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Health Care Information Review Proposal

Health Care Information Review Proposal

Nadhirah Lutchminarain

BHA-FPX4106- Introduction to Managing Health Care Information

Prof. Sonia Hussain

October 28, 2021

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Health Care Information Review Proposal

Table of Contents
Introduction...............................................................................................................................................3
Data Collection Plan..................................................................................................................................4
Cycle of health records information through the information life cycle from creation to destruction.
.................................................................................................................................................................... 5
Health Information Exchange..................................................................................................................5
Personnel Required...................................................................................................................................7
Data Security Plan.....................................................................................................................................9
The Laws Governing Health Information.............................................................................................10
Plan for the impact of HIPAA on health care personnel, policies, and procedures............................11
Benchmarking Plan.................................................................................................................................12
Quality and Change Management Strategies........................................................................................14
Evidence Based Best Practices and Procedures....................................................................................16
Implementation Process..........................................................................................................................16
Conclusion................................................................................................................................................18
References................................................................................................................................................19
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Health Care Information Review Proposal
Introduction

This proposal will outline the health care information review of the quality of care given to our

cancer patients over the past five years. By analyzing specific data, we can improve the quality

of care given to our cancer patients. The data that we will need to review would be the average

age at diagnosis, type of cancer, stage of disease at diagnosis, the types of treatments given, and

duration of treatment. This data will allow us to evaluate the effectiveness of treatment and

therapies and see what areas we should improve upon. The purpose of the study is to review and

assess data that has already been collected and increase our knowledge about how we can better

treat cancer patients. This information can be used to improve the quality of care in our facility

by defining what works best and what does not work for our patient population
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Health Care Information Review Proposal
Data Collection Plan

The following table will state the data required, the time to be reviewed and where and how it

will be collected.

Type of Data Time Period Information collected System

from Application to

collect

information

Average age at Last 5 years Patient Information REDCap is a

diagnosis of patient’s which includes, secure electronic

Type of cancer records medical history, data capturing

Stage of disease at personal details, (EDC)

diagnosis treatment history. Application

Types of treatments

given

Duration of treatment

Post Consultations
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Health Care Information Review Proposal
Cycle of health records information through the information life cycle from creation to

destruction.

5. Dispose
Patients
1. Creation of age to be
patient Record
collected from
patient record

Information

life cycle

4. Use 2.Retention
Post
Consultation
data

Type of Cancer , stages of

3.Maintainace
Cancer , Types of
treatment, Duration of
treatment.

Health Information Exchange

The use of information from a health information exchange (HIE) is a growing trend in many

hospitals. A hospital's HIE may be able to provide information about how patients with breast

cancer, colorectal cancer, lung cancer, and others were treated at the hospital. The use of an HIE

is a good idea because it saves the hospital money by reducing the amount of time that clerks

spend finding and entering data from paper charts into the computer. However, depending on

how well the HIE is designed and implemented, it can also have a negative effect on patient care.

HIE can be used to store patient information electronically, but if it is not used properly, it can
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Health Care Information Review Proposal
also negatively affect patient care. Hospitals that allow patients to share their personal health

information with other patients who may want to be tested for the same or similar disease can

end up having inferior care (or worse) than if the hospital was using its own data system.

However, there are many instances in which HIE helps improve patient care and reduce medical

errors, such as when it is used to keep track of patients who receive multiple treatments during an

illness.

The effects of HIE on patient care, regarding cancer care, have not been well-studied. It is not

clear whether HIEs improve the quality of care or reduce medical errors but being able to share

patient data electronically has a positive impact on patient care. A study by Blum et al. used a

computer simulation of a cancer hospital network to show that the use of an HIE could be

beneficial for cancer patient care. (Blum et al., 2003)

The effects of HIE on clinical knowledge and identification of best practices have also been

studied. The use of an HIE in a hospital is a way to collect and store information for patients. It

allows health care professionals to have access to the same information that is being used in their

daily practices without having to duplicate this information on paper or manually enter it into a

computer system. For this data to be useful, the hospital must transfer the knowledge from those

who used it most frequently from those who did not so those who have had less experience with

the practice will benefit from the information as well. Whenever new medical guidelines and

procedures are released, hospitals should be able to easily access this new research and apply it

immediately and appropriately to their patient population (Williams et al., 2009).

The effects of HIE on population health data and public health initiatives have been well-studied.

The use of data from an HIE can help public health initiatives and population-based research by

making it easier for people to see the data in a format that is easily understood. When this data is
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Health Care Information Review Proposal
combined with other ways of collecting and organizing data, such as electronic medical records

and other hospital resources, this will allow the information to be easily accessed when it is

needed most. HIE can also help in epidemiological research by allowing researchers to study

larger populations than they could in the past (Blum et al., 2003).

Personnel Required

Personnel Required to complete the health information review, which includes their needed

skills, required training and job aids are as follows:

Personnel Required Skills Needed Required Training Job Aids

Data Analyst Data visualization Degree in computer Computer

Data cleaning science Stationary

MATLAB Degree in Statistics

Python Or equivalent

SQL & NO SQL 3 to 5 years’

experience

Monitoring and Analytical skills Degree in Business

Evaluation officer People skills administration or

Project understanding economics.

Or equivalent

3 to 5 years’

experience
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Health Care Information Review Proposal
Project Manager Team Management Degree in any

Organizational skills management related

Risk and Time course.

Management Or equivalent

3 to 5 years’

experience

Data Clerk Computer skills Diploma

Organizational skills Or equivalent

Attention to detail 2 years’ experience

Strategies that will be employed to help personnel implement the review study:

1. Training on the process

2. Guides to assist personnel in completing the review

3. Computer programs to assist personnel in completing data entries

4. Formal policies and procedures for access and security of database to protect

confidentiality.

5. Storage of the database for a period after it is completed that should be long enough to

allow for maximum utilization, but not so long as to have critical information outdated by

then.
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6. A continuing education program that should be used to keep up with changes in

technology and changes in state laws, hospitals should follow these instructions carefully,

as there could be a cost involved with not following them.

7. We should consider partners to assist us with the study that will provide us with special

needs that we may not be able to meet.

8. Our database should be protected by both our own security measures and the biggest

contractors in the area should be protected to ensure confidentiality of patient

information.

9. We can always change our policies at any time, but it is suggested that these processes

are written down for all personnel to see, so there is no confusion or conflict in what is

supposed to be done, or what has been done in the past under different circumstances.

10. Our work groups should be small enough that they can have open communication, but

large enough to have representation from all areas within the hospital.

Data Security Plan

Required Policies and procedures include, but are not limited to:

1. The policy should describe those who will have access to the database, as well as those

who need to follow up with those that have been reviewed.

2. The policy should state procedures for the format of intake data, as well as identification

verification.

3. The policy should state what must be reviewed and how it will be reviewed.

4. The policy should identify a glossary of terms along with their definitions to make sure

that all personnel can understand them and use them properly in their review studies.
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Health Care Information Review Proposal
5. The policy should have a statement on what data will be reviewed.

6. The policy should have a statement of HIPAA rights of access and exceptions of access,

which must be followed by everyone involved with the review study.

7. We must have written procedures for notifying those that have been reviewed of negative

findings, as well as any changes in medical treatment or procedures that may be needed

because of the review process being conducted on their files.

8. We must have a written procedure for a decision-making process on treating patients who

are identified as having cancer, so we can make sure that those with cancer are being

treated appropriately and those who do not have cancer are not being treated

inappropriately.

The Laws Governing Health Information

Laws for health information confidentiality, privacy, and security:

 Health Information Privacy and Security Act of 2004, which regulates the use and

dissemination of Health Information and specific requirements for health information

privacy and security.

 HIPAA: Human Identity Prosthetics Act, which governs the use and maintenance of

identifiers used to describe individuals as well as their transfer to other organizations.

 Right to Privacy: The Constitutional right to privacy under the fourth amendment is

guaranteed by the United States Constitution as a protection against unreasonable

searches and seizures as set forth in Article 1, Section 8. The right to privacy includes

health information maintained by hospitals in electronic records systems. It protects

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Health Care Information Review Proposal
confidential communications between healthcare providers, patients, family members,

employers, or others with an interest in inpatient care.

 Nondiscrimination: The federal and state laws that prohibit discrimination in health care

may include confidentiality provisions. If a hospital does not follow the laws they may be

subject to lawsuits by patients who have been discriminated against.

 Lawsuits: It is unlawful for hospitals to disclose health information in any manner that

violates HIPAA and in following these laws it will reduce the risk of lawsuits and

possible fines.

Plan for the impact of HIPAA on health care personnel, policies, and procedures.

By understanding certain key terms, HIPAA can be used to improve patient care. Some of these

key terms are listed below:

1. Identifiers: Identifiers are used to describe individuals or their personal information in a

health care setting.

2. Protected Health Information (PHI): PHI is any individually identifiable information that

is created or received by a covered entity as part of providing health care services, and

that relates both to the individual’s physical or mental health or condition and to the

provision or payment for health care services. Some basic examples of PHI include

information such as medical records that may include the following identifiers: name,

address, phone number, and e-mail address, and social security number.

3. Covered Entities: Covered entities are healthcare-related entities such as hospitals,

medical offices, and health insurance companies.

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Health Care Information Review Proposal
a. A covered entity includes any person who furnishes, bills, or is paid for health

care in the normal course of business.

b. HIPAA regulations provide for a number of exceptions to the definition of

“covered entity” including government agencies or their contractors that do not

have patients or clients.

4. Administrative Safeguards: Administrative safeguards are policies and procedures that

are designed to protect the privacy and security of patient information.

5. Physical Safeguards: Physical safeguards are policies and procedures that prevent the

theft or loss of PHI and ensure that access to electronic files and computer programs is

limited and secure.

6. Technical Safeguards: Technical safeguards are policies and procedures that help prevent

the destruction, alteration, or disclosure of PHI using security measures such as firewalls,

encryption methods, etc.

7. Policies and Procedures: A written policy for each area within a hospital should be

created as a guide to those employees who have access to Protected Health Information

whether they are administrative staff, medical personnel, or other employees who have

access to PHI as part of their job duties.( Cohen,2018).

*These policies and procedures will be presented to personnel in different workshops and

briefings.
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Health Care Information Review Proposal
Benchmarking Plan

The following sauces can be considered for national data and quality measures related to cancer.

There are great sources to find guidelines for auditing healthcare providers regarding cancer

treatment and follow-up care. Some of these guidelines include the following:

1. National Comprehensive Cancer Network (NCCN)

2. National Cancer Institute (NCI)

3. American Society of Clinical Oncology (ASCO)

4. Quality Indicators for Head and Neck Cancers (QIINHNC)

5. The American Cancer Society (ACS),

6. The Centers for Medicare and Medicaid Services (CMS),

7. The Centers for Disease Control and Prevention (CDC)

8. The International Agency for Research on Cancer(IARC)

9. Society of Oncology Nursing Oncology Nursing Society National Cancer Institute

Whistleblower Program,

10. The Joint Commission National Quality Forum Whistleblower Program

We will use the national data and quality measures mentioned above as benchmarks of the

current care of people diagnosed with cancer by measuring the following:

1. Treatment and follow-up care of people diagnosed with cancer.

2. Data on the latest and best treatment and follow-up care of people diagnosed with cancer,

including:
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Health Care Information Review Proposal
3. For each state, we will use the national benchmarks to create a composite score for how

well each state is doing in providing quality treatment for people diagnosed with cancer-

related to certain types such as breast, prostate, colorectal, lung, and other cancers.

This will help us to determine where we can improve or expand our care for this condition. We

will also use this data to help us create a comprehensive audit of our current policies, procedures,

and guidelines for the treatment of cancer.

We can ensure data standardization by using the following resources:

• Care Quality Indicators (CQI)

• The CQI was developed by the National Committee for Quality Assurance (NCQA) to

collect information on quality of patient care. This is a national initiative that involves

health plans, hospitals, and doctors. It provides standardized measurements on all aspects

of healthcare so that different providers can be compared on an equal footing.

• National Database of Nursing Quality Indicators (NDNQI)

• The NDNQI was created by the American Nurses Association (ANA) to help improve

nursing practices, provide leadership in nursing education, and be accountable for care.

Quality and Change Management Strategies

Data outcomes could be used to perform quality improvement reviews by either Health Care

professionals or an internal audit team. This will help to improve processes and care for Cancer

patients. Results can be seen in the following areas:

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Health Care Information Review Proposal
1. We will determine if our practices meet the standards for quality cancer care set by

national quality indicators, expert committees, and accreditation organizations.

2. These results will be used to develop audit findings that identify strengths, weaknesses,

opportunities for improvement in our hospital’s Cancer Treatment services.

3. We will use this data to determine how well we are meeting the requirements of the Joint

Commission National Quality Forum Whistleblower Program.

The following can be considered as evidence-based best practices for policies and procedures

based on outcomes:

The following can be considered as evidence-based best practices for policies and procedures

based on outcomes:

1. HIPAA Security Rule

2. NIST Computer Security Assurance Guidelines (CSAG) for Federal Information Systems

and Organizations

3. Common Standards Core Capability Set for Health IT Standards (HITRUST)

4. CMS Meaningful Use Program requirements,

5. Quality Assessment Toolkit from the Department of Veterans Affairs 8-Digit Codes

Guide to Health Care Technology Management, 13C/922, Center for Devices and

Radiological Health, Rockville, MD - January 2011, Revision 2.

Best practices for departmental workflow for this task would be the following:
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Health Care Information Review Proposal

Project
Manager to Data analyst Monitoring Project
Brainstorm create a Data to be to analyze officer to manager to
ideas as a project plan collected by date trends document review and
team and analyze Data Clerk and bench all analyzed compile
with the marks data results
team

(Spencer,2013).

Evidence Based Best Practices and Procedures

The following are evidence-based best practices and procedures they could use to facilitate

needed changes:

1. Developing a comprehensive, multidisciplinary plan for implementing the new system

2. Developing the project team and the project charter

3. Identifying potential changes needed in departmental processes and procedures

4. Existing data sets to be examined to determine if they are current with current practices

5. Developing a comprehensive, multidisciplinary plan for implementing the new system

6. Key personnel involved in developing the project team and selecting technical solutions

7. Survey of departmental employees on their perceptions of how their work is currently

managed

8. Ensuring that adequate staff support is included in any implementation plan

(Oman,2008).

Implementation Process

Steps for implementing the information review study :

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Health Care Information Review Proposal
• Start with a large amount of data- raw data, aggregated data, or any other type of data.

• Examine the data to find out if there are any problems within your organization.

• Review the key statistics for each field of the dataset.

• Check all possible linkage rules.

• For each linkage rule find out which values are identified by that rule, then build a list of

links between those values.

• Search for cases where you have not got the right values.

• Look for missing values in columns with limited information, which will lead you to do

further analysis of the records.

• Look for different factors and their impact on the data.

• Compare the data with some other data sets to find out any trends in your organizations.

• With all these steps you will get a good picture of your organization and how well the

data is managed.

• Identify areas of improvement such as: landscape, climate, function, technology, etc.

• Consider any constraints such as: cost-savings, privacy impact assessments (PIA),

regulatory change requests (RCR), etc.

• Cost-benefit analysis where a reasonable return on investment may be achieved via cost

savings or minimizing security risks.

Time Frame: Probably an innovative time frame for this study would be to implement the data

review study within a reasonable timespan (8 months) to meet the turnaround time for the

hospital.
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Health Care Information Review Proposal
Conclusion

This proposed study will improve the quality of patient care for our physician group by

providing evidence-based best practices that will enhance OPD through standardization of data

collection tools, procedures that allow uploading of anonymized health care data, increasing

quality improvement, and enhancing marketing programs for clinical research. Cancer patients

will benefit from better outcomes with reduced suffering. The organizational benefits are to

receive recommendations on best methods of data collection, better methods of data

management, risk reduction strategies, and management of clinical trials. This is a time-

consuming process but will yield positive results in terms of cost savings and reimbursement.

The study will also provide valuable evidence to support the decision-making process by our

departmental leaders in developing policies and procedures for patient care.

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Health Care Information Review Proposal
References

Oman, K. S., Duran, C., & Fink, R. (2008). Evidence-based policy and procedures: an algorithm

for success. The Journal of nursing administration, 38(1), 47–51.

https://doi.org/10.1097/01.NNA.0000295634.18463.4d

Spencer, L. M., Schooley, M. W., Anderson, L. A., Kochtitzky, C. S., DeGroff, A. S., Devlin, H.

M., & Mercer, S. L. (2013). Seeking best practices: a conceptual framework for planning and

improving evidence-based practices. Preventing chronic disease, 10, E207.

https://doi.org/10.5888/pcd10.130186

Cohen IG, Mello MM.(2018). HIPAA and Protecting Health Information in the 21st Century.

JAMA. 2018;320(3):231–232. doi:10.1001/jama.2018.5630

Titler MG. (2020). The Evidence for Evidence-Based Practice Implementation. In: Hughes RG,

editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

https://www.ncbi.nlm.nih.gov/books/NBK2659/