Placement Portfolio in Health Information Management - Assignment Example

Placement Portfolio (Health Information Management) Table of Contents Table of Contents 1 Executive summary 2 Introduction 3 Discussion 4 Conclusion 13 Reference List 14 Executive summary The professional placement of students in Health Information Management is believed to be quite imperative for ensuring that the students obtain knowledge about the activities performed for improving the life of the related community. East Grampians Health Service (EGHS) (2008) is a rural hospital providing healthcare services for enhancing the health as well as lifestyle of the community. Professional placement enables the students to learn varied subjects such as Auditing, Coding, Freedom of Information (FOI) as well as Health Information System (HIS). These are considered to be amongst the most significant subjects performed with the purpose of improving the services provided to patients. A systematic evaluation of the provided care and services is conducted for improving the effectiveness of the healthcare agencies. The clinical documents of patients are coded in numeric or alphanumeric format for better identification of the diseases and treatment provided. The medical records and personal information of the patients are learnt to be recorded through Information and Communications Technology for maintaining information safety. The health information manager is entitled to ensure the quality and safety of medical records. Introduction The professional placement was conducted for three weeks in a rural hospital named East Grampians Health Service (EGHS) in Melbourne. The hospital is located in Grampians region of Victoria. EGHS was established in 1995 with the motive of providing excellent services as well as care to the community. EGHS was formed with the amalgamation of the Ararat and District Hospital as well as the Willaura and District Hospital and John Pickford House. The mission of this particular health care agency is to enhance the health of the community by way of providing better medical facilities in accordance with the requirements. Its ultimate motive is to attain a leading position in terms of providing enhanced rural health care facility to the community in Ararat as well as Willaura (East Grampians Health Service, 2008). The Clinical Placement Network (CPN) was founded with the purpose of providing clinical education throughout Australia. The health care facilities providing services within the boundaries of CPN are identified as its members. The education institutes within the access of CPN boundaries are also considered its members. The students who are provided professional placement in health information services need to learn Auditing, Coding, Freedom of Information (FOI), Health Information Services (HIS), Management as well as Informatics of Medical Facilities (The State of Queensland (Queensland Health), 2012). The Health Information Management courses help students improve their respective knowledge about culture as well as information systems related to the health care facilities. They help students develop professional and personal skills such as identifying health requirements, managing quality and developing interpersonal communication skills. Discussion The structure and function of the placement agency mainly concentrates on the task of successfully training the students. Through the training procedure, the students are able to gain proficient knowledge about the activities performed by the healthcare facilities. Placement Agency (EGHS) Academic University has an agreement with various healthcare facilities throughout Australia for educating students; it is a source of theories and knowledge. The students are placed in accordance with the information provided in the planning form. The Role of the Placement Agency EGHS is a rural health service facility with the motive of improving the health and life of the overall community. EGHS helps the students learn the activities which are performed for providing quality services to the patients. The Organisational Structure The students are assisted by an agency supervisor and academic supervisor for their clinical placement. The agency supervisor is supposed to have the task of developing activities for the students, and the academic supervisor is considered responsible for monitoring the placement process and the learning program intended for the students. Both the agency supervisor and academic supervisor ensure that the students are provided with the suitable kind of knowledge required for understanding the concept of the activities which are performed for improving the overall lives and services of the community. The employees of EGHS are believed to have performed in quite an efficient manner for collective development of the performance with regard to the mentioned healthcare agency (East Grampians Health Service, 2011). Victorian Admitted Data Set (VAED) The Department of Health (DOH) is assigned with the task of collecting morbidity data about the patients from the people of Victoria, private hospitals, and all medical care facilities (State Government of Victoria, 2012a). Weighted Inlier Equivalent Separation (WIES) WIES is a cost weight (W) which is associated with the amount of time spent in the hospital, which signifies the quantity of resources used in a Diagnosis Related Group (DRG) (State Government of Victoria, 2012b). Audit Audit of the medical healthcare agency, i.e. EGHS, is done to systematically analyse the superiority of care and services provided to the patients. It also evaluates the methods used for diagnosis and treatment along with the usage of different varieties of resources for improving the life of the patients. It measures the outcomes of the treatment provided for identifying the effectiveness of the medical agency (Royal College of Psychiatrist, 2012). Clinical audit is considered to be an essential procedure for developing the service quality provided to the patients. Moreover, it also greatly helps improve the medical facilities employed for the enhancement of community in which it operates. Audit plays a significant function in terms of offering education and training opportunities along with improving the efficiency of the healthcare agency with regard to the ultimate usage of the resources. The ultimate motive of audit is to enhance the performance of the healthcare agency by providing superior medical treatment and facilities to the patients. It also provides important information to the people about the effectiveness of the services and care provided for the development of the community. It builds a strong relationship among employees and agencies and ensures exceptional functioning of the medical agency. The process of audit is used for the purpose of comparing the achievements for developing the performance of the medical agency (Travaglia and Debono, 2009). Therefore, audit of EGHS offers the students the understanding of the performances of the particular medical facility and the services provided. Students also acquire knowledge about the functioning of facilities and the extent of care provided to the patients. The annual report also illustrates the degree of improvement in performance made by EGHS towards providing better health services to the community (East Grampians Health Service, 2011). Coding Clinical Coding is the process of transforming the written clinical documents relating to the patients in a numeric or alphanumeric format. It is considered to be a process of converting the depiction of injuries, diseases, and healthcare methods into a coded format. The clinical coding system is based on ICD-10 system of World Health Organisation (WHO), and the standard coding system which is used in Australian medical facilities is The International Statistical Classification of Disease and Related Health Problems, 10th Revision, Australia Modification (ICD-10-AM). This code format helps better identify the kind of treatment to be provided to the patients in an efficient manner. It helps access medical reports in accordance with the diagnoses and treatments provided for the benefits of the healthcare agency. It identifies symptoms and helps trigger awareness about threatening diseases in the concerned professionals. The information about the patient data and treatment provided are grouped with the use of certain software such as Diagnosis Related Group (DRG), which helps conduct clinical research and audit of the healthcare agency. Furthermore, it also acts as a method for utmost allocation of the resources, which in turn ensures the optimal performance of the agency. Clinical coding also helps the agency to formulate better plans in relation to the services and to improve the standards of care provided (Government of Western Australia, n.d.a). The personnel entrusted with the task of coding needs to be professionally skilled and to possess the information about medical terms and diseases. Clinical coders are needed to perform the task of studying medical records and identifying the diagnoses and procedures which are to be coded in accordance with the Australian coding standards (Government of Western Australia, n.d.a). Therefore, coding system helps students comprehend the methods of identifying the diagnoses and procedures which are to be coded in compliance with the related standards. Students acquire the knowledge about the techniques of coding conducted by EGHS from in process of managing the medical records. Freedom of Information (FOI) The Freedom of Information (FOI) was enacted in 1982 with the motive of providing the people of Australia the right to use varied information. The people are provided with the right to investigate the activities of the public sector and the government and to hold them accountable for the decisions taken. In order to access information regarding healthcare services, a person is initially required to lodge a request for FOI. The request for accessing government information should be submitted in a written format and should state the reasons for the requirement of such information. This particular act enables the community to be provided with varied forms of information under the administration of the government (Australian Government, Department of Health and Ageing, 2012). People are allowed to access their own medical records, personal information, and other relevant documents free of cost. However, certain information listed in FOI Act 1992 is restricted. In order to access other forms of information not related to a particular individual, one should pay a sum of AUD 30 (Government of Western Australia, n.d.b). Therefore, medical records and patient data of EGHS are secured from being accessed by other people. It helps the students identify the actuality that the information regarding patients is kept secured, and in order to access the information about a patient, a written request of FOI needs to be made. This particular process ensures the security of information. Healthcare Information System (HIS) The Healthcare Information System (HIS) is a method which collects data about the patients and other data relevant for the healthcare sector. The data collected are scrutinised for ensuring better quality as well as appropriateness of the facilities provided. The analysed data are converted into valuable information to facilitate enhanced decision-making. The produced information is used for making policies and managing the services provided by health care facilities (WHO, 2012). The Role of Health Information Manager The health information manager is bestowed with the responsibility of developing, planning, implementing and managing health information services for achieving the objectives of the healthcare agency. The manager ensures the security and effectiveness of the medical records. The manager is also entitled with the task of making decisions at all levels in a healthcare organisation. The other tasks include reporting, providing education in relation to confidentiality and privacy to the staff, coding and providing medical records to clinicians, preparing order forms for accessing medical records through the use of ORACLE, and monitoring the audit procedure among others (Health Information Management Association of Australia Limited – HIMAA, 2012). The medical records are stored in a protected room with minimum access by the staff, and every six months the codes are changed by the health information manager The Patient Master Index (PMI) The Patient Master Index (PMI) is a systematic or computerised method of recording patient data and information with a unique record number. PMI helps swiftly access medical records of the patients and ensure non-duplication of the records. The patient health record methodologies comprise source-oriented medical records, problem-oriented medical records, and clinical pathways. It ensures the accuracy of the data about a particular patient. The information system used in hospitals is Information and Communications Technology (ICT); it ensures the safety of medical records. The applications of ICT include UNITY, RIMS, AIMS and iPM (State Government of Victoria, 2012c). i.Patient Manager (iPM) i.Patient Manager (iPM) is a system of recording the data about the patients electronically in a single system. iPM is implemented in EGHS to gain faster access to the information about the patients by the doctors and nurses. It is considered quite an efficient system as it is less time consuming (Computer Sciences Corporation, 2012). HIS is a system for monitoring and evaluating varied data for providing valuable information to ensure enhanced decision-making with relation to healthcare facilities. Therefore, HIS is an important component for EGHS, which can facilitate better decision-making concerning the recorded medical data. It will help the students comprehend the valuable aspects and significance of medical records for improving the condition of the community. Therefore, the functions of HIS are summed up as: Provides medical records to varied clinics; Ensures the privacy of the information about patients; Reports to various departments of the medical unit; Assists in auditing; Codes the information about the patients according to certain parameters such as the date of birth; Certain health record filing systems are implemented in the hospital such as numerical and alphabetical filing. The inpatient movement procedure in the hospital takes place as follows: the patient is admitted to the hospital, the initial medical record of the patient is collected by the nurse, the record is sent to the ward clerk and then forwarded to the concerned doctor, and necessary treatment is conducted which may involve a surgical procedure. Conclusion The clinical placement of students in healthcare service helps them gain better knowledge of the activities which are performed for improving the quality of services provided to the patients. EGHS is a rural healthcare service facility which performs the activities with the motive of providing superior services to patients. Clinical placement helps the students acquire vast knowledge about the functioning and the services rendered. Auditing helps evaluate the performance of EGHS and devise plans for raising the degree of effectiveness of the services. The medical reports of patients are known to be recorded in the ICT system for ensuring the safety of information about the patients. HIS is required for maintaining the quality of medical reports and for providing authorised access to the information about patients. Reference List Australian Government, Department of Health and Ageing, 2012. Legislation. Freedom of Information (FOI). [Online] Available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/foi.htm [Accessed September 25, 2012]. Computer Sciences Corporation, 2012. Solutions. [Online] Available at: http://www.isofthealth.com/en-gb/Solutions/UK%20Patient%20Management/iPM.aspx [Accessed September 25, 2012]. East Grampians Health Service, 2008. About us. [Online] Available at: http://www.eghs.net.au/about [Accessed September 25, 2012]. East Grampians Health Service, 2011. 2011 Annual Report. [pdf] Available at: http://www.eghs.net.au/report [Accessed September 25, 2012]. Government of Western Australia, n.d.a. What is clinical coding? [Online] Available at: http://www.clinicalcoding.health.wa.gov.au/about/index.cfm [Accessed September 25, 2012]. Government of Western Australia, n.d.b. Accessing information in the public health system (under Freedom of Information (FOI). [Online] Available at: http://www.health.wa.gov.au/medical_records/ [Accessed September 25, 2012]. Health Information Management Association of Australia Limited – HIMAA, 2012. What is a HIM. [Online] Available at: http://www.himaa2.org.au/ [Accessed September 25, 2012]. Royal College of Psychiatrists, 2012. Clinical audit: What it is and what it isn’t. [Online] Available at: http://www.rcpsych.ac.uk/pdf/clinauditChap1.pdf [Accessed September 25, 2012]. State Government of Victoria, 2012a. Master patient index system will provide streamlined patient records access. [Online] Available at: http://www.egov.vic.gov.au/focus-on-countries/europe/countries-europe/austria/trends-and-issues-austria/e-health-austria/master-patient-index-system-will-provide-streamlined-patient-records-access.html [Accessed September 25, 2012]. State Government of Victoria, 2012b. Victorian admitted episodes data set. [Online] Available at: http://www.health.vic.gov.au/hdss/vaed/index.htm [Accessed September 25, 2012]. State Government of Victoria, 2012c. Definitions. [Online] Available at: http://www.health.vic.gov.au/casemix/definitions [Accessed September 25, 2012]. The State of Queensland (Queensland Health), 2012. Grampians clinical placement network. [Online] Available at: http://www.health.vic.gov.au/placements/cpn/grampians.htm [Accessed September 25, 2012]. Travaglia, J. and Debono, D., 2009. Clinical audit: A comprehensive review of the literature. [pdf] Available at: http://www.health.vic.gov.au. [Accessed September 25, 2012]. WHO, 2012. Health Information Systems. Healthinfo, pp. 44-58. Read More