There are almost 300 million individuals with health insurance in the United States, according to CNBC. Further, Canadian Science Publishing reports that about 2.5 million new scientific papers are published each year. All this means is that patient data needs to be accurate and of the highest quality to help with patient care.
Although patient health data is used by physicians to offer proper treatment and diagnosis, it also serves many other purposes. It can help accurately shape a medical facility’s offerings, future growth of the facility, and the industry’s ability to stay on top of trends in patient care.
Patient data can be gathered from multiple patients with the same diagnosis, and the medical industry can invest in specific equipment that will help treat these patients. The medical industry also uses patient data to identify and support research and studies that may help identify trends in patient care. Insurance companies use patient data to determine whether a claim should be paid. Government agencies use patient data to ensure that the medical facility is in compliance with the standards that govern it.
What Is Health Information Management?
Health information management is information management applied to health care. Health information management practices acquire, analyze, and protect medical information that is vital to providing quality patient care.
The health information management profession is supported by the American Health Information Management Association (AHIMA), founded in 1928. The mission of AHIMA is to advance the health information management profession by increasing the use of electronic medical records and information governance. AHIMA is working to advance the accuracy, reliability, and usefulness of health data.
Primary and Secondary Data
Primary data is the actual information in a patient’s records, whereas secondary data is generated from the information in the patient’s records. Without the accuracy of primary data, there can be a lot of issues with secondary data.
Primary data helps patients evaluate new drug side effects and researchers create vaccines and discover the causes of many different diseases. Accuracy in primary data supplied by the administrative medical assistant is vital to the health of the patient and the advancements in the health care industry.
Patient data is only as reliable as the person who is entering it into the medical database. In an effort to provide high-quality patient care, the administrative medical assistant must adhere to nine characteristics of quality patient data including validity, reliability, completeness, recognizability, timeliness, relevance, accessibility, security, and legality.
Validity – To be valid, patient data must be accurate. Accuracy must be kept for both paper and digital medical records. Common mistakes include misspellings, entering similar letters or numbers in error due to sloppy penmanship, and the transposition of numbers when they are entered into the computer.
Reliability – This can be a lifesaving measure to patient care. Physicians must have trust in patient data so that they are confident when treating a patient. For example, the medical record must be reliable if a patient has an allergy. It is important that a physician is able to trust this information when treating any illness or symptom.
With respect to medical research, having a high reliability means that the results are similar under consistent conditions. Scores that are highly reliable are accurate, reproducible, and consistent from one test to another.
Completeness – Patient data must be complete, as well as accurate. If a medical assistant fails to record a treatment, then the medical chart is not complete. The medical assistant is responsible for keeping patient records up-to-date and complete.
Recognizability – It is important to set a standard with respect to interpretation of data in the patient record. Two different medical assistants must interpret an abbreviation in the same way. This is why there are many standards for billing and coding of medical records. The use of ICD-10 (International Statistical Classification of Diseases and Related Health Problems), CPT (Current Procedural Terminology), and HCPCS (Healthcare Common Procedure Coding System) coding is important to keep medical records recognizable.
Timeliness – It is important for medical assistants to add patient information into charts as soon as it is available. Medical assistants may forget to add the information if they don’t do it right away. A lab report or test should be included in the medical record as soon as it is available in order for the physician to give proper care to a patient.
Relevance– Patient data must be relevant to the medical chart. Adding lots of personal notes and unimportant information into the medical record can slow down the physician’s ability to treat the patient. If it is not relevant, then it is not useful.
Accessibility – Electronic records are easier to access than paper records, especially since more than one person can view electronic records at the same time. However, per HIPAA (Health Insurance Portability and Accountability Act of 1996) regulations, only authorized individuals should have access to patient data. If paper based records are still in use, they must be returned to their proper place so the medical staff can access them when needed.
Security – Only authorized individuals should be able to access patient data. Precautions must be taken to safeguard patient data. The computer system should have a log-in process with a password and a firewall to allow only certain data to be accessed. Information should also be encrypted so patient data is available only to those authorized personnel who can unencrypt the patient data.
Legality – Medical records are regulated. Patient data should not be altered, and corrections should be made based on acceptable guidelines. The record must be completely legible and authenticated properly. Authentication is the process of proving something to be accurate, true, genuine, or valid.
With the switch to electronic medical records, administrative medical assistants are in high demand. Medical facilities need employees who can manipulate data while keeping patient data accurate and confidential.
Are you interested in the importance of accurate health information as an administrative medical assistant? The Medical Office Administration program at Hunter Business School prepares students with the skills and training necessary to provide excellent administrative support while working and playing a key role in running an efficient, productive office in a variety of medical and business environments.
Graduates of the Medical Office Administration program can obtain entry-level employment as a medical office specialist or patient coordinator in a hospital, clinic, or physician’s office. Additional possibilities include a billing, admissions, or health unit coordinator in private firms, medical offices, legal offices, or government organizations.