Full Answer Section

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3. Initial Record Review & Analysis:

• Description: The CDI specialist reviews the clinical documentation to identify opportunities for clarification, specificity, and completeness. They look for discrepancies, missing information, and potential coding impact.
• Visual Element: A box with a CDI specialist icon (e.g., person with a clipboard or looking at a computer screen) examining an EHR icon with notes or highlights.
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4. Physician Query Generation (if needed):

• Description: If the documentation is unclear or incomplete, the CDI specialist formulates a concise and non-leading query to the physician to request clarification. Queries can be electronic or paper-based.
• Visual Element: A box with a speech bubble pointing from the CDI specialist to a physician icon, containing a question mark.
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5. Physician Response to Query:

• Description: The physician reviews the query and provides additional documentation or clarification in the medical record.
• Visual Element: A box with a speech bubble pointing from the physician back to the EHR icon, containing text or a checkmark.
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6. Updated Documentation in Medical Record:

• Description: The physician’s response is integrated into the patient’s medical record.
• Visual Element: The EHR icon now appears with updated notes or information.
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7. Secondary Record Review & Coding Impact Assessment:

• Description: The CDI specialist reviews the updated documentation and assesses the impact on coding accuracy and quality metrics.
• Visual Element: The CDI specialist icon again reviewing the updated EHR icon, possibly with coding books or software icons nearby.
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8. Communication with Coding (if needed):

• Description: The CDI specialist communicates any relevant documentation clarifications or coding insights to the coding team.
• Visual Element: A box showing the CDI specialist icon communicating with a coder icon (e.g., person looking at coding software).
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9. Coding and Claim Submission:

• Description: The coding team assigns the appropriate codes based on the complete and accurate documentation. The claim is then prepared and submitted to the payer.
• Visual Element: A box with a coder icon working on coding software, leading to an arrow pointing to a payer icon (e.g., insurance company logo).
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10. Data Analysis & Reporting: * Description: CDI program data (e.g., query rates, agreement rates, impact on coding) is collected and analyzed to identify trends, areas for improvement, and measure program effectiveness. Reports are generated for stakeholders. * Visual Element: A box with graphs, charts, and a report icon. An arrow could loop back to “Identification of Records for Review,” indicating continuous improvement.

This workflow emphasizes the iterative nature of CDI, with ongoing review and communication to ensure accurate and complete clinical documentation that supports appropriate coding and reimbursement.

HIM Policy Topics in a Health Information Exchange (HIE) Setting

As an HIM professional interested in contributing to policy development for a newly established Health Information Exchange (HIE), several critical areas require attention to ensure the secure, efficient, and compliant exchange of patient health information. Based on AHIMA resources and general best practices, here are five policy topics an HIM professional could significantly contribute to:

1. Patient Consent Management for HIE Participation:

• Expounding: This policy would outline the processes for obtaining, documenting, and managing patient consent for their health information to be shared through the HIE. It needs to address different consent models (opt-in, opt-out, hybrid), patient rights regarding their data (e.g., access, restriction of sharing), and the legal and regulatory requirements surrounding consent for electronic health information exchange (e.g., HIPAA, state laws). The policy would detail the responsibilities of participating organizations in informing patients about the HIE and their consent options, as well as the technical mechanisms within the HIE to enforce patient consent decisions.
• HIM Contribution: HIM professionals possess expertise in patient rights, privacy regulations (like HIPAA), and consent management workflows. They can develop clear and legally sound policies that balance the benefits of information sharing with patient autonomy. They can also contribute to the development of patient education materials and staff training on consent procedures within the HIE context.

2. Data Quality and Integrity Standards for HIE Information:

• Expounding: This policy would define the standards for the quality and integrity of patient health information exchanged through the HIE. It would address data accuracy, completeness, consistency, timeliness, and validity. The policy would outline the responsibilities of participating organizations in ensuring their data meets these standards, including data validation processes, error correction mechanisms, and audit procedures. It might also address data standardization efforts (e.g., use of common data elements, terminologies, and code sets) to facilitate interoperability and meaningful use of the exchanged information.
• HIM Contribution: HIM professionals are experts in data quality principles and practices. They can develop policies that establish clear data quality metrics and guidelines for HIE participants. Their knowledge of data governance, data dictionaries, and data integrity safeguards is crucial for ensuring the trustworthiness and reliability of the information shared through the HIE.

3. Security and Access Control for the HIE:

• Expounding: This comprehensive policy would detail the security measures implemented to protect the confidentiality, integrity, and availability of patient health information within the HIE. It would address user authentication and authorization, access controls based on roles and responsibilities, encryption of data in transit and at rest, audit trails of access and modifications, incident response procedures, and security awareness training for HIE users. The policy would align with relevant security regulations (e.g., HIPAA Security Rule) and industry best practices.
• HIM Contribution: HIM professionals have a strong understanding of information security principles and HIPAA security requirements. They can contribute to the development of robust security policies that define appropriate access levels, outline procedures for managing user accounts, and establish protocols for responding to security breaches. Their expertise in data security safeguards is vital for maintaining patient privacy and trust in the HIE.

4. Data Retention and Destruction Policies for HIE Information:

• Expounding: This policy would outline the requirements for retaining and securely destroying patient health information exchanged through the HIE. It needs to address legal and regulatory requirements for record retention (which may vary by state and record type), as well as considerations for the long-term value of the data for research and public health purposes. The policy would detail the retention periods for different types of data, the procedures for secure data destruction (e.g., data wiping, physical destruction), and the responsibilities of participating organizations in adhering to these guidelines.
• HIM Contribution: HIM professionals are knowledgeable about record retention regulations and best practices for data destruction. They can develop policies that ensure compliance with legal requirements while also considering the practical aspects of managing large volumes of electronic health information within the HIE environment.

5. Policy on Handling Data Breaches and Security Incidents within the HIE:

• Expounding: This policy would define the procedures for identifying, reporting, investigating, and mitigating data breaches and other security incidents that may occur within the HIE. It would outline the roles and responsibilities of different stakeholders in the incident response process, including notification procedures (as required by HIPAA and other regulations), containment and eradication strategies, post-incident analysis, and steps for preventing future incidents. The policy would also address communication with affected individuals and regulatory agencies.
• HIM Contribution: HIM professionals are familiar with HIPAA breach notification requirements and best practices for incident response. They can contribute to the development of a clear and actionable policy that ensures timely and appropriate responses to security incidents, minimizing harm to patients and the HIE. Their understanding of data security and privacy regulations is crucial for navigating the complexities of breach management.

References:

1. American Health Information Management Association (AHIMA). (Search AHIMA’s website for resources on HIE governance, data integrity, security, and privacy policies).
2. Health Information Exchange (HIE) Governance and Policy Resources. (Many state and regional HIE organizations publish their policies and governance frameworks online, which can serve as examples).