Perspectives in health information management / AHIMA, American Health Information Management Association最新文献

The success or failure of a clinical documentation integrity (CDI) program is often evaluated using a designated set of metrics. However, these metrics change over time, and an understanding of these changes is critical to properly judge the efficacy of the CDI effort. The authors propose a model of the natural history of a CDI program based on commonly used CDI metrics. The authors believe that this model can assist CDI leaders in anticipating and understanding the course of CDI performance over time.

Introduction: Within revenue cycle management, billing is an important activity for physicians with financial implications across remuneration models. We assessed the self-reported billing confidence of residents and attending physicians practicing at an academic family health team in a single payer setting.

Methods: All residents and attending physicians working or who had worked at the team were invited to complete a 20-question electronic survey on their exposure to billing education and their self-reported confidence with various billing activities.

Results: Twenty-five percent (n=40) of eligible physicians completed the survey. There were statistically significant differences between attending and resident physicians' billing experience (median 117.5 vs. 7.5 months). Analysis of free text comments revealed the positive impact of early billing exposure and opportunities for longitudinal feedback.

Conclusion: Despite the small sample size, findings suggest that early exposure of family medicine residents to billing with standardized training contributes to a more positive experience during residency.

The COVID-19 pandemic led to an increase in cybersecurity attacks on organizations operating in the healthcare industry. Health information professionals and health executives are unable to limit the impact of data breaches on records their organizations handle. While current research focuses on prevention strategies and the understanding of the causes of data breaches, it failed to address how to mitigate the impact of successful cybersecurity attacks. This quantitative research paper examined the effect the healthcare entity type has on the number of impacted individuals for healthcare data breaches that occurred during the pandemic. Health information professionals will be able to mitigate the number of breached records based on their organizational type. Some of this paper's findings include the call for implementation of organizational frameworks aimed to protect patient information, and the call for further research to understand how other factors might affect the impact of healthcare data breaches.

Laboratory services are a crucial part of medical care and contribute to physicians' treatment-related decision-making. However, paper-based information exchanges between physicians' offices and laboratories waste physicians' time and prevent them from using outpatient test results in a timely and effective manner. To solve this problem, improve the safety and quality of patient care, and save patients' time and energy, the present study developed a web-based system for electronic information exchange between laboratories and offices in Microsoft Visual Studio with the ASP.net technology and the Microsoft SQL Server database. The developed web-based software met the needs of the users and stakeholders (physicians, laboratory personnel, and patients) in the laboratory service cycle. To evaluate the software, user satisfaction was assessed in terms of user interface, operational functionality, and system performance, indicating the acceptability of all the criteria from the viewpoint of the stakeholders. The developed web-based software enables electronic communication between offices and laboratories (two important healthcare bases), establishes information exchange (sending requests and receiving laboratory results) between these two bases, and also notifies the patients. The software gained the overall satisfaction of the users, and this highlights the need for electronic communications in the healthcare domain.

Introduction: Experiential learning supervised by a qualified preceptor has been an enduring requirement for accredited allied health academic programs.¹ Data show that students benefit from participating in experiential learning activities, such as an internship.² Further, studies show organizations are eager to hire new graduates who took part in some type of external hands-on experience.³Health information management (HIM) programs accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) require students to complete a supervised professional practice experience (PPE) before graduation to show proficiency of the curriculum requirements.⁴This study explored the challenges and barriers of professional practice experience for placing local and online baccalaureate students in hospital-based HIM departments from the preceptors' viewpoint. This study focused on the hospital setting for several reasons: gaining site approval is complicated, the centralized HIM department poses unique problems for hosting students, and to narrow the research focus to a setting commonly used among HIM academic programs.

Literature review: The PPE problems with placing and precepting students have been a long-standing concern in HIM education;⁵ however, there was limited literature available directly related to this problem of practice. An extensive literature search was conducted that yielded only a few research-based articles that provided limited information about the problem. Therefore, the literature review included related works from other allied health disciplines with similar issues with experiential learning.The overarching findings for allied health academic programs centered on issues at the healthcare organizational level, including legal concerns, cost, time, and productivity.⁶ Geographic location was yet another issue that prevented student placement. Additional concerns focused on lack of student or preceptor preparation for the experience.⁷.

Methods: This was a qualitative multi-case study conducted in 2021. A total of six cases, or participants, took part in this study. Participants completed a pre-interview survey to obtain demographic information before conducting semi-structured interviews online with health information management preceptors. The survey data were compiled and analyzed to inform the interviews.

Results: The study results indicate that HIM preceptors are challenged with placing and precepting students at their hospitals. Lack of support from senior leadership is a contributing factor. Additional issues center on planning and preparation. Keeping students engaged with the learning experience was another key finding. Lastly, this research uncovered an anecdotal finding about the lack of preceptor training provided to

While there is significant literature discussing physical and cybersecurity risks around health information technology in general, the number of publications that specifically address medical imaging is much smaller, and many of these focus on the technical security requirements for the exchange of medical images over public networks rather than practical guidelines for radiologists and technicians. This study examines the US Department of Health and Human Services database of reported breaches involving medical imaging from 2010-2020, identifies the most common contributing factors to those breaches, and offers recommendations for radiology practices to prevent each, based on the National Institute of Standards and Technology (NIST) guidelines as well as measures proposed in the literature on health information technology.

This study identifies the type, distribution, and interactions of US hospitals that identify as electronic-data-driven, patient-centric, and learning-focused. Such facilities, termed Health Information Interested (HII) hospitals in this study, meet the defining criteria for one or more of the following designations: learning health systems (LHS), Health Information Technology for Economic and Clinical Health (HITECH) meaningful use stage three compliant (MU3), Patient-Centered Outcomes Research Institute (PCORI) funded, or medical home/safety net (MH/SN) hospital. The American Hospital Association (AHA) IT supplemental survey and other supporting data spanning 2013 to 2018 were used to identify HII hospitals. HII hospitals increased from 19.9 percent to 62.4 percent of AHA reporting hospitals from 2013 to 2018. HII subcategories in 2018 such as the full LHS (37.2 percent) and MU3 (46.9 percent) were dominant, with 33.2 percent having both designations. This indicates increased interest in patient-centric, learning-focused care using electronic health data. This information can enable health information management (HIM) professionals to be aware of programs or approaches that can facilitate learning-focused, patient-centric care using electronic health data within health systems.

Vascular access (VA) is essential to inpatient care, and the documentation/coding practices for vascular access device (VAD) placement procedures remain unexplored. Accurate documentation may present benefits for patients, providers, and researchers. A retrospective analysis was performed in adult inpatients (2015 to 2020) using Cerner Real World Data™ to evaluate the utilization of CPT codes for VAD placement/replacement procedures. A total of 14,253,584 patient encounters were analyzed, 0.111 percent (n=15,833) of which received at least one VAD procedure code. Non-tunneled CVC procedures had the highest code rate (0.067 percent), while PIV/midline procedures were the least likely to be coded (0.004 percent). The annual proportion of code utilization increased from 10.9 percent in 2015 to 19.7 percent in 2020 (p<0.0001). Despite widespread use of VADs in the inpatient setting, the procedure coding rate was found to be remarkably low. Appropriate coding/documentation practices may ensure proper care by capturing VA-related patient history, and improve research quality and resource/staff allocation.

Objective: Awareness of the importance of social security systems continues to grow in Indonesia, as mandated by the amendment of the 1945 Indonesian Constitution Article 34 paragraph 2, which states the obligation of the Indonesian government to develop and implement a social security system for all Indonesian people. This study aims to evaluate the effectiveness of applying failure modes and effects analysis (FMEA) in managing inpatient medical records at the Dr. M. Djamil Padang Central General Hospital.

Material methods: This is a comparative research study that uses a retrospective approach and compares the data between 2017 and 2018 inpatient National Health Insurance (NHI) patient medical records. Study samples include randomly selected 24,005 files.

Results: The results showed a decrease in problematic claims by 13 percent and an increase in receipt of claims paid by 87 percent. There is a significant difference between the data in 2017 and 2018 in problematic claim decrease (p=0.000) and claim acceptance increase (p=0.000).

Discussion: It was found that the redesign process of the formation of hospital claims will make hospitals more organized, precise, effective, and efficient, therefore positively impacting hospital income. In addition, the redesign was carried out because of the large number of Social Security Administrator for Health patients; thus, it greatly affected hospital income.

Implication for health policies: The FMEA medical record flow process is very effective and can thus be implemented in hospitals.