Fundamentals of Health Information Management

460 Pages·2013·31.943 MB·English

by  Kelly J. Abrams, Candace J. Gibson, Murray Abrams, Gary B. Arnold, Sally Bulloch, Diane Caulfeild, Sandra Cotton, Gail Crook, Lori Driscoll, Cheryle Facey, Kathryn M. Frelick, Neil Gardner, Grant Gillis, Andrew McGregor Grant, Cheryl Hoffner, Zulianna Ibrahim, Akeela Jamal, Kerry Johnson, Laurie E. Kenward, Kathy Lavelle, Lili Levesque, Marci MacDonald, Carolyn McGregor, Jochen R. Moehr, Lori Moskal, Maria Muia, Brenda O'Reilly-Brunelle, Felicia Pantazi, Stefan V. Pantazi, Margaret Penchoff, Jennifer Percival, Sue A. Schneider, Brendan Seaton, Shane Singh, Tamara Stefanits, Ginette Therriault, Albert Crous Tsanaclis, Dag Von Lubitz, Anna Jane Woodman

Fundamentals of
Health Information Manasement
2"^^ Edition
Canada's
Health
'IJ Canadian Healthcare Association Information
Team
Jlnl Association canadienne des soins de sante Canadian Health Information Management Association
Canadian College of Health Information Management
WX173 F86 2013
Fundamentals of health information
management
2nd edition. C.2
Published by CHA, 17 York Street, Suite 100, Ottawa, ON KIN 9J6
Tel. [phone]; Fax [phone]
www.cha.ca
® 2013 Canadian Healthcare Association. All rights reserved.
Library and Archives Canada Cataloguing in Publication
Fundamentals of health information management / Canadian
Health Information Management Association. — 2nd edition
Includes bibliographical references and index.
ISBN 978-0-9878629-1-4 (pbk.)
1. Medical records—Management. 2. Medical records—
Management--Canada. 1. Canadian Healthcare Association.
RA976.F85 2013 651.5’04261 C2013-902367-4
The use of any part ol this publication, reproduced, stored in a retrieval system, or transmitted in any form or by
any means, electronic, mechanical, photocopying, recording, or otherwise, without the proper permission of the
publisher — or, in the case of photocop3dng or other reprographic copying, a license from the Canadian Copyright
Licensing Agency (ACCESS) —is an infringement of the law.
Desktop publishing and cover design by Killographics.
APA 6th Edition:
Abrams, K. J., & Gibson, C. J. (Eds.). (2013). Fundamentals of health Information management (2nd ed.). Ottawa,
ON: Canadian Healthcare Association.
PRINTED IN CANADA
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Fundamentals of
Health Information
Manasement
2'^^ Edition
Canada ‘s
Health
Canadian Healthcare Association Information
Team
Association canadienne des soins de sante adian lieallh Information Management Association
adian Colloxi* o( Hrallli InrorDiatlon Mana)inmcn(

Fundamentals of
Health Information Management
2ND EDITION
Contents
Acknowledgements.
About the Authors and Editors
Reviewers.
Chapter 1 Introduction.1
Learning Objectives.1
What is Health Information Management?.1
Health Information Management Curriculum Content.3
Trends m Health Information Management .3
Organization of the Book.A
Chapter 2 The Health Information Management Profession.7
Learning Objectives.7
Introduction.7
The History of the Canadian Health Information Management Association 8
Mission, Vision, Values, and Strategic Directions.9
Mission.9
Vision.9
Strategic Directions. 10
The Ceii:ified Health Information Management Professional .10
Credential and Title .10
Continuing Professional Eiducation (CPE) .10
HIM Curriculum Content . 11
HIM Program Accreditation.12
Professional Practice Briefs.12
Other HIM Associations.12
Provincial HIM Associations . 12
National Health Information Management Association (NHIMA).13
American Health Information Management Association (AHIMA).13
Commission on Accreditation of Health Informatics and Information
Management Education (CAHIIM).13
International Federation of Health Information
Management Associations (IFHIMA).Id
Health Informatics Associations. 1"^
COACH: Canadas Health Informatics Association. Id
Healthcare Information and Management Systems Society (HIMSS) ... H
American Medical Informatics Association (AMIA).Id
International Medical Informatics Association (IMIA). 15
Future Directions in HIM.15
Chapter 3 The Canadian Health Care System.19
Learning Objectives. 19
Introduction. 19
Health Care in Canada: An Overview and Brief Histoiy.20
Funding Canadas Health Care System.21
Deliveiy of Health Care Services.2d
The Role of the Federal Government.2d
The Role of the Provincial/Territorial Governments.2d
Regional Health Authorities.2d
Provision of Health Services.25
Health Care Facilities.26
Hospital-Based Ambulatory Care.27
Long-Term Care Facilities.28
Home and Community Care.28
Health Service Providers .29
Physicians.29
Nurses.29
Other Health Professionals.30
Addressing Public Health .30
The Changing Environment: Forces Shaping the
Future of the Health Care System .31
The Role of the HIM Professional.32
Chapter d Principles of Data and Health Information Management.39
Learning Objectives.39
Introduction.39
Data, Information, Knowledge, Wisdom Hierarchy.dO
Data.do
Knowledge .dO
Wisdom.do
DIKW Relationships and Pyramid.d 1
Types of Health Care Data.dl
Demographic.d 1
Clinical.d 1
Coded.d 1
Financial and Statistical.d 1
Aggregate.d2
Data Collection.42
Uses of Health Care Data.42
Principles of Information Management.43
Dimensions of Data Quality.44
Data Quality Initiatives.44
Data Quality Frameworks.44
Data Quality Work Cycle.45
Assessment of Data Quality.45
Documentation of Data Quality.46
Databases.46
Systems Development Life Cycle and Database Life Cycle.46
Types of Databases.48
Data Models and Data Modeling Process.48
Business Rules.49
Data Models.49
Entity Relationship Diagrams.49
Key Attributes.50
Structured Query Language.50
Role of Databases .50
Data Integrity.51
Data Security and Privacy.51
Database Security.51
Data Dictionary.51
Data Warehouse.52
Data Alining.53
Conclusion .53
The Role of the HIM Professional .54
Chapter 5 Clinical Classifications, Nomenclatures, and Terminologies.57
Learning Objectives.57
Introduction.57
Terms, Concepts, and Relations.58
Terminology Wocabulary.59
Terminology Examples.59
Ontologies.60
SNOMED CT®.61
SNOMED CT Structure.61
Classifications.62
Diagnostic and Statistical Manual of Mental Disorders .63
International Classification of Diseases.63
History.63
International Classification of Health Interventions.64
International Statistical Classification of Diseases and Related Health
Problems, Tenth Revision, Canada (ICD-IO-CA).64
Canadian Classification of Health Interventions .65
International Classification of Diseases for Oncology .66
International Classification of Functioning, Disability and Health.67
International Classification for Nursing Practice .67
International Classification of Primary Care.67
Resident Assessment Instrument .67
Coding Health Data.68
Automatic Coding.68
Automatic and Semi-Automatic Coding.69
Coding at the Point of Entry.69
Data Quality.69
Coding Standards.69
Abstracting Software and Encoders .70
Data Quality Committees.70
Data Quality and CIHI.70
Utilization of Data.70
Canadian Institute for Health Information.71
Grouping Methodologies.72
Case Mix Group+.72
Comprehensive Ambulatory Classification System.72
The Role of the HIM Professional.73
Chapter 6 Health Information Standards.77
Learning Objectives.77
Introduction.77
Framework for Health Information Standards.78
The Need for Standards .78
Standards Development Organizations.82
Standards Maintenance and Coordination Organizations.83
Standards Life Cycle.85
Needs Analysis/Assessment.86
Development. 86
Education and Training.87
Implementation .88
Conformance.88
Maintenance .89
Applying Health Information Standards .90
Data Messaging Standards.90
Data Structure Standards.91
Data Content Standards.92
Information and Data Management Standards.92
The Role of Health Information Standards in the Future.93
The Role of the HIM Professional .94