Week 9...

Week 9.....halfway. Two midterms done so we are on the downside. It is alot of information to try to absorb with these classes. I had no idea what I was getting in to (I may had said that before...lol). But, I truly didn't....this is so much more than I EVER thought it was going to be. I know we cannot possibly absorb it all, I just wish I felt like I was absorbing most of it. And truthfully, I probably am, I just don't feel like I am.

This week we covered security on the health records: administrative, physical, and technological security. The integrity of the data is of utmost importance so great measures need to be in place to protect the data. Administrative safeguards pertains to the process of securing data. This would be done by having a security officer in place, having the workforce trained in security measures, and other "non-tangible" security issues.

Technological measures are about the technology of the systems and records. This would pertain to things such as have computers safeguarded with password protection or access controls, having audit controls in place to monitor who, when, and why things are being used, monitored, or changed, and anything to do with authentication of access.

Physical safeguards are protecting the systems, themselves. For instance, having locks on doors that go into a networking room or storage room or facility, or attaching hard drives so they cannot be moved or carried out, and having privacy screens on monitors so unauthorized people cannot see what is on your monitor.

Security is of utmost importance and it goes much deeper than what I have mentioned, but, in a nutshell, it is about anything to do with securing health records of individuals by whatever means necessary.


We went on a field trip to St. Rita's in Lima, Ohio on Thursday. That was well worth the trip! We got a tour of the HIM department and got a very detailed description of what and how the department is run and what the duties are of all the people. That was VERY interesting! I am so glad I went. I saw a lot and it made a lot of what I have read and what I have been studying all make sense. The thing that surprised me the most was the fact that we encountered about 40 employees doing every function there is within the HIM department and every one of them was VERY busy. NOBODY was just sitting there with nothing to do! THIS shocked me! They run a 24/7 operation and they stated if you are the kind of person that likes all your work done at the end of your shift to get over it because that will never happen. They are never caught up enough that somebody has nothing to do. That is a good thing because I hate to be bored and just sit there with nothing to do.....guess I won't have to worry about that....all I have to worry about is finding a job once I graduate!

well, until next well....see ya!! ....Sharon

week 8....

We have been discussing the importance of secondary data, who uses it and why. First of all, secondary data is data that has been taken from health records and entered into databases and registries  It is used for various purposes including research, administration purposes, health of the population, quality, performance, and safety of patients. It is used by various users including health care workers, medical staff, federal agencies  and data banks.

Secondary data is usually aggregate data, or deidentified so the information can be used without any personal information tying it to the individual it is about. This keeps patient information private. However, just because it may not identify the patient, it is just as critical to protect this information as it is to protect primary data.

I never realized that E-codes could be used as a secondary data source. I thought it was just a code we had to use for places where traumas occurred. I now know they are very important for trauma registries. Trauma registries keep track of traumas that are reported from trauma centers, emergency rooms, and other ambulatory centers. If the E-code is not coded correctly, it can make an impact on society. ATV's and off road motorcycles are probably among the most incorrectly coded situations. When it is coded for either of these, they may mistakenly be coded as a highway accident and not off road. It is important for people's safety to get this right. If there is an abundance of accidents in a certain area, that area needs to be looked into to see if there is something unsafe, or signs need to be posted.

We also discussed state laws concerning child abuse and neglect. I have had some up close and personal experiences with this situation on many levels so I am very happy that the laws have changed to help to protect the victims. Also, in this day and age, more people are willing to stand up fro a victim when they see the abuse going on. Years ago...and some still do this....people would turn their heads and say that it was none of their business to get involved int he abuse/ neglect of a child.. Well,  guess what?..somebody has to protect these children and it is about time laws encourage people to do so by protecting them from civil and criminal charges for getting involved.

Week 7....

The semester is almost halfway over. I don't know where the time id going, but I feel a bit overwhelmed still will the class load I am carrying this semester. I didn't mind the quarters so much...not as many classes at a time. I keep telling myself next semester is only 4 classes and then I can breathe a bit (4 is much better than the 7  have right now!).

So, this week we are really covering secondary data and the role data stewards play in the role of handling this information. Secondary data is usually aggregate date and does not contain personal information that can identify the patient, thus protecting their identity. But this data is equally important to be protected as any other data that contains names and other demographic information about the patient  Secondary data can be used for many purposes such as research and disease and illness tracking. Data stewards have the responsibility to know how to disclose and protect all data, including secondary data. With all of the changes going on with EHR's data stewards have a very important role in protecting the data whether it be primary data or secondary data....it all has to be protected to the highest security levels.

We also learned more about clinical information systems. There are a great deal of clinical IS's available to help in the health care industry. Some will help make decisions based on the information that is input into the system, some will help will during patient registration, and some make it possible for health care provider to access medical files of their patients from home, a smartphone, a laptop, or a table so they may be able to watch their patient off site and make decisions for care from anyplace 24/7. There are so many different types of clinical IS's, I could go on and on and only scratch the surface as to what these can do and how they help in patient care on many different levels.

Another huge topic we discussed this week was the difference of how alcohol/drug abuse, psychiatric care, HIV/AIDS, and people with genetic records are handled. These types of records have an extra layer of protection per state laws on them. HIPAA doe snot differentiate, so it reverts to state laws to give the extra protection to people who may be shunned,  or adversely affected from society if these types of illnesses/ disorders would be made public. The records of some undergoing psychiatric care do not even have to be released to the patient is psychoanalysis notes are included in the record. Now if this person has stated they are going to commin some type of physical harm to another individual, or if another individual may be in some type of danger, it is the responsibility of the mental health care provider to report this information to let the possible endangered person be aware they may be in danger.

There are so many different rules and regulations pertaining to various types of care...like people with HIV/AIDS are very protected because of the stigma that goes along with these viruses. People are uneducated and with that comes fear....the fear of just not knowing. So, these people have that extra protection of privacy to protect them from other people, basically.

There was a lot of information covered and I have just touched on some of it. I have learned a lot, yet, still have a lot to learn. Some of that will come with the remainder of my education, and some will come with just working in the health care industry in the day to day experience I will get by being on the job.

Thanks for popping in....until next week!..
.....Sharon

week 6....

week 6....almost half way there. I am in the midst of getting ready for my practicum. I am trying to get it done at my local hospital. I had thought about doing it in a virtual manner through the virtual lab, but as I was reading my medical professionalism book I read about how your practicum would look great on a resume. Well, that got me thinking and I really want to go into a facility and see the day to day operations to know what I am really getting into once I do get a job. I am really hoping to get a job at my local hospital so I hope all of this EHR happenings makes some additional spots there....and that one of them is mine...lol

We have been learning all kinds of stuff in our classes. One of the topics we discussed was the tracking of prescription medication. This is very important in so many ways. If there were certain medications given for specific diseases/disorders,  tracking the prescriptions could tell researchers if the disease is spreading or how far it has spread, if it is getting worse (by more prescriptions being filled), or is on the downside (if it is not prescribed as often). It could also tell if narcotics are being given more often and then to whom. this could tell if someone is abusing or addicted to prescription narcotics and if the doctors just freely hand them out to anyone with a little pain when they come into the office.

We are currently have an outbreak of meningitis in the U.S. To date, 91 people have been affected and 7 deaths have occurred. This fungal meningitis is being contracted by the injection of steroids that are being used for back pain sufferers. The name of the steroid is methylprednisolone acetate. The bulk of this medication was shipped to a facility in Nashville, Tennessee, but there are cases in Florida, Indiana, Maryland, Michigan, Minnesota, North Carolina, Ohio, Tennessee, and Virginia. The manufacturer has shut down their facility to figure out where this is coming form and has recalled all of the product they have shipped. they are also contacting everyone who has had this steroid in the past 3 months. They are doing this by tracking this steroid. Tracking this tells them who has received it and they are all getting checked out. I contacted my daughter because our son in law gets steroid injections in his back quite often...and guess what....he goes Wednesday to get checked out to make sure he is ok. This is very scary, but it is great that they can trace this medication and find out who has it before they may get sick to get them help.

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.