Health Information Standards

Case Assignment

1. For this Case Assignment, you will be assuming the role of a lead person on a technology
   review committee at a multifacility regional hospital. Your committee has been tasked with
   evaluating the plausibility and possible selection of a new Health Information System that
   will enable the hospital to electronically collect and share patient medical history
   information among its various hospital centers and departments.
2. Currently, each hospital center maintains paper copies and files of patient records,
   which are separately managed and stored at each facility. Few of the electronically based
   information systems are integrated between the various centers and locations.
3. To add to the challenge, the CIO informs you that most of the members on the
   committee have limited experience with information systems and databases. However, the
   CIO is aware that you are studying Health Informatics, so she has asked you to help
   familiarize the committee with fundamental concepts related to database systems and
   relevant health information standards.
4. Specifically, the CIO (and your professor) request that you prepare a brief overview of
   the following:
   � Fundamentals of database characteristics and structure.
   � Various types of medical data and information records relevant to this project.
   � The importance of uniform terminology, coding, and standardization of the data.
   � Various information standards and organizations that may be applicable, and possibly
   required, for this project.
5. In addition, search the Internet and find three healthcare information systems vendors
   that offer electronic medical record products. Compare and contrast the functions and
   features of each product and barriers to implementation (financial, physical, and
   personnel).
6. Remember, your committee mostly comprises clinicians and other healthcare
   practitioners. Accordingly, they do not have a great deal of technical knowledge related to
   information systems.
7. Submit your assignment by the end of this module.

Health Information System

Database management
A general database correlated with all the data of study is usually collected once within a
well-defined as well as stated period. The study involves the collection of specific data that

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comprise data and medical records of previous dates used to diagnose medical complications.
However, this study does not relate top those that are carried out for prevalent unique and rare
diseases. Additionally, all the findings are computed and calculated with resolute averages and
any other statistical methodologies involving calculations of frequency. General databases also
comprise of methods that make use of individual data performance (Alexander, 2016). These
databases assist individual’s assessment in the most probable manner.
Effective health informatics and information system give the mechanism of the best
organization. The structure and characteristic of the health database in health informatics are that
the database is reliable and able to store all kinds of data relating to any medical records. The
database may contain a table of entities that should be easily correlated by all departments in the
health setting. This will imply that the relationship between the tables of entities can easily be
defined. The tables of objects should be easily mapped to give the best interpretation concerning
the medical data and information records.
The senior management plays a vital role in decision making and the formularization of
the planning process. In the health information system, the senior management is concerned
with;

1. Recognizing the complexities of the database and ease any of the arising
   complications by providing solutions about the health database.
2. Developing suitable website advanced content and help in developing essential
   management for the web content.
3. Developing a content of learning management in healthcare information system.

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Therefore, with this health information database, it is assumed that the senior
management committee plays an important role within the organization with a sole mandate of
structuring an efficient health informatics that develops the structure in its entirety.
Medical Records
West, Borland & Hammond (2015) point out that electronic medical and information
records documents information about the patient including current diagnosis, medical and past
medical history, treatment, family history as well as all relevant information corresponding to the
patient treatment. They are only released under patient or physician authorization.
This information and records about the patient are kept up to date and mark so that
reference can be made in future.
The records are usually in a tabulated form containing DOB columns, patient’s name, and
the name of the physician, clinical diagnosis, and the treatment plan used. All other relevant
information on the patient is contained in the Meta-data. Programming of reports and queries is
also necessary. Moreover, the data format that is used should be in the simplest way possible to
be readable and comprehended by any other person in health informatics.
The medical records in pocket card files and letter size folders are designed in a manner
that follows the format of coding systems and uniform technology that is a standard feature for
all other benefits such as:

1. The UMLS project can develop computer-based “Knowledge sources” that allows
   applications to retrieve any lost information arising due to terminology differences and relevant
   information scattering across databases.
2. It can allow for easy linkage of information systems such as bibliographic databases,
   expert systems, factual databases, and technology-based patient medical records.

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Health Information Standards
The formation of this healthcare information system and infrastructure needs the
incorporation of new and already existing architectures, services, and application systems. The
fundamental elements of this system are patient-oriented care that is simplified and enabled by a
Computer-based Patient Record system (CPR). Furthermore, continuousness of any healthcare
enabled and supported by allotment, sharing, and distribution of relevant patient information on
all information databases and networks, and the measurement outcomes are assisted by the
specificity and greater availability of information regarding healthcare informatics.
Coding of health information has changed over time because narrative clinical text can
now be translated to procedure and diagnosis codes. Coded data are gaining relevance in its use
in the assessment of quality healthcare, severity adjustments, evaluation of patient safety,
surveillance of public healthcare, supporting the decision in algorithm development. Coding can
meet the standards of an evolving need to capture medical data in a simple and standardized
format with a universal meaning applied at aggregate and individual levels. Data standardization
has enhanced interpretation of health information and the understanding of accuracy and quality
of data presented in a set of codes (Elkin et al., 2016). It has also allowed for great
transformational changes in classification systems in health and clinical terminology.

Medical records in databases identify both physicians and doctors in a manner that
maintains organization privacy and continuity. For instance, the patient medical records are
recognized and identified with a unique Social Security Number (SSN). Physicians are also
identified with their Universal Doctor numbers for purposes of registration in databases.

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The National Provider File is being developed by the Healthcare Financing
Administration (HFCA) to create a new identifier and provider for Medicaid and Medicare
services to include all sites-of-care and caregivers. It will also make Medicaid programs
available such as those provided by Center for Medicaid and Medicare Services (CMS). These
can also include government agencies that adopt search services. Also, the Healthcare Financing
Administration (HFCA) has also helped define the primary Medicare identifiers of provider
services.
The Uniform Cord Council maintains the Universal Product Code (UPC). This UPC is
used to label all healthcare products that are sold or supplied in retail settings. Moreover, The
National Drug Code (NDC) is an important identifier in healthcare informatics.

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References

Alexander, S. (2016). Designing a Database to Facilitate Efficient Information Management at
the Health Mentors Program Office.
Elkin, P. L., Johnson, H. C., Callahan, M. R., & Classen, D. C. (2016). Improving patient safety
reporting with the common formats: Common data representation for Patient Safety
Organizations. Journal of Biomedical Informatics, 64, 116-121.
West, V. L., Borland, D., & Hammond, W. E. (2015). Innovative information visualization of
electronic health record data: a systematic review. Journal of the American Medical
Informatics Association, 22(2), 330-339.