Perspectives in Health Information Management

Computerized clinical decision support systems (CDSS) are increasingly being used to facilitate the role of clinicians in complex decision-making processes. This systematic review evaluates evidence of the available CDSS developed and tested to support the decision-making process in primary healthcare for stroke prevention and barriers to practical implementations in primary care settings. A systematic search of Web of Science, Medline Ovid, Embase Ovid, and Cinahl was done. A total of five studies, experimental and observational, were synthesised in this review...

The transition to a new electronic health record (EHR) system requires an understanding of how the new system addresses the needs, business processes, and current activities of a healthcare system. To address such requirements, a multidisciplinary team conducted a current state workflow assessment (CSWFA) of clinical and administrative functions to elicit and document business processes (via process diagrams), requirements, workarounds, and process issues (i.e., user interface issues, training gaps) at one healthcare facility...

Primary care physicians (PCPs) have an important role in the identification and management of Attention Deficit Hyperactivity Disorder (ADHD). There is a paucity of research on PCPs' practices related to the discussion of educational interventions. We conducted a retrospective chart review using Natural Language Processing to extract data on how often PCPs in an outpatient clinic: 1) discuss educational support with patients and caregivers; and 2) obtain educational records. About three-quarters of patients had at least one term related to educational support included in at least one note, but only 13 percent of patients had at least one educational record uploaded into the electronic health record (EHR)...

OBJECTIVE: The expansion of mobile applications as a tool for road traffic health and safety may develop several issues from the perspective of information management. Quality assessment of these apps, especially from an information system management perspective, appears inevitable, as their possible low quality may cause irreversible injury or fatal consequences. This study aimed to evaluate the quality of the apps in the three subcategories of road traffic safety apps (including Accident Record and Report (ARR), Distraction Management (DM), and Vehicle Operating, Fixing, and Maintenance (VOFM)) using the Mobile Application Rating Scale (MARS), which rates 23 evaluation criteria organized in five domains (Engagement, Esthetics, Information, and Subjective Quality) with particular attention to the five rights framework of health information system...

The World Health Organization's International Classification of Diseases (ICD) has become the international standard diagnostic classification for reporting morbidity and mortality. In 2015, the United States transitioned from the 9th to 10th Revision. The update was necessary due to major structural limitations of the ICD-9 system. Concerns of the transition mainly centered around clinical usage and cost; however, there were concerns for overlapping codes with the same classification but different meanings between the two versions...

The objective of the study is to identify challenges and associated factors for privacy and security related to telehealth visits during the COVID-19 pandemic. The systematic search strategy used the databases of PubMed, ScienceDirect, ProQuest, Embase, CINAHL, and COCHRANE, with the search terms of telehealth/telemedicine, privacy, security, and confidentiality. Reviews included peer-reviewed empirical studies conducted from January 2020 to February 2022. Studies conducted outside of the US, non-empirical, and non-telehealth related were excluded...

Studies have quantified various specific benefits related to the use of medical scribes, finding physician workflow and productivity improvements, with some demonstrating marginal value or detrimental impact. However, this evidence base misses a critical underlying issue with the expanding number of physicians using medical scribes routinely. There are an estimated 28,000-33,000 peer reviewed biomedical journals worldwide, currently publishing an estimated 1.8-2 million scientific articles every year. Over a typical physician's career from the 11-13 years of undergraduate through medical school and specialty/residency training as well as 34-36 practice/care delivery years beyond (to age 65), this yields 84-94+ million peer reviewed journal articles that are published in the global medical literature and to be potentially consumed/ considered over a roughly 47-year career...

Since 2020, health informaticians have developed and enhanced public-facing COVID-19 dashboards worldwide. The improvement of dashboards implemented by health informaticians will ultimately benefit the public in making better healthcare decisions and improve population-level healthcare outcomes. The authors evaluated 100 US city, county, and state government COVID-19 health dashboards and identified the top 10 best practices to be considered when creating a public health dashboard. These features include 1) easy navigation, 2) high usability, 3) use of adjustable thresholds, 4) use of diverse chart selection, 5) compliance with the Americans with Disabilities Act, 6) use of charts with tabulated data, 7) incorporated user feedback, 8) simplicity of design, 9) adding clear descriptions for charts, and 10) comparison data with other entities...

No abstract text is available yet for this article.

The success or failure of a clinical documentation integrity (CDI) program is often evaluated using a designated set of metrics. However, these metrics change over time, and an understanding of these changes is critical to properly judge the efficacy of the CDI effort. The authors propose a model of the natural history of a CDI program based on commonly used CDI metrics. The authors believe that this model can assist CDI leaders in anticipating and understanding the course of CDI performance over time.

The COVID-19 pandemic led to an increase in cybersecurity attacks on organizations operating in the healthcare industry. Health information professionals and health executives are unable to limit the impact of data breaches on records their organizations handle. While current research focuses on prevention strategies and the understanding of the causes of data breaches, it failed to address how to mitigate the impact of successful cybersecurity attacks. This quantitative research paper examined the effect the healthcare entity type has on the number of impacted individuals for healthcare data breaches that occurred during the pandemic...

This study evaluated the readability and suitability of a university health center public website. Readability formulas estimated the reading grade and age required for comprehension of health information. The Suitability Assessment of Materials (SAM) instrument determined adequacy of the webpages for the intended audience. Readability showed the reading grade level, representing the youngest reader able to process the material, ranged from 10.1 to 14.6, averaging 12.5 (midway through 12th grade in the US educational system)...

Introduction: Within revenue cycle management, billing is an important activity for physicians with financial implications across remuneration models. We assessed the self-reported billing confidence of residents and attending physicians practicing at an academic family health team in a single payer setting. Methods: All residents and attending physicians working or who had worked at the team were invited to complete a 20-question electronic survey on their exposure to billing education and their self-reported confidence with various billing activities...

Despite the cooperative sharing of health information exchange (HIE), various distinct limitations and barriers are found (i.e., substantial time and resources are being used to achieve health information). This paper investigates the limits of healthcare information sharing policy implementation for patient referral systems in Thailand. Mixed-methods research methodology, both quantitative and qualitative mechanisms, are conducted. The study results present the correlation between the current HIE among the hospitals in patient referral systems and the limitations of implementing the HIE policy, composed of technical, economic, political, and legal barriers...

Objective: Awareness of the importance of social security systems continues to grow in Indonesia, as mandated by the amendment of the 1945 Indonesian Constitution Article 34 paragraph 2, which states the obligation of the Indonesian government to develop and implement a social security system for all Indonesian people. This study aims to evaluate the effectiveness of applying failure modes and effects analysis (FMEA) in managing inpatient medical records at the Dr. M. Djamil Padang Central General Hospital...

While there is significant literature discussing physical and cybersecurity risks around health information technology in general, the number of publications that specifically address medical imaging is much smaller, and many of these focus on the technical security requirements for the exchange of medical images over public networks rather than practical guidelines for radiologists and technicians. This study examines the US Department of Health and Human Services database of reported breaches involving medical imaging from 2010-2020, identifies the most common contributing factors to those breaches, and offers recommendations for radiology practices to prevent each, based on the National Institute of Standards and Technology (NIST) guidelines as well as measures proposed in the literature on health information technology...

Vascular access (VA) is essential to inpatient care, and the documentation/coding practices for vascular access device (VAD) placement procedures remain unexplored. Accurate documentation may present benefits for patients, providers, and researchers. A retrospective analysis was performed in adult inpatients (2015 to 2020) using Cerner Real World Data™ to evaluate the utilization of CPT codes for VAD placement/replacement procedures. A total of 14,253,584 patient encounters were analyzed, 0.111 percent (n=15,833) of which received at least one VAD procedure code...

Laboratory services are a crucial part of medical care and contribute to physicians' treatment-related decision-making. However, paper-based information exchanges between physicians' offices and laboratories waste physicians' time and prevent them from using outpatient test results in a timely and effective manner. To solve this problem, improve the safety and quality of patient care, and save patients' time and energy, the present study developed a web-based system for electronic information exchange between laboratories and offices in Microsoft Visual Studio with the ASP...

Background: Acute kidney injury (AKI) increases patient morbidity and mortality. In value-based care, the documented and coded diagnoses during hospitalization influences an encounter's relative weight (RW), including severity of illness (SOI), and risk of mortality, which ultimately determines reimbursement for care. The impact of a secondary diagnosis of AKI on RW in pediatric patients has not been evaluated. Methods: A single-center, retrospective observational study was conducted over six months...

Introduction: Experiential learning supervised by a qualified preceptor has been an enduring requirement for accredited allied health academic programs.1 Data show that students benefit from participating in experiential learning activities, such as an internship.2 Further, studies show organizations are eager to hire new graduates who took part in some type of external hands-on experience.3 Health information management (HIM) programs accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) require students to complete a supervised professional practice experience (PPE) before graduation to show proficiency of the curriculum requirements...