Chapter 7, Computers in HIM

Chart locator system

is designed to track the paper medical record and important because paper records are moved from place to place for patient care, quality reviews, coding, and many other purposes. Joint Commission regulations require medical records to be readily accessible for patient care and supports that mandate.

Birth certificate information system

is entered into a state-approved and this software reports births occurring in the healthcare facility to the stat health agency and may be developed by the state or by a vendor. Established by NCHS (National Center for Health Statistics) and any state-required data.

Expanders

is allow transcriptionists to type an acronym such as "CHF" and the full phrase "congestive heart failure" will automatically be spelled out, thus saving keystrokes and time and can typically be controlled by the facility.

Health quality indicator system

is an abstracting system that records information about the patient and the care provided to the patient and this software may be used by HIM department or other department performing this function. Users in the HIM department may be the coders or a separate group of employees with the necessary skills and qualifications to read, understand, and abstract information from the medical record into the quality indicator system .

Automated codebook encoder

is an encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index located in the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-1-CM) and Current Procedural Terminology (CPT) codebooks and similarity eases the transition from the book to the encoder.

Grouper

is assigns the codes entered into the encoder into the appropriate Medicare severity diagnosis-related group (MS-DRG) or other diagnosis-related group (DRG) and uses the appropriate grouping software for the insurer assigned to the patient. Most common grouper is the MS-DRG grouper including some Medicaid programs, have developed their own groupers for use in determining payment to the healthcare facility.

Clinical documentation improvement (CDI) software

is assists in identifying ways to improve clinical documentation in the health record and improves the code assignment will be improved because codes can be more specific. Another benefit of improved is more accurate reimbursement.

2 common registry:

1. Cancer (tumor) 2. Trauma registry

2 types of encoders:

1. Rules-based encoders 2. Automated codebook encoder

Release of Information (ROI) system

designed to manage the processing of requests for protected health information (PHI) received and processes by the HIM department. Use of the system beings when a new request is entered into it and continues to track the request as it is processed and acts as a historical database of all requests processed and ultimately used to generate reports.

Rules-based encoders

is require the user to type in the name or portion of the name of the diagnosis or procedure and this entry into the encoder generates a list of suggestions from which the coder selects. Example: if the coder types in pneu-, the encoder may suggest pneumonia and pneumonitis. From there the coder scrolls down until the proper code is selected.

Computer-assisted coding (CAC)

is system requires the health record to be electronic for the system to have the clinical data to analyze.

Chart deficiency system

is the medical record comes to the HIM department with a deficiency then the documentation omission is record and tracked. Deficiencies can be in paper, imaged, or electronic records depending on the system used and should be linked to the hospital information system so that patient, name, discharge date, other demographic information are maintained and automatically populated.

Transcription system

is the transcriptionist then types the actual report and should be interfaced with the hospital information system so that the patient name, medical record, and date of service are already populated within the system.

Natural language processing (NLP)

is to analyze clinical data to identify diagnoses and procedures and to assign the appropriate ID-10-CM, 1CD-10-PCS, and CPT code to the system and is a technology that coverts human language (structured or unstructured) into data that can be translated then manipulated by computer systems.

Cancer registry information system

is tracks information about the patient's cancer from the time of diagnosis to the patient's death and extremely complex and track very detailed information regarding diagnosis and treatment.

Trauma registry software

is tracks patients with traumatic injuries from initial trauma treatment to death.

Dictation system

is used by physicians to dictate various medical reports such as the operative report, history and physical, and discharge summary. The physician uses this to dictate but the HIM department uses the system to transcribe the report. The physician dictates history and physical examinations, discharge summaries, radiology reports autopsy reports, catheterization reports, and other designated reports into the dictation system.

Disclosure management system

track the disclosures made throughout the healthcare organization for reporting purpose and this tracking is required by the Health Insurance Portability and Accountability Act (HIPPA). The covered entities must provide the patient with an accounting of disclosures upon request and may be part of the ROI system or may be separate system used by HIM and non-HIM departments.

Encoder

used by coders to select the appropriate code for the diagnosis(es) and procedure(s) supported by the medical record.