What is connectivity between computer systems?
Capacity of health record systems to provide communication linkages and allow the exchange of health record data among information systems; Its’ linkage between the systems to enable information exchange.
What are institutional users are and be able to identify some of them.
Healthcare delivery organizations
1. Provide services
2. Evaluate and monitor use of resources
3. Seek reimbursement
1. Determine if documentation supports reimbursement requested
Medical review organizations
1. Evaluate the adequacy and appropriateness of care provided
1. Prove or disprove hypotheses related to disease processes and treatments
2. Experimental patient care
3. Disease registries
1. Students have hands-on education
2. Case studies
1. Improve quality of services provided
2. Periodic survey
3. Review patient records
4. Institutional Users
Government licensing agencies
1. Certify facilities to receive funding
2. Review records to confirm compliance with regulations
1. Used to make decisions related to healthcare reimbursement, effectiveness of healthcare services
2. Create federal and state databases
Be able to identify some quality characteristics of information.
Accuracy – Data are correct
Accessibility – Data are easily obtainable
Comprehensiveness – All required data elements included (i.e. patient i.d., contents of treatment, advanced directives, problem list, diagnoses, etc.)
Consistency – Data are reliable
Currency and Timeliness – Data should be up-to-date
Granularity – Attributes and values of data defined at correct level of detail for the intended use
Precision – Expected data values
Relevancy – Data are useful
Know the difference between data and information. Data is basic factors about people, processes, measurements, conditions, and such facts
Information is data that has been collected and analyzed meaning
Be able to define clinical decision support. Notify physician of abnormal test results Assist in diagnosing and selecting treatment
Access to reference materials such as pharmaceutical formularies
Know what privacy, confidentiality and security are…….be able to define them all.
Privacy – right of individuals to control access to their personal health information
Confidentiality – expectation that personal information will be shared only for the intended purpose
Security – protection of privacy of individuals and confidentiality of health records
What is the function of a health record?
Health record is principal repository for data and information about healthcare services provided to the individual patient
Documents the who, what when, where, why, and how
Many people have multiple health records
Other Names for Health Records:
1. Patient records – inpatient setting
2. Medical record – physician