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HIM
Health Data Quality Management and Improvement
Module 10 – Health Data Quality Management and Improvement
Data quality management and improvement in healthcare imply implementing a systematic
framework to verify data sources, validate data quality, eliminate data errors, and execute
processes for ensuring the accuracy, consistency, comprehensiveness, completeness, currency,
and reliability of data generated in healthcare. This module reviews various health data
management and improvement strategies for capturing, maintaining, and continuous
improvement of health data quality.
Module 10 Objectives:
After completing this module, you should be able to:
•
•
•
•
Distinguish between primary and secondary data sources.
Apply AHIMA Data Quality Management Model to health data management.
Formulate strategies for ensuring health data quality management.
Develop policies and processes for the continuous improvement of health data quality.
Module 10 Readings
Health Information Management: Concepts, Principles, and Practice
Chapter 7 – Data Capture, Maintenance, and Quality, pgs. 169-191.
Health Information Management Technology: An Applied Approach
Chapter 4 – Healthcare Data Sets and Standards, pgs. 139-173.
AHIMA Data Quality Management Model
The Value of Data Quality in Healthcare
What is Data Quality Management
What is the Importance of Data in Healthcare Information Systems
How to improve data quality in healthcare
Discussions – Minimum of 250 words
According to a recent report (https://dataladder.com/data-quality-in-healthcare-data-systems/ )
38% of US healthcare providers have incurred an adverse event within the last two years due
to patient matching issues.
Briefly discuss what is meant by data quality in healthcare. Are any of these issues mentioned
in this report? How do data quality characteristics listed in this report compare with the
AHIMA Data Quality Management Model
(https://library.ahima.org/PB/DataQualityModel#.YxzlBXbMKUk )? If you need to apply
any five of these data quality characteristics in your healthcare facility, which of these would
you select and why?
Assignment
Review AHIMA Data Quality
Management https://library.ahima.org/PB/DataQualityModel#.Y6nun3bMKUk
The healthcare facilities use data for multiple purposes like diagnosing, treatment, and
billing. Who are the beneficiaries of the healthcare data management quality programs? What
are benefits of the data quality management in healthcare for different stakeholders? What
data quality characteristics are most important for managing healthcare data quality?
Why? How would you ensure high data quality maintenance in your facility as the HIM
Director?
Your APA formatted assignment comprising 2-4, double-spaced, typed in 12-point Times
New Roman (or 11- point Calibri) excluding the Cover and Reference pages should be
submitted by Tuesday mid-night. Use credible evidence to support your ideas
Response to Discussions
POST 1
According to Ziad in “Data quality in healthcare – Benefits, challenges, and steps for
improvement” of 2022 (last year), she quoted “38% of US healthcare providers have incurred
an adverse event within the last two years due to patient matching issues” (Ziad, 2022). From
this quote, she wants to clarify the impact of in-quality data in health care. So what is data
quality and how will it help? Data quality is closely related to how the organizations -settingup the data or data standards (LaTour & Eichenwald, 2013). According to AHIMA (2012), the
quality data should have the ten characteristics: accuracy, accessibility, comprehensiveness,
consistency or reliability, currency, clear definition, details or granularity, precision,
relevancy, and timeliness. In the mentioned blog, she identifies some more characteristics like
validation, identifiability, provenance, usability, and security as well as confidentiality (Ziad,
2022). Then, she goes on to how to ensure the quality data in health care. The very first one is
“profile sources that store health data (Ziad, 2022).” Well organized data to information is just
going to help in improvement data quality. Thus, when the organizations need to “add missing
information,” “clean and standardize data values,” “match duplicate patient records,”
“deduplicate matching entities,” or “merge records and retain information,” the jobs are just
get easier (Ziad, 2022).
Back to the characteristics of quality data, the common ones between AHIMA’s standards and
Ziad’s list are availability and accessibility, accuracy, completeness, currency, and
consistency. Therefore, those characteristics should always be considered and implemented in
order for achieving the quality of health care data.
References
LaTour, K. M., & Eichenwald, S. (2013). Health Information Management: Concepts,
Principles, and Practice (Fourth ed.). AHIMA
Ziad, Z. (2022, June 27). Data quality in healthcare – Benefits, challenges, and steps for
improvement. Data Ladder. October 21, 2023, https://dataladder.com/data-quality-inhealthcare-data-systems/
POST 2
Healthcare involves many decisions each day which can change the course of a patient’s life,
with consequences as drastic as even death. In order to make good decisions, providers require
knowledge, which is derived from information, which is derived from data. This is why data is
so valuable to healthcare organizations. However, data is only as valuable as it is useful and the
quality of data can vary considerably. High-quality data must be compliant with one of the
recognized data quality standards, which aim to ensure documentation and the data collected
from it is complete, accurate, and accessible (Eichenwald & LaTour, 2013). Some data quality
requirements as mentioned by Ziad include accessibility, accuracy, validation, completeness,
currency, consistency, identifiability, provenance, usability, and confidentiality (Ziad, 2023).
These compare quite well to the AHIMA characteristics of data quality as well, which also
include granularity and precision as well as many of those mentioned above, though they are
captured within different names. The only one not carried over is security/confidentiality (Data
Quality, 2015).
If I were to select five characteristics to help my facility, Clive Behavioral Health, I would first
choose accuracy. Much of our data contradicts itself, even for one patient during a single
encounter. Names are often misspelled, birth dates entered incorrectly, phone numbers entered
incorrectly, and sometimes even duplicate account creations or reassigning a different MRN to
an existing patient. Merging these accounts can help and would be a good start (Ziad, 2023).
Accessibility would also be a good choice for Clive. Currently we are using many systems,
including paper charts which are not easily accessible, Word documents stored in a shared drive,
two partial EMRs, and MS4 which is a backend administrative system. Not all employees can
access these systems, and many employees have access to information they should not have.
Thirdly, I would choose consistency as data is inconsistent among these applications leading to
miscommunication and delays in patient care. Next, Data comprehensiveness would be a good
choice, as many data elements are not collected during patient stays, particularly those to be
collected on paper. Finally, timeliness is an area which is a slight struggle as systems must be
manually updated as it is currently set up, which does not often happen within an acceptable
amount of time.
Resources:
Data Quality Management Model (2015 update) – retired. Journal of AHIMA. (2015).
https://library.ahima.org/PB/DataQualityModel#.YxzlBXbMKUk
Eichenwald, S. & LaTour, K. (2013). Health Information Management: Concepts, Principles,
and Practice, Fourth Edition: Vol. 4th ed. AHIMA Press.
Ziad, Z. (2023, August 25). Data quality in healthcare – benefits, challenges, and steps for
improvement. Data Ladder. https://dataladder.com/data-quality-in-healthcare-data-systems/
less
HCAD
Presentation Draft & Peer Review of Financial Analysis
Introduction to Healthcare Financial Management
READ:
•
•
10 PowerPoint Tips for Preparing a Professional
Presentation https://www.makeuseof.com/tag/10-tips-for-preparing-a-professionalpresentation/
“How to Design a Professional PowerPoint
Presentation.” https://designshack.net/articles/graphics/how-to-design-a-professionalpowerpoint-presentation/
DO:
1. Post team draft PP to the discussion thread NLT
2. Respond and post feedback to your peers NLT
3. Continue working on Group Project: Healthcare Finance Organizational Analysis and
video-Presentation due in week 11,
ADDITIONAL RESOURCES:
•
Chapter 17 in Gapenski’s Healthcare Finance: An Introduction to Accounting and
Financial Management, Seventh Edition
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chapter
7
Health Information
Functions
Lisa A. Cerrato, MS, RHIA and
Jane Roberts, MS, RHIA
Learning Objectives
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Identify typical health information management functions
Explain the purpose and techniques used for the maintenance of the master patient
index in paper-based and electronic environments
Identify operational techniques for managing traditional HIM functions in paperbased, hybrid, and electronic record environments
Discuss techniques used in the processing, storage, retrieval, and maintenance of
health records in paper-based, hybrid, and electronic environments
Explain the use of quality control techniques used for paper-based, hybrid, and
electronic health records and for supporting services such as medical transcription,
release of information, and coding functions
Discuss the concept of the legal health record and how it is applied
Describe practices for authorization and access control of health records in paperbased, hybrid, and electronic formats
Recognize the interrelationship between the HIM department and other key departments within the healthcare organization
Describe the purpose, development, and maintenance of registries and indexes
such as the master patient index, disease index, and operation index
Discuss the functions and responsibilities of common HIM support services,
including cancer and trauma registries, birth certificate completion, and statistical
and research services
315
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Chapter 7
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Explain the relationship of accreditation, licensing, and standards requirements to
HIM functions and how compliance with these is monitored
Describe techniques used in the management of the HIM department, such as
policy and procedure development and the budgeting process
Key Terms
Abstracting
Access control
Alphabetic filing system
Alphanumeric filing system
APC grouper
Authentication
Authorization
Back-end speech recognition
Certificate of destruction
Clinical coding
Computer-assisted coding (CAC)
Concurrent review
Corrections
Deemed status
Deficiency slip
Delinquent record
Destruction
Digital dictation
Duplicate medical record number
Encoder
Enterprise master person/patient index
(EMPI)
Free-text data
Front-end speech recognition
Health information exchange (HIE)
Health record number
Hybrid record
Index
The Joint Commission (TJC)
Legal health record
Master patient index (MPI)
Medical transcription
Middle-digit filing system
MS-DRG grouper
Natural language processing (NLP)
Nonrepudiation
Numeric filing system
Operation index
Outguide
Overlap
Overlay
Patient account number
Policies
Procedures
Purged records
Quantitative analysis
Reassignment
Record completion
Record processing
Record reconciliation
Registry
Release of information (ROI)
Requisition
Resequencing
Retention
Retraction
Retrospective review
Serial numbering system
Serial-unit numbering system
Standard
Storage and retrieval
Straight numeric filing system
Terminal-digit filing system
Transcription
Unit numbering system
Version control
Virtual HIM
Voice recognition technology
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Health Information Functions
317
Introduction
Health information management (HIM) involves a wide variety of functions that are critical to the operations of the healthcare organization and the healthcare delivery process.
This chapter examines the functions of the HIM department and looks at the different
management and supervisory processes that HIM professionals assume in the organization. Several chapters in this book are related to this chapter and focus on the purpose and
content of patient health records, the different technologies used in obtaining and retrieving patient information, the different information systems used in healthcare organizations, the importance of maintaining data integrity, and ensuring data confidentiality.
HIM functions usually involve ensuring the quality, security, and availability of health
information as it follows the patient through the health system. The HIM department also
monitors the quality of patient information, ensuring that the information is maintained
and protected in accordance with federal, state, and local regulations and the guidelines
issued by various accrediting bodies.
Among the HIM department’s most important functions is that of storage and retrieval
of patient information. The electronic health record (EHR) is rapidly replacing paper-based
record and hybrid record systems. Paper-based record systems are transitioning to hybrid
record systems. Hybrid record systems are evolving into electronic record systems. As
healthcare organizations make the transition to an electronic health record (EHR), paper
or hybrid record systems may still be used to store patient information. Regardless of the
type of storage system used, patient information must be stored in a manner that ensures
its accessibility to authorized users whenever and wherever it is needed.
In most healthcare organizations, the HIM department also manages several critical
support services. In addition to the storage and retrieval function, the HIM department also
typically manages the following support services:
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Record processing
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Monitoring of record completion
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Transcription
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Release of patient information
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Clinical coding, abstracting, and clinical data analysis
The services managed by the HIM department vary depending on the organization.
Besides the typical HIM functions, the HIM department may manage the following functions:
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Research and statistics
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Cancer and/or trauma registries
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Birth certificate completion
An interdepartmental relationship exists between the HIM department and many other
departments within a healthcare organization. HIM functions support patient care, quality
and resource management, billing, and patient registration. The functions associated with
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318
Chapter 7
patient care, quality and resource management, billing, and patient registration also affect
the processes managed by the HIM department. The information systems department and
HIM work together to support the electronic health record environment.
Theory into Practice
A patient arrives at the admitting department of a hospital and is admitted as an inpatient to
the medical floor. The registration clerk asks the patient if he has ever been seen or admitted to the hospital before. The patient states that he has never been admitted to this hospital.
Upon a search of the registration system (master patient index) by using the patient’s name,
and date of birth, the clerk finds that the patient had been seen at the hospital previously as an
outpatient. The registration clerk updates information in the computer by asking the patient
questions. The patient’s demographic information and insurance information is updated in
the computer. The insurance card is scanned and entered into the computer. The information
put into the registration system is automatically sent to the hospital’s electronic health record,
thus, the patient’s health record is created. The patient is transported to the medical unit.
Once in the room, the patient’s nurse introduces herself and does an assessment of the
patient and carries out the orders received by the patient’s physician. While on the unit, the
patient has blood drawn for laboratory tests. The patient’s physician visits the patient later
that afternoon and dictates a history and physical examination. Each clinician and physician that enters the room enters information regarding the patient in the computer located
in the patient’s room. The history and physical examination report is remotely transcribed
by the transcriptionist and the report is electronically transmitted into the electronic health
record (EHR). The patient stays in the hospital for four days and is discharged home.
Eighty percent of the health record at this hospital is either captured at point of service via direct input by the clinician, electronically transmitted, or COLD fed into the
EHR. The HIM department’s record processing clerk checks to make sure the record is
received electronically and that any loose sheets are retrieved from the nursing units and
scanned into the EHR. The electronic health record is then analyzed for deficiencies and
coded. Because a high percentage of the health record is structured data within the EHR,
the medical coder checks the codes assigned by the computerized assisted coding (CAC)
system to assure that the correct codes were assigned accurately. The medical coder also
abstracts any information not found by the CAC system. The physician completes deficiencies found in the health record. The record is completed.
The medical codes and abstracted data from the health record are electronically sent to
the business office. The medical coding information, registration information, and charges
entered from various departments are used to generate a bill. The bill is sent to the patient’s
insurance company.
HIM Functions and Services
HIM functions are information-centered. This means that they typically involve ensuring
information quality, security, and availability. The medium in which the information is
stored will dictate how the specific functions are carried out. The goal of the health record
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Health Information Functions
319
system is to ensure that accurate information is available to authorized users to support
quality patient care. For example, storage of information in paper-based records involves
different types of tasks than does storage of information in electronic records.
Figure 7.1 provides a description of a fictional HIM department with paper-based,
hybrid, and electronic records. The description includes many of the HIM functions discussed in this chapter. It is important to note that these are typical functions. Not all HIM
departments are identical in organization or in the functions they perform. Table 7.1 summarizes the some of the typical functions of the HIM department for paper-based and
hybrid records and EHRs.
Figure 7.1. HIM functions at Community Hospital Medical Center
Community Hospital Medical Center is located in the suburbs of a large southeastern city. It is a nationally
recognized leader in providing specialty and primary healthcare services and in conducting groundbreaking
research in the treatment of various health disorders. Located on a fifty-acre campus, the facility includes:
• A 516-licensed-bed facility that includes a Level I trauma center and a 50-bed neonatal intensive care
unit, a 16-bed pediatric ICU, and 25 general pediatric beds
• A cancer center with facilities for research, diagnosis, and treatment
• An outpatient center that includes specialized examination and treatment rooms, a clinical laboratory, a
diagnostic radiology department, and an ambulatory surgery department
The facility is affiliated with a local medical school and provides education and training for third- and
fourth-year medical students as well as internships and residencies for physician training.
The HIM department is responsible for all health records for the entire facility including both inpatient
and outpatient records. The medical training aspect of the facility adds another complicated dimension to
the management of the health records.
The functions performed within the HIM department include:
• Record processing (concurrent and retrospective analysis and monitoring of health record content)
• Record completion
• Storage and retrieval of health records (including monitoring and tracking of health record location)
• Release of patient information
• Clinical coding of diagnoses and procedures
• Transcription of medical reports (excluding pathology and radiology reports)
• Statistical and internal report generation
• Cancer and trauma registry
The HIM department is staffed with the equivalent of 63 full-time employees and operates 24 hours a day,
7 days a week. The following organizational chart shows how the operations in the department are organized.
HIM Services
Record Processing
• Assembly/analysis
• Storage and retrieval
• Record completion
• Medical transcription
Compliance/Research
• Clinical coding
• Research (cancer registry
and trauma registry)
Release of Information
• External requests for patient
information
• Birth certificates
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Chapter 7
Table 7.1. Table of common HIM functions
Function/Service
Storage and
retrieval
Description
Paper-based system:
• Patient care information documented on paper and housed in file folders.
• Records retrieved for patient care purposes, quality improvement studies, audits, and other authorized
uses.
• Records are delivered to the nursing units, outpatient surgery, and the emergency room as the patient is
admitted or being treated.
Hybrid system:
Patient care information documented both on paper and in the computer.
• Record is accessible to patient care areas via the computer by use of an electronic document
management system (EDMS).
• If hospital is transitioning to the EHR, portions of the health record may be printed for use on the
patient care unit.
EHR system:
• Patient care information captured at point of service and/or electronically transmitted to the EHR.
• Same electronic components utilized in the hybrid record, but the record resides entirely in electronic
format with work processes performed via the computer.
Record processing/
completion
Paper-based:
• After the patient is discharged from the hospital, the record is retrieved from the nursing unit. The
record is then assembled or put in an order prescribed by the facility’s policy and procedure manual.
For example, the face sheet is usually the first page in the paper record.
• Receipt of the health record is checked with a discharge list in a process called record reconciliation.
• The postdischarge record order is usually different than the order of the record on the nursing unit.
• After the record is assembled, it is analyzed for deficiencies, such as missing reports and signatures.
• Physicians visit the HIM department to complete deficiencies in records.
• The record is reanalyzed after completion to assure completeness of the process. Deficiencies are
cleared from the computer.
Hybrid system:
• Portions of the record can be directly inputted into the EHR through computer interfaces (for example,
transcribed reports, laboratory reports, emergency records, etc.). After the patient is discharged from
the hospital, the paper record is prepared for imaging (scanning).
• Receipt of the health record is checked with a discharge list in a process called record reconciliation.
• Physicians complete the record from a computer that may be located remotely from the hospital.
• If electronic signatures, computer key, and electronic completion rules are applied, the deficiency
system is updated once the physician completes his/her records.
• Records are analyzed for deficiencies either manually by the HIM staff and/or by rules built into the
computer system.
EHR system:
• Receipt of the health record is checked with a discharge list in a process called record reconciliation.
• Entire health record available via the computer for completion. Work queues in the computer are used
to route health records to appropriate person or area for completion.
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Health Information Functions
321
Table 7.1. Table of common HIM functions (continued)
Function/Service
Transcription
Description
Paper-based system:
• May be completed in-house or outsourced to an outside service.
• Physician dictates reports into a dictation system that records the voice. The transcriptionist types
(transcribes) what the physician has dictated.
• The transcribed report is placed in the chart.
• Reports commonly transcribed include: operative reports, history and physicals, discharge summaries,
radiology reports, pathology reports, and consultations.
Hybrid and EHR system:
• The process is basically the same as in the paper-based system, except that the transcribed reports
are electronically added to the health record that resides within the computer. Speech recognition
technology may be applied to the front-end and back-end of the transcription process to facilitate the
process.
Release of
information (ROI)
Paper-based system:
• Reviews requests for health records for validity to assure compliance with federal and state regulations.
• Logs and verifies validity of requests for patient information.
• May copy the record in response to valid requests or may provide record for an outsourced copy
service to process.
• May go to court in response to a subpoena or court order.
• Must have in-depth knowledge of laws and regulations governing the release of information.
Hybrid and EHR system:
• ROI process is basically the same as in the paper-based environment.
• As the EHR evolves there may be opportunities for the HIM professional’s role to be expanded.
Clinical coding
Paper-based system:
• A code number(s) is/are assigned to the diagnoses and procedures documented in the health record.
The coder looks the code number up in a coding book or by entering key words into the computer
using software called an encoder.
• ICD-9-CM and CPT are the two primary coding systems used in a hospital setting. ICD-10-CM and
ICD-10-PCS will replace ICD-9-CM.
• Other information is abstracted from the record for reporting and reimbursement purposes.
• Coding takes place on-site within the HIM department.
Hybrid and EHR system:
• The process is the same as the paper-based system, except that in the EHR environment, the record that
is reviewed is the electronic health record.
• Coding may be remote to hospital; home-based coding is possible.
• Computer-assisted coding may be utilized.
• Data abstracting may be reduced or eliminated as automatic data capture is implemented.
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Chapter 7
The functions (storage and retrieval, record processing, record completion, transcription, release of information [ROI], clinical coding) discussed here might be considered the most fundamental responsibilities of most HIM departments. (The processes that
support these HIM functions are discussed later in this chapter.) As mentioned earlier, in
some institutions, HIM functions also include clinical quality performance activities, research
and statistics, maintenance of cancer and other registries, support for medical staff committee
functions, and responsibility for birth certificate submission to state departments of public
health. Even though these functions may not fall within the traditional range of HIM department responsibilities, health information technicians (HITs) sometimes do perform them.
Master Patient Index
Probably the most important index used by the HIM department is the master patient index
(MPI). The MPI is the permanent record of every patient ever seen in the healthcare entity.
The MPI functions as the primary guide to locating pertinent demographic data about the
patient and his or her health record number. Without the information contained in the MPI,
it would be almost impossible to locate a patient’s health record in most organizations that
use a numeric filing system. The demographic information entered in the PMI supplies the
patient identifying information for the health record and its supporting databases. Therefore the MPI is the initial point of documentation of the health record. An enterprise master patient index (EMPI) references all patients in two or more facilities (e.g. integrated
healthcare delivery system or health information exchange [HIE]).
The amount of information contained on each patient in the MPI varies from facility
to facility. The recommended core data elements for an EMPI include: (AHIMA 2010b)
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Internal patient identification (medical record number)
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Person name
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Date of birth
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Gender
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Race
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Ethnicity
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Address
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Telephone number
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Alias/previous/maiden names
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Social Security number
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Facility identification
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Universal patient identifier (not yet established)
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Account—visit number
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Admission encounter—visit date
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