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Information ManagementInformation Management
D1 - S3D1 - S3
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TheThe goalgoal
TheThe goalgoal of the information managementof the information management
function is to support decision making tofunction is to support decision making to
improve patient outcomes, improve health careimprove patient outcomes, improve health care
documentation, improve patient safety, anddocumentation, improve patient safety, andimprove performance in patient care, treatment,improve performance in patient care, treatment,
and services, governance, management, andand services, governance, management, and
support processes.support processes.
While efficiency, effectiveness, patient safety,While efficiency, effectiveness, patient safety,
and the quality of patient care can be improvedand the quality of patient care can be improved
by computerization and other technologies, theby computerization and other technologies, the
principles of good information managementprinciples of good information management
apply to paper-based or electronic methods.apply to paper-based or electronic methods.
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A hospitals provision of care, treatment, andA hospitals provision of care, treatment, and
services is a complex endeavor that is highlyservices is a complex endeavor that is highly
dependent on information.dependent on information.
When many individuals and areas throughoutWhen many individuals and areas throughout
the hospital are involved in the provision ofthe hospital are involved in the provision of
care, treatment, and services, their work iscare, treatment, and services, their work iscoordinated and integrated.coordinated and integrated.
As a result, hospitals treat information as anAs a result, hospitals treat information as an
important resource to be managed effectivelyimportant resource to be managed effectively
and efficiently.and efficiently.
Managing information is an active, plannedManaging information is an active, plannedactivit .activity.
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The hospitals leaders have overallThe hospitals leaders have overall
responsibility for managing information, justresponsibility for managing information, just
as they do for managing the hospitalsas they do for managing the hospitalshuman, material, and financial resources.human, material, and financial resources.
The quality of care, treatment, and services isThe quality of care, treatment, and services is
affected by the many transitions inaffected by the many transitions ininformation management that are currently ininformation management that are currently in
progress in health care, such as the transitionprogress in health care, such as the transition
from handwriting and traditional paper-basedfrom handwriting and traditional paper-based
documentation to electronic informationdocumentation to electronic informationmanagement, as well as the transition frommanagement, as well as the transition from
free text* to structured and interactive text.free text* to structured and interactive text.
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The Information Management Function:The Information Management Function:
Coordinates collection of data and information;Coordinates collection of data and information;
Makes clinical/organizational information fromMakes clinical/organizational information from
one system available to another;one system available to another; Organizes, analyses, interprets, and clarifiesOrganizes, analyses, interprets, and clarifies
data;data;
Generates and provides access to longitudinalGenerates and provides access to longitudinal
data; anddata; and Provides the capability to link patient care andProvides the capability to link patient care and
non-patient care data over time; internal andnon-patient care data over time; internal and
external information sources; data andexternal information sources; data and
information from literatureinformation from literature
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Information Management ObjectivesInformation Management Objectives
Assure timely, easy access to data/information,Assure timely, easy access to data/information,
balanced with security requirements;balanced with security requirements;
Assure data accuracy and data comparability byAssure data accuracy and data comparability byfollowing available standards and guidelines;following available standards and guidelines;
Produce and use aggregate, comparative, andProduce and use aggregate, comparative, and
external knowledge-based information to improveexternal knowledge-based information to improve
patient safety and quality of patient care,patient safety and quality of patient care,treatment, and services;treatment, and services;
Increase collaboration and information sharing;Increase collaboration and information sharing;
Redesign information-related processes forRedesign information-related processes for
efficiency and effectiveness.efficiency and effectiveness.
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Information Uses in HealthcareInformation Uses in Healthcare
Clinical/service decision makingClinical/service decision making
Organization decision-makingOrganization decision-making
Performance ImprovementPerformance ImprovementEducationEducation
ResearchResearch
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DECISION MAKING PROCESSESDECISION MAKING PROCESSES
If we are to make appropriate decisions toIf we are to make appropriate decisions to
truly improve the care and servicestruly improve the care and services
provided to our patients over time, weprovided to our patients over time, wemust collect quality data that converts intomust collect quality data that converts into
understandable, useful information:understandable, useful information:
DATADATA leads toleads to INFORMATIONINFORMATION
leads toleads to KNOWLEDGEKNOWLEDGE
leads toleads to DECISION MAKINGDECISION MAKING
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Traditional Clinical ModelTraditional Clinical Model [See Diagram]:[See Diagram]:
In the past and near presentwithoutIn the past and near presentwithout
good datawe relied upon our opinion,good datawe relied upon our opinion,logic, intuition, rationalization, rumor,logic, intuition, rationalization, rumor,
and/or hearsay to lead us toand/or hearsay to lead us to
recommendations and hopefullyrecommendations and hopefully
appropriate action to improve the qualityappropriate action to improve the qualityof care and service. In essence, we hadof care and service. In essence, we had
no defined process for decision makingno defined process for decision making..
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Opinion
Intuition
Logic
Rationalization
Rumor
Hearsay
Recommendations/
Actions
No Defined Process
Decision Making: Traditional Model
(Data Deficient)
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Quality Management ModelQuality Management Model [See Diagram]:[See Diagram]:
In a data-based model of decision making, the informationIn a data-based model of decision making, the information
management function closely resembles scientific methodmanagement function closely resembles scientific method
- Design is based on proposal/hypothesis;
- Design enables data collection;- Data, through statistical analysis, leads to information;
- Information must be interpreted and understood to lead to
knowledge;
- Knowledge leads to wisdom and appropriate decision making;
- Decisions in quality management fall into three categories of
activity (the "Quality Management Cycle"):
-- Quality Planning
-- Quality Control/Measurement
-- Quality Improvement
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Knowledge
Information Design
Data
Information
Management
Cycle
Quality ImprovementQuality Planning Quality Control
Statistical
Analysis Collection
Interpretation /
UnderstandingProposal /
Hypothesis
Decisions Decisions
Decision Making: QM Model
(Data-Based)
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INFORMATION MANAGEMENTINFORMATION MANAGEMENT
PROCESSESPROCESSES
Key ProcessesKey Processes must be effective to achieve themust be effective to achieve the
information management goal:information management goal:
Identify information needs (assessment);Identify information needs (assessment); Plan and design the information managementPlan and design the information management
structure;structure;
Capture, organize, and report data/information;Capture, organize, and report data/information;
Process and analyze data/information;Process and analyze data/information; Store and retrieve data/information;Store and retrieve data/information;
Transmit, display, disseminate, integrate, andTransmit, display, disseminate, integrate, and
use data/information;use data/information;
Safeguard data/information.Safeguard data/information.
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Steps in the Information Management ProcessSteps in the Information Management Process
Identify critical information needs;Identify critical information needs;
Define data elements;Define data elements;
Determine data collection plan;Determine data collection plan;
Acquire/collect data;Acquire/collect data;
Aggregate and display data;Aggregate and display data;
Analyze data; Present data/information;Analyze data; Present data/information;
Report information;Report information;
Act on information;Act on information;
Collect more data to assess the decision.Collect more data to assess the decision.
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MANAGEMENTMANAGEMENT
OFOF
THE LEGAL ASPECTSTHE LEGAL ASPECTS
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CONFIDENTIALITY OF PATIENT INFORMATIONCONFIDENTIALITY OF PATIENT INFORMATION
Confidentiality in healthcareConfidentiality in healthcare deals both with thedeals both with the
patient's personal right to privacy and the need for thepatient's personal right to privacy and the need for the
organization to maintain the confidentiality of allorganization to maintain the confidentiality of all
information pertaining to peer review and theinformation pertaining to peer review and themeasurement and analysis of patient care provided bymeasurement and analysis of patient care provided by
licensed independent practitioners.licensed independent practitioners.
Confidential informationConfidential information is information that one keepsis information that one keepsor entrusts to another with the understanding that itor entrusts to another with the understanding that it
will be kept private and not shared.will be kept private and not shared.
Protected informationProtected information is information that cannot beis information that cannot beobtained b others or used in a court of law.obtained b others or used in a court of law.
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Information in the Medical RecordInformation in the Medical Record
The patient's physical medical record is the propertyThe patient's physical medical record is the property
of the healthcare provider facility.of the healthcare provider facility.
The provider is responsible for safeguarding both theThe provider is responsible for safeguarding both the
record and the informational content against loss,record and the informational content against loss,defacement, tampering, and unauthorized use.defacement, tampering, and unauthorized use.
Written policy must stipulate just how the providerWritten policy must stipulate just how the provider
complies with state statutes and accreditationcomplies with state statutes and accreditationstandards.standards.
The patient is considered the owner of theThe patient is considered the owner of the
information in the U.S. and can access and copy thatinformation in the U.S. and can access and copy that
information by signing a release form.information by signing a release form.
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Information in the Medical Record 2Information in the Medical Record 2
Well-defined policies on the use and disclosureWell-defined policies on the use and disclosure
of medical information, encompassing all patient-of medical information, encompassing all patient-
identifiable record systems maintained within theidentifiable record systems maintained within the
organization, must be in place.organization, must be in place.
These systems generally include the medicalThese systems generally include the medical
record, as well as abstracts, studies, registers,record, as well as abstracts, studies, registers,
etc., in any form, e.g., paper, electronic, audio, oretc., in any form, e.g., paper, electronic, audio, or
Internet.Internet.
For psychiatric cases, psychotherapy informationFor psychiatric cases, psychotherapy information
is maintained separately and made available asis maintained separately and made available as
necessary {A HIPAA requirement}.necessary {A HIPAA requirement}.
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Consent and Internal Use of PatientConsent and Internal Use of Patient
InformationInformation
ConsentConsent
Patients in most acute care healthcare settingsPatients in most acute care healthcare settings
give advance writtengive advance written consent (assent; agreement)consent (assent; agreement),,
even though such consent is optional undereven though such consent is optional underHIPAA, for:HIPAA, for:
- Medical and surgical treatment: The provision,
coordination, or management of healthcare services
by one or more providers, including consultation
between providers and referrals from one provider toanother; and
- Release of sufficient medical information to the payer
to assure payment, e.g., confirm benefits entitlement,
determine necessity for treatment, validate orders
and charges.
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ConsentConsent
Written consent may or may not be obtained inWritten consent may or may not be obtained in
primary and specialist care office practices.primary and specialist care office practices.
Two types of consent formsTwo types of consent forms should be obtained:should be obtained:
- A general admission or treatment consent, asapplicable (information provided by the
organization, but not necessarily by the
practitioner);
- A special consent form for highly technicaltesting, medical, or surgical treatment
(information provided by the practitioner).
Patients give separate informed consent prior to
performance of specific surgical, radiological,and other invasive and high-risk procedures
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Internal Use:Internal Use:
Generally, written authorization by patients isGenerally, written authorization by patients is not requirednot required forfor
use of their personal health information by the provideruse of their personal health information by the provider
organization inorganization in healthcare operationshealthcare operations, those internal activities, those internal activities
encompassing:encompassing:- Quality, utilization, and risk management, including case
management and care coordination;
- Competency assurance activities, e.g., staff performance
evaluation, LIP credentialing and reappraisal, and peer
review;
- Infection surveillance and control;
- Patient safety;
- Education of patients' families;
- Other auditing, legal, insurance, business, and generaladministrative activities.
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However, it is now standard practice in theHowever, it is now standard practice in the
U.S., because of HIPAA in aU.S., because of HIPAA in a Notice ofNotice of
Privacy Practices,Privacy Practices, to:to:
- Inform patients of possible intended
uses of identifiable health information
and their right to restrict use ordisclosure;
- Make a good faith effort to obtain
written acknowledgement of receipt of
the Notice; and
- Post the Notice in a prominent location
in the facility.
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Those in provider organizations permitted access to medical recordThose in provider organizations permitted access to medical record
information for organization operationsinformation for organization operations withoutwithoutwritten authorizationwritten authorization
of the patient include:of the patient include:
- Governing body, and designees, to ensure quality of patient care;
- Chief Executive Officer (CEO);
- Physicians and healthcare personnel involved in the care;
- Chiefs of clinical services and clinical department directors, along
with designated committees, for performance measurement and/or
individual performance evaluation, including peer review);
- Duly appointed committees/QI teams of the organization, in
determining the quality of care and requisites for accreditation, andall support staff;
- Health information management/medical record personnel;
- Designees of the CEO as needed regarding legal and risk
management concerns or health services planning.
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INFORMED CONSENTINFORMED CONSENT
DefinitionDefinition::
Adequate information is provided to theAdequate information is provided to the
patient or legal representative in order forpatient or legal representative in order forthe patient or legal representative to makethe patient or legal representative to make
a rational, informed decision to permita rational, informed decision to permit
medical-surgical treatment.medical-surgical treatment.
The patient is free to reject recommendedThe patient is free to reject recommended
treatmenttreatment
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PROCESSPROCESS
Information for special procedures must beInformation for special procedures must be
provided by the practitioner performing theprovided by the practitioner performing the
procedure and must include:procedure and must include:- The full extent of the treatment plan;
- The extent of the side effects and risks
involved;
- Alternative treatments available;
- The risks of non-treatment.
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To constitute proof of consent:To constitute proof of consent:
-- A valid written consent must contain the following elements:A valid written consent must contain the following elements:
-- The exact name of the procedure under consent;
-- The consenter's understanding of:
--- The nature of the procedure--- Alternatives
--- Risks and benefits involved
--- Probable consequences of non-treatment
-- Date of consent;
-- Witness.
-- Informed consent forms requiring the patient's signatureInformed consent forms requiring the patient's signature
prior to treatment become a permanent part of the medicalprior to treatment become a permanent part of the medical
record.record.
-- Oral consent, though just as legally binding, is difficult toOral consent, though just as legally binding, is difficult toprove in court.prove in court.
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CONFLICT OF INTERESTCONFLICT OF INTEREST
An organizationwide policy concerningAn organizationwide policy concerning case or peercase or peer
review "conflict of interest"review "conflict of interest" should be incorporated intoshould be incorporated into
Quality Management and Utilization ManagementQuality Management and Utilization Management
Plans, as well as into medical staff bylaws, ifPlans, as well as into medical staff bylaws, ifapplicable, or other peer review committeeapplicable, or other peer review committee
documents, depending on the entitys structure.documents, depending on the entitys structure.
A typical statement might read:A typical statement might read:
In order to minimize the potential for conflict ofIn order to minimize the potential for conflict of
interest, no committee member or reviewer shallinterest, no committee member or reviewer shall
participate in the review of clinical cases in which heparticipate in the review of clinical cases in which he
or she is primary care giver, is a participant in aor she is primary care giver, is a participant in a
specific situation under review, or has any economicspecific situation under review, or has any economic
interest either in the case or with the practitionerinterest either in the case or with the practitionerunder review.under review.
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CONFLICT OF INTEREST 2CONFLICT OF INTEREST 2
If at any time potential for conflict of interest isIf at any time potential for conflict of interest is
identified, the medical or department director,identified, the medical or department director,
committee chairperson, or the chief of staff shallcommittee chairperson, or the chief of staff shall
seek the objective expertise of other qualifiedseek the objective expertise of other qualifiedpractitioners, either from other departments orpractitioners, either from other departments or
committees, from other like organizations, orcommittees, from other like organizations, or
from the community as deemed appropriate.from the community as deemed appropriate.
In managed care, a statement might read:In managed care, a statement might read:Any and all providers who have a personal,Any and all providers who have a personal,
professional, and/or financial involvement with aprofessional, and/or financial involvement with a
medical case being reviewed will be excusedmedical case being reviewed will be excused
from participating in the review of said case.from participating in the review of said case.
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Release of InformationRelease of Information
Based on government regulationsBased on government regulations
Written consent for outside releaseWritten consent for outside release
Release without written consentRelease without written consent
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Release of informationRelease of information
A written consent is required for anA written consent is required for an
organization to release patient informationorganization to release patient information
to anyone outside the organization.to anyone outside the organization.A typical release-of-information formA typical release-of-information form
should have the following elements:should have the following elements:
Patient's name
Name of individual/ organization
requesting information
Reason for release of information
Anticipated use of information released
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Release of informationRelease of information
Exact material to be released
Time that the release of information is validDocumentation that information is released
only to the individual/organization above
Signature and date of the patient or legal
representative (as defined by policy/state
law)
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Confidentiality Policy/procedureConfidentiality Policy/procedure
Identification of individuals with accessIdentification of individuals with access
to informationto information
Delineation of specific information toDelineation of specific information towhich individuals have accesswhich individuals have access
Requirements for individuals withRequirements for individuals with
access to information to keep thataccess to information to keep that
information confidentialinformation confidential
Requirements for release of healthRequirements for release of health
informationinformation
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Confidentiality Policy/procedureConfidentiality Policy/procedure
Requirements for removal of medicalRequirements for removal of medical
recordsrecords
The patient's medical record is the propertyThe patient's medical record is the property
of the healthcare facilityof the healthcare facility
Medical records should be removed fromMedical records should be removed from
the organization's jurisdiction andthe organization's jurisdiction and
safekeeping only in accordance with a courtsafekeeping only in accordance with a courtorder.order.
Mechanisms for securing informationMechanisms for securing information
against unauthorized intrusion, corruption,against unauthorized intrusion, corruption,
and damageand damage
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Confidentiality Policy/procedureConfidentiality Policy/procedure
Portions of medical records may bePortions of medical records may be
stored separately,stored separately,
Organizations can restrict access toOrganizations can restrict access tocomputer files or portions of computercomputer files or portions of computer
files by the use of security codes or byfiles by the use of security codes or by
restricting certain computer operations torestricting certain computer operations to
specific terminals and/or individualsspecific terminals and/or individuals An organization that relies onAn organization that relies on
computerized information should have ancomputerized information should have an
adequate backup plan for each computeradequate backup plan for each computer
applicationapplication