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Standardization & Accreditation in Health Care Informatics

Instructor: Maya Shapland

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.

Standardization and accreditation are discussed as the strong foundations of healthcare informatics and technology used for patient records and care. The organizations creating the standards and accreditation are reviewed with examples.

Healthcare Informatics

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.

Interoperability players involved in patient care
Interoperability

Standardization

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.

  1. Technology Standards such as billing standards that allow medical coding and billing
  2. 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

Healthcare Informatics Standards Workflow
HIT Flow

Accreditation

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.

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