Lower Mainland Health Information Management (HIM) is celebrating HIM Week, March 23 to 27, by recognizing the staff in Registration, Transcription, Records Management and Coding and the roles they perform along the patient journey from admission to discharge and beyond. This year’s theme is The Domino Effect of Data Quality.

Registration

A patient/client’s journey in the health care system begins with registration, which forms the foundation of their electronic health record (EHR). It involves the collection and verification of the patient/client’s identity, demographic information, contact and insurance details, plus visit specific information such as type of service, providers (physicians) and location.

Establishing an accurate patient/client identity is essential to creating a complete electronic health record that supports continuity of care and shared client data across settings, as well as allows a secondary use of the data. Incorrect patient/client identity can result in information unavailability, patient safety concerns, duplication of effort and loss of confidence in the electronic health record.

Registration involves multiple locations, departments and staff; therefore, HIM performs a key stewardship role for the Lower Mainland health authorities by ensuring the integrity of registration data. This is accomplished by establishing and monitoring registration standards and best practices; training on scheduling and registration related topics; providing expertise for registration business requirements and workflow as well as monitoring data quality and performing required data remediation. HIM plays a key role in the Provincial Enterprise Master Patient Index (EMPI) project, core EHR initiatives and innovative technology advancements to improve all aspects of registration data capture.

Registration processes approximately 15,000 visits daily across the Lower Mainland health authorities. When best practices and standards are not adhered to, this can result in poor or incorrect registrations.

Transcription

Did you know that every day, Transcription Services processes approximately 18,500 dictated minutes (averaging 5,300 reports a day) by approximately 1,260 unique dictating authors across the Lower Mainland? Their voice files are completed using various methods — traditional transcription of voice to text, as well as back-end speech recognized text editing.

Dictating authors access the dictation system via the telephone through a 1-855 number or site local and are prompted to manually enter patient visit information. This ensures the correct patient and visit information is attached to that transcribed report and accurately reflects the care that patient received while in hospital (inpatient & outpatient).

The transcriptionist/editor also relies on verbally dictated information to confirm correct patient selection and carbon copy recipients. Patient visit information is continuously updated from the patient registration systems, where registration clerks enter information at the time of the patient visit that is then captured downstream on the dictation/transcription system.

Once the transcribed report is completed, the finalized report uploads to the patient care information systems, Excelleris, physician electronic medical records and CareConnect. The transcribed record is a vital tool for continuity of care between hospital clinicians and community based clinicians. The final phase of the report’s journey is completed by the Coding and Health Records teams through analyzing the transcribed report for data analysis/financial and deficiency management and ensuring the report is available on the patient’s record.

Quality assurance checks are an essential component of transcribed reports. If incorrect patient information is entered at the time of dictation, an incorrect patient visit could be selected by the transcriptionist/editor. This impacts the delivery of the result to the correct location within the patient information system, and there can be a risk of attaching a dictation to the wrong patient.

Records management & release of information

Release of Information (ROI) is the release of confidential personal information from a patient’s health record.

Lower Mainland Health Information Management follows the B.C. Freedom of Information and Protection of Privacy Act. The Act sets out the access and privacy rights of individuals and establishes an individual’s right to access records including access to a person’s own personal information.

Release of Information staff have guidelines in place to ensure consistent, timely and accurate administration of ROI processes and to ensure the patient’s right to privacy is protected.

Personal information in a health record may be released in the following circumstances:
• Continuity of Care: For example, the Emergency Department urgently needs access to information to treat a patient.
• With patient consent: For example, patient consents to ICBC, WCB or a lawyer accessing their information.
• Statutory requirement, such as the Coroner’s Act.
• A court order.

Lower Mainland Health Information Management ROI Departments receive and respond to an average of 17,700 requests per period, or more than 230,000 requests per year. Great care is taken to ensure that only required information is released to authorized requestors.

Coding

Did you know that each inpatient or surgical daycare visit is coded? What’s coding, you ask? Clinical coding is the process of capturing patient visit data in accordance to national, provincial and hospital standards in a structured manner. It includes the coding of diagnostic and intervention elements, and codes like ICD-10.

Canadian Coding Standards are 511 pages long. Each abstract, or visit, goes through automated data quality checks developed by CIHI and programmed by the vendor, as well as internal data quality checks by HIM, before each period submission is electronically submitted. Last year for B.C., with over 440,000 inpatient records in the national database, B.C. achieved 0.1% outstanding hard error rate per 10,000 records.

The coder goes through the chart extremely thoroughly to capture the required information. The data forms part of a structured clinical database and is submitted to the Canadian Institute of Health Information (CIHI) and the Ministry of Health (MOH) as part of hospital routine reporting. The data is used internally by Decision Support, Utilization and Finance, just to name a few. Externally, the data is used by MOHs, CIHI, additional hospitals, research institutes and others for benchmarking, trending, population health, hospital performance and more.

In recent years, the data has also been used to improve clinical documentation, Accreditation Canada compliance metrics like Medication Reconciliation and Clinical Care Management metrics compliance like 48/6. Some of our latest involvement has to do with electronic health record development, Clinical & Systems Transformation (CST) or MyHealthSystem, like nomenclature standard (data mapping) in SNOMED-CT and health information exchange readiness using standardized templates and structured data. Coders love nomenclature so if you have a question about ICD, DSM or SNOMED just ask away … they’re more than happy to help.

HIM business solutions

HIM has established technological infrastructure to support Lower Mainland (LM) Health Information Management Data Quality programs, known as the HIM Data Mart. It addresses the technical challenges that come with consolidating and organizing data and enables more advanced and automated data quality reporting. Some examples of this include: reporting against data that exists in multiple LM networks and different source systems, and providing access to LM HIM data in a secure environment to HIM staff that are located in different LM locations to perform data mining.

Predictive analytics

Operational data provides us with the ability to predict the future! Statistical methods and machine learning algorithms are used to calculate the likelihood of events happening. By capturing daily activities and consistently accumulating historical data, analytical models can be built to forecast service volumes, uncover potential risks from past patterns and identify key areas for improvements. Combining these with human reasoning allows us to make the smartest decisions possible to optimize efficiency through the patient journey.

Privacy

Lower Mainland Health Information Management staff are committed and legally bound by the Freedom of Information and Protection of Privacy Act to protect your privacy. From the moment you receive care from a Lower Mainland facility, that information is recorded in your health record. Health Information Management staff manages, protects and secures your information by applying high privacy and security standards. That means we will treat your personal information confidentially, only use and share it for authorized purposes and securely store and protect it.

We hope you have learned something new about the importance of data quality this HIM Week. For more information on HIM services, please visit our intranet page or contact us at HIM@providencehealth.bc.ca!