Today's Wound Clinic - Spring 2008 - (Page 15)

inwhole before having to produce it, rather than after being asked to do so. Hospital records custodian can be a big help here, particularly since there are security issues involved. (For help, see the American Health Information Management Association, AHIMA, report, “Guidelines for Defining the Legal Health Record for Disclosure Purposes,” go to, library.ahima.org.) (EMRs). Compared to other US industries, the healthcare system has been slow to effectively incorporate information technology into the work environment. According to former Secretary of Health and Human Services,Tommy Thompson “The most amazing thing about 21st century medicine is that it’s held together by 19th century paperwork.” The Computer-based Patient Record Institute (CPRI) stated that if providers continue with their current paper systems, they will lack the tools needed to manage the quality and costs of healthcare, the scientific basis for healthcare will continue to be undermined, and healthcare reform will be impeded. What is slowing adoption of health information technology (HIT)? HIT is expensive and providers are uncertain as to the value they will derive for their investment. Furthermore, while doctors or hospitals are the ones who have to purchase HIT, as much as 80% of the potential healthcare savings accrue to insurers. And, like all technological advances, HIT is in a constant state of evolution.What if the system purchased today is obsolete tomorrow? What if it is not compatible with some system the hospital already has? For all of these reasons, clinicians find it difficult to decide how to incorporate technology into their practices. Nevertheless, electronic medical records are coming to every hospital, and to every clinic, one way or another. your medical records. More recently, the situation got even more interesting. In 2004, President Bush issued an Executive Order requiring HHS to develop a national health information network (NHIN) within 10 years, overseen by a new HHS office,The Office of the National Coordinator for Health Information Technology. A number of bills have been introduced in Congress to speed the development of a national system of electronic health records. USING RECORDS FOR BENCHMARKING AND QUALITY ASSURANCE Healthcare providers are expected to participate in continuous quality improvement. This means constantly examining practices to identify inconsistencies in patient care and look for opportunities for improvement. Thus, medical records provide important information about practice patterns on groups of patients, not just one individual. We can evaluate this through benchmarking. The American Productivity and Quality Centre (APC) provides a number of useful benchmarking guidelines, which are relevant to healthcare processes. The first step is for a clinic to know its own data, meaning that clinics must decide what parameters are relevant to its overall management goals. What parameters should staff follow? Healing rates, the number of patients in service after a certain number of days, the number of patients receiving a certain type of therapy, the revenue generated? Then if possible, a clinic must identify a HIPAA compliant way to compare its own data with that of other facilities. The APC has shown that companies that support benchmarking gain operational benefits and see higher financial paybacks in comparison to organizations, that do not. However, the process of benchmarking is almost impossible without some sort of computer technology. SO WHAT’S A CLINIC TO DO? Each wound center must critically assess their specific documentation needs. Not only must the mechanism of data storage be determined, but data retrieval must be determined as well. If paper is deemed adequate for individual patient records, then outcomes data and photographs will likely need to be managed by some other mechanism. Questions that follow will consist of:What information is important? How will it be kept? Who will keep it and how will it be used? Medical documentation, like medical care is a process and defining a system to improve your documentation might actually result in improving medical care for the patients. FOR MORE INFORMATION VISIT: The American Health Information Management Association (AHIMA) www.ahima.org/about/about.asp HIPAA AND THE NATIONAL HEALTH INFORMATION NETWORK In 1996, Congress passed The Health Insurance Portability and Accountability Act (HIPAA). Its original purpose was to set a national standard for electronic transfers of health data, but Congress also saw the need to address growing public concern about the privacy and security of personal health data. The HIPAA Privacy Rule, issued by the US Department of Health and Human Services (HHS), became effective for most healthcare providers on April 14, 2003. The regulations are too broad to be discussed here but they have likely affected some aspect of every practice, particularly in how to handle access to 2004 Code of Ethics - Body of Knowledge and the 2004 November/ December Journal of AHIMA http://library.ahima.org/xpedio/group s/public/documents/ahima/pub_bok1 _024277.html The American Productivity and Quality Centre www.apqc.org/portal/apqc/site/?path =/research/index.html ADOPTING TECHNOLOGY The $1.7 trillion dollar US healthcare industry spends twice as much per capita as Scandanavia or Britain. However, the US has poorer health outcomes. One reason for this discrepancy may be slower adoption of electronic medical records Documentation and Compliance Policies www.hsc.unt.edu/policies/QuAssure/ Clinical%20Documentation&Complian ceManual042704.pdf) The Office of the National Coordinator for Health Information Technology www.hhs.gov/healthit/measuring.html Today’s Wound Clinic Spring 2008 15 http://library.ahima.org http://www.ahima.org/about/about.asp http://library.ahima.org/xpedio/groups/public/documents/ahima/pub_book1_024277.html http://www.apqc.org/portal/apqc/site/?path=research/index.html http://www.hsc.unt.edu/policies/QuAssure/Clinical%20Documentation&ComplianceManual042704.pdf http://www.hhs.gov/healthit/measuring.html

Table of Contents Feed for the Digital Edition of Today's Wound Clinic - Spring 2008

Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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