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Health IT Standards for Health Information Management Practices (HIT Standards for HIM Practices)

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Health IT Standards for Health Information Management Practices (HIT Standards for HIM Practices) Integrating the Healthcare Enterprise 5 IHE IT Infrastructure (ITI) White Paper 10 Health IT Standards for Health Information Management Practices (HIT Standards for HIM Practices) 15 Revision 1.1 20 Date: September 18, 2015 Author: ITI Planning Committee Email: [email protected] Please verify you have the most recent version of this document. See here for Published 25 versions and here for Public Comment versions. Copyright © 2015: IHE International, Inc. IHE IT Infrastructure White Paper – Health IT Standards for Health Information Management Practices (HIT Standards for HIM Practices) ______________________________________________________________________________ Foreword Integrating the Healthcare Enterprise (IHE) is an international initiative to promote the use of standards to achieve interoperability among health information technology (HIT) systems and effective use of electronic health records (EHRs). IHE provides a forum for care providers, HIT 30 experts and other stakeholders in several clinical and operational domains to reach consensus on standards-based solutions to critical interoperability issues. The primary output of IHE is system implementation guides, called IHE Profiles. IHE publishes each profile through a well-defined process of public review and trial implementation and gathers profiles that have reached final text status into an IHE Technical Frameworks. 35 This white paper is published on September 18, 2015. Comments are invited and can be submitted at http://www.ihe.net/ITI_Public_Comments. For on-going development work, see http://wiki.ihe.net/index.php?title=HIT_Standards_for_HIM_Practices 40 General information about IHE can be found at: http://ihe.net. Information about the IHE IT Infrastructure domain can be found at: http://ihe.net/IHE_Domains. Information about the organization of IHE Technical Frameworks and Supplements and the process used to create them can be found at: http://ihe.net/IHE_Process and 45 http://ihe.net/Profiles. The current version of the IHE IT Infrastructure Technical Framework can be found at: http://ihe.net/Technical_Frameworks/. HL7®, HEALTH LEVEL SEVEN®, CCD®, CDA®, and FHIR® are trademarks owned by Health Level Seven International and are registered with the United States Patent and Trademark Office. ______________________________________________________________________________ 2 Rev. 1.1 – 2015-09-18 Copyright © 2015: IHE International, Inc. IHE IT Infrastructure White Paper – Health IT Standards for Health Information Management Practices (HIT Standards for HIM Practices) ______________________________________________________________________________ 50 CONTENTS 1 Acknowledgement...................................................................................................................... 4 2 Introduction ................................................................................................................................ 6 2.1 Need, Goal and Objectives, Scope and Outcome ............................................................... 7 55 2.2 Intended Audience .............................................................................................................. 9 3 Methodology ............................................................................................................................ 10 3.1 Method .............................................................................................................................. 10 3.2 Project Participants ........................................................................................................... 11 3.3 Project Tasks, Timeline and Deliverables ........................................................................ 12 60 4 Overview of Health Information Management ........................................................................ 14 4.1 HIM Professionals (Actors) .............................................................................................. 14 4.2 HIM Practices (Actions) ................................................................................................... 15 4.3 Health Information (Products) .......................................................................................... 16 4.4 Information Governance ................................................................................................... 19 65 4.4.1 Principle of Information Availability: Business Requirements ................................. 21 4.4.2 Principle of Information Integrity: Business Requirements ...................................... 22 4.4.3 Principle of Information Protection: Business Requirements ................................... 23 4.5 HIM Practice CheckList ................................................................................................... 24 4.6 HIM Practice Use Cases ................................................................................................... 24 70 4.7 Glossary ............................................................................................................................ 25 5 Gap Analysis of HIT Standards to Support HIM Practices ..................................................... 26 6 Recommendations .................................................................................................................... 27 7 Roadmap .................................................................................................................................. 30 Appendix A: HIM Practice Checklist ........................................................................................... 32 75 Appendix B: HIM Practice Use Cases .......................................................................................... 39 B.1 Use Case A1.1: All documents are accounted for within a specific time period post completion of the episode of care ..................................................................................... 39 B.2 Use Case A1.2: Record is closed as complete within a specific time period post completion of the episode of care ..................................................................................... 43 80 B.3 Use Case A2.1: Documents within the record can be viewed by or released to the external requestor ............................................................................................................................ 45 B.4 Use Case A3.1: An audit log of the episode of care record .............................................. 47 B.5 Use Case A3.2: An audit log of requests for release of information and accounting of disclosures ......................................................................................................................... 48 85 Appendix C: Glossary ................................................................................................................... 49 Appendix D: HIT Standards for HIM Practices ........................................................................... 53 HL7®, HEALTH LEVEL SEVEN®, CCD®, CDA®, and FHIR® are trademarks owned by Health Level Seven International and are registered with the United States Patent and Trademark Office. ______________________________________________________________________________ 3 Rev. 1.1 – 2015-09-18 Copyright © 2015: IHE International, Inc. IHE IT Infrastructure White Paper – Health IT Standards for Health Information Management Practices (HIT Standards for HIM Practices) ______________________________________________________________________________ 1 Acknowledgement 90 This white paper was developed with the support from the American Health Information Management Association (AHIMA) - the not-for-profit membership-based healthcare association representing more than 101,000 health information management (HIM) and informatics professionals who work in more than 40 different types of entities related to our nation’s public health and healthcare industry. AHIMA is committed to advancing information governance in 95 the healthcare industry to ensure the quality and integrity of all types of information necessary to safe, high quality, cost effective care and the improvement of the health of individuals and populations. This white paper was developed as a part of a new globally-focused AHIMA initiative on Information Governance (IG) 1,2,3 – an organization-wide framework for managing information 100 throughout its lifecycle and supporting the organization’s strategy, operations, regulatory, legal, risk, and environmental requirements. 4 This IG Initiative is a key component of AHIMA's overall strategy to develop guidelines, operating rules and standards for healthcare documentation practices. AHIMA formed a Task Force of HIM professionals – subject matter experts (SMEs) – to provide 105 expertise for aligning HIM practices and capabilities of health information systems through health information technology (HIT) standards. Their work was facilitated by the AHIMA Standards Team. Table 1 presents the list of the Task Force members. 1 American Health Information Management Association (AHIMA). Information Governance Principles for Healthcare (IGPHC). Chicago, IL. 2014. URL: http://www.ahima.org/~/media/AHIMA/Files/HIM- Trends/IG_Principles.ashx 2American Health Information Management Association (AHIMA). Information Governance (IG) Infographic – What is IG? Chicago, IL. 2014. URL: http://www.ahima.org/~/media/AHIMA/Files/HIM- Trends/IG_Infographic.ashx 3 Cohasset Associates and American Health Information Management Association (AHIMA). Professional Readiness and Opportunity.
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