Maya has worked in the clinical, education, and management sections of healthcare for over 25 years and holds bachelor's degree in Speech and associate degree in Nursing.
Clayton is a nurse, caring for patients in a busy surgical unit and using electronic health records (EHR) to document the care given to his patients using the most up-to-date standards of care provided. The standards to be met and the ability to use this information is crucial to quality and safety of patient care.
Our healthcare systems are complex and many times the information and standards of care are so varied that it is hard to bring all the pieces together and get the information to the person who needs it when they need it. Efforts to bring healthcare together have been going on for decades but, with the advance of information technology, the process became easier.
Healthcare informatics technology surrounds the merging of clinical information with computer technology to form digital workflows for clinical and non-clinical staff in the care of patients. The goals are far-reaching in healthcare from the bedside to the behind-the-scenes work needed to ensure quality and safety for patients. HI goals are:
- Reduce costs by assisting providers in coordinating care
- Increase efficiency of care through streamlining workflow
- increase safety of patients by reducing errors
Another concern is access by providers to the health record. Interoperability has made the patient's health record more accessible to those caring for patients. Here's what it may look like in your community.
Clayton now has information at the click of a mouse and can document in the record because of the work in healthcare informatics. Standardization development organizations (SDO) are highly focused teams that develop standards surrounding particular needs for healthcare technology. The Department of Health and Human Services serves as leadership for these organizations. Organizations are working together blending information into formats needed by different areas of the hospital where Clayton works. Let's follow the yellow brick road to some of these organizations.
- American National Standards Institute (ANSI) Brings multiple agencies and participants from the U.S. together to formulate Informatics standards and accreditation.
- American Society for Testing and Materials (ASTM) Builds standards for general use in healthcare information technology such as security, confidentiality, decision-making capability, storing information, creating the ability to function, and workflow.
- Current Procedural Terminology (CPT) was formed by the American Medical Association and provides codes used for each procedure performed on patients and, when submitted to the payor, leads to reimbursement.
- Institute of Medicine and Patient Safety Data Standards is collecting, classifying, and coding patient safety information.
- The Digital Imaging and Communications in Medicine (DICOM) developed standards facilitating the transmission of digital radiological imagery.
Every day Clayton uses the information available to care for each phase of his patient's stay. Two types of standards are important for Clayton, technology and messaging standards.
- Technology Standards such as billing standards that allow medical coding and billing
- Messaging Standards:
- HL7 or health level 7 is clinical data creation, storage, and communication for the electronic health record
- X12N Financial data to be stored and shared and provides confidentiality
- DICOM Provides images such as x-rays and transfer images to health record
- NCPDP Prescription drug programs and business
Standards organizations must be accredited as meeting standards by the American National Standards Institute (ANSI). The ANSI drives the bus and the other organizations get on the bus.
The Joint Commission (TJC) has developed standards that lead to accreditation what must be met for the healthcare information technology at Clayton's hospital. The goal is to make sure the informatics used meets high-quality marks for quality, safety, confidentiality, and recognition by the Centers for Medicare and Medicaid to receive reimbursement for services. Clayton plays a vital role in making sure the computer he uses is protected from breaches in security and he is able to find needed information swiftly. Clayton also reports problems in the workflow so changes can be addressed. Frontline staff is a vital resource for creating a workflow that is safe.
When the healthcare facility is surveyed for accreditation, healthcare informatics is an important piece of the puzzle.
Healthcare informatics as a whole can be overwhelming and look fragmented. Standardization organizations have worked to bring clarity and focus to the technology making information available for the clinician and non-clinical areas. All of these organizations are under the Department of Health and Human Services. The American National Standards Institute (ANSI) brings accreditation to the organizations developing Healthcare Information Technology HIT standards.
These are important terms to know about working in HIT:
Healthcare informatics is the merging of clinical information and workflow with computer information to aid the clinical staff to care for patients. It has produced the electronic medical record or EHR. Making patient information to providers from many areas is called interoperability and is networked by information systems to help coordinate patient care.
Standards in healthcare informatics are being set by standardization development organizations (SDO) and provide a framework for the area they are responsible for.
- Digital Imaging and Communications in Medicine (DICOM) is the standard organization responsible for imaging storage and transfer within the record.
- HL7 is responsible for the creation, function, and communication of the patient's electronic health record.
- X21N is responsible for financial and confidentiality standards for the HIT.
There are many more organizations involved in the creation and functionality of healthcare information technology (HIT).
Accreditation is accomplished to make sure the standards are being met and to foster reimbursement for services. The organizations responsible for accreditation are American National Standards Institute (ANSI) and The Joint Commission. The Centers for Medicare and Medicaid (CMS) will not provide reimbursement if the healthcare information systems used are not up to the standard of care outlined by these organizations. Staff will be interviewed to determine if they know how to use the system as they are working and what they should do if the system fails.
Medical Disclaimer:The information on this site is for your information only and is not a substitute for professional medical advice.
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