1. Introduction to Healthcare Information Technology
Chapter Six
Document Imaging and Problem Solving

2. Objectives
Describe frequently used healthcare image file types and their characteristics
Identify medical interface components
Explain the interface diagnosis process
Describe the clinical software troubleshooting process
Explain the need for and use of change control in the clinical environment

3. Healthcare IT: Challenges and Opportunities
Recent study results:
Fewer than two percent of hospitals employ a comprehensive EHR system
Challenges to integration of an EHR system
Interfacing dissimilar systems
Example: x-rays produce images on cellulose or polyester film
Film image must be digitized
Alternatively, x-ray machine modified to output digital images

4. Document Imaging
Images must be organized into standardized format for storage
Image files may be composed of:
Pixels (small picture elements)
Bitmap data
Vector (geometric) data
Combination of these data types

5. File Types Different applications for image files
Reason for existence of different file types
Characteristics of image files
Quality
Size
Resolution
Compression

6. Characteristics Image quality File size Compression
Describes how well the image file maintains fidelity of the source image
High-quality images appear more like the source than low-quality
File size
Described by number of bytes needed to store data
Compression
Technique to reduce size of a digital image file

7. Characteristics (cont’d.)
Image resolution
Refers to the number of pixels in an image
Typically stated as number of pixels high by number wide
Multiplying pixel counts gives a single resolution number
Example: digital camera with resolution of 2048 x 1536 pixels
Said to have resolution of three megapixels

8. Characteristics (cont’d.)
Four image file types commonly used in health care
Graphics Interchange Format (GIF)
Joint Photographic Experts Group (JPG or JPEG)
Portable Document Format (PDF)
Tagged Image File Format (TIFF)

9. Table 6-1 Image file formats and characteristics
© Cengage Learning 2013

10. Scanning and Indexing Storing image data in data files
Key part of creating an electronic document storage and retrieval system
Typical hospital can create hundreds to thousands of electronic images per day
Scanning
Process of converting paper–based data into electronic format

11. Figure 6-1 Desktop scanner
© Konstantin Shevtsov/

12. Scanning and Indexing (cont’d.)
Electronic file considered protected health information
Metadata
Data used to describe image attributes
Examples: creation date, patient ID
Data is included with the image file
Will vary greatly, depending on application, how data is used, and applicable regulations

13. Scanning and Indexing (cont’d.)
Storage
Process of saving data for future retrieval and use
Database
Structure used to store data
Index
Data structure that allows for fast data retrieval

14. Optical Character Recognition (OCR) and Structured Data
Data arranged in a defined manner
Unstructured data
No predefined arrangement
Examples: bitmap images, audio files, most text files
Optical character recognition
Process of converting scanned images of handwritten or printed text into computer readable text

15. Medical Interface Components
Health Level Seven (HL7)
Nonprofit, accredited standards development organization
Develops standard languages for formatting electronic messages between healthcare providers
HL7 message components
Segments presented in a defined sequence
Segments may be optional, required, and/or repeatable

16. Medical Interface Components (cont’d.)
HL7 message segment example

17. Medical Interface Components (cont’d.)
HL7 message example

18. Medical Interface Components (cont’d.)
Commonly used HL7 message types
ACK: general acknowledgment
ADT: admit, discharge, transfer
BAR: add/change billing amount
DFT: detailed financial transaction
Example ADT message subtypes
A01: patient admit
A02: patient transfer
A03: patient discharge
A04: patient registration

19. Medical Interface Components (cont’d.)
HL7 message segment standard contents
MSH: message header
SFT: software segment
EVN: event type
PID: patient identification

20. Table 6-2 Common HL7 message segments
© Cengage Learning 2013

21. E-Prescribing
Electronic transmission of a prescription to a pharmacy from the point of care
Can lower the cost of medication transactions
Improves management of traditional medication administration problems
Medication reconciliation
Process of avoiding medication inconsistencies across care settings
Can be accomplished with process integrated with an EMR

22. E-Prescribing (cont’d.)
Bedside medication verification (BMV)
Method of verifying correct medications are administered to the right patient
Commonly accomplished with barcodes and barcode scanner
Drug allergy interactions (DAI)
Certain drugs or drug combinations can cause allergic reactions in some patients
Helpful to maintain accurate database of patient allergy list
May be accomplished using CPOE system

23. E-Prescribing (cont’d.)
Formulary
List of medications covered by a third-party payer
Formulary checking
Part of an e-prescribing process
Verifies prescribed medications are in the formulary

24. Billing Medical information from the provider’s EMR/EHR system
Used to create an electronic version of the bill
Transmits to third-party payer (outbound communication)
HL7 billing segments
PID: patient information
PV1: visit information
FT1: financial transaction
IN1: insurance information

25. Billing (cont’d.) HL7 billing segments (cont’d.) Billing clearinghouse
IN2: additional insurance information
IN3: additional insurance information, certification
GT1: guarantor
AUT: authorization information
Billing clearinghouse
Validates claims to ensure free of errors
Then transmits to specified payer over secure connection

26. Diagnosing Interface Problems
Troubleshooting
Systematic approach to determine source of problem
Four troubleshooting steps
Identification
Generation
Determination
Confirmation

27. HL7 Message Problems Common problem with HL7 messages
Improperly formatted patient demographics
Example: patient’s SSN is 123-4T-5678 when it should be
Communication link errors
Generated as a result of failure in a fax, network, or Internet connection
Common in areas with aging communications infrastructure or frequent power interruptions

28. E-Prescribing Problems
Inaccurate patient demographics
Patient medical history may be inaccurate
Variety of causes
National standard for e-prescribing
Developed by the National Council for Prescription Drug Programs (NCPDP)
SCRIPT Standard Implementation
E-prescribing messaging standard using segments and fields

29. E-Prescribing Problems (cont’d.)
SCRIPT message example

30. Billing Problems Superbill
Form used by providers to quickly list patient’s procedures and diagnosis for reimbursement
Commonly adapted for a specific provider
Includes patient demographic data, CPT procedure codes, ICD diagnostic codes
May cause errors if data is inconsistent with other data

31. Billing Problems (cont’d.)
Billing software configuration settings examples
Bill patient for missed copays?
Display diagnosis description?
Display procedure description?
Rendering provider?
Scheduling provider?
Service location?
Supervising provider?
Some configuration settings are important for accurate data transmission

32. Medical Device Problems
Check for power first
Brownouts or voltage sags may cause medical device interface issues
Less common power problems
Blackouts
Spikes
Surges
Electrical noise
Use an uninterruptible power supply (UPS) on the device or central power system

33. Table 6-3 Less common power problems
© Cengage Learning 2013

34. Medical Device Problems (cont’d.)
Network and communication problems
Network failure can cause data corruption
Some devices can be configured to perform differently by adjusting configuration settings

35. Troubleshooting Clinical Software Problems
Types of clinical software
Auditing systems
Billing systems
Coding systems
CPOE systems
EMR/EHR systems
Lab information system (LIS)
Patient care planning systems

36. Troubleshooting Clinical Software Problems (cont’d.)
Types of clinical software (cont’d.)
Pharmacy information system (PIS)
Patient tracking systems
Patient scheduling systems
Radiology information system (RIS)
Workflow management systems
Defined plan for troubleshooting integrated software systems
Imperative for the HIT professional

37. Locate the Affected Modules or Fields
Troubleshooting process steps
Identify system malfunctions or symptoms
List possible causes
Determine cause of the problem
Develop and test solution
Confirm the problem has been solved
Approach for first step
Divide the problem into smaller domains
Work backward in the system from where the problem appears

38. Determine Data Types Data type error
Data classified based on properties (text, numeric, binary)
Database and software applications expect data to be of a certain type
Check configuration to ensure user inputs have been checked for correct data types
Manual configuration change may have allowed errors to be introduced into the system

39. Escalate When Necessary
When software problem cannot be solved through normal troubleshooting methods:
May need to be escalated (reported) to another technical support group
Problem escalation process
Describes who should be contacted first
Technical support groups often organized into tiers
Initial call to support group will encounter Tier 1 support
Escalates to Tier 2 if problem cannot be resolved

40. Table 6-4 Tiered technical support
© Cengage Learning 2013

41. Change Control Clinical software modules used together
Integrated system
Increases overall system complexity exponentially
Software regularly changes over time
New requirements and regulations
Bug fixes or performance improvements

42. Procedural Systematic Customization
Change control system
Procedure for systematic software customization
Specifics required for a change control system
Change compliance reporting
Defining specific change process activities
Delineating testing and cutover processes
Developing a change schedule
Identifying impacts of change
Specifying staff roles regarding change control

43. Governance Board
Risk and cost of failure with software change may be quite high
Governance
Alignment around objectives, strategies, tools and methods to minimize change failure
Change management governance board (CMGB)
Group with responsibility to approve changes that may result in critical service interruption

44. System Patching and Updates
Types of software changes
Patch
Fix for specific software problem
Update
Includes larger changes than patches
Can add features or functionality
Issued less frequently than patches

45. Change Scheduling Scheduling software changes
Challenging in a highly integrated environment
Some clinical software systems are used around the clock, every day of the year

46. Change Scheduling (cont’d.)
Change scheduling process questions
Is there a backup system?
Can collected data be recovered during the system downtime?
Will the downtime impact any life support systems?
Were all impacted departments notified, and did they approve the proposed schedule?
Can the old system be rolled back if the updates are not functional?
Answers to above questions will affect the update schedule

47. Change-Control Environments
Four stages in software change process
Development
Writing new program code to address need
Quality assurance (QA) test
Ensures software meets functional requirements and defined performance behaviors
User test
Assesses whether software meets user requirements
Production (live)
Software is released to be used in a live environment

48. Summary Images must be organized into a standard format for storage
Scanning is the process of converting printed data into electronic format
Data can be classified as structured or unstructured
For information to be shared, a common language or format must be used
Health Level 7 is a standards development organization

49. Summary (cont’d.)
An HL7 message is composed of groups of message segments presented in a predefined sequence
Troubleshooting uses a systematic approach to determine the source of a problem
Software regularly changes over time
Increases complexity of clinical software management
Change control process is needed