Health Data Management

Transcription

1 Western Technical College Health Data Management Course Outcome Summary Course Information Description Career Cluster Instructional Level Total Credits 2.00 Total Hours Introduces the use and structure of health care data elements, data sets, data standards, their relationships to primary and secondary record systems and health information processing. Health Science Associate Degree Courses Types of Instruction Instruction Type Lecture Lab Credits/Hours 1 CR / 18 HR 1 CR / 36 HR Course History Last Approval Date 1/21/2016 Target Population Students enrolled in the HIT Associate degree program. Pre/Corequisites Prerequisite Intro to the Health Record Textbooks Health Information Management Technology: An Applied Approach Student Member Package. 4th Edition. Copyright Sayles, Nanette. Publisher: American Health Information Management Association. ISBN- 13: Required. Health Information Technology. 3rd Edition. Copyright Davis, Nadinia A. and Melissa LaCour. Publisher: Elsevier Science. ISBN-13: Required. Course Outcome Summary - Page 1 of 7

2 Learner Supplies Microsoft Office (Word, Powerpoint). Students purchase software on their own ( ). Vendor: To be discussed in class. Required. Core Abilities 1. Apply mathematical concepts Demonstrate ability to value self and work ethically with others in a diverse population Program Outcomes Model professional behaviors and ethics (HIT & MCS) 3. Maintain electronic applications to manage health information (HIT)/Use electronic applications to support coding External Standards Title Association Status HIT 2015 Std Update Active Target Standards I.A.1. Apply diagnosis/procedure codes according to current guidelines (Domain: Data Content Structure and Standards; Subdomain: Classification Systems) I.A.2. Evaluate the accuracy of diagnostic and procedural coding (Domain: Data Content Structure and Standards; Subdomain: Classification Systems) I.B.1. Analyze the documentation in the health record to ensure it supports the diagnosis and reflects the patient s progress, clinical findings, and discharge status (Domain: Data Content Structure and Standards; Subdomain: Health Record Content and Documentation) I.B.2. Verify the documentation in the health record is timely, complete, and accurate (Domain: Data Content Structure and Standards; Subdomain: Health Record Content and Documentation) I.B.3. Identify a complete health record according to, organizational policies, external regulations, and standards (Domain: Data Content Structure and Standards; Subdomain: Health Record Content and Documentation) Course Outcome Summary - Page 2 of 7

3 I.C.1. Apply policies and procedures to ensure the accuracy and integrity of health data (Domain: Data Content Structure and Standards; Subdomain: Data Governance) I.D.1. Collect and maintain health data (Domain: Data Content Structure and Standards; Subdomain: Data Management) I.D.2. Apply graphical tools for data presentations (Domain: Data Content Structure and Standards; Subdomain: Data Management) I.E.1. Identify and use secondary data sources (Domain: Data Content Structure and Standards; Subdomain: Secondary Data Sources) I.E.2. Validate the reliability and accuracy of secondary data sources (Domain: Data Content Structure and Standards; Subdomain: Secondary Data Sources) II.B.2. Apply retention and destruction policies for health information (Domain: Information Protection: Access Dislosure Archival Privacy and Security; Subdomain: Data Privacy Confidentiality and Security) III.A.1. Utilize software in the completion of HIM processes (Domain: Informatics, Analytics and Data Use; Subdomain: Health Information Technologies) III.A.2. Explain policies and procedures of networks, including intranet and Internet to facilitate clinical and administrative applications (Domain: Informatics, Analytics and Data Use; Subdomain: Health Information Technologies) III.H.1. Apply policies and procedures to ensure the accuracy and integrity of health data both internal and external to the health system (Domain: Informatics, Analytics and Data Use; Subdomain: Information Integrity and Data Quality) V.A.2. Collaborate with staff in preparing the organization for accreditation, licensure, and/or certification (Domain: Compliance; Subdomain: Regulatory) V.A.3. Adhere to the legal and regulatory requirements related to the health information management (Domain: Compliance; Subdomain: Regulatory) V.B.1. Analyze current regulations and established guidelines in clinical classification systems (Domain: Compliance; Subdomain: Coding) VI.F.1. Summarize a collection methodology for data to guide strategic and organizational management (Domain: Leadership; Subdomain: Strategic and Organizational Management) VI.F.4. Apply information and data strategies in support of information governance initiatives (Domain: Leadership; Subdomain: Strategic and Organizational Management) VI.F.5. Utilize enterprise-wide information assets in support of organizational strategies and objectives (Domain: Leadership; Subdomain: Strategic and Organizational Management) VI.K.1. Apply knowledge of database architecture and design (Domain: Leadership; Subdomain: Enterprise Information Management) Course Competencies 1. Collect health data Domain Cognitive Level Evaluating Course Outcome Summary - Page 3 of 7

4 Maintain electronic applications to manage health information (HIT)/Use electronic applications to support coding 1.1. through an exam or project(s) (such as creating a paper or electronic data collection tool) 1.1. you utilize health data elements that correspond to given data sets 1.2. you demonstrate compliance with established quality form characteristics (margins, font, identification etc.) 1.a. Differentiate between data and information 1.b. Illustrate the transformation of a single data element to information 1.c. Discuss the benefits of standardized data 1.d. Describe the purpose and scope of data sets (UHDDS, UACDS, MDS, OASIS, HEDIS, DEEDS, ORYX) 1.e. Match health data sets to the healthcare setting in which they are used 1.f. Collect data using data set definitions 1.g. Compare the advantages of paper versus electronic forms for data collection 1.h. Discuss the characteristics of a quality form (paper or electronic) 1.i. Apply principles of computer views design 1.j. Examine health information from secondary data sources (indexes, registries, databases) 1.k. Use data modeling techniques and uniform dataset definitions to provide structure for data collection 2. Apply policies to ensure the quality of health data Domain Cognitive Level Applying Apply mathematical concepts through an exam or project(s) 2.1. you verify the quality of given health data against the data quality attributes 2.a. Discuss factors affecting data quality 2.b. Discuss the impact of quality data and information governance on the quality of healthcare provided 2.c. Discuss the role of the medical staff, nursing staff and allied health providers in the assurance of quality health data 2.d. Examine the data quality attributes (accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, timeliness) 2.e. Verify the quality of health data 3. Compare clinical terminologies used in healthcare data collection, reporting and exchange Domain Cognitive Level Understandin g Course Outcome Summary - Page 4 of 7

5 3.1. through an exam or project(s) 3.1. you differentiate between the uses and application of given clinical terminologies and vocabularies 3.2. you differentiate between characteristics (including code structure) of given clinical terminologies and vocabularies 3.3. you illustrate the use of clinical terminologies in the electronic health record 3.a. Differentiate between vocabulary, terminology, nomenclature and classification system 3.b. Trace the development of various clinical terminologies used in healthcare 3.c. Discuss the uses and applications of various clinical terminologies 3.d. Differentiate between EHR vocabularies and coding systems used for research and billing 3.e. Describe characteristics of given clinical terminologies (such as ICD,, CPT, HCPCS, DSM) 3.f. Discuss the purpose of mapping in comparison pf patient data 4. Compare standards for the electronic transmission and exchange of health data Domain Cognitive Level Understandin g Maintain electronic applications to manage health information (HIT)/Use electronic applications to support coding 4.1. through an exam or project(s) 4.1. you compare the uses and application of given data standards 4.2. you compare the characteristics (e.g. content, code sets used etc.) of given data standards 4.3. you compare the uses and application of given messaging standards 4.4. you discuss the national initiatives related to the electronic transmission and exchange of health data (HIPAA, HITECH, ONC, NHII, ARRA) 4.a. Discuss how problems with the US healthcare system have influenced demand for EHRs 4.b. Explain why codified data is necessary to achieve a functional EHR 4.c. Explain the importance of interoperability and how it is accomplished through the use of standards 4.d. Identify standards that support interoperability (vocabulary, structure/content, messaging, security) and discuss their importance in the EHR environment 4.e. Differentiate vocabularies used in the EHR (MEDCIN, Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT), Logical Observation Identifier Names and Codes (LOINC), RX Norm, Medical Dictionary for Regulatory Activities (MedDRA), UMDNS, Various Nursing vocabularies) 4.f. Describe how structure and content standards are facilitated through the use of standardized data definitions/data dictionary 4.g. Differentiate messaging standards (HL7, DICOM, NCPDP, ANSI X12, ASTM International E31) 4.h. Describe methods to ensure security when using electronic data interchange for transactions involving identifiable patient data 4.i. Recognize the impact of various initiatives on the development of data standards (HIPAA, HITECH, ONC, NHII, ARRA) 4.j. Discuss the applicability of the HIPAA privacy and security rules 4.k. Describe the importance of a unique identifier for patients and providers Course Outcome Summary - Page 5 of 7

6 4.l. Discuss how a National Health Information Infrastructure will improve the effectiveness, efficiency and overall quality of healthcare in the US via a National Health Information Network 5. Comply with accreditation, certification and legislative requirements for health record documentation Domain Cognitive Level Applying Demonstrate ability to value self and work ethically with others in a diverse population. Model professional behaviors and ethics (HIT & MCS) Maintain electronic applications to manage health information (HIT)/Use electronic applications to support coding 5.1. through an exam or project(s) 5.1. you perform quantitative analysis of health records (paper and/or electronic) according to given guidelines 5.2. you enter deficiencies into an electronic deficiency management system 5.3. you illustrate or perform physician deficiency/delinquency processing procedures 5.4. you generate documents from an electronic deficiency management system (deficiency slips, physician notification letters, and/or reports etc.) 5.a. Explain the need for timely recording of medical data from the standpoint of provider, patient, HIM department, Business office, external regulators, others 5.b. Differentiate between the types of analysis (qualitative, quantitative, legal & statistical) 5.c. Examine documentation requirements of accrediting organizations, state/federal legislation, and medical staff rules etc. 5.d. Differentiate between records that are deficient and those that are delinquent 5.e. Compare methods to authenticate computerized and handwritten health documentation 5.f. Examine how the shift from paper to electronic records affects HIM department record completion processes 5.g. Evaluate the options (electronic and manual) for collecting and maintaining record deficiencies 5.h. Perform procedures for managing physician record completion processes (updating deficiencies, determining physician delinquency status, running physician letters, etc.) 5.i. Discuss the goals of clinical documentation improvement 6. Maintain the health record (paper & electronic) Domain Cognitive Level Applying Apply mathematical concepts. Maintain electronic applications to manage health information (HIT)/Use electronic applications to support coding 6.1. through an exam or project(s) Course Outcome Summary - Page 6 of 7

7 6.1. you assemble health records according to a given chart order 6.2. you illustrate the process of scanning (from prep through quality checking and correction) 6.3. you track the location of paper records using paper or electronic system 6.4. you retrieve patient data using the MPI 6.5. you select the best storage alternative for a given situation(s) 6.6. you apply policies for record retention and destruction 6.a. Differentiate between various chart order methodologies (source oriented, chronological etc.) 6.b. Discuss the concept of universal chart order; include the advantages and disadvantages 6.c. Describe attributes of proper information storage (accessibility, quality, security, flexibility, connectivity, efficiency, etc.) 6.d. Compare various health record storage options (file systems, electronic options, fiche, off-site etc.) ( advantages/disadvantages of each etc.) 6.e. Illustrate the steps involved in scanning records for optical/digital storage from prep and initial scan through quality check and error correction 6.f. Illustrate the process (electronic and manual) for tracking the location of health records as the move throughout the facility 6.g. Describe the purpose of the master patient index (MPI) 6.h. Examine the data collected and maintained in the MPI 6.i. Calculate retention and destruction time frames using given guidelines 6.j. Explain how retention guidelines affect health record storage and filing needs. 6.k. Illustrate the process for destroying records. Course Outcome Summary - Page 7 of 7