Your physician group is no different than other organizations. It wants to find ways to improve the quality of care it provides to patients. This, in turn, helps the physician group remain profitable and stay in business. As a result, the senior leaders of your physician group have asked you to provide a documentation review of the quality of care provided by the office. As the office manager, you are the one responsible for the management of the health information within the office and the review of information to determine whether providers met quality of care standards. Determining this will require you to:
Identify a disease or condition served by the physician group.
Determine what patient information is needed and where to retrieve it.
Compare your overall office data to the national benchmarks.
Typically, in the workplace, the physician group’s specialty area (cancer, diabetes, dermatology, et cetera) would dictate the disease or condition for which you would be collecting information. For the purpose of this assessment, however, you may select the disease or condition that interests you from this list:
Asthma.
Diabetes.
Myocardial infarction.
HIV/AIDS.
Cancer.
Select the disease or condition that is important to you and that you want to study. Perhaps you have the disease or condition. Perhaps a family member or friend does. Remember you will be working with this condition in the remaining course assessments.
Now that you have determined the disease or condition you are going to study, you will need to begin collecting protected health information (PHI) for the patients treated by your physician group who have the condition you are studying. You will need to consider carefully the privacy, security, and confidentiality of the information within the patients’ office records. Determining how you, as the office manager, will maintain data security is a key aspect of your work. You are responsible for knowing and understanding the types of documentation, applications, and information systems used within and outside of the office. All information moves through a life cycle from creation to destruction. Regulations, policies, and procedures strictly control this ongoing process. The office manager needs to know this life cycle and where to locate information when it is needed.
For this assessment, you will write a section of a proposal about how the documentation on previous patient care will be retrieved, from where it will be retrieved, and how that data will be kept secure during retrieval and review. Remember that you are focusing on retrieving and analyzing existing documentation within the office.
For this section of your proposal:
Identify the disease or condition and the population that will be the focus of your study.
Explain your plan to manage this information from collection to storage to destruction.
Identify legal considerations and a plan for compliance for the PHI you are collecting.
In later assessments in this course, you will continue on with your proposal and begin to plan for how you will compare the office data you have collected to the national benchmarks. Remember: You will not be able to actually do this comparison. You are simply preparing a proposal for senior leaders about how you would go about performing this work.
Please read the scoring guide for this assessment to better understand the performance levels relating to each criterion on which you will be evaluated.
You will not be writing the entire proposal for this assessment; only parts of it. You will add to your proposal in later assessments and complete it in Assessment 3. Be sure this part of your proposal includes all of the following headings, and your narrative addresses each of the bullet points:
Introduction
Identify the disease or condition from the following list for which you will review the quality of care:
Asthma.
Diabetes.
Myocardial infarction.
HIV/AIDS.
Cancer.
Explain the reasons for your choice.
Information Collection
Complete the following:
Determine the patient population to be reviewed.
Evaluate which information system or systems best provide the needed information.
Determine the specific documentation you are looking for. Explicitly state the reasons for each and all of your choices. Be sure to answer all of the following questions in your narrative:
Do you want to review information only from your office? Or do you also want to review information for hospital admission and/or emergency room visits?
Do you wish to review all patients who have ever been treated for the selected condition? Or only those treated within a specific time frame? Will you only review patients within certain demographic parameters?
What type of documentation do you want to review? This may include:
History and physical (H&P).
Discharge summary.
Progress notes.
Labs.
Radiology.
Others.
Identify where you are going to find the information you need. Which information system or systems would be best to use, and what information can you collect from each system? Possibilities include:
Pharmacy.
Point of care (POC).
Results management.
Computerized physician order entry (CPOE).
Determine the type of system or systems (financial, administrative, clinical, et cetera) you would use.
Information Life Cycle
Complete the following:
Describe how you plan to manage this information from collection to destruction. Be sure to address all of these questions in your narrative:
How will the information be collected and documented? By whom? In what context?
How will the information be stored?
How will you control access to the information?
How can you ensure the documentation meets interoperability standards?
What are the advantages and disadvantages of integrating your office information with an HIE?
What challenges exist regarding the standardization of health information?
When and how will the information be destroyed?
Legal Considerations
Complete the following:
Differentiate between the legal aspects of health information confidentiality, privacy, and security, as it applies to your proposal.
Apply laws governing health information confidentiality, privacy, and security.
Determine whether the information you are retrieving requires the use of PHI.
If not, why not?
If so, summarize how the PHI will be used.
Plan for how the Health Insurance Portability and Accountability Act (HIPAA) will impact health care personnel, policies, and procedures in your proposal.
Conclusion
Briefly summarize the value of the documentation review you are proposing to be performed.
