Sinclair Hospital Case Study

SINCLAIR HOSPITAL’S HEALTH INFORMATION DEPARTMENT

Information by Karen Motley who is part of Health Information Management at Sinclair Hospital.

Introduction

Sinclair hospital is a part of six hospital network which have other medical offices and as well as clinics. The hospital is an acute medical facility with 305 beds, per year it attends to 6300 inpatient, 17000 emergency patients, 8500 outpatient and 13600 clinics visit. Inpatient visit is where patients stay and sleeps in the hospital as they receive treatment. Other terms used in the hospital includes inventory visit this occurs when a patient comes to the hospital and receives an outpatient surgery e.g. appendectomy and goes home after a short recovery period.25000 case of diagnostic

encounter are recorded per year this happens when patients comes to the hospital for testing e.g. x-ray or blood test. The services provided by the medical facility includes: Community health, primary care, home health, heart care, cancer care among others.
Like other hospitals, Sinclair has a Health Information Management department (H.I.M) which is located in an area that is accessible to the public and away from care patients. It is required that the H.I.M department to be kept secured to prevent unauthorized persons from assessing the department without any permission. At Sinclair this is ensured by provision of windows which allows customers to interact with the employees of this department e.g. greeting them without having their away into the department. The dressing code of employees working at the department is business casual which ensures the maintenance professional image. Every employee has a badge which contains the name of the hospital, their name as well as the name of the department. The badges are worn at all times, it required that they be visible and worn above the belt, this enables the patients as well as other visitors to identity and associate the employees with the facility also they grants assess to restricted areas. Unauthorized persons which includes the public and some of the facility employees must have permission in order to access this restricted areas and this has to be recorded on the name of the employee in charge.
Information about the patent health is recorded and stored in the H.I.M department.

For example, consider a patient who is in an emergency situation and he is brought to Sinclair hospital by means of the ambulance, information about the patient will be recorded following a number of steps. Typically the patient will be received from the ambulance and a nurse will enter the heath data of the patient into electronic records document. As the patient continues to be seen by other health providers e.g. physicians, their health data will be recorded in electronic health care data. The computer in turn will build the data record of the patient. Assuming that the patient had been admitted in the facility sometimes ago, these will have a unique record number that will always be assigned to that patient. Apart from this unique code, the patient will also be given an account number which will be different in all encounters. The essence of using different account numbers will be to facilitate group charges. For example, consider a patient who had been admitted a week ago with malaria, he will be given an account on that day. A week after, if he is admitted to the same facility with a different kind of illness say allergic reactions he will be given a different account with same unique code. When finding the charges of the patient it will be in form of groups since it represents different

entities.
Scanning of documents will be followed once recorded data of the patience is collected, this will ensure that the paper record about the patient is made available in the electronic system. The collection of records for scanning begins by visiting the nursing units to collect documents not in the electronic health record (EHR), this is done by employee responsible for scanning. Scanning of the documents involves a number of stages this includes: Propping helps in making sure that the document is not torn or tattered and it helps in getting the paper into scanner. This is followed by checking for customer’s identification number if not available they are looked for. Scanning of the records follows this is the simplest step since it involves feeding of the paper into the scanning machine. Indexing and quality assurance follows to ensure the documents matches customer encounter. Finally a proper document destruction mechanism is employed to ensure that no patient’s private information is available in paper document, at Sinclair a giant shredding machine is employed.
Scanning of the records is followed by analysis process which is done by the health information management department. Analysis is done to: ensures all documents are signed and completed, proper documentation and to record deficiency. The deficiency in the records is located through: entering the deficiency code, this is followed by allocating the right deficiency. This ensures that the records are efficiently completed which is very crucial.
Inpatient coding, this is done by the inpatient. The major reason for this is to ensure: that the quality standards meet and monitored for compliance. The inpatient coders like majority of the coder in Sinclair works from their homes. They are provided by with a home computer which contains the hospital system. However, the coders claim that although working from homes is more advantageous, it requires self-discipline a good example being, while at home various issues may crop up which may require once attention, but if it’s during the hospital working this will require one to forego other issues and carry out their duties as coders. The time of working while at home is treated as though one is at office. The main advantage of working from home is that there is no travelling to office every day.
Physician incomplete record area is among the sections in the health information management department.

Its responsibilities includes deficiency verification, assigning physician notices of deficiency record. This process requires to be time, if the physician does not comply with the given notice, they are reported to the chief of staff. The record are stored in accordance to the completion standards which is defined by the federal regulation for persons with the age above 18years, their records should be kept for a minimum of 6 years, while children who are under 18years their records should be kept until they attain an age of 21years plus a minimum of 6

years.
Release of medical information is also a function of the health information management department. The medical information is normally given to whoever asks for information. The section responsible for the release of the information works between 8:00am to 10:30pm. However, they receives continuous phone calls as well as mails from the patients, other health care providers, detainees, Insurance companies as well as other agencies that need information from health records. However, the validation of requests is under patient authorization. Various steps are involved during the validation process this entails: Confirmation of patient admission in hospital, E.H.R. to locate patient’s name, validation of all names and signature and Printing or fax or cd creation of the record. This is done in a timely manner. If the information is breeched, consequence such as arrest or being jail will be faced. Some paper records available can be destroyed later on. Patients privacy and confidentiality is taken seriously in this section of H.I.M. currently, some records can be accessed by patients through signing into their patient portal.
Other sections includes: R.A.C contractor which is responsible for determining overpay and underpay, ensuring timely and accurate response, develop training facilities for physicians and challenge denials of payments over and under. Computer laboratory training which entails teaching new H.I.M. Officials and new software. Transcription coordinator translates spoken word into written word (voice recognition) and ensures that medical reports are connected to right patient plus correct information. Cancer registry deals with collection, management and recording of data with diagnosis the information should be accurate and timely. This useful in entering cancer data into the national cancer database, planning for clinical trials as well as organization for education programs about cancer.
Privacy officer: Oversees all activities related to hospital network health information, ensure compliance to federal and state laws. Training education of new employees about the do’s and don’ts. Challenges experienced by the privacy officers includes, advancement in technology e.g. use of smartphones and social media. However, the major objective is to ensure that patient information is secured and private. IS&T (information system and technology) duties includes: paying physician offices visits, Implement and support designated software application and training and support for the system. Data Quality management office it ensures compliance to the standards. Project management the section is responsible for: leading a project from the initial stage to execution stage, software development, and coordinate transition activities. Senior data analyst duties determining the trends and patterns which can help in increasing efficiency and reducing costs. It involves working with business intelligence tools other duty includes teaching programs on data interpretation.
The H.I.M. is headed by the H.I.M. Director, among the qualifications for this position includes having a bachelor degree in health information management, experience and having other required credentials. The duties of the director includes: Overall function of H.I.M., Budgeting, monitoring, planning and interacting ensuring quality and efficiency of areas and process, Strategic planning , keeping up with requirements of regulatory bodies among other duties. The H.I.M. staffing entails two shifts a day 6:00am up to midnight, it has one site manager and supervisor, has 24 employees working outside HIM department. Coding is centralized and has lots of employees these includes: 34 Inpatient coders, 33 Diagnostic coders and 22 Ops and observation coders. Some skills needed for the director includes good communication and leadership skills, building and maintaining key relationship and being life learners.
All the sections of the health information management department works together for common good of the hospital by providing quality service to customer by ensuring: accurate, efficient and effective management of HIM.