In this brief, we define the essential characteristics of cloud computing and the applications in a Canadian healthcare context. The security and privacy challenges, of particular importance to health information management professionals, and the end benefits of adopting a cloud computing model are also highlighted.
This Professional Practice Brief (PPB) outlines the importance of and reasons for conducting a Privacy Impact Assessment (PIA). It discusses what should be included, highlights some complications that might arise and delves into the role an HIM plays in the process.
This PPB will discuss the topic of mentoring, specifically its application to the HIM profession as a platform for skill and knowledge sharing. The target audience is members of the HIM profession; however, it must be emphasized at the outset that mentoring relationships are often established outside the HIM domains.
The reality of health care is rising costs. Utilization management (UM) is increasingly important to address the paramount importance of balancing costs and quality health care. This professional practice brief (PPB) will concentrate on UM as it pertains to acute care. Key areas of concern for an effective UM program will be examined, including: Appropriateness of admission, Length of stay, Conservable bed days, Readmission rates, Discharge planning, Alternate level of Care, and Wait times. The valuable contribution of the HIM professional will be highlighted throughout.
It is no secret that technological advances have dramatically changed the business of health care delivery and administration. This PPB on Naming Clinical Forms discusses one facility’s experience in this area and highlights the value of the HIM skill set in supporting the process.
An exciting and expanding opportunity for the Health Information Management (HIM) professional lies within the primary care setting. As technology advances with the move to the electronic health record (EHR), it is evident that HIM expertise is needed at the primary source of health information. This practice brief delivers an overview of HIM in the primary care setting and within Family Health Teams including areas for HIM involvement and reasons why HIM professionals should be a part of the Family Health Team model.
What is research? This PPB is intended to highlight what research is and how HIM professionals can be involved. The document discusses the types of research, associated paradigms, and tools as well as the basic steps to the research process
The focus on patient safety and quality care has resulted in many initiatives in agencies, the regulatory environment, the information and communication domains, education, research and professional ethics. All of these are influenced by changing evaluation methodologies, new technology and system innovation issues. The role of the HIM professional within patient safety spans the scope and breadth of eHealth transformation, standards setting, system functions, information and screen design, MPI, documentation practices, technology, performance management, patient advocacy, ethics, workflow, data quality, and data reporting. This PPB provides an overview of the many agencies and influences that have increased the profile of Patient Safety and Quality Care in Canada and the important role of the HIM professional.
Telemedicine is a method of enabling the delivery of health care to patients/clients at a distance, using different telecommunication and information technologies eliminating barriers such as distance, patient mobility, and challenges related to health professional or specialist access and availability. As Health Information Management (HIM) professional opportunities expand beyond traditional hospital and clinical care settings, the area of Telemedicine is worth exploring. This PPB provides an overview of opportunities for the HIM in telemedicine.
Within the healthcare industry there is a growing need and increasing urgency for the establishment of sound guiding principles to support evolving electronic health records (EHR). This paper explores many of these principles within the health care industry.
This PPB identifies 28 components to be considered in the transition of the paper-based to EHR HIM Department from getting started to forms, interfaces and comprehensive departmental plans. In addition, it provides references to additional reference material.
This PPB discusses computerized coding tools, identifying the influence of the technologies, and provides guidance on how coding professionals of today can position themselves for the coming coding revolution.
There is a perception that it is permissible to access and uses data for secondary purposes if an individual/organization ‘owns’ the media. Linking, sharing, and retrieving information has been made easier by technology in that it can be transmitted, shared, and leveraged for a myriad of purposes to multiple users more quickly. This PPB discusses secondary use of health data considering key factors including: the status of the data in the context of a legal record; the de-identification of data; contracts and business arrangements, provincial/federal laws; and the right of the individual about whom the data is collected.
The transformation from paper-based to EHR will impact every aspect of health information management. Every fundamental will need to be rethought and affirmed or discarded. To face this future, HIM professionals must envision the future and develop a mapping strategy; this PPB provides key steps and resources for this process.
The PPB identifies a list of standards to reference in data dictionary development, evaluation of health data software applications, EHR tools, and general management processes to ensure information integrity and reliability.
The migration of health care organizations to the EHR will affect the entire HIM profession. Many new and altered job titles and roles are emerging. This brief highlights a number of the new opportunities within the evolving HIM profession.
This PPB is intended to increase the HIM professional’s understanding of how the technology works, the driving forces for this technology, and the benefits and risks. It provides a glossary of terms and illustrates the work flow, tasks and best practices for this new technology and process.
With the evolution of the EHR, organizations are becoming cognizant of EDMS to manage both paper and electronic computer generated documents. This PPB is a compilation of best practices detailing the keys steps and issues in implementing an EDMS.
Successful EHR implementations require people skills – everything from leadership, communication and training to change management. This PPB outlines some of success factors for EHR adoption and the people skills for HIM professionals. Tools that can assist in assessing readiness of change are identified.
This PPB discusses the technology and legal requirements associated with FAX transmission. It identifies 10 recommendations for safely using this communication technology, and a few steps in dealing with a breach.
Health care organizations have many approaches to the sharing of health care data. This PPB describes several types of linkages and the three levels of complexity in the practical application of EHR technologies.
Identity theft is the ‘crime of the 21st century’, and health care organizations are particularly vulnerable due to the wealth of information collected, stored, maintained, and transmitted. This PPB identifies practical preventive guidance; how to resolve ID theft in an MPI; and discusses how to respond to an ID theft within your organization.
This PPB discusses select new communication technologies (such as Bluetooth) and the challenges associated with these. Specific advice is given in how to deal with these technologies as they become mainstream in health care delivery.
Information systems are only as good as their data. Without agreed clearly defined terms and definitions, validity and reliability of data are suspect. The data dictionary is a building block of effective health information systems supporting health care delivery. This PPB defines a data dictionary, explains their purpose, and provides specific guidelines to create and maintain this pivotal EHR component.
Structured data enhance the flow of information into an EPR and ultimately into the pan-Canadian EHR. HIM professionals must understand the data standards and how these standards support effective information management. This PPB discusses data dictionaries, data standards, and data content to support an EPR.
With the development of local, regional, and provincial networks for the exchange of health data, it is important that HIM professionals are aware of the many related privacy and security issues. This PPB provides a brief description of the types of HIE environments, and discusses some of the considerations within legal and operational issues. These include: variations is laws; data sharing agreements; accountability for privacy; consent; ensuring safeguards; and identity management.
Most HIM departments never experience a disaster, however a well-designed action plan will protect health information (regardless of format) from damage and minimize disruption. This PPB provides guidance in creating a disaster plan specific to health information.
Quality health care depends on the availability of quality data. Without accurate and appropriate content in a usable and accessible form, the incredible value of the EHR will not be realized. This PPB identifies 5 best practices, and the potential technical challenges for data quality.
This brief offers guidelines to prevent potential EHR documentation fraud including guidelines for electronic documentation, a check-list and three case studies.
At some point in their career, it is likely that an HIM professional will need to provide a compelling solid rationale to a Senior Manager. This PPB will outline the key steps in creating an effective Business Case and provides a checklist for reference.
Clinical care relies on the basic premise that an organization can accurately identify clients. An enterprise master patient/person index (EMPI) is a software application that identifies persons in an integrated delivery network across disparate registration, scheduling, financial, and clinical systems.
A fundamental principle of CSA Model Code for the Protection of Personal Information is that of Informed Consent. The corollary of this is that the person has the right to withhold or withdraw consent to disclosure. This PPB discusses the challenges, limitation and legislation of limiting disclosure, and articulates suggestions for addressing a person’s request to ‘lock’ their data.
Email can be effective in facilitating communication between health care providers and patients. It offers many benefits, but requires safeguards different than other communication such as paper and phones. This PPB outlines some of the challenges and benefits of email, as well as identifies recommendations for the HIM professional in dealing with this communication medium.
This PPB discusses the connection and working relationship between Health Information Management and Health Information Technology in the developing EHR. These two different but related disciplines are essential to the successful development and deployment of the EHR in Canada. An understanding of the three domains that require collaboration will assist an HIM professional to become a valuable member of an EHR team and bring needed skill-sets to an organization.
A new component of the Electronic Health Record is the Personal Health Record (PHR). Created, owned, maintained and shared by the individual, the PHR will impact the existing health care records regardless of setting, and therefore will impact the HIM professional. The advent of the PHR will require the HIM professional to rethink organizational approaches to health information collection, dissemination and access and to adapt to ever-changing new technologies.
With a demonstrated understanding of basic internet and IT terminology related to data exchange, HIM professionals can improve communication between technical and clinical professionals. Serving as a bridge between the professions, HIM professionals can facilitate the successful adoption and use of exchanged clinical information
Standards are the most effective and efficient way to facilitate interoperable systems. If Canada’s health service delivery organizations implemented the same standards in their information management systems, data and information exchange would be facilitated. With the transition to the Electronic Health Record, HL7 is one standard with which HIM professionals should be familiar. This PPB describes HL7 at a high level and identifies references and resources available to all HIMs.
A pan-Canadian Electronic Health Record requires standards – technical, data, process, information, etc. These standards must be developed, implemented, monitored, and changed as appropriate and these activities must be coordinated. One key piece of the implementation of standards is the Health Standards Council. This Professional Practice Brief is a primer on what a Standards Council is, how it operates, and identifies common activities and goal of Councils across Canada.