HITT 1301/1001 AUSTIN COMMUNITY COLLEGE Semester PROGRAM: COURSE NUMBER: Health Information Technology HITT 1301/1001 Health Data Content and Structure COURSE TIME/LOCATION: Hybrid/Online FACULTY NAME: OFFICE HOURS/LOCATION: Phone: Email: Website: www.austinccedu/health/hitt Arranging conferences/appointments: by appointment COURSE DESCRIPTION: Introduction to systems and processes for collecting, maintaining, and disseminating primary and secondary health related information. Instruction in delivery and organizational structure to include content of the health record, documentation requirements, registries, indices, licensing, regulatory agencies, forms, and screens. 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. Distinguish between data and information. 2. Explain the structure and use of health information such as individual, comparative and aggregate. 3. Give examples of health information media such as paper, computer, or web based. 4. Identify and describe application software. 5. Distinguish between the content of health records in the acute care inpatient, hospital outpatient/asc and physician office settings. 6. Distinguish between primary and secondary data sources. 7. Give examples of the most common registries and indexes found in hospitals. 8. Describe data presentation methods: tables, graphs, charts, bar and pie charts, histograms, polygrams. 9. Define data mining. 10. Describe the elements of data security systems. 1
11. Identify and define terms associated with data integrity. 12. Define security processes and monitoring. 13. Define data recovery. 14. Identify manual and automated techniques used in storage and maintenance of health records. 15. Distinguish between healthcare datasets (i.e. UHDDS, UACDS, HEDIS and DEEDS) and the delivery setting in which they are used, and identify the types of data collected. 16. Compare the format and content of various types of outpatient health records. 17. Locate clinical data reported on the UB 04/CMS 1500 claim forms in health record documentation. 18. Explain the coding function and discuss the importance of documentation in coding. 19. Explain the value of implementing ICD 10 and ICD 10 PCS. 20. Distinguish between the basic concepts and terms associated with the electronic health record (EHR). 21. Distinguish between a physician s health record and a patient s personal health record (PHR). 22. Explain the importance of adopting a national patient identifier in building the national healthcare information infrastructure, and provide examples of how a patient s identification can affect data integrity. 23. Distinguish between licensure and accreditation and identify examples of each. 24. Understand the history of the healthcare delivery system. 25. Describe the basic organization in the most common healthcare organizations including the physician office and the acute care hospital. 26. Identify the various licensing and regulatory agencies in the healthcare industry. 27. Distinguish the terms: clinical quality assessment, infection control, utilization management, case management and risk management. 28. Explain the elements of a corporate compliance plan. 29. Explain the movement in Medicare to connecting quality of care with payment policies (ACO). 30. Identify coding and reimbursement systems used in the physician office, hospital outpatient/asc and acute care patient settings. 31. Describe differences between commercial, managed care and federal insurance plans. 32. Define, describe and explain the purpose of the case mix index. 33. Describe hospital related statistical terms. 34. Define severity of illness systems. 35. Summarize the information included in vital statistics. 36. Describe descriptive and inferential statistics. 37. Describe the health information management department functions and purpose. 38. Explain the Code of Ethics for HIM professionals. 39. Describe the role of the health information management professional in performance improvement, utilization management and risk management functions. 40. Differentiate the various types of healthcare disciplines and providers in the continuum of care. 2
41. Explain the general functions, purposes and benefits of health information technology systems. 42. Assess the major types of information system applications used in healthcare organizations. 43. Describe health information systems, including, but not limited to: administrative, patient registration, ADT, EHR, PHR, lab, radiology, pharmacy. 44. Define quality control functions for EHRs 45. Compare health information systems in terms of their ability to support the requirements of a healthcare enterprise. 46. Identify coding and payment components used in the physician office, hospital outpatient/ ASC and acute care inpatient settings. 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: Healthcare Data Management Subdomain A: Healthcare Data Structure, Content and Standards 1. Collect and maintain health data (data elements, data sets and databases). 2. Conduct analysis to ensure documentation in the health record supports the diagnosis and reflects the patient s progress, clinical findings and D/C status. Subdomain B: Healthcare Information Requirements and Standards 1. Monitor and apply organization wide health record documentation guidelines. Domain II: Health Statistics, Biomedical Research and Quality Management Subdomain A: Healthcare Statistics and Research 1. Collect, maintain, and report data for clinical indices/databases/registries to meet specific organization needs such as medical research and disease registries. 2. Collect, organize, and present data for quality management, utilization management, risk management, and other related studies. 3. Comprehend basic descriptive, institutional, and healthcare vital statistics. Subdomain B: Quality Management and Performance Improvement 1. Abstract and report data for facility wide quality management and performance improvement programs. 2. Analyze clinical data to identify trends that demonstrate quality, safety and effectiveness of healthcare. 3
Domain III: Health Services Organization and Delivery Subdomain A: Healthcare Delivery Systems 1. Apply current laws, accreditation, licensure and certifications standards related to health information initiatives from the national, state, local and facility levels. 2. Differentiate the roles of various providers and disciplines throughout the continuum of healthcare and respond to their information needs. Subdomain B: Healthcare Privacy, Confidentiality, Legal, and Ethical Issues 5. Apply and promote ethical standards of practice. Domain IV: Information Technology and 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, e mail, 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. Subdomain B: Data, Information, and File Structures 1. Apply knowledge of database architecture and design (such as data dictionary) to meet departmental needs. Subdomain C: Data Storage and Retrieval 1. Use appropriate electronic or imaging technology for data/record storage. 2. Query and generate reports to facilitate information retrieval using appropriate software. 3. Apply retention and destruction policies for health information. 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. 4
Domain V: Organizational Resources Subdomain A: Human Resources 1. Apply the fundamentals of team leadership. 2. Participate in and work in teams and committees. DISCIPLINE/PROGRAM STUDENT LEARNING OUTCOMES: Upon completion of the Certificate in Medical Coding, the student will be able to: A. Use common software packages (spreadsheets, word processing, presentation, and graphics) and those software packages specific to Health Information Technology B. Gather, interpret, analyze and monitor data used for quality management and performance improvement programs that relate to Health Information Technology C. Analyze and validate coding and coding data accuracy and compliance with federal and coding guidelines D. Compute, interpret and analyze healthcare statistics E. Apply and interpret the concepts of the Electronic Health Record (EHR) F. Apply policies and procedures to comply with reimbursement and reporting requirements that align themselves with major insurance programs, federal healthcare legislation, national diagnoses and procedure coding systems and the process for completion and submission of claims. 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. 5
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 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 1301 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 pages. 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. TEXTBOOK: Health Information Management Technology An Applied Approach; Third Edition, Author: Merida L. Johns, PhD, RHIA, Editor, ISBN 9781584262596 INSTRUCTIONAL METHODOLOGY: Classroom and Online Blackboard 6
GRADING SYSTEM: The Health Information Technology courses use the following scale for determination of final grades: A = 90 100% B = 80 89% C = 70 79% D= 60 69 F = below 60 A grade of 70% or above is required for passing any subject area. METHOD OF EVALUATION: 10% of your grade will be based on assignments, quizzes and onsite classes 30% on exams 30% on Midterm 30% on Final 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 will be subject to a 10 point penalty if submitted after the posted due date and then a reduction of 10 points per day thereafter. Assignments will not be accepted if submitted 4 or more days after the posted due date (including weekends). Exam Policy: All exams are taken in the ACC testing centers and there is a window of 5 days to take an exam. If a student misses one exam for a documented medical or family emergency, a comprehensive makeup exam can be taken in the last week of the semester. If any other exams are missed or if an exam is missed for any other reason, a grade of 0 will be given. If a student misses more than one exam, a zero will be given for the second missed exam. EXAMS MUST BE TAKEN NO LATER THAN THE DEADLINE DATE ON THE COURSE SCHEDULE. 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. 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. 7
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 Deadline for Spring Semester: Friday following Spring Break Deadline for Summer Semester: Friday following the 4th of July In all cases an incomplete cannot be requested unless 1/2 of the required coursework has been completed. For HITT 1301, you must have completed the following: Exam #1, Midterm and activities up to the Midterm Date. 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 http://www.austincc.edu/current/needtoknow. 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 8
http://www.austincc.edu/health/hitt/resources.php 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 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 http://www.austincc.edu/support/osd/ 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 http://www.austincc.edu/ehs. 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 http://www.austincc.edu/emergency/. Please note 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 9
individual will be dismissed from the day s activity, may be withdrawn from the class, and/or barred from attending future activities. 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 email All College e mail 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 email 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 http://www.austincc.edu/accmail/index.php. For help setting up your ACCeID, ACC Gmail, or ACC Blackboard, see a Learning Lab Technician at any ACC Learning Lab. Testing Center Policy 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 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 http://www.austincc.edu/testctr/ 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: http://www.austincc.edu/s4/ Links to many student services and other information can be found at: http://www.austincc.edu/current/ 10
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: http://www.autincc.edu/tutor/students/tutoring.php 11
HITT 1301 Health Data Content and Structure Course Outline/Schedule WEEK/ TOPIC AREA/OBJECTIVE DATES 1 Distinguish between data and information Give examples of health information media such as paper, computer and web based Explain the structure and use of health information such as individual, comparative and aggregate. 2 Distinguish between the content of health records in the acute care inpatient, hospital, outpatient/asc and physician s office setting. READING ACTIVITIES OTHER ASSIGNMENTS Chapter 1 HIM profession Data and Documentation Activities: Chapter2 Purpose and function of the record 1) Bad Habits Activity 2) Physician Practice Activity Blackboard Paper Records Review Virtual Lab Chart Repository Exercise Concepts Summary Exercise: My PHR website review and Practice brief reviews, Chapters 3 and 4. Real World Case Review activity Student Paper: Review of technology advances and impact on quality of care Group Discussion: Primary and Secondary Data Sources 3 Identify manual and automated techniques used in storage and maintenance of health records. Chapter 3 Content and Structure of the Record Written Project: Research and summarize internet information on record storage software Student Report: HEDIS Student Report: ORYX Report: JCAHO National Patient Safety Goals Implementation and Achievement Activity 12
4 Explain the importance of adopting a national patient identifier in building the national healthcare information infrastructure, and provide examples of how a patient's identification can affect data integrity. Distinguish between the basic concepts and terms associated with the electronic health record (EHR). Distinguish between licensure and accreditation and identify examples of each. 5 Distinguish between healthcare data sets (i.e. UHDDS, UACDS, HEDIS, and DEEDS) and the delivery setting in which they are used, and identify the types of data collected. Explain the elements of a corporate compliance plan. Explain the coding function and discuss the importance of documentation in coding. Describe the case mix index. Define severity of illness systems Explain the coding function and discuss the importance of documentation in coding. 6 Describe differences between commercial, managed care and federal insurance plans. Give examples of the most common registries Chapter 4 EHR AHIMA Journal article: Written summary Chapter 5 Healthcare data sets and standards Chapter 6 Clinical vocabularies and Classification systems Chapter 7 Reimbursement Methodologies Meaningful Use Initiative Written Summary Licensure and Accreditation discussion Article Summaries on Computer Assisted Coding Written summary: Case mix index US Hospitals. Application Exercise: Organization of the Severity of Illness Index Student One Page Summary in Blackboard: Explain what your understanding of the importance of the coding function and the importance of documentation in coding. Web search Assignment: Commercial vs. Federal Insurance Plans Class Discussion: Registries and Indices 13
and indexes found in hospitals. Summarize the information included in vital statistics. Revised: Distinguish between primary and secondary data sources. 7 Identify and describe application software Chapter 8 Health Information Functions Discussion: NCHS data sharing and use Exam #1 over Chapters 1, 2, 3, 4, & 5 Written Summary: Description and Use of Application Software 8 Define hospital related statistical terms. Describe descriptive and inferential statistics. Describe data presentation methods: tables, graphs, charts, bar and pie charts, histograms, polygrams. Describe the role of the health information management professional in performance improvement, utilization management, and risk management functions. Distinguish the terms clinical quality assessment, infection control, utilization management, case management and risk management 9 Describe the basic organization in the healthcare including the physician office and acute care hospital. Identify the various licensing and regulatory Chapter 9 Secondary Data Sources Chapter 10 Healthcare Statistics Chapter 11 Clinical Quality Performance Improvement & Management Chapter 12 Healthcare Delivery Systems Discussion: Statistics in the Healthcare setting Discussion: Descriptive Vs. Inferential Statistics Terminology Matching Exercise Discussion: HIM Professional s role in PI, UM and Risk Management Functions Discussion: Quality/Process Improvement Terminology Student Report: Structure and Operation of Selected Healthcare Facilities Student Essay: Licensing and Regulatory 14
agencies in the healthcare industry. Explain the movement in Medicare to connecting quality of care with payment policies (ACO) 10 Differentiate the various types of healthcare disciplines and providers in the continuum of care. Explain the Code of Ethics for HIM professionals. Distinguish between the basic concepts and terms associated with the electronic health record. 11 Describe health information systems, including but not limited to, administrative, patient registration, ADT, EHR, PHR, lab, radiology pharmacy, voice recognition technology. Explain the general functions, purposes, and benefits of health information technology systems. Distinguish between the basic concepts and terms associated with the electronic health record. Chapter 12 Health care Delivery Systems (continued) Chapter 15 Fundamentals of Electronic Information Systems Agencies in Long Term Care Discussion: Concept and Purpose of CMS Accountable Care Organizations Exam #2 Chapters 6, 7, 8, 9, 10 & 11 Discussion: Healthcare Disciplines and Providers of Care Discussion: Code of Ethics for HIM Professionals Exercise: EHR terms Discussion: HIM and Voice Recognition Technology Student Assignment: Real World Case Respond to questions. Discussion: Data Dictionary, Data Modeling, Data Warehousing Explain the elements of a well designed screen image. List the functions that would make it easy for a staff member to navigate the screen. 12 Identify manual and automated techniques used in storage and maintenance of health records. Identify manual and automated techniques used in storage and maintenance of health records. Chapter 16 Introduction to Electronic Health Information Systems Student Assignment: Internet research: Storage Management Software Student Assignment: Internet research: Storage Management Software 15
Distinguish between the basic concepts and terms associated with the electronic health record. 13 Assess the major types of information system applications used in healthcare organizations. Define quality control functions for EHRs. Define data mining. 14 Describe the elements of data security systems. Identify and define terms associated with data integrity Define security processes and monitoring. Chapter 16 Introduction to Electronic Health Information Systems (continued) Chapter 17 Information Security 15 Describe the fundamentals of leadership Chapter 18 Principles of Organization and work Planning Discussion: Definitions of data dictionary, data modeling and data warehousing Classroom Presentation and Discussion: Advantages and Disadvantages of Information System Applications Discussion: Functions and Design in EHR Discussion: Data Mining Activities Discussion: Data Security Discussion: Data Integrity and Authentication Discussion and Definitions: Security Processes and Monitoring Discussion: Discuss the fundamentals of leadership 16 Final Exam Final Exam Final Exam over Chapters 12, 15, 16, 17 & 18 16