes responsibility for conduct compatible with the mission of the college as an educational institution. Students have the responsibility to submit coursework that is the result of their own thought, research, or self-expression. Students must follow all instructions given by faculty or designated college representatives when taking examinations, placement assessments, tests, quizzes, and evaluations. Actions constituting scholastic dishonesty include, but are not limited to, plagiarism, cheating, fabrication, collusion, and falsifying documents. Penalties for scholastic dishonesty will depend upon the nature of the violation and may range from lowering a grade on one assignment to an F in the course and/or expulsion from the college. See the Student Standards of Conduct and Disciplinary Process and other policies at The complaints and grades dispute process can also be found at the above site and is located in your Health Information Technology Program handbook at Student Rights and Responsibilities Students at the college have the rights accorded by the U.S. Constitution to freedom of speech, peaceful assembly, petition, and association. These rights carry with them the responsibility to accord the same rights to others in the college community and not to interfere with or disrupt the educational process. Opportunity for students to examine and question pertinent data and assumptions of a given discipline, guided by the evidence of scholarly research, is appropriate in a learning environment. This concept is accompanied by an equally demanding concept of responsibility on the part of the student. As willing partners in learning, students must comply with college rules and procedures. Statement on Students with Disabilities Each ACC campus offers support services for students with documented disabilities. Students with disabilities who need classroom, academic or other accommodations must request them through the Office for Students with Disabilities (OSD). Students are encouraged to request accommodations when they register for courses or at least three weeks before the start of the semester, otherwise the provision of accommodations may be delayed. Students who have received approval for accommodations from OSD for this course must provide the instructor with the Notice of Approved Accommodations from OSD before accommodations will be provided. Arrangements for academic accommodations can only be made after the instructor receives the Notice of Approved Accommodations from the student. Students with approved accommodations are encouraged to submit the Notice of Approved Accommodations to the instructor at the beginning of the semester because a reasonable

11 amount of time may be needed to prepare and arrange for the accommodations. Additional information about the Office for Students with Disabilities is available at Safety Statement Austin Community College is committed to providing a safe and healthy environment for study and work. You are expected to learn and comply with ACC environmental, health and safety procedures and agree to follow ACC safety policies. Additional information on these can be found at Because some health and safety circumstances are beyond our control, we ask that you become familiar with the Emergency Procedures poster and Campus Safety Plan map in each classroom. Additional information about emergency procedures and how to sign up for ACC Emergency Alerts to be notified in the event of a serious emergency can be found at You are expected to conduct yourself professionally with respect and courtesy to all. Anyone who thoughtlessly or intentionally jeopardizes the health or safety of another individual will be immediately dismissed from the day s activity, may be withdrawn from the class, and/or barred from attending future activities. Use of ACC All College communication to students will be sent solely to the student s ACCmail account, with the expectation that such communications will be read in a timely fashion. ACC will send important information and will notify you of any college related emergencies using this account. Students should only expect to receive communication from their instructor using this account. Likewise, students should use their ACCmail account when communicating with instructors and staff. Instructions for activating an ACCmail account can be found at For help setting up your ACCeID, ACC Gmail, or ACC Blackboard, see a Learning Lab Technician at any ACC Learning Lab. Testing Center Policy if applicable. Under certain circumstances, an instructor may have students take an examination in a testing center. Students using the Academic Testing Center must govern themselves according to the Student Guide for Use of ACC Testing Centers and should read the entire guide before going to take the exam. To request an exam, one must have: ACC Photo ID Course Abbreviation (e.g., ENGL) Course Number (e.g., 1301) Course Synonym (e.g., 10123) Course Section (e.g., 005) Instructor's Name

12 Do NOT bring cell phones to the Testing Center. Having your cell phone in the testing room, regardless of whether it is on or off, will revoke your testing privileges for the remainder of the semester. ACC Testing Center policies can be found at Student and Instructional Services ACC strives to provide exemplary support to its students and offers a broad variety of opportunities and services. Information on these services and support systems is available at: Links to many student services and other information can be found at: ACC Learning Labs provide free tutoring services to all ACC students currently enrolled in the course to be tutored. The tutor schedule for each Learning Lab may be found at:

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