course identification - neosho.edu · b. standards for electronic data and electronic data...

Health Information Technology Fall 2007

Course Syllabus

COURSE IDENTIFICATION Course Prefix/Number: ALHT 110 Course Title: Introduction to Health Information Technology Division: Outreach and Workforce Development Program: Health Information Technology Credit Hours: 3.0 Initiation/Revised: Fall 2007/Fall 2011 Assessment Goal per Outcome(s): 80% CLASSIFICATION OF INSTRUCTION Vocational COURSE DESCRIPTION This course is designed to give the student a working knowledge of health care delivery systems; the health information profession; the definition and the purpose of the medical record; the systems and processes for collecting, maintaining and disseminating health information; numbering, retention and storage of medical information; forms control and design; indexes and registers; release of patient information, security, privacy, confidentiality, and ethical issues; documentation requirements; regulatory requirements of healthcare organization, accrediting and licensing agencies, and computerized information management systems utilized by health information management departments. PREREQUISITES AND/OR COREQUISITES Microcomputer Application TEXT/WEBSITE/RESOURCES *The official list of textbooks and materials for this course are found on Inside NC. Johns, Merida, PhD, RHIA, Health Information Management Technology: An Applied Approach. 3rd Edition Chicago: American Health Information Management Association, July 2010. ISBN: 9781584262596 AHIMA Journal http://www.ahima.org American Health Information Management Association www.jcaho.org Joint Commission of Healthcare Organization (JCAHO) www.aha.org American Hospital Association American College of Surgeons web site


NCCC library site COURSE OUTCOMES/ COMPETENCIES (as Required)

1. The student will demonstrate knowledge of the history and the roles of the Health Information Management profession.

a. Demonstrate knowledge of the development of the health information management profession and the evolutions in it to accommodate the changes in the healthcare environment.

b. Demonstrate knowledge of the responsibilities of healthcare professionals. c. Identify the roles and responsibilities of health information management

professionals in the development and maintenance of health record systems.

d. Identify the typical functions performed by the health information management (HIM) department.

e. Demonstrate knowledge of different operational techniques for managing traditional HIM functions.

f. Demonstrate knowledge of the interrelationship between the HIM department and other key departments within the healthcare organization.

g. Demonstrate knowledge of several techniques used in the management of the HIM department, such as policy and procedure development and the budgeting process.

h. Identify the role of the health information management professional in creating and maintaining secondary records.

2. The student will demonstrate knowledge of the definition, purpose, functions, content, format and agencies involved in the health record.

a. Demonstrate knowledge of the purpose, structure and certification process of the American Health Information Management Association.

b. Define the term health record and the various uses of it. c. Identify the different users of the health record and its importance to each

user. d. Describe the function of the health record and understand the content of

health records in various healthcare settings. e. Describe the components of health record data quality. f. Recognize the documentation requirements of accreditation organizations

and state and federal government agencies. g. Describe the different formats used for health records in healthcare

organizations. h. Identify techniques used in the storage and maintenance of health records. i. Discuss the functions and responsibilities of common HIM support

services, including cancer and trauma registries, birth & death certificate completion, and statistical and research services.

j. Identify prominent health information standards development organizations.


3. The student will demonstrate knowledge of the electronic health record (EHR) and healthcare data sets and their importance.

a. Describe the advantages of electronic health records over paper-based and hybrid health records.

b. Introduce the concept and evolution of the electronic health record and identify and define terms associated with the EHR.

c. Relate the various initiatives local, regional, and national adoption of EHR and health information technology (HIT).

d. Describe the current state of EHR adoption and the technologies that help transition to the EHR.

e. Discuss the EHR challenges and the supporting roles of health information management professionals in addressing them, especially with respect to privacy, security, and legal aspects.

f. Describe the purpose, development and maintenance of registries and indexes such as the master patient index, disease index, and operation index.

g. Describe the purpose and importance of healthcare data sets. h. Identify the common health information standardized data sets. i. Explain the healthcare data needs in an electronic environment. j. Discuss how data standards are developed and their importance. k. Explain the relationship of core data elements to healthcare informatics

standards in electronic environments. l. Describe current federal initiatives to support EHR development and to

create a national health information network. m. Distinguish between primary and secondary data and between patient

identifiable and aggregate data. n. Identify the internal and external users of secondary data. o. Compare and describe the registries/indexes used in hospitals according to

purpose, methods of case definition and case finding, data collection methods, reporting, follow-up and pertinent laws and regulations affecting registry operations.

p. Define the terms pertinent to each type of secondary record or database. q. Discuss agencies for approval and education and certification for cancer,

immunization, and trauma registries. r. Distinguish among healthcare databases in terms of purpose and content. s. Compare manual and automated methods of data collection and vendor

systems with facility-specific systems. t. Recognize appropriate methods for ensuring data security and the

confidentiality of secondary records.

4. The student will demonstrate a basic understanding of the clinical vocabularies, classification systems and reimbursement methodologies.

a. Describe the coding & reimbursement process. b. Discuss the history of coding and reimbursement process.


AHIMA DOMAINS Domain 1: Health Data Management Subdomain A: Health Data Structure, Content and Standards

1. Collect and maintain data sets and databases 2. Conduct qualitative analysis to assure that documentation in the health record

supports the diagnosis and reflects the progress, clinical findings and discharge status.

4. Comply with national patient safety goals as related to abbreviation usage 5. Verify timeliness, completeness, accuracy, and appropriateness of data and data sources (e.g., patient care; management; billing reports and/or data bases)

Subdomain B: Healthcare Information Requirements and Standards 1. Monitor the accuracy and completeness of the health record as defined by

organizational policy, external regulations and standards 3. Apply policies and procedures to assure organizational compliance with regulations and standards.

Domain 2: Health Statistics, Biomedical Research and Quality Management Subdomain A: Healthcare Statistics and Research

1. Abstract and maintain data for clinical indices/databases/registries Domain 3: Health Services Organization and Delivery Subdomain A: Healthcare Delivery Systems

1. Comply with accreditation, licensure, and certification standards from government (national, state, and local levels) and private organizations (e.g., Joint Commission on Accreditation of Healthcare Organizations{JCAHO})

4. Understand the role of various providers and disciplines throughout the continuum of healthcare services

Subdomain B: Healthcare Compliance, Confidentiality, Ethical, Legal, and Privacy Issues 2. Apply regulatory policies and procedures for access and disclosure of protected health information (PHI) Domain 4: Information Technology and Systems Subdomain A: Information and Communication Technologies 3. Use specialized software in the completion of HIM processes (e.g., chart management; coding; release of information) 4. Apply policies and procedures for the use of networks, including intranet and internet applications to facilitate the electronic health record (HER), personal health record (PHR), public health, and other administrative applications. Subdomain B: Data, Storage and Retrieval

1. Use appropriate electronic or imaging technology for data/record storage 2. Maintain integrity of patient numbering and filing systems 3. Design forms, computer input screens, and other health record documentation

tools 4. Maintain integrity of master patient/client index/Enterprise Master Patient

Index(EMPI) 5. Query and generate reports using appropriate software 6. Design and generate reports using appropriate software


7. Coordinate, use and maintain archival and retrieval systems for patient information (e.g., in multiple formats)

Subdomain D: Healthcare Information Systems 1. Collect and report data on incomplete records and timeliness of record

completion 2. Maintain filing and retrieval systems for health records

COURSE OUTLINE I. Introduction

A. Early History of Health Information Management B. Evolution of Practice C. Today’s Professional Organization

II. Functions of the Health Record A. Purpose of the Health Record B. Users of the Health Record C. Functions of the Health Record

III. Content and Structure of the Health Record A. Content of the Health Record B. Specialized Health Record Content C. Documentation Standards D. Format of the Health Record

IV. The Electronic Health Record A. The Ideal Electronic Health Record System B. Evolution of the Electronic Health Record C. Initiatives and Framework for the Electronic Health Record D. Creation of Electronic Health Record Systems E. Information Management in an Electronic Environment F. Future Directions in Information Technology

V. Health Information Technology Functions A. HIM Functions and Services B. HIM Interdepartmental Relationships C. Management of Health Record Content and Processes D. Quality Control and Monitoring for Health Record Systems E. Indexes and Registries F. Management and Supervisory Processes G. Future Directions in Health Information Management Technology

VI. Healthcare Data Sets A. Standardized Healthcare Data Sets B. Standards for Electronic Data and Electronic Data Interchange C. Evolving Health Information Standards

VII. Secondary Data Sources A. Differences between Primary and Secondary Data Sources and Databases B. Purposes and Users of Secondary Data Sources C. Types of Secondary Data Sources D. Processing and Maintenance of Secondary Databases


VIII. Clinical Vocabularies and Classification Systems A. Clinical Vocabularies

B. The Coding Process C. Coding Technology D. Coding and Corporate Compliance

IX. Reimbursement Methodologies

A. Healthcare Reimbursement Systems B. Healthcare Reimbursement Methodologies C. Medicare prospective Payment Systems D. Processing of Reimbursement Claims

SCHEDULE This class meets online for weekly learning units. The class materials for each unit will be available for a minimum of eight days, starting the first day of the semester and ending at the end of the midterm exam. OFFICIAL SCHEDULE IS LISTED IN CLASS!

Week 1 Assignments

Introduction Misc items

Familiarize yourself with the course tabs and complete Mandatory Quiz under coursework.

Complete the Student Objective/Occupational Intent Form if you have not done so already. (Mail or email to NCCC HIT Program Coordinator, [email protected]).

Complete the Introduction under collaboration forum. Watch the AHIMA Video in the collaboration forums and post a

response. Take the Academic Honesty quiz.

Week 2 Early History of

Health Information

Management, & Evolution of

Practice

Read Chapter 1. Visit AHIMA.org and post one benefit of being a member on

collaboration forum. Visit the AHIMA Web site and research the qualifications for

certification examinations and post on collaboration forum. Test over Chapter 1.

Week 3 Functions of the Health Record

Read Chapter 2. Complete Real World Case #1 (pg 53) homework assignment. Collaboration forum - AHIMA/KHIMA national/state committees. Test over Chapter 2.

Week 4 Content and

Structure of the Health Record

Read Chapter 3. Collaboration forum - Ethical Coding Standards. Ch 3 Application exercise homework. Test over Chapter 3.

Week 5 Electronic Health

Record Read Chapter 4. Collaboration forum – EHR Careers. PAPER - Complete Compare and Contrast paper, see file exchange

assignment on EHR, PHR, and CCR via file exchange-do not email to instructor.

Week 6

Electronic Health Record

VA VistA virtual EHR activity. Chapter 4 test.


Week 7

Health Data Sets and Standards

Read Chapter 5. Do Chapter 5 Application Exercises. Do Chapter 5 Test.

Week 8 Health Data Sets and Standards

Abstract completion. Collaboration forum – Professional Ethics. ICD-10-CM web search homework. Complete AHIMA student application, if you have not done so

already, for extra credit. MIDTERM Midterm Open (10/18/11 – 10/21/11) – No retakes!

Mid-Term Covers topics in weeks 1-8Week 9

Clinical Vocabularies

&Classification Systems

Reimbursement Methodologies

Read Chapter 6. Do Chapter 6 test.

Read Chapter 7. Do Chapter 7 test.

Week 10 HIT Functions

Read Chapter 8. Do Chapter 8 Quiz. ROI processing assignment.

Week 11 Secondary Data

Systems

Read Chapter 9. Chapter 9 quiz. Collaboration forum – Registry search.

Week 12 Healthcare

delivery systems Read Chapter 12. Chapter 12 quiz. Real World Case.

Week 13 Ethical Issues in

HIT Read Chapter 13. Collaboration forum - Ethical/Malpractice. Chapter 13 test.

Week 14 Healthcare Statistics

Read Chapter 10 Pg 517-577 Chapter 10 test

Week 15 Group

Assignment Submit group assignment on Professional Ethics.

Week 16

FINAL EXAM Proctored final exam (12/6 – 12/10/11) NO RETAKES!

INSTRUCTIONAL METHODS/GRADING/STUDENT REQUIREMENTS AND METHODS OF EVALUATION A cumulative point system is used. Your class assignments will include reading, review questions, written reports, case studies, Website research, projects, practice exercises, discussion questions, chapter quizzes and examinations. The chapter examinations will be a part of each learning unit and are completed after the unit assignments, and prior to starting the next unit. Possible points for written reports, case studies, projects, and exams will vary and tracking of your total points for each assignment or exam will be available on the course Website. Class assignments will be evaluated for accuracy,


content, form, knowledge of subject matter, application of knowledge and ability to communicate effectively. Class participation is an essential element to your success in this course. You are expected to complete practice exercises and respond to the discussion questions with at least one posting (5 points). Complete assignments by the due date. Late assignments will be docked 10% and only accepted 1 day past due date. Make-ups for exams or assignments are only permitted under special circumstances and with prior approval by the instructor. Borderline grades will be viewed in terms of timely completion of assignments and class participation. Total points accumulated during the semester will be calculated into a percent and graded on the scale below. GRADE SCALE Letter grades will be given using the following scale: A = 90-100% B = 80-89% C = 70-79% D = 60-69% F = 59% and below ASSESSMENT OF STUDENT GAIN Student gain will be determined by student improvement in each of the areas of student competencies. ATTENDANCE POLICY Absences that occur due to students participating in official college activities are excused except in those cases where outside bodies, such as the State Board of Nursing, have requirements for minimum class minutes for each student. Students who are excused will be given reasonable opportunity to make up any missed work or receive substitute assignments from the instructor and should not be penalized for the absence. Proper procedure should be followed in notifying faculty in advance of the student’s planned participation in the event. Ultimately it is the student’s responsibility to notify the instructor in advance of the planned absence. Unless students are participating in a school activity or are excused by the instructor, they are expected to attend class. If a student’s absences exceed one-hundred (100) minutes per credit hour for the course or, in the case of on-line or other non-traditional courses, the student is inactive for one-eighth of the total course duration, the instructor has the right, but is not required, to withdraw a student from the course. Once the student has been dropped for excessive absences, the registrar’s office will send a letter to the


student, stating that he or she has been dropped. A student may petition the chief academic officer for reinstatement by submitting a letter stating valid reasons for the absences within one week of the registrar’s notification. If the student is reinstated into the class, the instructor and the registrar will be notified. It is the responsibility of the student to properly drop the course. Students, who are still enrolled in this class after the final drop date, but fail to participate in class, are at risk for a failing grade. Your grade will be based on the total points accumulated through the last date of participation. ACADEMIC INTEGRITY NCCC expects every student to demonstrate ethical behavior with regard to academic pursuits. Academic integrity in coursework is a specific requirement. Definitions, examples, and possible consequences for violations of Academic Integrity, as well as the appeals process, can be found in the College Catalog, Student Handbook, and/or Code of Student Conduct and Discipline. This online class allows you to work independently or with other students in the class. For your own benefit, you need to complete all assignments on your own unless otherwise indicated. Do not use the work of others and submit it as your own. You may refer to the textbook and resources when taking tests online, however the tests are timed and you may lose points if you exceed the time limit. The true test of what you learn in this class will be demonstrated when you take the AHIMA certification exam to become a Registered Health Information Technician. The expectation for this class is for you to be professional and ethical – do your own work. CELL PHONE POLICY: Student cell phones and pagers must be turned off during class times. Faculty may approve an exception for special circumstances. Note: Information and statements in this document are subject to change at the discretion of NCCC. Changes will be published in writing and made available to students.

NOTE: If you are a student with a disability who may need accommodation(s) under the Americans with Disabilities Act (ADA), please notify the Dean of Student Development, Chanute Campus, Student Union, 620-431-2820, Ext. 213., or the Dean, Ottawa Campus, 785-242-2607 ext 312, as soon as possible. You will need to bring your documentation for review in order to


determine reasonable accommodations, and then we can assist you in arranging any necessary accommodations. DISCLAIMER: This syllabus is a broad outline of subject matter intended to be covered. It does not mean that everything herein will be covered, nor does it limit the content of the class to the material described. Information and statements in this document are subject to change at the discretion of NCCC. Because Introduction to Health Information is basic to understanding many of the other courses in the Health Information Technology program, a grade of C or better is required to continue the program.

course identification - neosho.edu · b. standards for electronic data and electronic data...

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