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

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

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

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

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

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

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

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)

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

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

Figure 6-1 Desktop scanner © Konstantin Shevtsov/www.Shutterstock.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HL7 Message Problems Common problem with HL7 messages Improperly formatted patient demographics Example: patient’s SSN is 123-4T-5678 when it should be 123-45-6789 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

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

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

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

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

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

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

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

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

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

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

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

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

Table 6-4 Tiered technical support © Cengage Learning 2013

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

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

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

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

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

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

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

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

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