RECM1001 - Fundamentals of Health Information

Management I Midterm Notes

WEEK 1 - INTRODUCTION TO HIM
Essential Skills of HIMs
• Ability to think critically

What is HIM?
• De nition: the collection, analysis, storing, protecting and ensuring the quality
of patient health information; re ects on the healthcare experience for the
patient from the initial time of entering health care facility to time of discharge
• Health Information professionals focus on:
• The content of the physical health record
• The management of health care information
• The collection of health data to tell the patient’s story and experience
• The translation of data into usable forms of information
• This process requires ensure correct handling of health information
• Health information can be:
• Paper based, hybrid (paper+digital), or fully electronic health record (EHR)
• HIM professional must have wide range of biomedical knowledge, provincial
and federal laws, data analysis and how to connect computer systems that
collect data
• More data analysis skills needed which requires critical thinking and ability to
analyze the accuracy of the data
• Roles for HIM Professionals:
• Immediate patient care, disease surveillance, planning, managing resources,
research, intelligent decisions
• Work with the entire clinical team, contribute to health care delivery, use
technologies to capture, report, manage and analyze data, and to support
the quality of patient care
• HIM Job titles:
• Coding classi cation specialist, Privacy o cer, Health data analyst, Clinical
data analyst, Patient information assistant, Clinical research analyst, Health
Information specialist
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 WEEK 2

Characteristics of a Profession
• An occupation that requires extensive training and the study and mastery of
specialized knowledge
• Has a professional association
• Has a commitment to a code of ethics and process of certi cation or licensing
HIM Profession
• The only profession whose core responsibility is to maintain the quality of the
data collected
• Must ensure that the health information is accurate, accessible, con dential,
and secure
• Roles and Responsibilities:
• Establishing standards for the recording of complete data to ensure
information is stored e ciently
• Enables e cient retrieval as per relevant legislation
• Ensures clinical documentation complies with legal requirements
• Interprets and translates clinical documentation into standardized codes
• Supports the growth and development of computer technology for the
purposes of capturing, storing, and retrieving health data in the electronic
systems
HIM Credential and Title
• Professional Credential - CHIM
• Professional Title - Certi ed HIM Professional
HIM Professional Education
• Required to be successful in a 2-year diploma program
• Required to write and pass National Certi cation Exam (NCE)
• Maintain certi cation by participating in continuous professional education
(CPE) credits, minimum 36 every 3 years
HIM Professional Association History
• CHIMA - Canadian Health Information Management Association
• CHIMA was previously named CAMRL - Canadian Association of Medical
Librarians ~ 1942
• In late 1960s, CAMRL Board of Directors identi ed the need for health record
professional skills and granted a credential requirement
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 • 1972 - CAMRL changed its name to CCHRA - Canadian College of Health
Record Administrators to oversee education standards and professional
certi cation
• 1976 - the Association (CAMRL) and College (CCHRA) amalgamated and
functioned under one leadership; CAMRL changed its name to CHRA
(Canadian Health Record Association)
• 2003 - CHRA became CHIMA (Canadian Health Information Management
Association) which represents all HIM professionals across Canada
• CHIMA grants recognition of competence to an individual based on meeting
the requirements of graduating from a 2-yr program and successfully passing
the National certi cation exam (NCE)
• CHIMA also provides learning content to all accredited HIM programs in
Canada based on LOHIM (Learning Outcomes for Health Information
Management)
CHIMA - Four Domains of Practice
• E-HIM - to advance the expertise of health information professionals in the
development of EHR and to lead the providers through the transition from
paper to EHR
• Privacy - CHIMs are custodians of the patient’s record and must establish
processes to protect the patient’s personal information including unauthorized
access, use, disclosure, modi cation or destruction
• Data Quality - health information collected must be at the highest level of
quality as it is an important resource for utilization management and quality of
care within health care facilities.
• Goal - advance standardization through studies and audits and promotion of
CHIMs as experts in data quality
• HIM Standards - allow one to standardize the collection, representation, and
communication of data used in EHRs and across di erent computer and
information systems
• Eg. Content of electronic forms with standard responses used at health care
facilities @ waiting area kiosk -> results in same standardized information
collected from all new patients
CHIMA - Future Plans
• To de ne new and/or enhanced credential/designations
• Develop new advanced certi cation programs
• To review and update the existing learning outcomes
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 • To investigate opportunities for an educator network
• To increase the number of CHIMs with advance standing in HIM and those in
leadership roles
HIM Code of Ethics
• CHIMs pledge to protect patient privacy and con dential information
• CHIMs pledge to conduct themselves in the practice of the profession with
honour and dignity
• CHIMs strive to improve one’s professional knowledge
• A violation of the code of ethics is a ground for disciplinary action, including
revocation of credentials
Why was the Code of Ethics developed by CHIMA?
• To provide guidance in ethical behaviour, to set out values, principles and
standard of practice for CHIMs
CHIMA Code of Ethics
1. Strive at all times to provide services consistent with he quality of health
care, promotion, and prevention
2. Strive at all times to protect the privacy, security, and con dentiality of
health information in any form or medium
3. Perform duties diligently and o er only those services for which one is
quali ed
4. Conduct oneself in the practice of the profession so as to bring honour
and dignity to oneself, the HIM profession, and CCHIM
5. Conduct oneself in an ethical manner consistent with the values of the
CCHIM and report any unethical practices to the appropriate authority
6. Strive to improve one’s professional knowledge and competence through
continuing education and lifelong learning
7. O er leadership and a proactive, innovative approach to advancements in
health information management practices
8. Abide by the policies and by-laws of the CCHIM and actively support its
strategic directions
9. Support and mentor students, peers and colleagues to develop and
strengthen the workforce and profession
10. Respect the dignity and worth of every person
History of the Health Record
• 1920s - health record was identi ed that a complete and accurate health
record and its content lend to an e cient healthcare system
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• At that time, “medical record” = simple chronological, mostly incomplete,
paper-based explanation of the care received and services provided
• Still,, it was an important tool for physicians to use in clarifying their
experience with the patient, training purposes, quality hospital care, aiding in
the diagnosing and determining treatment of disease
• As medicine advanced, medical record became a source-based origin of data
and information - creation of “Club of Medical Record Clerks” was born
Changes in the Health Record
• Health record changed from paper based -> hybrid (combination of paper +
computer-based) -> fully electronic computerized record (EHR)
• Before: health record was a brief description of a patient’s hospital stay
identifying their conditions and treatments
• Recently: detailed collaboration of handwritten entries, dictated reports and
computer print out reports, re ecting the contribution of many di erent
healthcare providers
Necessities of the Health Record
• Health record provides proof of what has been done for the patient during the
episode of care
• Describes the patient’s progress and response to treatment and explains the
outcomes of the care provided
• Is needed for communicating information about a patient’s conditions and
treatment to physicians to improve the continuity of care
Changes in the Health Record Created Other Changes
• HIM directors/managers -> from managing records and sta -> to
standardizing patient’s health record procedures and formats
• Creating the foundation for the transition from a paperless record system to a
computerized system
• Responsible for training of sta with the new computer system(s)
• Responsible for ensuring that documentation and records management
processes are instituted together with the con dentiality and security
necessary for the electronic changes to a computer based system
Who is the custodian of the health records?
• In a doctor’s o ce - doctor owns
• In hospital - the hospital owns, kept in a safe keeping in HIM department
• In clinics - clinic owns, doctor in charge is responsible
• In a pharmacy - pharmacy owns, pharmacist would be responsible
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 • Health record = physical property of the healthcare facility; healthcare
professional who compiles the record are the custodians
Hospital Record
• Patients Categories:
• Ambulatory - emergency, day surgery, clinics; stay is less than 24 hours
• Inpatient - stay in hospital is greater than 24 hours; given a written order for
admission to an inpatient bed
• 4 Categories:
• Medical - planned treatment for a medical condition, no surgery
• Surgical - treatment includes planned surgical procedure
• Obstetrical - an obstetrical condition, redelivery, post delivery
• Newborn - patient was born during episode of care; after 28 days ->
paediatrics
Functions of a Health Record
• To facilitate the ongoing care and treatment
• To support clinical decision making and communication among clinicians
(~risk management)
• To document services provided to the patient
• To provide information for the evaluation of the quality and e cacy of the care
provided
• To provide information in support of medical research
• To help facilitate the operational management of the facility (eg. Change in
population demographics)
• To provide information as required by local and national laws and regulations
Longitudinal Health Record
• A compilation of an individual patient’s medical history from birth to death
• Helps to prevent medical errors since there is information on patient’s
allergies, history of diseases, surgeries, post medical problems, and all can be
available before treatment decisions are made
• Di cult to achieve on paper-based record because patient’s record from all
providers are separated on di erent paper systems (per clinic or o ce) and
records are not linked
• On an electronic record - patient’s records are linked within a hospital but may
not be linked to other organizations
Responsibility for Quality Documentation
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• Provider of care - responsible for ensuring that entries made in the record are
of high quality which is established by the facilities bylaws, rules and
regulations for the record content
• HIM professionals - responsible for ensuring that the providers of care
understand the regulations and standards for proper documentation
Data Found on a Health Record
• Administrative Data - entry code, admit category, patient service, health care
provider, date of admission, separation dates
• Demographic Data - patient’s name, address, telephone number, date of birth,
next of kin
• Clinical Data - diagnoses and interventions related to the patient
• Financial Data - recorded on the rst page/screen of the record, such as
payment information, OHIP, WSIB
Clinical Data
• Information on patient’s health record which is related to the patient’s
condition, course of treatment and progress
• Reports that contain clinical data : history & physical note, physicians orders,
consultation reports, nursing notes, ancillary service reports (lab, radiology
reports), surgical service reports (operative notes, anaesthesia reports,
recovery room reports, discharge summary)
Clinical Observations
• Documented in the patient’s health record in di erent formats
• Progress notes, history notes, consultation notes, nursing notes, surgical
notes

WEEK 3
Brief History
• Immigrants who arrived in Canada before 1900 faced many health risks, in
transit and upon arrival
• People relied more on home remedies and folk medicine than on doctors or
nurses
• Countless people turned to patent medicines, unconventional cures or
miraculous healers
• Only the wealthy Canadians were able to see paid doctors and seek care in
hospitals
• The country’s capacity to treat illness and injuries was primitive
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History and Healing Practices of Indigenous Canadians
• Health and healing ceremonies dates back centuries
• Indigenous healers ~ “medicine man” and “shaman”
• Very little information documented as practices were passed on by word of
mouth
• Many of the healers and elders with knowledge died during epidemics and
from diseases introduced by non-Indigenous people
Early Events in the Evolution of Canadian Health Care
• Early 19th century -> Canadians paid doctors, hospitals, pharmacists out of
pocket for services received
• Spread of disease was not understood at this time, hospitals were crowded,
treating mostly the poor
• 1919 -> Department of Health was created by the Federal government
focusing on STI, children’s health
• Department of Health and Welfare (1944) is known today as Health Canada
• Health Canada pays for refugee claimants health insurance under the Interim
Federal Health Program
• Post-WWII -> middle class Canadians felt impact of limited access to
healthcare; poor -> charities, rich -> proper care
• 1948 - National Health Grants introduced; $30 million grant to improve
hospitals, train physicians, fund research -> “hospital building boom”
• 1957 - Hospital Insurance and Diagnostic Services Act -> all residents were
entitled to receive health care services in an acute care hospital deemed
necessary by a physician
• 1961 - Medical Care Insurance Act (Medicare) was passed by Tommy Douglas
who believed in a combined comprehensive hospital and medical insurance
plan for everyone
• Tommy Douglas - “father of Medicare” -> launched Canada’s rst public
health-care program in Saskatchewan
• Doctors -> furious, went on strike; 3 weeks later, strike collapsed
• First time that health care was considered a right, not a privilege; being sick
wouldn’t condemn families to poverty
• 1966 - Medical Care Act was passed by Honourable Justice Emmett Hall
• “Free” health care was not “welfare”; it’s an economic necessity
• Healthy people meant healthy economy
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 • Recommended doubling the amount of physicians to prepare for an aging
population -> to prevent a risk of shortages of health care services
• 1977 - Established Programs Financing (EPF) Act - to cover additional
extended health services and post-secondary education
• Replaced the previous 50/50 to a block transfer - one payment from federal
government to cover all services
• Health care costs continued to grow, faster than the GDP; so hospitals started
cutting back on services
• 1977, 1978 - governments set restrictions on fees paid to doctors -> resulted
in doctors extra billing their patients
• Public thought extra billing was unfair, and limited access to health care
services
• Justice Emmett Hall was asked to review the situation who made
suggestions together with the Parliamentary Task Force ~ birth of Canada
Health Act
• Canada Health Act (CHA)
• Establishes criteria and conditions that the provinces and territories must
ful ll to receive the full federal cash contribution under the Canada Health
Transfer Act (CHT)
• Aim of CHA: to ensure that all eligible residents of Canada have reasonable
access to insured health services on a prepaid basis, without direct charges
at the point of service for such services
• Primary Goal: to provide equal, prepaid, and accessible health care services
to eligible Canadians according to the criteria and conditions of CHA
• Criteria and Conditions of the CHA
• Criteria:
• Public Administration - managed by a public authority on a non-pro t basis
• Comprehensiveness - allows eligible persons to have medically needed
prepaid services by physicians and hospitals
• Accessibility - eligible persons have reasonable access to all health
services
• Universality - eligible residents entitled to 100% coverage to all insured
health services provided under the provincial plan
• Portability - eligible persons covered for health services in other provinces
• Conditions
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 • Information - requires each provincial and territorial government to provide
the federal government with information about the insured health care
services and extended health care services for the purposes identi ed in
the CHA (where HIMs play a role)
• Recognition - requires each provincial and territorial government to
recognize the federal nancial contributions to both insured and extended
health care services
• After Canada Health Act
• Health care system -> di cult to function within the allowed budgets
• 1990s - hospitals began restructuring, downsizing, cutting service and sta ,
closing buildings -> widespread shortages
• “Health care teams” -> new concept of health care; increased access to
primary care services -> after-hour clinics, telephone help lines, extended
o ce hours
Health Care Delivery
• = process of providing health care
• Most common way = face-to-face delivery
• Can be delivered in one’s home and/or community by homeware services,
homemaker services, nurses, and physicians
• Health care delivery ~ delivering quality health care, the best possible care and
achieving the best possible outcomes
Three Categories of Healthcare
• Primary care
• The rst contact people have with the health care system
• First contact for the diagnosis, treatment, and follow-up for a speci c health
problem
• Enables access to routine screening (~annual check up)
• Could be through a doctor, a nurse, phone or computer-based services
• Provided by family doctors, home care and public health nurses,
pharmacists, physiotherapists, and dentists
• Secondary care
• Health care provided by a physician who specializes in speci c areas of
medicine/surgery
• Emphasizes on early detection, screening, and treatment (~surgical
interventions)
• Given by specialists
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 • Patient must be referred by their family doctor (primary care provider) before
seeing a specialist
• Tertiary care
• More complex health care services provided by specialists in a large
academic health care centre, also require a referral
• Specialized facilities for major surgeries and treatments
• Trauma centres, cardiac centres, paediatrics hospitals, cancer treatment
centres
• Specialized facilities for inpatient mental health programs and services
• Utilized for reducing death and disease by implementing treatment and/or
rehabilitation
Provision of Health Services
• Acute care hospitals
• Chronic care facilities
• Community care clinics
• Home care - patient’s home
• Delivered by a variety of providers, doctors, nurses, nurse practitioners and
others
Acute Care - Inpatients
• Services for patients who spend more than 24 hours, who receive room and
board services and continuous nursing services
• Services delivered to inpatients in a hospital setting most often over a 24-hour
period and usually have a length of stay less than 30 days
• Private rooms -> not covered by government insured plans, unless it becomes
medically necessary such as for isolation purposes, or compassionate care
Ambulatory Care
• Healthcare that is provided in a practitioner’s o ce, a clinic, emergency care,
day surgery care, on a non-resident (outpatient) basis
• Patients go obtain healthcare services and return home the same day
• Ambulance services -> not addressed in the CHA -> each province may have
their own guidelines
• Ontario residents -> pay ~$220-240 if the ambulance was used for non-
medical reasons which is determined by the hospital, to limit the abuse of the
service
• Patients arriving in a hospital -> responsible for a co-payment charge of $45
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• Air ambulance -> covered if identi ed as being “medically necessary” by a
physician and resident has valid OHIP card
Long-term or Chronic Care
• Health care given in a non-acute care facility to patients who require 24 hour
supervised nursing and related services for more than 30 consecutive days ~
nursing homes, rehabilitation hospitals
• Mainly rehabilitative and supportive rather than curative; requires little or no
technology
Government Roles
• Roles and responsibilities of Canada’s health care system ~ shared between
federal and provincial-territorial governments
• Main function of Federal government -> in uence over the control of the
funding given to the provinces/territories
• Provincial/territorial government -> oversees matters relating to the personal
health of their population:
• Promoting good health
• Preventive care
• Health maintenance
• Diagnosis and treatment of health problems
Federal Government
• Government departments, organizations and agencies
• Cabinet -> centre of the federal government
• Current Prime Minister -> Justin Trudeau
• Cabinet directs the federal government ~ determines priorities and policies,
ensures their implementation
• Provides leadership, advice and direction on healthcare issues on a national
and international level, but has little power over the health care of individual
Canadians except for certain groups (refugees, Armed personnel, correctional
services employees, Inuit and First Nations)
• No legal power over health care in provincial or territorial jurisdictions
• Federal government control the health care funding to provinces and territories
only
Funding of Health Care
• Financed by 3 levels of government - federal, provincial/territorial, municipal
• Money raised for nancing ~ taxes => allocated from general provincial
revenues, employers, private insurers
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 • Each province and territory has a method of nancing health care services not
covered by federal funding -> payroll tax deductions, premiums, and general
revenue
Provincial Plans
• 13 separate insurance plans, run by 10 provinces and 3 territories ~ Medicare
• All insurance plans are bound together by Canada Health Act (CHA), funded
by the federal government
• To receive funding, provinces and territories must abide by the CHA
• Insurance plan covers hospital care and medically necessary treatment for
eligible residents
Local Health Integration Network
• Are non-pro t corporations that work with local health providers and
community members to determine the health service priorities of their regions
• Responsible for planning, funding and managing health services in their
communities
• Accountability and transparency -> very important
• LHIN; report to the Ministry of Health and Long Term Care (MOHLTC)
• LHINs are funded by MOHTLC, which determines, plans, and funds the health
services deemed as necessary
• Ford PC government -> eliminated 800 full-time positions in LHINs and 6
health care agencies (Cancer Care Ontario, Health Quality Ontario, Trillium Gift
of Life, Health force Ontario, etc.)
• LHINS and agencies were closed and merged into the new “Super Agency” in
2019
• LHINS are responsible for:
• Hospitals, community care access centres (CCACs), community support
service organizations, mental health and addiction agencies, community
health centres (CHC), long-term care homes
• These services were integrated in each of their speci c geographic areas
Roles of Health Canada
• Works collaboratively with the provinces and territories on creating funding
policies and nancing projects (transferring money and tax points for health,
education and social programs)
• Plays an authoritarian role, ensuring and enforcing penalties for
noncompliance of CHA
• Is a service provider responsible for health care coverage for speci c groups
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• Is a primary source of information -> conducts research projects and provides
feedback on policy development
• Interacts with other nations (globally)
• Participates in health promotion and disease prevention
Roles and Responsibilities of Public Health Agency of Canada (2004)
• Promote and protect health of Canadians through leadership, partnership,
innovation and action in public health
• Purpose: to focus on e ective e orts to prevent and monitor chronic disease
and injuries, to respond to public health emergencies and infectious diseases
and outbreaks
• Federal government plays a role in public health in conjunction with provincial,
territorial and local governments
• Serve as a central point for sharing Canada’s expertise with the rest of the
world
• Apply international research and development to Canada’s public health
programs
• Strengthen intergovernmental collaboration on public health and facilitate
national approaches to public health policy and planning
• 4 branches of PHAC
• Preventing Disease and Injuries - infectious disease and emergency
preparedness
• Responding to public health threats - public health practice and regional
operations
• Promoting good physical and mental health - health promotion and chronic
disease prevention
• Providing information to support informed decision making - strategic policy,
communications, and corporate services
Funding Models used by Government for Funding distribution
• Health Based Allocation Model
• Based on expected expenses determined by demographic pro le of the
community, mix of services and complexity of care
• Quality-Based Procedures
• Focuses on the number of patients treated and number of procedures
performed, considering a “best practice” approach
• Block-transfer/global funding
• Lump sump; determined by the previous year’s expenditure
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 • Patient based funding - monetary incentives are provided to hospitals (by
reaching targeted goals) to maximize the quality of care delivered in the most
cost-e ective manner (specialty services)
• Service Based funding - case-mix approach; patients with similar medical
problems and undergo similar treatments are grouped using a formula, the
cost of services are estimated, and the amount of funding is related to how
many patients are treated
• Line by line Funding - itemizes the cost of speci c services and equipment
within a hospital, popular in BC and NB
Health care premiums in Ontario is paid by:
• Ontario Health Insurance Plan, commonly known as OHIP, funded by a payroll
deduction tax by residents who are employed, and by businesses/employers
in Ontario and by transfer payments from the Government of Canada
• Payroll deductions is based on annual taxable income (<$20,000)
• Employers health tax contribution - based on a percentage of the yearly
payroll
• Other sources of funds by provincial, territorial and municipal governments for
other services
• Third-party health insurance plans (Sun Life, Blue Cross, The Co-operators)
The Move to Contain Costs of Health Care
• Previously, health services concentrated on services carried out in a hospital,
long term care facilities or in a doctor’s o ce
• Late 1980s - provincial health commissioners concluded health services could
be delivered more e ciently by integrating services across local regions
• Move to regionalization of services as a strategy to contain costs, involve the
community in health care needs, and to address those needs within a
community
• Regional Health Authorities (RHA) = health care organizations responsible for
health care administration in a de ned geographic region within a province or
territory
Funding vs. Delivery of Health Care
• Funding = money, Delivery = sta (face to face)
• Hospitals
• Primarily private not-for-pro t organizations
• Majority of services in a hospital are delivered by private for pro t businesses
(eg. Food and meal preparation, cleaning, maintenance, security, laundry)
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 • Laboratory and diagnostic services -> private, for pro t services
• Hospital negotiates the cost-e ective services and pays for them from the
funds given by the government
• Physicians operate as private for pro t businesses -> they deliver health care
services and are paid by the government by using varying formulas
• Physicians who have their own private practice pay for their own business
expenses
• Hospital nonessential services:
• Semiprivate or private rooms, television, telephone, medical enhancements
or treatment deemed “not medically necessary” (eg. Fibre glass casts
instead of plaster cast, cosmetic surgery, cataract surgery, MRI scans not
covered by insurance plans)
• Patients must pay for these services and any services not deemed
“medically necessary”
Direct cost vs Indirect cost of Health Care
• Direct cost -> treatments and services; nurse’s salaries, doctor’s visits,
surgery, rehabilitation, hospital maintenance
• Indirect cost -> loss of productivity, earnings, workers no longer able to
receive income impacts Canadian economy
Universal Health Care in Canada
• Pros:
• Lowers health care costs for an economy
• Forces hospitals and doctors to provide same standard of care at low cost
• Eliminates administrative costs by eliminating need to deal with private
insurance
• Cons:
• Forces healthy people to pay for others’ medical care
• Without nancial incentive, people may not be as careful with their health
• Most universal health systems report long wait times for elective procedures

WEEK 4
Integrated Delivery Network
• Provides a full range of healthcare services along a continuum of care to
ensure patients get the right care at the right time from the right provider
• Goal: to deliver high quality and cost-e ective care in the most appropriate
setting
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 • Most hospitals are integrated into their communities through ties with area
physicians and other healthcare providers, clinics, and outpatient facilities
Hospitals:
• 4 characteristics:
• Organized medical sta
• Permanent inpatient beds (>24 hours, receive room and board, continuous
nursing services)
• Have around the clock nursing services
• Perform diagnostic and therapeutic services
Types of hospitals:
• Classi ed according to:
• Number of beds - based on number of beds that is equipped and sta ed for
patient care
• Adult beds, paediatric beds, maternity beds, special categories
• Types of services provided -some hospitals specialize in certain types of
services and treat speci c illnesses (psychiatry, trauma, rehab, cancer,
obstetrics)
• Type of patients served- some hospitals specialized in serving speci c types
of patients (paediatric specialized services)
• For-pro t or not-for-pro t status - private hospitals vs public hospitals
• Type of ownership - most common ownership in Canada is government
owned or private foundations
Organization of Hospital Services
• Acute care hospitals:
• Board of Directors - setting the overall direction of the hospital; “governing
board” or “board of trustees”;
• Works with the CEO (chief executive o cer) and the leaders of the
organization’s medical sta to develop the hospitals strategic direction as
well as its mission vision and values;
• Establishes bylaws in accordance with the organization’s legal and
licensing requirements, selecting quali ed administers, approving the
organization and makeup of the clinical sta , monitoring the quality of care
• Continue to face strict accountability in terms of cost containment,
performance management (maintain reputation), and integration of services
to maintain scal stability and to ensure the delivery of high-quality patient
care
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 • CEO - not part of the Board; CEO answers to the Board whereas Board
does not answer to the CEO; is responsible for day-to-day operations of
the hospital, accountability of the employees and budget
• Professional medical sta
• Physicians who have received extensive training in various medical
disciplines (internal medicine, orthopaedics, obstetrics, surgery)
• Primary objective = to provide high quality care to patients who come into
the hospital
• Most medical sta are not actual employees of the hospital -> they bill the
hospital, not the patient
• ~ 80% of physicians are self-employed professionals working on a fee-for-
service basis
• Executive administrative sta
• Leader of the administrative sta = CEO
• CEO is responsible for implementing the policies and strategic direction set
by the hospital’s Board of Directors; also responsible for building an
e ective management team and coordinating the hospitals services
• Executive management team -> responsible for managing nances,
ensuring the hospital complies with the federal and provincial regulations,
standards and laws that govern the delivery of healthcare services
• Medical and surgical services
• Patient care (nursing) services
• Diagnostic and laboratory services
• Support services (nutritional services, cleanings services, and HIM services)
Hospital Departments
• Most Acute Care Hospitals:
• Emergency department, Urgent Care, Medicine, Surgical Unit, Nursing
department, DI department, Laboratory, Pharmacy, Maintenance/
housekeeping, Food services, Security; bold=have their own databases
• Specialist Units:
• Burn unit, trauma centre, cardiology or coronary care unit (CCU), intensive
care unit (ICU), neurology, cancer centre, obstetrics and gynaecology
Healthcare Services
• From simple preventative vaccinations to life saving heart transplants
• Provided by physicians, nurses and other clinical providers who work in:
ambulatory care, acute care, long term care (psychiatric or rehabilitation)
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 • Provided in hospitals, clinics, homes, hospices, public health departments
Allied Health Professionals
• Health professionals other than doctors and nurses who share responsibilities
for the delivery of healthcare services by assisting, facilitating, and/or
complimenting the work of clinicians (doctors and nurses)
• Examples: pharmacist, nuclear medicine technologists, occupational therapist,
physical therapist, physician assistant, radiation therapist, dietitian, etc
• Usually employees of the hospital, under di erent nancial budget from
doctors and nurses
• Can also complete the health record
Patient Care Services
• Most of patient direct care in hospitals is provided by nurses
• Physicians determine the type of treatment each patient is to receive
• Nurses play a wider role in the treatment planning and case management
• Largest clinical department in terms of sta ng, budget, specialized services
o ered, clinical expertise required
• Depends on patient needs - specialized equipment (surgery, chemotherapy),
psycho-social needs (psychotherapist), assistance with medication, homeware
needs
Diagnostic and Therapeutic Services
• Diagnostic - Includes clinical laboratory, radiology and nuclear medicine
• Therapeutic - includes radiation therapy, occupational therapy, physical
therapy ~ all performed by allied health professionals
Ancillary Support Services
• Provide vital clinical and administrative support services to patients,
physicians, visitors and employees
• Ex. Pharmaceutical services, HIM services, social work, food and nutrition
Acute Care Services
• Services for patients who spend more than 24 hours, receive room and board
services, and continuous nursing services
• Services delivered to inpatients in a hospital setting most often over a 24-hour
period and usually have a length of stay less than 30 days
Ambulatory Care Services
• Healthcare that is provided in a practitioner’s o ce, a clinic, emergency care,
day surgery care, on a non-resident (outpatient) basis
• Patients obtain services and return home the same day
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 Long-term care
• Healthcare given in a non acute care facility to patients who require inpatient
nursing and related services for more than 30 consecutive days, such as
nursing home, rehabilitation hospitals
• Mainly rehabilitative and supportive rather than curative which requires little or
no technology
Management vs Leadership
• Leader
• Inspires, motivates, establishes direction, coaches, leads, seeks
opportunities, supports, empowers
• Leaders generate actionable understanding which brings people together
• Success of the organization depends on the collaboration of all its people
with uni ed vision and strategy
• Manager
• Manages, organizes, plans, coordinates, follows the vision, evaluates,
facilitates, budgets
Management Functions
• Planning - missions, vision, values
• Organizing - line authority, sta authority
• Leading - communicating, directing and motivating
• Controlling - Balanced Scorecard (BSC), Monitoring Performance
• Balanced Scorecard (BSC)
• A set of measures derived from the strategies and overall vision of an
organization to communicate strategies and stimulate changes for the
management team -> kind of like a report card
• Addresses learning, internal operations, customer operations, nancial
success
Performance Management
• Assessment of the employee’s performance compared to performance
standards or performance goals
• Development of performance goals
• Development of a plan for a professional development
• 360-degree evaluation
• Focus + Competence + Consequence + Feedback => Preferred Behaviour
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 HIM Functional Areas
• Patient registration - info from MPI has been downloaded to appropriate
databases
• Record processing
• Medical transcription - HIM department, dictated report -> uploaded to EHR
• Release of patient information - fully electronic records, hospitals may have
this department other than HIM
• Coding and abstracting - entered data quality, submission to CIHI
• Research - data can be used for research -> demographic vs clinical data, etc
• Records management centre -> qualitative and quantitative data analysis, data
reporting
HIMs and the Health Record
• Health record = legal and business record for the health care professional or
facility
• Primary purpose = to facilitate the provision of quality health care and to
promote e ective communication among the members of the health care team
• Is physical property of the health care facility, clinic, or health professional that
compiles the record
• Is a compilation of facts of an individual’s visit to a health care setting
(hospital, clinic, family physician’s o ce)
• The physical copy of health record -> be served as evidence in legal
proceedings
• Used in the accreditation of a facility
• Data collected from health record -> determines funding levels
• Contains data that can be used as a resource for planning, quality assurance,
risk management, patient safety and research
Types of Data
• Demographic: personal data elements ~ patient’s name, DOB, gender, postal
code;
• unrelated to the individual’s health status or services provided during the
episode of care
• Used for identity management
• Clinical: recorded by a health care provider (doctor, nurses, physiotherapists,
radiologist, etc) that documents the signs, symptoms, diagnosis, treatments,
personal history, family history related to the individual
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 • Used for continuum of care, communication between health care providers,
planning, billing, and research
• Administrative: times of surgery, patient service, health care provider, date and
time of admission, separation dates and times, length of stay, wait times
• Used for decision making, planning, accountability, e ciency, etc
• Financial: recorded on the rst page/screen of the record, such as payment
information
• Used for budgets, planning, policies, etc
• What to do with all the data?
• Large amounts of data -> quantity of information -> generates knowledge ->
required to obtain wisdom
• Each step up the pyramid answers questions about and adds value to the
initial data
• Data - raw facts, gures, numbers, which have no meaning on their own
• Information - data reveals meaning
• Knowledge - implies familiarity, awareness shaped by person’s experience
• Wisdom - knowledge of numbers/values are used to make decisions (doctor
can prescribe treatment plan)
Database
• Data is information; Database = a place where the data is stored, like a library
that contains a bug collection of books
Technologies that support EHR
• Database - used to collect and process data in an integrated manner;
• Data repository - used to incorporate special indexing and management
functions to capture, sort, process and present information back to the user
very quickly; used for processing transactions like entering, retrieving, and
processing data for one speci c patient and purpose at a time
• Data warehouse - designed to receive data (extracted data from a repository)
and process the data in an aggregated form (combining a whole bunch of
elements); the warehouse holds both current and historical data from 1 or
more systems across an organization
Data must have Integrity
• Data integrity - maintenance of, and the assurance that accuracy and
consistency of data is continuous over its entire life-cycle; free of
inconsistencies and anomalies -> the driving force in the EHR systems and is
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 a critical aspect to the design, implementation and usage of any system which
stores, processes, or retrieves data
• Data should be treated as a valuable asset to the organization
• Data integrity and data security go hand in hand, even though they’re separate
concepts
• Data validation should apply at all levels of the organization, through the
processes, the users, and all activities
• 4 points of Data Integrity:
• Data should clearly demonstrate why it was observed, who recorded it, when
it was observed and recorded, and who is the data about
• Data should be recorded as it was observed, and at the time it was executed
• Data should be accessible and preserved in its original form
• Data should be free from errors
Data Quality and the EHR
• There is an increase in the reliance upon data network systems
• Computerized data has been recognized to have serious problems with
incomplete, missing or inaccurate information
• Poor data quality can lead to medical errors, which can be damaging to the
health of patients, the quality of care given and involve risks to the patients
• The quality of data is dependent on accurate information at the point of entry
Potential Data Risks
• Glitches that cause inaccurate recording of patient’s name
• System design aws resulting in linking wrong patients together
• Individuals using the EHR follow the commands of what the system tells them
to do
• Incorrect medical terminology or computer system chooses the incorrect item
• Clinicians are able to choose free text which lead to human errors or spelling
mistakes impacting the data quality and integrity causing complications to the
patient
Ensuring Data Security
• Data Security - protecting the data against accidental or intentional use by
unauthorized users
• Data Privacy - concerns the rights of the individuals and the organizations to
determine the requirements of data usage
• Con dentiality - ensuring that the data is protected against unauthorized
access and only is used for an authorized purpose
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 Privacy and Security of Data
• Large amount of available data on the EHRs -> privacy and security
considerations are critical
• Canadian eHealth model -> facilitate the sharing of data for patient care,
public health surveillance, health research, electronic communication between
and amongst patients and providers
• (Patients) Fear of undesirable consequences -> nancial loss or the loss of
personal dignity arising from misuse of data (discrimination, social stigma)
• Public support for EHRs -> how well healthcare providers and governments
keep PHI (personal health information) private and secure
• Some provinces have health-speci c privacy legislation
Privacy Legislation Governing Health Information
• PIPEDA - Federal - Personal Information Protection and Electronic Documents
Act
• Relating to data security;
• how private sector organizations collect, use and disclose personal
information in the course of commercial business
• enable individuals to access and manage personal information collected by
organizations
• PHIPA - Ontario - Personal Health Information Protection Act
• Protect the privacy of individuals who receive health care in Ontario
• Establishes consistent rules governing the collection, use and disclosure of
personal health information in the hands of ‘health information custodians’
such as doctors, hospitals or other health care providers
• FIPPA - Ontario - Freedom of Information and Protection of Privacy Act
• Protect the privacy of individuals
• PIA - Privacy Impact Assessment
• Goal: to e ectively manage privacy risks and identify whether appropriate
safeguards are in place to protect PHI
Privacy and Security of Data on the EHR
• EHR -> technology outpace policy; concerns about privacy and how to deal
with privacy issues
• Private policy requirements require constant attention and monitoring
• Continual need for the aggressive use of audit capabilities -> strong
monitoring policies needed to decrease the risks of breaches
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 • Should increase the training on the comprehensive privacy programs at all
levels of healthcare delivery to avoid potential risks of privacy issues

WEEK 5
Electronic Health Record (EHR)
• Technology has transformed medical records from paper folders to electronic
les
• Technology has also changed the processes by which medical professionals
retrieve and analyze that data
• Updates, changes and retrieving health data can all be completed quickly and
accurately
How is health data retrieved?
• Previously
• if health data was required from one location, new location would have to
request copies of that patient’s medical records from previous location
• Transfer of health data in a form of a folder (paper copies) were sent to the
new location through sta or postal service, then waited for the records to
arrive at the new location
• Electronic data
• Immediate access to vital clinical, administrative and demographic
information to health care providers and facilities
• Data retrieval functions a ect the patient’s diagnosis and treatment and
entities outside the health care facility (ie. insurance adjusters to
pharmacists)
Types of Health Data Important to Coding
• Administrative, demographic, clinical, coded and nancial data
• Administrative - entry code, admit category, patient service, health care
provider, date of admission, separation dates
• Demographic - patient’s name, address, telephone number, date of birth, next
of kin
• Clinical - diagnoses and interventions related to the patient
• Financial - payment information; insurance coverage, OHIP number, MIS
functional standards which measure the resources and activities associated
with the visit activities
• Coded - clinical data changed to codes based on standardized nomenclatures
and classi cations systems
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 What type of Reports are on Patient’s records?
Clinical Data & Reports
• Information on a patient’s health record which is related to the patient’s
condition, course of treatment and progress
• Reports found:
• History & physical note, physician’s orders, consultation reports, nursing
notes, ancillary service reports (lab and radiology reports), surgical service
reports (operative notes, anaesthesia reports, recovery room reports),
discharge summary
Can health data be shared with anyone?
• No, needs authorization
Security of Data
• Health care professionals must not allow unauthorized access to sensitive
patient information
• PHIPA ~ Nov 2004 -> contains clause on protecting patient privacy
• Requires that health care professionals take prudent steps to protect the
con dentiality of health information
• FIPPA (each province has their own FIPPA act)
• Protects the privacy of people’s personal information existing in the
government records
What is Classifying Data?
• Technology -> abundance of available information
• Need methods of organizing data to improve analytics, accessing information
and/or comply with new regulations
• Data Cataloguing -> classifying data -> action or process of grouping
something according to shared qualities or characteristics
• Health data cataloguing/classifying -> alphanumerical code according to ICD
10 CA and CCI
• ICD 10 CA -> International Classi cation of Diseases, 10th revision Canadian
• CCI - Canadian Classi cation of Interventions
ICD 10 CA and CCI
• Used by health care professionals, health insurance companies, public health
agencies around the world to represent diagnoses and interventions related to
the patient’s visit to a hospital
• Assigned to every emergency visit, day surgery visit, and inpatient admission
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• Alphanumerical code for every disease, disorder, injury, infection, and
symptom
• Codes are used for everything from processing health insurance claims to
tracking disease epidemics and compiling worldwide mortality statistics
What is Coding?
• Transferring health data into computer language, which can be stored into
computer programs (abstracting system) that can be transformed into
meaningful health care information
• Only HIM professionals can code charts or audit them
How is health data coded in the health care system?
• Automatic - codes are computer generated from text without human
intervention
• Semi-automatic - a person must physically choose and enter a code from a
list provided by the computer
What is the purpose of coding?
• Purpose: to provide health care data that can be stored, indexed and easily
retrieved
• Encoded data -> can be aggregated, tabulated and sorted for statistical
analysis
• Can be used for individual case analysis, or provide access to the individual
source document
What is actually coded?
• Diseases, conditions, injuries
• Procedures, interventions
• Severity of illness
• Causes of accidents
• Results of lab tests, pathology specimens
• Causes of death, patient’s outcomes, other related health care issues
Rules for Coding
• Ambulatory coding vs Inpatient coding
• Codes for diseases / conditions vs symptoms
• Procedures vs Interventions
• Sequencing of the codes (most important ~ least important)
• Importance of codes
• Coding rules are documented on the CIHI’s coding standards
 Role of CIHI
• CIHI mandates what is required to be collected (jointly by federal and
provincial/territorial ministers of health)
• Provides essential data and analysis on Canada’s health system and the health
of Canadians
• Tracks data in many areas supplied by hospitals, regional health authorities,
medical practitioners, governments
• Data and reports focus on health care services, health spending, health human
resources, population health
• Identi es and promotes national health indicators - measures life expectancy,
what we spend on health per capita - things used to compare health status
and health-system performance and characteristics
What is Coding data used for?
• Statistical uses: ethology and incidence of disease, planning, managing quality
of care, research, establishing funding rates
• Individual uses: reimbursement, education, research and speci c studies
Who Utilizes Coded Data?
• Epidemiologists and researchers
• Recurrences of diseases
• Identify areas at high risk
• Develop medical knowledge
• Identify trends
• Evaluate treatment options
• CEOs
• Planning - do we need to close a oor? Hire another physician? Prepare the
budget?
• Evaluating - what are safety aspects of care? Outcome of care? Risks of
data breaches?
• Monitoring - should we look at establishing sta ng requirements? Delivery of
care? Reviewing case loads?
• Utilizing resources - what are wait times for the OR rooms? ER and ICU?
What is the mortality rate? Complication rate after surgery? Readmission
rate?
• Insurance companies and government
• Establish funding rates
• Determine specialty needs
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 • Identify needs
• Managers
• Measure and evaluate quality and accuracy
• Measure safety and e cacy of health care services
• Measure productivity of sta
Purpose of classifying and retrieving data
• Health care needs have changed
• New viruses
• Chronic conditions, disease of modernization, mental health
• Conditions resulting from diet and lifestyle
• Health care services, and resources are in high demand and expensive in all
levels
Classifying Data at Di erent Levels of Care
• Primary - ICPC (in USA and worldwide, PHC indicators used in Canada)
• Secondary - ICD 10 CA/CCI
• Tertiary - ICD 10 CA/CCI, ICD-O, DSM-IV
• Continuing Care - CCRS, RAI-MDs, RAI-MH, RAI-HC
Primary Care
• Routine care, care for urgent but minor/common health problems, mental
health care, maternity and child care, psychosocial services, liaison with home
care, health promotion and disease prevention, nutrition counselling, end-of-
life care
• Primary Health Care Reporting System
• CIHI -> leader in improving primary health care (PHC) data and information
across Canada
• Pan-Canadian Primary Health Care Electronic Medical Record Content
Standard (PHC EMR CS) -> created as a pan-Canadian solution to facilitate
the capture of structured EMR data at the point of care
• Clinician-Friendly Pick Lists (CFPL) -> developed to focus on data at the
point of care
• Lists of clinician-validated terms commonly used in PHC settings
• Developed to support aggregate level reporting and analysis
• CFPL terms were mapped to recognize code systems, using ICD 10 CA,
CCI, ICD-9, SNOMED CT
• Intended to capture information to facilitate standardized data capture at
the point of care
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 • Used for population and disease surveillance
• PHC priority indicators focus on the data relevant to the PHC environment
• CFPL Mapping:
• ICD-10-CA and ICD-9:
• Health concern - chronic conditions, comorbidities, ambulatory care
and family practice sensitive conditions, special interests of population
health, major previous medical history
• Out of scope: signs and symptoms, suspected/query conditions, past
surgeries
• Clinician assessment - diagnoses, comorbidities, chronic conditions,
ambulatory care sensitive conditions
• Out of scope - signs and symptoms, past history
• Social behaviour - negative social behaviours (abuse of prescription
drugs, tobacco use, etc)
• Out of scope - occupations, positive social behaviours
• Reason for visit - high frequency complaints, symptoms, follow ups,
requests for referral/services/medicine renewals
• CCI
• Intervention - services/procedures relevant to PHC setting (eg.
Counselling, education, examinations, past surgical interventions
performed outside the PHC setting but relevant to PHC care)
• Out of scope - activities captured discretely in other data elements (eg.
Diagnostic imaging tests, medications, lab tests, vaccines)
• Diagnostic imaging test ordered - diagnostic imaging tests required for
priority indicators such as cancer screening (mammogram) and bone
density screening (bone mineral densitometry), high frequency and
special interest diagnostic imaging tests
• SNOMED CT
• Referral service - types of specialty services (eg. Cardiology)
• Out of scope - specialist descriptions (eg. Cardiologist), low frequency
services (eg. Faith healer)
• Vaccine administered - high frequency and mandatory vaccines and
those included by the National Advisory Committee on Immunization
(NACI); supports indicators on in uenza, pneumococcal and childhood
immunizations
• Ambulatory Care
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 • National Ambulatory Care Reporting System (NACRS)
• contains data using ICD 10 CA/CCI codes for all hospital-based and
community based ambulatory care
• No inpatient data - day surgery, outpatient clinics, emergency departments
• Client visit data is collected at time of service in participating facilities
Secondary Care - Inpatients
• Discharge Abstract Database - DAD - developed in 1963
• Captures administrative, clinical data using ICD 10 CA/CCI, and
demographic information on hospital inpatient discharges (including deaths,
sign-outs, and transfers)
• Data is received directly from acute care facilities or from their respective
health/regional authority or ministry/department of health
• Facilities in all provinces and territories except Quebec are required to report
ICD 10 CA Organization
• Organized by chapters, blocks and categories
• Chapters: 23 chapters
• Represents diseases/conditions by body systems, signs and symptoms,
abnormal clinical ndings, external causes of morbidity and mortality,
factors in uencing health status, and morphology of neoplasms
• Blocks - subdivisions of the chapters into 3 character categories
• Eg. D50~D53 Nutritional anemias
• Categories - 3 characters (alpha character + 2 numeric characters) each may
represent a group of related conditions or a single disease entity
• Eg. C00-C99 for malignant neoplasms
Organization of CCI in Sections
• Section 1 - Physical/Physiological Therapeutic Interventions
• Section 2 - Diagnostic Interventions
• Section 3 - Diagnostic Imaging interventions
• Section 4 - not in use
• Section 5 - Obstetrical and Fetal Interventions
• Section 6 - Cognitive, psychosocial and sensory therapeutic interventions
• Section 7 - Other healthcare interventions
• Section 8 - Therapeutic interventions strengthening the immune system
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 CCI Fields example
Field 1 Field 2 Field 3 Field 4 Field 5 Field 6

B AA BB AA BB B

Section Group Intervention Approach or Quali er Quali er

Technique

Body system What is being Devices being Relates to

or site done? used (screw, tissue or grafts
nail)

CCI Intervention Attributes

• Attributes are indicated along side of each CCI code
• Attributes are separate data elements to the CCI code
• Function - to provide extra detail about the intervention that may be useful for
researchers or utilization analysts
• Assignment of the attribute codes - determined at the national, provincial/
territory and local levels
• Pink attributes - mandatory at the national level
• Yellow “S” attributes - mandatory when applicable
• New coders should include all intervention attributes when applicable

Tertiary Care
• International Classi cation of Diseases for Oncology - ICD-O
• Multi-axial classi cation of the site, morphology, behaviour, and grading of
neoplasms
• Topography axis - uses the ICD-10 classi cation of malignant neoplasms for
all types of tumours (except those categories which relate to secondary
neoplasms and to speci ed morphological types of tumours)
• Provides a greater detail for non-malignant tumours than what is provided in
ICD-10
• Includes topography for sites of hematopoietic and reticuloendothelial
tumours
• Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text
Revision (DSM-IV-TR)
• A manual published by the American Psychiatric Association (APA)
• Includes all currently recognized mental health disorders
• Used by mental health professionals to describe the features of a given
mental disorder
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 • Indicates how the disorder can be distinguished from other, similar problems
• Coding system utilized in DSM-IV is designed to correspond with codes from
the ICD-9 or 10 CA
Continuing Care - CCRS
• Continuing Care Reporting System - developed by CIHI which provides a
range of ICD 10 CA codes and 3 category codes to help clinicians code
diseases and other health conditions that frequently occur in continuing care
(~long term care speci c)
• Pick list of codes was developed for the CCRS because the diagnosis coding
does not need the same level of detail as an acute care setting
What is a Nomenclature?
• A systematic listing of proper names
• Disease nomenclature = listing of the proper name for each disease
• SNDO - Standard Nomenclature of Diseases and Operations
• Developed in 1942, used in 1950s so all hospital can compare diseases and
operations across the country
• SNOMED - Systematized Nomenclature of Medicine
• Clinical terminology nomenclature
• Contains more than 993,420 English language descriptions or synonyms for
exibility in expressing clinical concepts
• Eg. Pain in throat = sore throat, throat pain, throat discomfort, throat
soreness
• ENCODE-FM - The Electronic Nomenclature and Classi cation of Disorders
for Family Medicine
• Created in 1992 by 3 Ontario physicians
• Comprised of symptoms, complaints, diagnoses, disorders and reasons for
encountering that most commonly occur in a primary care setting
• Perhaps used in conjunction with PHC and/or pick lists?
• LOINC - Logical Observation Identi er Names and Codes
• Clinical vocabulary designed to facilitate the exchange of lab results for
clinical care, outcome management and research
• Has the capacity to communicate clinical diagnostic results between
databases - in the EHR and in other databases
What is a classi cation system?
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 • A systematic arrangement of elements within a subject (diseases, injury, other
reasons for health care) into groups or categories according to predetermined
criteria
Types of Classi cation Systems
• DSM-IV - Diagnostic and Statistical Manual of Mental Disorders
• Initially developed to give more objective terms for psychiatric research
• Prior to DSM, communication between psychiatrist was not uniform
• ICD-O - International Classi cation of Diseases for Oncology
• Used in tumour or cancer registries for coding the site (topography) and the
histology (morphology) of neoplasms, usually obtained from a pathology
report
• ICD-10 - International Classi cation of Diseases
• Purpose = to promote international comparability in the collection,
classi cation, processing and morbidity and mortality statistics
• ICD 10 CA - Canadian version of ICD
• Alphanumeric characters, starting with a letter followed by 2 digits (called the
rubric) then a decimal, and possibly up to 3 more digits
• Divided into chapter for each body system and/or related factors
• Provides one category for each and every disease or morbid condition
• Eg. Diabetes: E- -,- -
• CCI - Canadian Classi cation of Interventions
• A multiaxial framework which consists of 6 elds and 8 sections
• Alphanumeric structure with a code length of up to 10 characters
• First 5 make up the “rubric” and describe “what is being done”
• Last 5 make up the “quali ers” and describe “how the intervention is being
done”
• CIHI - Canadian Institute for Health Information
• Independent, not-for-pro t organization that provides essential data and
analysis on Canada’s health system and the health of Canadians
• Tracks data from information supplied by hospitals, regional health
authorities, medical practitioners and governments
• Identi es and promotes national health indicators
• coordinates national health information standards
• Creates analytical reports for decision making
• Focuses on : health care services, health spending, health human resources,
population health
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 • Informs Canadians about the factors a ecting good health
• Provides information to help government establish sound health policies
• Supports the calculation of hospital and regional funding as required by
some provincial/territorial ministries of health
• Conducts analyses on trends or to track patient outcomes over time; eg.
Survival rates for transplant recipients
• Supports quality improvement in health service organizations
• Helps manage the health care system e ectively and make the best use of
resources
• Collects 3 broad categories of health information
• Health services information - provided by hospitals, di erent types of
procedures performed, how long patients had to wait
• Health care professionals - provides data on how many doctors and nurses
are working in hospitals, community care facilities, and medical o ces
• Health care spending - provides data on how much is spent on drugs,
hospitals, physicians, who pays for these services, private or public
Health Indicators
• Standardized measures used to compare health status and health system
performance among di erent jurisdictions and di erent populations in Canada
• Measures things such as life expectancy, and what we spend on health per
capita
• Aim to support Regional Health Authorities (LHINs) in monitoring the health of
their population and the functioning of their local health system through quality
comparative information
Where does the data come from?
• Mainly from government health departments, hospitals, continuing care
centres, and other health care organizations
• Discharged Abstract Database (DAD) - largest database - received by 85% of
Canadian hospitals from inpatient visits
• National Ambulatory Care Reporting System - NACRS - Canadian database
for ambulatory care visits
• CIHI only receives an “abstract”, not the complete record
• Each abstract contains coded information (eg. Number of days in hospital,
reason for stay)
What is the relationship between Coded and Health Care?
• Health care industry -> technology -> optimum performance
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 • Coding - data collection process - required to produce workload measurement
information in healthcare and to satisfy the demands of healthcare delivery
• 4 Important characteristics -> reliable, valid, complete, timely data -> will help
to prevent diseases, avoid mechanical errors, and contribute to decision
making
Elements of Data Quality
• Reliability - coded data is reliable when multiple coders assign the same
codes to the same type of patient with the same type of conditions/diseases
• Validity - accurate assignment of codes that re ect the patient’s diagnoses
and procedures for that visit
• Completeness - coded record represents all the patient’s relevant diagnoses
and procedures
• Timeliness - record is coded in a timely manner, meeting deadlines, within the
time frames assigned

WEEK 6

HIMs and the Health Record

• Health record = legal and business record for the health care professional or
facility
• Primary purpose of the health record = to facilitate the provision of quality
health care (cost and funding to the hospitals) and to promote e ective
communication among the members of the health care team
• We are telling the patient’s story in alphanumerical terms which are then
translated into data
• The health record is the physical property of the health care facility, clinic, or
health professional that complies the record
• Healthcare Value = Quality of care / Cost of Care
Source-Oriented Health Records
• The conventional or traditional method of maintaining or organizing paper-
based health records
• Records are organized according to the source or department (eg. Lab reports
are led together, all diagnostic imaging or surgical reports, which are led
together by sections
• Advantage - all similar information is kept together, making it easier to
compare changes over time
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• Disadvantage - care providers need to access di erent sections of record
whether paper or electronically to see the most recent information
• Majority of hospitals are set up using source-oriented format whether they
have the EHR or paper based records
Problem-Oriented Health Records
• Data is organized by the patient’s medical problems as identi ed in the:
• H & P and the initial lab report ndings (tests, procedures and other
treatments)
• Progress notes are organized so all healthcare team can easily follow the
course of treatment
• Problems may be active or inactive
• Active - condition(s) that requires current medical management or further
diagnostic treatment
• Inactive - previous or resolved condition(s) that may continue to impact the
patient’s health, such as a chronic condition of diabetes or high blood
pressure requiring regular medication
• Not usually practiced in the hospital
SOAP Format of Organizing Information
• A method of organizing information documented on the patient’s record
• S - subjective ndings, symptoms
• A description of the condition in the patient’s own words
• O - objective ndings, lab and test results
• Factual, straightforward, repeatable facts
• A - analysis, appraisals, judgments based on ndings
• Preliminary diagnosis based on the physician’s assessment of the subjective
and objective
• P - plan, continuing or revision of care
• A plan for treatment based on the physician’s assessment
What are Standards?
• An agreed way of doing something
• Published documents that establish speci cations and procedures designed
to ensure the reliability of the materials, products, methods, and/or services
people use every day
• Addresses a range of issues, including various protocols that help ensure
product functionality and compatibility, facilitates interoperability and supports
consumer safety and public health
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 Health Information Standards
• If health care service delivery organizations implement the same standards in
their information management systems, they would be able to exchange data
within and across organizations
• Standards = most e ective way to facilitate cost e ective, interoperable
systems
• Eg. Date of admission, date of birth, discharge date -> yyyy/mm/dd -> all use
same format
• Allows the collection and communication of health data in EHRs and across
di erent computer information systems
• Documentation standards are required for the transfer of information from
the hospital information system to the laboratory, operating room, and
pharmacy
Interoperability
• The ability for technology systems and devices to exchange, interpret, and
store data using common standards;
• the ability of health information systems to work together within and across
organizational boundaries in order to advance the e ective delivery of
healthcare for individuals and communities
• Eg. Infusion pump -> programmed to deliver uids or medications at
calculated rates through an IV to a patient; medication formula is
programmed into the pump to ensure the correct dosage and duration
• 2 key levels of interoperability: structural and semantic
• Structural Interoperability = the ability to transfer data from 1 system to
another for a de ned purpose, with preservation of the meaning of the data
at the data eld level
• Used to transmit data from 1 organization to another or 1 application to
another
• Eg. Yyyy/mm/dd = structural; same format for MPI or prescriptions
• Semantic Interoperability = the information systems receiving the data can
understand and use it
• Using a speci ed structure for data exchange, de ned representation
appropriate for the intended purpose, preservation of the meaning of the
data, and the added interpretation through application of health
terminologies or code systems to the data exchanged
• Eg. CP = chest pain or cerebral palsy
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Health Information Standards
• HL7 = Health Level 7 Messaging Standards
• ISO = International Organization for Standardization
• IHE = Integrating the Healthcare Enterprise
• HIMs need to monitor, implement, and contribute to the advancement of
health information standards as they continue to evolve in Canada and
internationally
Health Level 7 International
• A “not-for-pro t”, accredited standards developing organization dedicated to
providing a comprehensive framework and related standards for the exchange,
integration, sharing, and retrieval of electronic health information that supports
clinical practice and the management, delivery, and evaluation of health
services
• Level Seven = seventh layer of the International Organization for
Standardization (ISO), seven-layer communications model for Open Systems
Interconnection (OSI), which is the application layer and supports functions
including data exchange structuring
• Focus on the format and the content of the data exchange, rather than the
transportation method
• Hospitals at Level seven = hospitals are completely electronic and have met
the standards put forward
HL7
• Data must be presented in a standardized structure to be universally
understood
• All health care data must be sent in a standardized health care language to be
understood
• Was developed so that data could be better understood
• HL7 standards allow di erent independent health care information systems to
‘talk’ to one another, even if they are using di erent languages
• Supports clinical practice and the management, delivery, and evaluation of
health services
• HIMs are responsible for ensuring and maintaining the quality of health
information, not the technical component of the information systems
• There is a greater need in standardization of data content in the EHR and HL7
helps
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 • Data dictionary - set of data elements identi ed and de ned in a standard way
understood by all systems and people
• Is used to align and appropriately interpret health data
• Hims must ensure that the data dictionary in their organization are complete,
accurate and based on standards
Health Information and Data
• Health information formats = text, alphanumerical data, images, audio, video,
etc.; available from multiple sources, shared by providers, departments,
hospitals and jurisdictions
• Advancement in computer technology -> improved clinical decision making by
linking clinical and nancial data
• Volume of data is progressively increasing -> issues regarding data quality,
access, storage, retention and disposal need to be addressed
• Recall DIKW
• Data (or facts) = represent speci c characteristics about patients
• Stored on a patient’s health record from all levels of care
• Data and information are compared, combined, interpreted by physicians
and other providers to diagnose diseases, develop treatment plans, assess
the e ectiveness of care and determine patient’s prognosis
Security Controls
• EHR can be vulnerable without proper security controls
• Security controls allow only authorized personnel with access to information;
allows only certain users to access certain screens of the record; provides a
ag that pops up on a computer screen or alerts IT specialists of who is
accessing the record
• No rewall protection or improper backing up measures -> EHR is vulnerable
• Organizations that collect data must consider how the information will be
constructed whether by paper or electronically
• Requirements of the physical layout and functionality of the paper forms or
screens on the computer must be consistent
• Standards should be in place as part of the ongoing reviews and revisions to
re ect new data elements
• Version controls -> needed to ensure that the latest revisions or changes are
made available
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 Security Safeguards
• Administrative safeguards - covers policies and procedures, contracts and
plans for security, policies associated with information access including
appropriate clearance procedures, termination procedures, members of the
workforce, backup plans, disaster recovery plans
• Physical safeguards - protecting the environment including applicable doors
with locks, preparation in place for oods, re, re alarms, smoke detectors,
badging and escorting visitors, workstation use and security
• Technical safeguards - access controls, audit controls, person or entity
authentication, transmission security
In uences on the Health Care Environment
• Greater awareness and focus on risk management and patient safety
• Safety - emerging important risk factor, especially with electronic information
• Risks due to technology: errors in software products, security issues, quality
issues, human factor issues
What is Risk Management?
• Risk = a function of 2 aspects of an event; the likelihood of an event occurring
and the impact of the event
• Positive and negative risks
• Risk Management = the processes, procedures and structures that are
directed towards realizing bene ts while managing adverse e ects
• Purpose = to establish a way to make decisions that will eliminate and/or
minimize the consequences of losses, thereby increasing the quality and
improving quality of care and patient safety
Three Types of Risks and Risk Management
• Privacy Risks - Canada has mandated legislations (PIPEDA, PHIPA, FIPPA) to
protect data and preserve the privacy rights of individuals
• Security Risks - computer viruses can cause a system to crash; security
safeguards are implemented to limit the risk
• Safety Risks - associated with possible errors in medical devices or medical
errors related to imperfections to software products
• Employing risk management policies increase patient information safety
systematically as well as the organization’s assets, accreditations,
reimbursement and funding mechanisms, reputation and community standing
The Need for Standards
• Standards help to:
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 • Assess and improve upon the quality of health services
• Determine what type of care should be o ered and identify gaps in the
current systems
• Improve health and safety in the workplace
• Identify best practices, leading to reliable and higher quality health services
• Determine e ciency
Standards Life Cycle
• Needs analysis/assessment
• Development
• Education and training
• Implementation
• Conformance
• Maintenance
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