Some Personal EHR Stories

I am a patient at two separately owned and operated healthcare provider organizations that are within walking distance of one another. Fortunately, both organizations use the same “core” EHR system.  Unfortunately, the EHRs currently do not talk to one another or even look or act alike. Because also I am a health information management and health information technology professional, I’ve found several flaws in these providers’ EHR systems. The organizations either do not know how to correctly configure their EHR systems or have failed to do so properly. Flaw 1: Male with Cancer I requested the release of my medical record from one … Continue reading

What One Needs To Know About Electronic Records Management

Below is a step-by-step, basic, electronic records management guide — to help protect those electronic records that need to be protected while allowing access to to those electronic records that need to be shared; to gain value from using various computer applications while addressing compliance and governance standards. First, clearly define as “documents” all content generated in (for example) GoogleDocs, SharePoint 2013, Dropbox or Box.  A document is any analog or digital, formatted, and preserved “container” of structured or unstructured data / information.  A document can be word-processed or it can be a spreadsheet, a presentation, a form, a diagnostic … Continue reading

Managing the Complexities of Consumer-grade Enterprise Platforms

Consumer-grade services (a.k.a., enterprise platforms) vendors include Google, Microsoft (MS), Accellion, Box, Dropbox, and others. The services (or applications or tools) provided by these vendors on their platforms include but are not limited to file storage / sharing and synchronization (FSS), mobile content management,  document management, and, perhaps, most importantly, project / team collaboration. For example, Google’s comprehensive suite of cloud-based services, Google Drive (FSS), includes but is not limited to Google Docs (collaborative office / productivity apps, now housed in Google Drive), Google Mail/Calendar, and Google Sites (sharing information on secure intranets for project / team collaboration).  Box’s suite … Continue reading

The Case for One Source of Truth

The notion of managing and being accountable for the health status of defined populations requires much more sophisticated clinical data collection methods and skills than most healthcare organizations have today.  However, for decades, numerous coded systems have been used to successfully capture clinical data for reporting purposes, such as quality initiatives and outcome measurements, as well as for reimbursement and other, myriad purposes.   Such coded systems, which health information professionals categorize as either clinical classification systems[1] or clinical terminology systems[2], can continue to be used to assist in determining prospective, pre-emptive care management on covered populations.  However, no single … Continue reading

Accent on Objects

It has been many years since I acknowledged patient record subpoenas for medical malpractice lawsuits and other legal actions as an HIM professional and designated custodian of records (COR). But the process was memorable. During the 1970s, one was not able to reproduce analog paper and photographic film or send records by postal mail or courier to the courts.  Rudimentary paper and film photocopy machines only recently were introduced into healthcare organizations, and the courts required the personal delivery of “original” source documents and records by a COR.  Consequently, upon receiving patient record subpoenas, I took a large cardboard box … Continue reading

Quality Information For Quality Healthcare

I promise not to provide another comment regarding the “Meaningful Use” of the electronic health record (EHR).  That’s because I strongly believe that health professionals should be more concerned about the meaningful use of the health information than of the EHR. Patient health information comes from a multitude of sources – hospitals, physician offices, pharmacies, off-site laboratories, radiology facilities, long-term care facilities.  Therefore, instead of raising questions regarding the meaningful use of implemented EHRs, health professionals must raise other questions that need immediate answers, such as how will all this information be compiled? Who will be ultimately responsible for this … Continue reading

Cleaning Up Document Imaging’s Image

Since the late 1980s, when one of the technologies of electronic document management systems (EDMSs), document imaging technology (a.k.a., document capture technology), first was implemented in U.S. healthcare provider organizations to manage (i.e., digitize) the organizations’ massive amounts of medical, financial, and administrative analog documents, many health information management (HIM), healthcare information technology, and other related professionals did not understand that document capture technology is NOT the only technology of an EDMS.   Other EDMS technologies include: Automatic IdentificationTechnologies – EDMS technologies that allow documents to be automatically identified.  The following are examples of EDMS automatic identification technologies: Automatic / Intelligent … Continue reading

The Cost Savings Realized by Single-Platform Solutions

Medicare cutbacks, increased mergers and acquisitions, and declining revenues and margins are daily realities for healthcare provider organizations. Yet so are costly and often mandatory IT initiatives, such as replacing or implementing electronic health and financial record (EH&FR) systems, integrating and securing the next mobile form factor of computing devices, converting to ICD-10 for reimbursement purposes, and meeting the Affordable Care Act requirements. How does a CIO not compromise on health information technology (HIT) delivery and still maintain cost containment priorities? A well-developed, single HIT platform strategy for most applications can realize cost savings by optimizing the IT infrastructure, regardless … Continue reading

Formal HIT Education

For the past two years or so, I have been researching four-year baccalaureate degree programs in health information technology (HIT), where I expected students in such programs to earn a BS degree, a Health Information Technologist title, and, perhaps be ready to sit for a rigorous certification exam. No such programs exist in US colleges and universities – online, on-campus, or combination – as far as I know, except perhaps one at Miami (Ohio) University’s regional campuses. (NOTE: I am not referring to four-year baccalaureate degree programs in health information management or HIM, which are complementary to but different from … Continue reading

Structured and Unstructured Data, I Adore You Both

Calling all electronic patient record systems (EPRS) structured data! Yes, all you electronic health / medical, administrative, and financial systems’ data elements that are binary, discrete, computer-readable, and, typically, are stored in relational databases with predefined fields … you tidy, typically core, transactional and mined elements. Hello? I’m talking about all you digital, patient demographic, financial, and clinical health data that are sitting in master patient indices, insurance claims, clinical histories, problem lists, orders, test results, care plans, and business intelligence reports — to mention just a few. Meet unstructured data! Yes, all you EPRS data that are non-binary, non-discrete, … Continue reading