Week 5....

We are discussing data sets, data dictionaries, terminology, and vocabulary in my health records class this week. Kind of sounds boring, huh? Well, they are all very important topics in the health care field.

Vocabulary standards are to keep everything consistent because certain words mean certain things. That is important so everyone in the field calls a diagnosis the same thing. Like one person cannot document pharyngitis and another person document sore throat in the same record....it is pharyngitis through and through.

Data sets are basically a uniform way to collect data so everyone collects the same data, the same way, every time. There are different data sets for different health care settings.

• Uniform Hospital Discharge Data Set (UHDDS) is the data set that is used in short term inpatient settings, or hospitals. There are 20 elements of data for the UHDDS. Those elements are: personal identification, birth date, sex, race & ethnicity, residence, hospital identification admission date, type of admission, discharge date, attending physician identification, operating physician identification, principal diagnoses, other diagnoses, qualifier for other diagnoses, external cause-of-injury code, birth weight of neonate, procedures and dates, disposition of the patient, patients expected source of payment, and total charges. So, every hospital everywhere would collect this same data. This standard has been set by the federal government.
• Uniform Ambulatory Care Data Set (UACDS) is used in outpatient settings such as physician's offices, medical clinics, same-day surgery centers, outpatient hospital clinics & diagnostic departments, emergency treatment centers, and hospital emergency departments. The UACDS has some of the same elements as the UHDDS such as personal identifier, residence, date of birth, gender, & race/ethnicity.This makes it easier to compare data within the same facility. The UACDS also has some elements specific to ambulatory care such as the reason for the encounter, place of encounter, diagnostic services, problem diagnoses or assessment, therapeutic services, preventive services, disposition, living arrangements, and marital status. These last two elements are needed to know if the patient will have help at home when leaving after surgery. Unlike UHDDS, these elements are not mandated by federal regulations so they are recommended elements, rather than being required elements. 
• Minimum Data Set (MDS) is used for long-term care settings such as residential facilities for people who are not able to live alone due to a chronic illness or disability. MDS is a  federally mandated assessment form to collect demographic and clinical data on nursing home residents. This data collected are used to develop a resident assessment protocol (RAP) for each resident. This helps to lay out the care plan for each resident. There are 20 elements in the MDS: demographic information, identification & background info., cognitive pattern, communication/hearing patterns, vision patterns, mood and behavior patterns, psychosocial well-being, physical functioning & structural problems, continence in past 14 days, disease diagnoses, health conditions, oral/nutritional status, oral/dental status, skin condition, activity pursuit patterns, medications, special treatments and procedures, discharge potential and overall status, assessment information, and therapy supplement for medicare PPS.
• Outcomes and Assessment Information Set (OASIS) is the data set to gather information about Medicare beneficiaries in the home health setting. OASIS data are basically used for reimbursement purposes for home health services. OASIS has more than 30 data elements and are grouped in the following categories: patient tracking items, clinical record items, patient history and diagnoses, living arrangements, sensory status, respiratory status, cardiac status, elimination status, neuro/emotional/behavioral status, activities of daily living, instrumental activities of daily living, medications, care management, therapy need and plan of care, emergent care, and data collected at transfer/discharge

This is just the tip of the iceberg with all of the information we have covered this week between this class (HIT2100), HIT2000, and HIT2200. 

It is mind boggling! But here we are ending week 5 already. I feel like it is going to be May before I know it and I will not not be stressed over homework but trying to find a job to enter this industry. It seemed so far away when I started in the fall of last year now I am almost halfway through this semester and I have completed 4 quarters prior to this. Crazy!!!

Johns, M. L. (2011). Health Information Management Technology An Applied Approach. Chicago, IL: AHIMA.

Week 4....

This week we talked about data definitions, vocabulary, terminology, and dictionaries on our discussion board. All of this criteria is so important in the understanding and communication of health care records and just the every day language of the health care industry. If we did not have terminology standards to follow it would be chaos. Everyone would be calling the same thing by a different name, so with the standards, everyone calls a certain disease the same name every time.

With the emergence of the EHR it will be imperative to have a specified set of terms to use. this is so critical that only a central authority has the rights to change or add anything to the vocabulary. That makes it nice so not just anyone can go in and change things because they want it to be something else for some reason.

Data definitions are just another way to say that each data in the record is defined. One example of a data definition would be for race. When filling out a form it asks for race and there is a defined explanation of what they want and it will always be the same.

There are so many standards coming with the EHR. these standards are required for the privacy of the patients health records. The more I learn, the more I am realizing just how secure our health records are going to be. I mean, paper-based records are so vulnerable to damage by fire, liquid, or a humans interaction of some kind. They also have a vulnerability to be seen when they shouldn't be. An EHR has to be accessed by an authorized user of the system and cannot be left lying on someones desk for prying eyes. Can it be left on the computer screen? Yes, it can, but the majority or programs have a "time out" after a certain period of non-use and in the health care field, I would like to think a password would be needed to open it back up. Care is still needed by the end user no matter what type of health record they are dealing with, either paper-based or EHR to maintain the privacy of the patient.

There are so many federally mandated rules, regulations, and safeguards to protect EHR's, I can now relax a bit and enjoy the ride.....and what a ride this is going to be! I am nervous, yet excited, to be entering into the health care industry. Many options await me after graduation!

So, until next week....TA! TA!!! Have a great week!! :o)

Week 3 (already??!!)

Time is flying, yet it is dragging....that make sense? lol Seems like the weeks are flying by but I am pretty overwhelmed with 6 classes and don't see a light at the end of my tunnel, but I will get through it. :o)

This week in our learning, we got to have a bit of fun. We had a scavenger hunt to do as an assignment, but it was not hunt any scavenger hunt....we had to do it with the help of virtual lab. What this entailed was having questions that needed answers about certain (fictional) patients. We had to find them and then find the information we needed to answer the questions. When I started this, it was not the easiest task, but once I figured out my way around the virtual lab, it was actually quite fun! It was not hard to do, it was just the not knowing where anything was at the start of the assignment. When I completed my assignment, I was very thankful for EHR's. Every now and then I would click on a link that would bring up a copy of a paper record and my heart would sink thinking I needed to decipher something on that, but I didn't (thankfully). The more I learn about EHR's, the more thankful I am that I am going to miss most of the paper-based records.

Speaking of that, we also had discussions about EHR's, the paper-based records, and the hybrid records and the pros and cons of each of them. To be honest, I do not think there are very many "pros" for paper-based records. They are hard to read if handwriting is illegible, they are not very secure, they can only be used by one person at a time, they can be damaged or destroyed via water, fire, or mishandling, and when a test has been ordered, there is a much longer wait for the results, to name a few of them.

EHR's have mostly pros--they are computer based records that are input from start to finish (admission or encounter through discharge or completion of office visit). Everything is very easy to read, it can be changed and corrected, tests or lab results can be easily searched and located, many users can use the same record at once, lab tests are entered so the physician can see the result immediately, they are more secure, and the list goes on. Some of the cons are incorrect entries, numbers being transposed, and a system crash within the facility.

Hybrid records are a mix of EHR's and paper-based records. A hybrid record is the result of the changing from paper-based to EHR. The paper-based records are actually scanned into electronic form so they can be easily searched and located, but they cannot be altered or corrected within the system. You would have to change the paper record and re-scan it into the electronic form for a change or corrections. Another con is  the record is now in different places. If every single document fro the paper file does not get scanned in then it is not the complete record and something could be overlooked or the healthcare provider would have to locate the paper-based record to look at that. However, finding a document that has been scanned in could save a great deal of time instead of have to sift through a stack of papers in a paper-based file looking for a lab report that may not be in order.

I am glad to be stepping into the healthcare industry when such great changes are taking place.

Hmmm.....

What a week it has been! My head is swimming with all of this information I am trying to put into it. I am truly feeling a bit overwhelmed...ok....a LOT overwhelmed! lol However, I think I am retaining some of this information. I never realized there was so much information, rules, regulations, and laws involved with HIT. I mean, I knew there would be, I guess, but never REALLY thought about how much I was going to be reading and learning and trying to absorb. I really just wanted to code when I started all of this! There is so much more to HIT than "just" coding.
With all of that being said, I am excited to see this field expanding and changing into the electronic health record (EHR). It will be so nice when all of this is done with the computers. We had the chance to look at some real medical records this last week. Of course, the names were removed so the person is still protected with their right to privacy, but the information was there--all scribbled out and very difficult to read. Some of it was completely unreadable. Some of the records were not fully photocopied so we got partial pages and incomplete documents. One of the records had numerous scribbles, words written above and below the scribbled out words, and the words were written all over the pages....like, not on lines, but written diagonally! WHAT A MESS!!!! That made me very thankful for this transition to EHR's. I don't know how people can decipher those kinds of records, and hopefully, it will all be switched over by the time we graduate and have to deal with all of this.
Even with all of my doubts and fears, I am very much looking forward to entering into this ever-changing field!!