Health Information Standards

The process of strengthening health systems is by its very nature focused on empowering health organizations to initiate activities that seek to empower the quality of care delivery and hospital operations. Health agencies usually try the least demanding procedures, to cut down on cumulative costs, simplify, and harmonize overlapping regulations to implement approaches that address the collective good of the American health consumers. It is thus, important that any leader engaged in the process understands and owns the implementation process. The objective of this task is to analyze health information standards and regulations for health systems to come up with a flexible action plan presented to the CEO and board of directors with information and guidance for strengthening the health system. The framework builds upon documentation of health records guidelines related to the Joint Commission (TJC) (2014), to come up with a comprehensive strategy on the best practices for enhancing the existing health system in order to reduce the unnecessary burden and cut on operation costs. The revision will allow the health system greater flexibility and freedom to come up with the most effective ways to manage health care delivery by overcoming outdated requirements for outpatient services.

Health Record Documentation Guidelines

Health record documentation guidelines form an integral part of the process of streamlining and designing effective regulatory framework for increased innovation, economic growth, job creation, and market competitiveness. The guidelines are intended to reduce the procedural burdens on health care providers when documenting medical records. In this regard, this study evaluates the most feasible and viable guidelines for increased competency in developing a robust action plan for the health system based on the (Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services, 2012).

Single governing body for several health systems

A single governing body will be responsible for overseeing the operations of multiple hospitals. A member or members of each hospital medical staff will be included in the governing body as a way of ensuring effective communication and coordination of operations.

Role of other Practitioners in Medical Staff

For continued patient care, treatment and services aimed at promoting continuity of care within the health system, the regulatory guideline allow for the broadened concept of medical staff to allow hospitals the flexibility to include other eligible practitioners in the medical staff. In accordance with the State law, all professionals will function under the medical staff rules. This change is intended to allow the other practitioners to perform all the duties and functions as per their scope of practice.

Medical Staff Leadership

Podiatrists will be responsible for the conduct and organization of the medical staff.

Nursing care Plan

The hospital has a large team of nurses, who sometimes overwhelms the hospital management. The nursing care plan guideline allows health organizations to have a stand-alone nursing care plan that addresses nursing and other disciplines.

Blood transfusion and intravenous medical administration

This guidance will eliminate the requirement for non-physician personnel to undergo specialized training to administer these medical procedures. Instead, those who administer the medications will abide by the State law and medical staff policies and procedures.

Order by other Practitioners

The guideline will allow drugs and biological to be administered by orders of other practitioners apart from a doctor as per the hospital policy and State law. It will also allow documentation and signing of medication orders by other care providers. 

Standing Orders

The guideline will allow the hospital to use standing orders with a requirement to the medical staff, pharmacy, and nursing staff to approve written or electronic standing orders so long as they are based on evidence-based and nationally recognized guidelines and recommendations.

Authentication of Orders

It is now mandatory as per the regulatory authority that all orders must be dated, timed, and authenticated a practitioner who is responsible for the patient care.

Outpatient Services Director

We seek to remove the burdensome and outdated requirement of having a single director for outpatient services to manage all outpatient departments in the hospital system. Rather, we recommend for the adoption of separate directors for each outpatient department due to the robustness and demand of services.

Pharmaceutical services

The slogan “quality assurance program” will be replaced by “quality assessment and performance improvement program” as a way of improving the administration of drugs.

Best Practices in Satisfying the Required Guidelines

In order to ensure the requirements of these guidelines are disseminated and implemented within the hospital system, established mechanisms are necessary for continued compliance. Firstly, as partners in efforts to attain quality practice within the hospital setting, health record staff and hospital managers have a shared responsibility and accountability for ensuring practical documentation practice. These strategies include having in place effective systems to support accurate and concise documentation of practice in health records. Appropriate policies and procedures are also necessary to ensure effective documentation systems and management of information. Leaders have a duty to encourage the hospital staff to take part in the decision-making process about the selection, implementation, and evaluation of documentation systems. Similarly, access to reliable and appropriately maintained equipment is mandatory for effective documentation practice.

Data Integrity and Quality of Health Information Exchange

Data integrity and quality of health information exchange involves ensuring the accuracy of the complete medical records. It focuses on information governance, amendments, and record corrections as well as auditing the record for enhanced validity. As it is inaccurate data, can adversely affect the quality of the whole health system operations plans and employability. The overarching goals are to ensure accurate information in health records for improved efficiency in the delivery of patient care and safety. With the advancement of Health Information Exchange, Congress through the National Coordinator for health Information Technology is trying to modernize how data is stored and shared. Resources are available to assist providers to navigate through these efforts (“Getting Started with HIE,” 2014). Besides, the demand for electronic health information exchange is on the rise amidst growing efforts to ensure quality, safety, and efficiency. In light of today’s electronic medical setting, there are several ways to ensure data integrity and quality in health information exchange. Based on the report by Miliard (2012), the first step is to establish a program to test and certify all electronic records to ensure reliable data exchange. The plan involves setting up automated testing programs to verify that once the system is tested, it is capable of sharing information with other systems. A coalition will be set up and tasked with testing and certifying that the interfaces are consistent across the various systems within the organization.

Best Practices for Integration, Interfaces, and Data Reliability

At the very least, data standards are principal informatics necessary for the flow of information through existing infrastructures. According to Aspden, Corrigan & Wolcott (2004), common standards are necessary for patient and clinical data to share integrated information infrastructure for data to be collected and reused for multiple purposes. However, there is a chief obstacle to achieving this capability, which is the adoption of optimized data standards for organizing, representing, and encoding information so that its information can be understood and accepted by the receiving systems. In this regard, data standards represent an integral part of data integration, interfaces, and reliability. At the most basic level, data standards best practices involves defining what to be collected, how to represent the received data, and ways to encode the data for transmission. Alongside the data elements, are the data types that define the form of the information represented. Such include date, time, coding items that depend on terminologies for understanding. Similarly, specific codes must be identified within the terminologies to represent data elements. For the larger clinical terms, this is usually a major obstacle as there may be thousands of terminologies. Of importance to understand is that universal data standard is critical for simplified and streamlined information as well as to allow information systems that transfer data to function in an integrated way.

Health Information Exchange Model

Health Information Exchange models typically refer to how health records information is stored and how authorized members can have access to this data. The choice of architecture is usually influenced by the privacy and security practices of an organization.

Centralized Model

The model is also known as the consolidated model and data is stored in a single data warehouse or a repository (Covich, Jones & Moris, 2011). Usually, participants submit and update patient information regularly as they view it through external delivery methods. The model is suitable for community networks, and it is to search and query data. Along with that, it can also be used to help in big data analysis in local public health issues. Unfortunately, as Covich et al. note, the model has one weakness, its over-reliance on participants to submit and update data, which can result in a double entry of data from multiple sources. It also requires resources and competent on-going management and maintenance for the central warehouse.

Federated Model

The model also referred to as the decentralized or distributed model stores data at the point of service, and a participant who is a member of the organization share their information with the rest of the members of the team. Usually, it uses a Record Locator Service (RLS) for maximized privacy and security of health records (Gkoulalas-Divanis & Loukides, 2015). The RLS has the locators to the source of information but does not contain the actual medical records information. Depending on the independent databases, the information stored can be consistent or inconsistent. As opposed to the centralized model, data in the federated model is always up to date, and system failure does not affect the whole system. Participants are responsible for the security and privacy of their data and must ensure it is not accessed by unauthorized entities.

Hybrid Model

The hybrid model is a mixture of both the centralized and the federated models (Gkoulalas-Divanis & Loukides, 2015). Usually, organizations adopt a modified hybrid model with independent databases for each data source and replicate all the benefits of the federated model, while leveraging the economies of centralized management capabilities. The approach relies on virtual servers and is more cost efficient and scalable, with additional security that is not easy to maintain through the two methods.

References

“Getting Started with HIE.” 2014. Health IT.gov. Retrieved from: https://www.healthit.gov/providers-professionals/health-information-exchange/getting-started-hie

Aspden, P., Corrigan, J., Wolcott, J., Erickson, S. M., Institute of Medicine (U.S.)., & Institute of Medicine (U.S.). (2004). Patient safety: Achieving a new standard for care. Washington, D.C: National Academies Press.

Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services. (2012). Medicare and Medicaid programs; reform of hospital and critical access hospital conditions of participation. Final rule. Federal Register, 77(95), 29034-29076.

Covich, J., Jones, D. R., Moris, G., Bates, M., eHealth Initiative., & Thomson Reuters. (2011). Governance models for health information exchange. Washington, D.C.: EHealth Initiative.

Gkoulalas-Divanis, A., & Loukides, G. (2015). Medical data privacy handbook. Cham: Springer

Miliard, M. (2012). Coalition launches HIE testing Initiative. Healthcare IT News. Retrieved from:

The Joint Commission. (2014). Chapter: Record of Care, Treatment, and Services. Retrieved from: https://foh.psc.gov/tjc/roc/standards.pdf