information management d1 s3- ai

8/14/2019 Information Management D1 S3- AI

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Information ManagementInformation Management

D1 - S3D1 - S3


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TheThe goalgoal

TheThe goalgoal of the information managementof the information management

function is to support decision making tofunction is to support decision making to

improve patient outcomes, improve health careimprove patient outcomes, improve health care

documentation, improve patient safety, anddocumentation, improve patient safety, andimprove performance in patient care, treatment,improve performance in patient care, treatment,

and services, governance, management, andand services, governance, management, and

support processes.support processes.

While efficiency, effectiveness, patient safety,While efficiency, effectiveness, patient safety,

and the quality of patient care can be improvedand the quality of patient care can be improved

by computerization and other technologies, theby computerization and other technologies, the

principles of good information managementprinciples of good information management

apply to paper-based or electronic methods.apply to paper-based or electronic methods.


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A hospitals provision of care, treatment, andA hospitals provision of care, treatment, and

services is a complex endeavor that is highlyservices is a complex endeavor that is highly

dependent on information.dependent on information.

When many individuals and areas throughoutWhen many individuals and areas throughout

the hospital are involved in the provision ofthe hospital are involved in the provision of

care, treatment, and services, their work iscare, treatment, and services, their work iscoordinated and integrated.coordinated and integrated.

As a result, hospitals treat information as anAs a result, hospitals treat information as an

important resource to be managed effectivelyimportant resource to be managed effectively

and efficiently.and efficiently.

Managing information is an active, plannedManaging information is an active, plannedactivit .activity.


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The hospitals leaders have overallThe hospitals leaders have overall

responsibility for managing information, justresponsibility for managing information, just

as they do for managing the hospitalsas they do for managing the hospitalshuman, material, and financial resources.human, material, and financial resources.

The quality of care, treatment, and services isThe quality of care, treatment, and services is

affected by the many transitions inaffected by the many transitions ininformation management that are currently ininformation management that are currently in

progress in health care, such as the transitionprogress in health care, such as the transition

from handwriting and traditional paper-basedfrom handwriting and traditional paper-based

documentation to electronic informationdocumentation to electronic informationmanagement, as well as the transition frommanagement, as well as the transition from

free text* to structured and interactive text.free text* to structured and interactive text.


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The Information Management Function:The Information Management Function:

Coordinates collection of data and information;Coordinates collection of data and information;

Makes clinical/organizational information fromMakes clinical/organizational information from

one system available to another;one system available to another; Organizes, analyses, interprets, and clarifiesOrganizes, analyses, interprets, and clarifies

data;data;

Generates and provides access to longitudinalGenerates and provides access to longitudinal

data; anddata; and Provides the capability to link patient care andProvides the capability to link patient care and

non-patient care data over time; internal andnon-patient care data over time; internal and

external information sources; data andexternal information sources; data and

information from literatureinformation from literature


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Information Management ObjectivesInformation Management Objectives

Assure timely, easy access to data/information,Assure timely, easy access to data/information,

balanced with security requirements;balanced with security requirements;

Assure data accuracy and data comparability byAssure data accuracy and data comparability byfollowing available standards and guidelines;following available standards and guidelines;

Produce and use aggregate, comparative, andProduce and use aggregate, comparative, and

external knowledge-based information to improveexternal knowledge-based information to improve

patient safety and quality of patient care,patient safety and quality of patient care,treatment, and services;treatment, and services;

Increase collaboration and information sharing;Increase collaboration and information sharing;

Redesign information-related processes forRedesign information-related processes for

efficiency and effectiveness.efficiency and effectiveness.


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Information Uses in HealthcareInformation Uses in Healthcare

Clinical/service decision makingClinical/service decision making

Organization decision-makingOrganization decision-making

Performance ImprovementPerformance ImprovementEducationEducation

ResearchResearch


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DECISION MAKING PROCESSESDECISION MAKING PROCESSES

If we are to make appropriate decisions toIf we are to make appropriate decisions to

truly improve the care and servicestruly improve the care and services

provided to our patients over time, weprovided to our patients over time, wemust collect quality data that converts intomust collect quality data that converts into

understandable, useful information:understandable, useful information:

DATADATA leads toleads to INFORMATIONINFORMATION

leads toleads to KNOWLEDGEKNOWLEDGE

leads toleads to DECISION MAKINGDECISION MAKING


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Traditional Clinical ModelTraditional Clinical Model [See Diagram]:[See Diagram]:

In the past and near presentwithoutIn the past and near presentwithout

good datawe relied upon our opinion,good datawe relied upon our opinion,logic, intuition, rationalization, rumor,logic, intuition, rationalization, rumor,

and/or hearsay to lead us toand/or hearsay to lead us to

recommendations and hopefullyrecommendations and hopefully

appropriate action to improve the qualityappropriate action to improve the qualityof care and service. In essence, we hadof care and service. In essence, we had

no defined process for decision makingno defined process for decision making..


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Opinion

Intuition

Logic

Rationalization

Rumor

Hearsay

Recommendations/

Actions

No Defined Process

Decision Making: Traditional Model

(Data Deficient)


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Quality Management ModelQuality Management Model [See Diagram]:[See Diagram]:

In a data-based model of decision making, the informationIn a data-based model of decision making, the information

management function closely resembles scientific methodmanagement function closely resembles scientific method

- Design is based on proposal/hypothesis;

- Design enables data collection;- Data, through statistical analysis, leads to information;

- Information must be interpreted and understood to lead to

knowledge;

- Knowledge leads to wisdom and appropriate decision making;

- Decisions in quality management fall into three categories of

activity (the "Quality Management Cycle"):

-- Quality Planning

-- Quality Control/Measurement

-- Quality Improvement


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Knowledge

Information Design

Data

Information

Management

Cycle

Quality ImprovementQuality Planning Quality Control

Statistical

Analysis Collection

Interpretation /

UnderstandingProposal /

Hypothesis

Decisions Decisions

Decision Making: QM Model

(Data-Based)


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INFORMATION MANAGEMENTINFORMATION MANAGEMENT

PROCESSESPROCESSES

Key ProcessesKey Processes must be effective to achieve themust be effective to achieve the

information management goal:information management goal:

Identify information needs (assessment);Identify information needs (assessment); Plan and design the information managementPlan and design the information management

structure;structure;

Capture, organize, and report data/information;Capture, organize, and report data/information;

Process and analyze data/information;Process and analyze data/information; Store and retrieve data/information;Store and retrieve data/information;

Transmit, display, disseminate, integrate, andTransmit, display, disseminate, integrate, and

use data/information;use data/information;

Safeguard data/information.Safeguard data/information.


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Steps in the Information Management ProcessSteps in the Information Management Process

Identify critical information needs;Identify critical information needs;

Define data elements;Define data elements;

Determine data collection plan;Determine data collection plan;

Acquire/collect data;Acquire/collect data;

Aggregate and display data;Aggregate and display data;

Analyze data; Present data/information;Analyze data; Present data/information;

Report information;Report information;

Act on information;Act on information;

Collect more data to assess the decision.Collect more data to assess the decision.


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MANAGEMENTMANAGEMENT

OFOF

THE LEGAL ASPECTSTHE LEGAL ASPECTS


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CONFIDENTIALITY OF PATIENT INFORMATIONCONFIDENTIALITY OF PATIENT INFORMATION

Confidentiality in healthcareConfidentiality in healthcare deals both with thedeals both with the

patient's personal right to privacy and the need for thepatient's personal right to privacy and the need for the

organization to maintain the confidentiality of allorganization to maintain the confidentiality of all

information pertaining to peer review and theinformation pertaining to peer review and themeasurement and analysis of patient care provided bymeasurement and analysis of patient care provided by

licensed independent practitioners.licensed independent practitioners.

Confidential informationConfidential information is information that one keepsis information that one keepsor entrusts to another with the understanding that itor entrusts to another with the understanding that it

will be kept private and not shared.will be kept private and not shared.

Protected informationProtected information is information that cannot beis information that cannot beobtained b others or used in a court of law.obtained b others or used in a court of law.


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Information in the Medical RecordInformation in the Medical Record

The patient's physical medical record is the propertyThe patient's physical medical record is the property

of the healthcare provider facility.of the healthcare provider facility.

The provider is responsible for safeguarding both theThe provider is responsible for safeguarding both the

record and the informational content against loss,record and the informational content against loss,defacement, tampering, and unauthorized use.defacement, tampering, and unauthorized use.

Written policy must stipulate just how the providerWritten policy must stipulate just how the provider

complies with state statutes and accreditationcomplies with state statutes and accreditationstandards.standards.

The patient is considered the owner of theThe patient is considered the owner of the

information in the U.S. and can access and copy thatinformation in the U.S. and can access and copy that

information by signing a release form.information by signing a release form.


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Information in the Medical Record 2Information in the Medical Record 2

Well-defined policies on the use and disclosureWell-defined policies on the use and disclosure

of medical information, encompassing all patient-of medical information, encompassing all patient-

identifiable record systems maintained within theidentifiable record systems maintained within the

organization, must be in place.organization, must be in place.

These systems generally include the medicalThese systems generally include the medical

record, as well as abstracts, studies, registers,record, as well as abstracts, studies, registers,

etc., in any form, e.g., paper, electronic, audio, oretc., in any form, e.g., paper, electronic, audio, or

Internet.Internet.

For psychiatric cases, psychotherapy informationFor psychiatric cases, psychotherapy information

is maintained separately and made available asis maintained separately and made available as

necessary {A HIPAA requirement}.necessary {A HIPAA requirement}.


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Consent and Internal Use of PatientConsent and Internal Use of Patient

InformationInformation

ConsentConsent

Patients in most acute care healthcare settingsPatients in most acute care healthcare settings

give advance writtengive advance written consent (assent; agreement)consent (assent; agreement),,

even though such consent is optional undereven though such consent is optional underHIPAA, for:HIPAA, for:

- Medical and surgical treatment: The provision,

coordination, or management of healthcare services

by one or more providers, including consultation

between providers and referrals from one provider toanother; and

- Release of sufficient medical information to the payer

to assure payment, e.g., confirm benefits entitlement,

determine necessity for treatment, validate orders

and charges.


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ConsentConsent

Written consent may or may not be obtained inWritten consent may or may not be obtained in

primary and specialist care office practices.primary and specialist care office practices.

Two types of consent formsTwo types of consent forms should be obtained:should be obtained:

- A general admission or treatment consent, asapplicable (information provided by the

organization, but not necessarily by the

practitioner);

- A special consent form for highly technicaltesting, medical, or surgical treatment

(information provided by the practitioner).

Patients give separate informed consent prior to

performance of specific surgical, radiological,and other invasive and high-risk procedures


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Internal Use:Internal Use:

Generally, written authorization by patients isGenerally, written authorization by patients is not requirednot required forfor

use of their personal health information by the provideruse of their personal health information by the provider

organization inorganization in healthcare operationshealthcare operations, those internal activities, those internal activities

encompassing:encompassing:- Quality, utilization, and risk management, including case

management and care coordination;

- Competency assurance activities, e.g., staff performance

evaluation, LIP credentialing and reappraisal, and peer

review;

- Infection surveillance and control;

- Patient safety;

- Education of patients' families;

- Other auditing, legal, insurance, business, and generaladministrative activities.


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However, it is now standard practice in theHowever, it is now standard practice in the

U.S., because of HIPAA in aU.S., because of HIPAA in a Notice ofNotice of

Privacy Practices,Privacy Practices, to:to:

- Inform patients of possible intended

uses of identifiable health information

and their right to restrict use ordisclosure;

- Make a good faith effort to obtain

written acknowledgement of receipt of

the Notice; and

- Post the Notice in a prominent location

in the facility.


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Those in provider organizations permitted access to medical recordThose in provider organizations permitted access to medical record

information for organization operationsinformation for organization operations withoutwithoutwritten authorizationwritten authorization

of the patient include:of the patient include:

- Governing body, and designees, to ensure quality of patient care;

- Chief Executive Officer (CEO);

- Physicians and healthcare personnel involved in the care;

- Chiefs of clinical services and clinical department directors, along

with designated committees, for performance measurement and/or

individual performance evaluation, including peer review);

- Duly appointed committees/QI teams of the organization, in

determining the quality of care and requisites for accreditation, andall support staff;

- Health information management/medical record personnel;

- Designees of the CEO as needed regarding legal and risk

management concerns or health services planning.


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INFORMED CONSENTINFORMED CONSENT

DefinitionDefinition::

Adequate information is provided to theAdequate information is provided to the

patient or legal representative in order forpatient or legal representative in order forthe patient or legal representative to makethe patient or legal representative to make

a rational, informed decision to permita rational, informed decision to permit

medical-surgical treatment.medical-surgical treatment.

The patient is free to reject recommendedThe patient is free to reject recommended

treatmenttreatment


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PROCESSPROCESS

Information for special procedures must beInformation for special procedures must be

provided by the practitioner performing theprovided by the practitioner performing the

procedure and must include:procedure and must include:- The full extent of the treatment plan;

- The extent of the side effects and risks

involved;

- Alternative treatments available;

- The risks of non-treatment.


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To constitute proof of consent:To constitute proof of consent:

-- A valid written consent must contain the following elements:A valid written consent must contain the following elements:

-- The exact name of the procedure under consent;

-- The consenter's understanding of:

--- The nature of the procedure--- Alternatives

--- Risks and benefits involved

--- Probable consequences of non-treatment

-- Date of consent;

-- Witness.

-- Informed consent forms requiring the patient's signatureInformed consent forms requiring the patient's signature

prior to treatment become a permanent part of the medicalprior to treatment become a permanent part of the medical

record.record.

-- Oral consent, though just as legally binding, is difficult toOral consent, though just as legally binding, is difficult toprove in court.prove in court.


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CONFLICT OF INTERESTCONFLICT OF INTEREST

An organizationwide policy concerningAn organizationwide policy concerning case or peercase or peer

review "conflict of interest"review "conflict of interest" should be incorporated intoshould be incorporated into

Quality Management and Utilization ManagementQuality Management and Utilization Management

Plans, as well as into medical staff bylaws, ifPlans, as well as into medical staff bylaws, ifapplicable, or other peer review committeeapplicable, or other peer review committee

documents, depending on the entitys structure.documents, depending on the entitys structure.

A typical statement might read:A typical statement might read:

In order to minimize the potential for conflict ofIn order to minimize the potential for conflict of

interest, no committee member or reviewer shallinterest, no committee member or reviewer shall

participate in the review of clinical cases in which heparticipate in the review of clinical cases in which he

or she is primary care giver, is a participant in aor she is primary care giver, is a participant in a

specific situation under review, or has any economicspecific situation under review, or has any economic

interest either in the case or with the practitionerinterest either in the case or with the practitionerunder review.under review.


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CONFLICT OF INTEREST 2CONFLICT OF INTEREST 2

If at any time potential for conflict of interest isIf at any time potential for conflict of interest is

identified, the medical or department director,identified, the medical or department director,

committee chairperson, or the chief of staff shallcommittee chairperson, or the chief of staff shall

seek the objective expertise of other qualifiedseek the objective expertise of other qualifiedpractitioners, either from other departments orpractitioners, either from other departments or

committees, from other like organizations, orcommittees, from other like organizations, or

from the community as deemed appropriate.from the community as deemed appropriate.

In managed care, a statement might read:In managed care, a statement might read:Any and all providers who have a personal,Any and all providers who have a personal,

professional, and/or financial involvement with aprofessional, and/or financial involvement with a

medical case being reviewed will be excusedmedical case being reviewed will be excused

from participating in the review of said case.from participating in the review of said case.


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Release of InformationRelease of Information

Based on government regulationsBased on government regulations

Written consent for outside releaseWritten consent for outside release

Release without written consentRelease without written consent


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Release of informationRelease of information

A written consent is required for anA written consent is required for an

organization to release patient informationorganization to release patient information

to anyone outside the organization.to anyone outside the organization.A typical release-of-information formA typical release-of-information form

should have the following elements:should have the following elements:

Patient's name

Name of individual/ organization

requesting information

Reason for release of information

Anticipated use of information released


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Release of informationRelease of information

Exact material to be released

Time that the release of information is validDocumentation that information is released

only to the individual/organization above

Signature and date of the patient or legal

representative (as defined by policy/state

law)


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Confidentiality Policy/procedureConfidentiality Policy/procedure

Identification of individuals with accessIdentification of individuals with access

to informationto information

Delineation of specific information toDelineation of specific information towhich individuals have accesswhich individuals have access

Requirements for individuals withRequirements for individuals with

access to information to keep thataccess to information to keep that

information confidentialinformation confidential

Requirements for release of healthRequirements for release of health

informationinformation


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Requirements for removal of medicalRequirements for removal of medical

recordsrecords

The patient's medical record is the propertyThe patient's medical record is the property

of the healthcare facilityof the healthcare facility

Medical records should be removed fromMedical records should be removed from

the organization's jurisdiction andthe organization's jurisdiction and

safekeeping only in accordance with a courtsafekeeping only in accordance with a courtorder.order.

Mechanisms for securing informationMechanisms for securing information

against unauthorized intrusion, corruption,against unauthorized intrusion, corruption,

and damageand damage


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Portions of medical records may bePortions of medical records may be

stored separately,stored separately,

Organizations can restrict access toOrganizations can restrict access tocomputer files or portions of computercomputer files or portions of computer

files by the use of security codes or byfiles by the use of security codes or by

restricting certain computer operations torestricting certain computer operations to

specific terminals and/or individualsspecific terminals and/or individuals An organization that relies onAn organization that relies on

computerized information should have ancomputerized information should have an

adequate backup plan for each computeradequate backup plan for each computer

applicationapplication

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