Healthcare informatics is the analysis and the interpretation of data about patient information and their treatments. Health Information Technology is a highly organized, easily accessible and manageable database system in a medical practice that is highly productive and cost effective. In regards to cost effectiveness, there is a reduction in staff cost which ultimately saves medical practices and hospitals money. Due to the fact that the use of electronic health information EMR/EHR, is utilized in the improvement of quality care and requires the exchange of patient information, there have been an increase need for patience security and privacy. It is in this respect that HIPAA was established. The continual need for patient security and privacy also brought about the establishment of collaboration governance guiding health information technology infrastructure. (Rundio & Wilson, 2010).
Health Information Technology for Economic and Clinical Health (HITECH) Act was passed by law by President Obama on February 17, 2009 for the implementation and meaningful use of HIT. HITECH provides HHS “the authority to establish programs to improve health care quality, safety, and efficiency though the promotion of health IT, including electronic health records and private and secure electronic health information exchange” (“HealthIT”, n.d.). The “meaningful use” of certified EHR technology to improve patient care. Hogan and Kissam (2010) state that: “the meaningful-use provision of the so-called stimulus law was intended to address questions that some have raised about the quality of widespread use of electronic health records alone to improve the quality of healthcare.” U.S. HHS has now set forth definitions if what constitutes meaningful use under proposed regulations.
Health care information technology has resulted in the reduction of medical errors and lawsuits. Based on some evidence provided by the health care legislation and HITECH Act, which includes the positive results from providers with information technology systems in place. With the advent of EHR, errors pertaining to prescriptions and medication have reduced, and patient records are easily accessible. Medical professionals have readily available access to patient information and medical records which means speedy treatment in also an emergency situation. In the case of monitoring illnesses and outbreaks, HIT is very effective because of its capabilities in tracking and reporting patient information. In addition the quality and safety of patient care have improved and simultaneously reducing cost for medical practitioners/
The move from paper medical records to electronic record keeping has increased and brought about patient safety and privacy in respect to patient access records, the use and disclosure of patient information. Thus in 1996, the health Insurance Portability and Accountability Act known as HIPAA was passed. HIPAA’s main goal is to improve the efficiency and effectiveness of the system by providing protection of the patient in terms of their health information. This privacy rule includes not only the protection of patient information it also defines how patient information should be used and also how information should be disclosed. I believe that the privacy rule provides patients with more control than ever pertaining to their own health records. HIPAA security rule addresses who is covered by the HIPAA privacy rule and the precautions to be taken for proper protection of electronic health information (“HealthIT”, n.d.).
EHR is possible due to the evolution of technology for information capture, storage, and exchange. Documentation is complied throughout the treatment of a patient. It begins with admission to a service and concludes with discharge form care. The four categories of information are administrative, demographic, financial and clinical. It is imperative that complete information be documentated to facilitate quality and continuity of care for a patient and to serve the legal, statistical, and reimbursement needs of the facility and healthcare provider. Data are collected in the form of dates, numbers, symbols, images, illustrations, texts, lists, charts, and equations.
Physicians, surgeons, and nurses are the main authors of clinical documentations. The EHR is a repository that contains data on patients. These data source contains large amounts of clinical documentation stored as data and information. Health record data are the basis of morbidity and mortality that is vital statistics reports and healthcare-related indexes, registries, and databases. Much of the statistical data collected in hospital reports, indexes, registries, and databases are submitted to state, federal, and international agencies. The most important function of the health record is the collection of information in the patient’s medical condition and progress throughout his or her treatment. These agencies are responsible for policy making and healthcare delivery, services, research and education. Included in the utilization of data is the focus on how healthcare organizations use their resources. Some hospital utilizes its data to ensure that customers receive appropriate levels of services and that the services are performed in an efficient and cost-effective way. State and federal government regulations require hospitals to conduct utilization management review. Health record information is used as the basis for utilization management review of a healthcare organization’s resources. Determination of medical necessity are based on whether the services can be expected to have a reasonable beneficial effect on the patient’s physical needs and quality of life. For example the WHO, uses record-based statistics to track the incidence of disease worldwide and to plan public health initiatives accordingly. Health records are used as educational tools by medical schools, dental schools, nursing schools, and allied heath training programs. Data contained in the health record are required for research, statistical reporting, cancer registries, trauma registries, and birth certification registration to name a few public health uses. Documentation needed for research ranges from identification of candidate health records for projects to actual review of selected records and abstract preparation or collection of data from them for the physician o clinical researcher.
Providing research assistance to clinicians and medical staff committees is also part of the data utilization process. The data indexes are used to sort data in a variety of ways to assist study if certain data elements. Additionally, HIM departments collect and calculate various statistics about the operations of the healthcare facilities and clinical practices they serve. The HIM professional may be called upon to assist research by providing information for a clinical trials. Using health record data to guide these studies and document results can lead to new medical discoveries and treatment modalities.
Included in the utilization of data is the focus on how healthcare organizations use their resources. Some hospital utilizes its data to ensure that customers receive appropriate levels of services and that the services are performed in an efficient and cost-effective way. State and federal government regulations require hospitals to conduct utilization management review. Health record information is used as the basis for utilization management review of a healthcare organization’s resources. Determination of medical necessity are based on whether the services can be expected to have a reasonable beneficial effect on the patient’s physical needs and quality of life.
My thoughts on the reflection on data fit with my initial impression of healthcare informatics definition was that a patient’s vital medical information is scattered across medical records kept by many different caregivers in many different locations, and all of the patient’s medical information is often unavailable at the time of care. For example when I go to the emergency room, too often I am seen by doctors with no access to my critical medical information, such as allergies, current medications, current treatments, prior diagnoses, and medical history and this might be true across the board for the general population. There was another instance whereby I was prescribed medication and was told to follow up with my family doctor. I went to see my doctor after a couple of days and he prescribed a totally different medication and his diagnosis was different from the ER doc. This made me think that ER physicians might not always have the best information to select the best treatments for their patients maybe. Further, they also do not have ready access to complete information about their patients; do not know how other doctors are treating their same patients, or maybe how other healthcare providers around the country treat patients with the same condition. These conditions set the stage for preventable medical errors.
I now that the notion that innovation in health information technology, such as electronic health records, and the secure exchange of medical information has not only transformed the healthcare in America by reducing paperwork, preventing medical errors, improving administrative efficiencies, improving healthcare quality, reducing healthcare costs, and increasing access to affordable healthcare.
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Hogan, S., Kissam, S. (2010) Health Affairs. Measuring Meaningful Use. 29.4, 601-606
Srinivasan, D. 2013, Impact of Healthcare Informatics on Quality of Patient Care and Health Services.