Last Updated 06 Jul 2020

Healthcare Information Management

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Laws are created, enacted and enforced in healthcare. US congress federal laws re enacted within the legislative process and are enacted by the federal, state, local county governments. Each state has their own constitution. It provides laws to each state and is secondary to the United States Constitution. In order to enact and enforce the state constitution, the law bill is flowed from federal to state legislatures. Once the law is written and signed by the president (federal) or the governor (states) it is called statutes.

At times, there are multiple statutes that are written at the same level of government and it could address the same subject matter. For example, HAIFA and ARRAY may address the same subject. Legal language may contain the same wording between the two statutes. Federal statutes may address state laws. For instance, ARRAY may provide financial information in the form of grants to get health information technology established under electronic medical records. There have been times where state statutes were written by one state that is written differently to another state.

For example, New York State may have a statute addressing a patient's access to his or her own records, and Pennsylvania may be silent to patient access. Many statutes are no easily enacted and enforced, which could cause a conflict. Each state needs to be able to resolve a dispute. A conflict of laws deals with disagreements between state and federal Jurisdictions over the same issue. Government laws often are decided and regulated by administrative agencies. This is often a practice in administrative agencies.

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The legislature level of government delegates to the administrative agency power to adopt regulations and decide how statutes, rules and regulations apply to enforced and Administrative Procedures exist in both state and federal levels. They cannot make decisions until they have given advanced notice and allowed affected parties and opportunity to bring up an argument for or against the action. Legislatures are limited to both the US Constitution and State Constitutions when coordinating authority to government agencies.

Branches of Government Federal and each state have branches of government within the constitution system. The powers of government have three different branches: legislative, executive and Judicial. The legislative branch enacts the laws, the executive branch enforces and administers the laws, and the Judicial branch interprets the laws. The Legislative branch enacts laws. They determine who needs new laws and the hangers of existing laws. At the federal and state level, are often split by two houses such as the Senate and the House of Representatives.

At the federal level, the Senate and House of Representatives are referred to the Congress. At the legislative level, both houses must pass identical versions of the bill before they can be sent to the chief executive for signature. This is typically passed by the Joint conference committee. When this group is used, the bill is then resubmitted to both houses before it is sent to the chief executive for signature. The Executive branch enforces and administers the laws. It is organized at a departmental basis. Each department is assigned a specific task or responsibility.

These departments are divided into administrative agencies and they are given the responsibility to administer and enforce legislation. In Healthcare, providers often deal with the Executive branch of the government. For example, Health and Human services control Medicare payments to healthcare providers. The chief executive has a large role in the Executive branch. Once the chief executive signs a bill then it becomes law and if the bill is rejected, then the bill is vetoed. He or she issues executive orders; these orders are implemented and give direction to the administrative agencies.

The Judicial branch interprets the law. It brings resolution to disputes. If parties cannot resolve conflicts then they can enforce a lawsuit. This will enforce the court to resolve their legal issues. The court applies the law to the particular dispute. It looks into all relevant statues, constitutional provisions and administrative facts. They determine the shape and structure of the Judicial system. A Judicial branch of government oversees the court system in the United States and explains the meaning f the constitution and all laws passed by congress.

Principles and Theories of liability Health Information Managers often deal with liability in Healthcare institutions. Party's rights and reputations to Health institutions. Each healthcare institution has levels of relationships that deal with theories of liability and they deal with different levels of lawsuits. There are three different Healthcare relationships that are common in a lawsuit: Physician-patient Relationships, Hospital-patient Relationships, and Hospital-physician Relationships. Physician-patient Relationships are the heart of healthcare in the United States.

Without patients, physicians would not be able to practice their skills. In the Physician-patient Relationship, the process begins when the patient requests the physician for treatment and the physician agrees to give treatment to him or her. The most common challenges associated with healthcare management is breech duty of care. The physician has to be obligated to give treatment from beginning to end. He or she may be liable to maintain a certain standard of care. If the physician fails to do so, then the patient has grounds of medical malpractice.

Hospital-patient Relationships begins when the patient is admitted to the hospital. The patient needs to sign forms agreeing to pay for treatment. The Hospital-patient relationship ends when the patient is discharged or when the patient leaves the hospital against medical advice. The most common challenge associates with healthcare management falls under the Emergency Medical Treatment and Active Labor Act (METALS). The physician must treat the patient, transfer the patient or discharge the patient. If the physician violates METALS, he or she can be fined over $20,000.

When the physician fails to do something for the patient in the hospital, then he or she may be in a Negligence type lawsuit. The physician needs to be able to follow through with patient care. Hospital-physician Relationships begin when the physician is credentialed. In order to practice at a hospital, he or she needs to file paperwork with the medical staff office in order to practice. The Hospital board reviews the physician's background, experience and licenser in order to be able to practice in the hospital system. One of the most common challenges associated with healthcare management is Corporate Negligence.

The Hospital is responsible with patient care and treatment. The hospital needs to be able to make sure the physician is retaliated in the hospital system in order to treat the patient. ANIMA Code of Ethics Ethics is an essential base of the Healthcare Information Management professionals. It's a guideline for healthcare providers, healthcare professionals and the public. Each of the Code of Ethics gives the physicians a pinpoint of what medical ethics he or she is to follow. For instance, the physician shall keep in confidence whatever she/he may learn about a patient in the discharge of professional duties.

The physician shall divulge information only when required by law or when authorized by patient (McKay D, 2010). This Code of Ethic law gives an diagnoses confidential or risk a lawsuit by the patient and each of the rules are required by federal and state laws. Overview of Ethics There are different ethical challenges and theories related to healthcare, health management and supervision. In healthcare, the challenges could arise when it comes to conflicts of interest. For instance, if an employee oaf healthcare institution wishes to work for a staff physician at his practicing office.

This would be k to do but in order to work for this physician; he or she would need to sign a conflict of interest waiver due to HAIFA laws. The physician may have the same patients as the hospital provider but there will be some issues in regards to patient confidentiality when he or she works at the hospital system. As the healthcare industry faces unique and rapidly evolving legal challenges, it's critically important that industry leaders make an open and steadfast commitment to ethical business practices. (Professional Services Close-up, 2010).

Health Management ethics involves requiring documents and access to and release of information, ease of sharing information electronically, and changes to reimbursement and coding systems. An ethical challenge for Health Management utilizes coding reimbursement and quality review. With the demand of patient information, health management professionals deal with challenges of sensitive patient information. They need to be able to protect the privacy of the health record. Supervision ethics serves as role models, they also encourage ethical behaviors and monitors employee conducts.

Serving role models, he or she needs to be able to confront the problems and handle them in a constructive way. They need to be able to accept responsibility for mistakes and be able to deal with the predicament. A supervisor needs to be able to monitor employee conduct as a part of their performance evaluation. The evaluation needs to be able to state how the employee applies ethical standards within the workplace. Biomedical Issues Biomedical issues are a common function of the healthcare world today. Patients and providers will not be able to be protected.

There are several different types of Bioethics issues in today's healthcare industry. Those include: Beginning of life, Sustaining and Improving Quality of Life, Death and Dying. Beginning of life has fundamental beliefs and values about reproduction and legislations. Family Planning refers to controlling the size oaf family or spacing the births within the family. Abortion terminates pregnancy before the viability of a fetus. Prenatal ethics questions situations that involve a period surrounding the birth; Eugenics improves humans heredity factors.

Sustaining and Improving Quality of Life helps a person continue to live due to quality of life issues, diseases and organ transplantation to prolong life. HIVE/AIDS is Organ Transplant is a form of surgery where a body part (such as heart, kidney, or liver) is transferred from an individual to the affected person. Genetic science deals with gene therapy and stem cell research. Death and dying ethics deals with types of procedures related to the end of life. Planning for end of life gives a way that a patient can plan in advance for the level of care he or she will receive at the end of life (ex: DNA).

Euthanasia is practiced by causing a death painlessly to end suffering. Withholding/Withdrawing life support is very similar to planning for end of life. This allows the family to make the decision about the patient. Interest in aging and dying has increased substantially, in large art because of recent biomedical advances, the shift from a sacred to a secular conception of death, and the death awareness movement (Shabby R, 2007). Legal requirements for health record content Health records need to be accurate and complete. Healthcare managers need to design and manage health record systems in the health institution.

Using a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (PIPER) designed to more deeply engage patients in preventive care and health promotion Statutory (Grist, A, 2011) Provisions need to be reviewed for legal requirements. Those are federal, state or municipal codes. Regulatory Provisions delegate powers to the executive agency responsible for licensing the healthcare facility. They govern the healthcare facilities health records. Accrediting Standards is a process that a certification of competency, authority or credibility is presented.

It is used as a standard or care in malpractice actions against healthcare providers. Institutional Standards are detailed listings or health record content for healthcare facilities. Professional Guidelines is a list that lath organizations publish that address the existence and content of health records. Retention and Destruction of Medical record requirements vary from state to state. Each state has their own record retention policy. The Health Information manager must determine whether an imaging record is more important than paper record form. Each medical record has a record retention file.

They are retained by microfilm/microfiche, magnetic tape, and electronic system. They are achieved for a period of 5 years . Each record has a statute of limitation as long as there is no lawsuit attached to it. Every institution faces a prospect of destroying records during a prolonged period of time. HAIFA security rules require destruction security practices. If a healthcare facility does not follow the privacy rule it could result in fines and punishments. Healthcare facilities protect the confidentiality of Patient Health Information (PHI) by hiring a contractor to destroy the records internally.

Cornerstone Records Management is a company that retains records for many hospital systems. To ensure the safe and secure disposal of sensitive business information, including computer disposal and destruction and digital media and Destruction services provide total destruction solutions for all document-shredding needs (Thomas C, 2011). In order to destroy a medical record, the facility should provide a certificate of destruction. The Certificate of Destruction shows where, when, who destroyed the file in event that particular health record would be needed in a lawsuit.

The certificates are evidence in event there is a lawsuit or investigation showing that there is an absence of the medical record. The health records are owned by the healthcare provider. The health facility decides on how much the medical record is used. Ownership was never much in bout in an age of paper-based records, but now that information. Can be easily digitized and freed from any particular storage medium, confusion reigns (Politics and Government Week, 2010). Today's standard, the patient has a right to access his or her medical record. The health facility acts as the executor of the medical record.

The patient has a right to his or her medical record and what is in it. The health information manager needs to be aware of this rule and review all state laws utilizing the governmental guidelines of patient records. General Health records are basic record about a patient seen in a facility. It is a collection of documents that provides an account of each episode in which a patient visited or sought treatment and received care or a referral for care from a health care facility. Specialized patient records are records that patients have when they are undergoing a specialist physician care.

For example, someone who may have a mental illness, drug/alcohol issues, or HIVE information. It's important to follow HAIFA laws for protection and privacy with specialized patient records. The only way to disclose specialized patient records is to sign a release of information form in writing and meet state law requirements. Specialized concerns of Health Information Management There are many aspect trends of Risk Management. Risk management identifies operational and financial risks or loss of a healthcare facility, and its patients, visitors and employees.

It measures to lessen unavoidable risks and losses, covers inevitable losses at a lower cost. The connection between Risk Management and Health information Management utilizes the enforcing and educating healthcare providers in patient record requirements. Documentation, Security and Confidentiality are 3 connections between Health Information Management and Risk Management. Proper documentation is one connection Risk management has with Health Information Management. The Health record is the main document with any liability action.

Security falls mostly on Health Information Management. It gives the health record purpose of patient care, access to patient specific health information on behalf of the patient and retention of records. Confidentiality is also associated with Health Information Management. The healthcare provider is to maintain the patient information within the confines of the health facility. If the health record is not held y confidentiality, the risk management program may involve many lawsuits such as breach of contract, breach of confidentiality and right to privacy. ND preventing abuse within the medical record. Compliance programs ensures the establishment of effect internal controls that promote adherence to the applicable local, state, and federal laws and regulars and the program requirements of federal, state, and private health plans (McKay D, 2010). There are written standards of conduct, policies and procedures. Effective compliance program designed to prevent criminal conduct before it happens (Demure P, 1993) The chief compliance officer oversees the program and has regular effective education and training programs for employees.

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