I never thought this would get here....week 15....this is the last week of the semester....shew. I made it...I have arrived! It goes much faster than I thought it would. I will be graduating before I know what is going on, then into the work force I must go. I am nervous, but it will be ok. Change is scary, but it is inevitable to grow as a person, so change I must do.
My last assignment was an annotated bibliography. I had no idea what that even was but I did one. I jsut hope it was done right. But at this point in time, it is what it is and here it is:
Annotated
Bibliography
This site
speaks of the privacy issues for HIPAA regulations. There are links for
consumers and covered entities alike. For a consumer, it tells of who has to
follow the HIPAA laws, who does not have to follow the laws, what information
is protected, how it is protected, who can look at private health information
and what rights the consumer has over their private health information.
It also
explains who is considered a covered entity and how to know if your facility is
a covered entity. The site also has much more valuable information pertaining
to HIPAA laws on security and privacy of healthcare records.
This site
is a very short but very important link. It is one page that explains the
unacceptable abbreviations to be used and shy they are unacceptable. For
instance it explains if something is 1mg it should never having a trailing zero
as in 1.0 mg because it may be mistaken as 10 mg instead of 1 mg.
The above
site talks of bad habits that need to be avoided during electronic
documentation. One of the easiest habits to get into is the copy/paste
functions. When doing a copy/paste, every single word has to be read to make
sure it is the proper documentation for this patient and if the whole idea is
to save time, then it is not very time-saving to have to completely go over
everything and correct what may or may not be wrong.
The two
links above talk about the privacy issues of HIV/AIDS and mental health laws.
There are certain issues such as these that do not strictly follow the rulings
for other privacy rules or regulations for “normal” illnesses or diseases. Most
generally, HIV/AIDS, mental health, drug abuse/addictions, and genetic disorders
are governed by state laws.
The above
site talks of the importance of the HIMs role in securing the health records.
The privacy, security, and confidentiality of a person’s health record is of
utmost importance to anyone that handles the health records in any aspect. This
site also discusses some of the roles a HIM professional can maintain within a
facility.
The above
site talks about data stewardship. Data Stewardship is so important because the
data steward is “the keeper of the data” to put it simply. A data steward
designates who gets what information and the extent of that information they
have the rights to.
The above
link has a vast amount of information within this website. It has links for
health IT tools and resources and many, many more things. It is a site about
information technology in the healthcare industry. AHRQ wants to improve the
health care for all Americans and there are many resources within this site to
help anyone in the healthcare industry.
The above
site has a vast amount of information about the privacy and security of HIEs,
the risks involved in security gaps, who is responsible for those gaps, and
much more. I cannot begin to list everything this site beholds. It talks of
data stewardship and what exactly the entails by defining the roles and
responsibilities of data stewardship. It also talks of risk assessment and risk
analysis in an attempt to avoid cybercrimes and serious breaches of information.
Another topic is talks about is PHI: who has access and to what extent that
access is given.
This site
is a very valuable site since it has so much information that is critical in
the field.
The above link talks about the relationship between business
associates and covered entities. It is very important for the overseer of
health information to know who is a covered entity or a business associate. A
covered entity is very much responsible for the privacy and security of private
health information contained in medical records. A business associate is not necessarily
a covered entity so the rules are a bit different. This document explains what
it what and who is who pertaining to the rights and release of personal health
information to whom.
HIPAA has
very strict rules about the privacy and security of health information. It
requires someone to be in charge of all of the security and privacy aspects and
that is where the Chief Privacy Officer or Security Officer comes into play.
There is a critical need for one person to be over all of the rules and
regulations of privacy and security issues. This person would be the one to set
the policies and procedures within the facility and would also be the one to
accept the complaints and get to the bottom of issues dealing with privacy and
security within the facility.
This links
talks of the “ownership” of health care data. It used to be the patient was the
“owner” of their healthcare record, but with everything going electronic,
changes had to be made to maintain the security of those private records. There
is also the matter of secondary data and the de-identification of records.
Another matter that needed to be dealt with is the record as a business or
legal record. There are so many things to consider now that everything is going
electronic. Someone has to maintain the ultimate control over these records or
they would be released to just anyone and people personal information would no
longer be private.
CAC or
computer aided coding has many attributes for point of care coding. It allows
for the software to pull certain trigger words during documentation and will
automatically generate codes in ICD-9/10. This is a huge time saver for the
coders as they no longer have to read every single word of the documentation
from the healthcare provider to decipher and code. The coder can now simply
review and verify the codes that the CAC has chosen prior to sending it to the
biller to be submitted for reimbursement.
Although
CAC is up and coming in the industry, the need for human interaction will
always be needed for complete and accurate coding. A computer can decipher
words and automatically generate codes, but it cannot be 3rd party
payer specific with all of the different rules and guidelines 3rd
party payers insist upon. So, human interaction is needed to tweak the codes
and verify what the computer has chosen to make sure it is all in compliance
with the 3rd party payer specific requirements.
The Isabel
website was a great tool to find out about. This is a point of care diagnosis
checker that is full y functional with the EMR. It will assist healthcare
providers at point of care to help with diagnoses of patients. IT also has a
symptom checker for patient use. This would never be a replacement for direct
healthcare from a physician but it is a great tool to check what your physician
has told you if you are uneasy with the diagnosis you get. This tool can help
decide if you want a second opinion for your diagnosis.
There are
times when HIM professional may have to hold a health record in a higher regard
as far as privacy is concerned. This would be done for a high profile record,
such as a celebrity. In this case, the HIM professional may want to enable use
of a “record hold”, de-identify the record, access restrict the records, or
enter an alias to allow for greater security for the record. Mental health,
HIV/AIDS patients, drug abuse/addiction records, and people with genetic
problems all need a higher level of security and the HIM professional must know
how to treat all of the special circumstances surrounding these types of
situations.
This site
has so much information in it (as many do). This talks of HIM and HIT and the convergence
of the two with the electronic healthcare environment. Three area of convergence
of the two are: maintaining confidentiality and security of patient
information, using and maintaining data and information, and terminology asset
management. HIM professionals play a strategic role in the infrastructure for
national health information. Him professionals also are in the mainstream for
protecting the security of the EHRs. They are also responsible for the
interoperability of the exchange of healthcare information.
With
physicians making the move from paper-based records to electronic health
records, there is a great deal to think about and be aware of. For the initial transition,
the physician has to be concerned with the fact that more medical malpractice
suites may be filed due to the physician not being used to the documentation
process of the EHR compared to the paper based records they have always been
used to. The risk of errors may increase with the EHR until physicians get used
to it. Errors can also escalate from coders because, just as we all became reliable
on spell check functions, coders can rely on the system they are using to catch
coding errors. This would be a huge blunder. When you become so comfortable as
to rely on a computer to catch your errors, mistakes are going to be made.
This site
goes over the actions of switching from paper based records to EHRs. It gives
you tips and information from the planning stages of moving all of the records
from paper to EHR, keys factors to consider, assessment, setting goals,
specifics on scanning the records, and the actual process…like who will oversee
the scanning, who will actual scan the documents and what will be done with the
paper charts once they are all scanned into the system. Even though I don’t
think I will ever have to deal with any of this, it is nice to know just in
case I get involved with some of this somewhere down the line in my career. Not
all physician or facilities are switched over completely so with me graduating
in May, I have a chance of maybe getting involved in some of this. Better to have
the information ready in case I need it than to be lost in the process.
The quality
of the healthcare records depend entirely on the quality of the data that is
input from the end user. If bad data is input, the quality of the data within
the record is not good. There are certain guidelines and standards for data to
be used within a healthcare record. The data used must be accurate, concise,
complete, and universally understood by all data users anywhere. This site also
covers the best practices to ensure data quality.
This site
is the Office of the National Coordinator for Health Information Technology. It
is a site that is maintained by the U.S. Department of Health & Human
Services. There are many different links for various information. It has news,
events, & resources as well as HITECH programs and d=federal advisory
committees.
According
to the U.S. Bureau of Statistics, an estimated 51000 health IT professionals
will be needed in the future. This site offers different roles the Health IT
professional may take within their profession. It lists opportunities and
requirements for those opportunities. This is something all of us within the
curriculum need to look into since we are all new and there are so many
different avenues we can take within the profession we have chosen.
I made this link bold because this
is VERY important for my future. I went into this curriculum to be a coder and
nothing more. Now that I am here, I realize there is so much more to this filed
than being “just” a coder. That is still where my heart is, in coding, but I
cannot ignore all of the other opportunities that will lie at my feet once I
graduate and get ready to enter in the work force in this rapidly changing
field.
This is
actually a site for an occupational outlook for Health Information Technicians.
I found this to be very interesting as it gives the outlook on jobs and what
the duties are that is expected out of different occupations within this field.
I have to find my niche in this industry so any information and help I can get
to guide me into my little “place” I will accept.
I think
this site is a very important site. It talks about a disaster recovery plan for
healthcare information. They learned a lot of things form hurricane Katrina in
the recovery of healthcare information. There is so much information in all of
the various links on this website; I cannot begin to give a good summary of
them. I definitely wanted to keep this site as a go-to with my professional life
in the healthcare industry on my horizon.
