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Data Capture, Standards And The EHR Paper

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Data capture, standards and the EHR. HIM practices revolve around information stewardship and data governance. Data governance includes an “inventory of the organization's resources and how they are managed, organized, and controlled, as well as the process for the application of the rules to the applicable information resources in the information inventory” (AHIMA, 2011). Data standardization is an element in data stewardship that affects the use of data for quality and patient safety programs. Numerous roles and responsibilities are emerging as data is being standardized across organizational systems. “HIM professionals are experts in data content standardization and have the necessary skills and competencies to advance improved validation, capture, analysis, and output of information for quality and patient safety initiatives” (AHIMA, 2011). As the industry shift towards …show more content…

HIM professionals have also become involved with managing the use of vocabularies and clinical code sets within their organization. While traditionally this has primarily revolved around code sets for diagnosis and procedure classifications such as ICD and CPT, the evolution of the EHR and the increasing use of other clinical data such as laboratory results and drugs will increase the types of code sets that will need to be managed. Accurate data assignment, capture, analysis, and trending of healthcare operations for decision making has evolved in the HIIM field to facilitate the aggregation of data from multiple sources to enable the capture of data once so it can be repurposed many times. Capturing information that supports a more accurate measurement of healthcare quality, such as determining how adverse events (i.e., injuries caused by medical management, not the underlying disease) actually occur in hospitals is just one

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The purpose of this paper is to provide a brief overview of the structure of a project about the adoption of clinical information systems on patients’ safety in the Canadian context for the Minister of Health. A report on patient safety at an international panel suggested that adoption of standard classification systems in healthcare could significantly improve patients’ safety through leveraging the healthcare data to conduct quality improvement initiatives. The health information manager (HIM) and Standards Branch at the Ministry of Health were tasked to develop a project of introducing the use of International Classification of Diseases and Health Related Problems Tenth Revision, Canada (ICD-10-CA) and Systematized Nomenclature of Medicine

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The healthcare industry generates a great amount of data every day, as a form of record keeping, patient care, compliance, and regulatory requirements. Just a decade ago, all this data was stored in the form of hard copy form, now it is rapidly transforming to digital data which is called EMR (Electronic Medical Record). The digitalization of the healthcare has not just reduced cost of care, but also improved quality of care due to the abundance data that organizations receive from the EMR to identify the flaws in their system. I work in the healthcare industry where improving quality of care is our primary goal. We use software called eCW , which is an integrated system.

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