The newly formed Quality Regional Healthcare LLC is now the largest integrated healthcare delivery system in the region. The organization provides patient services through three major hospitals (Mercy Healthcare, Hope Healthcare, and Grace Healthcare) and includes 800 affiliated physicians. As a result of the merger, the organization has three major quality and safety outcomes and strategic goals:

· Promote effective communication and coordination of care

 · Improve healthcare quality and patient safety as well as reduce harm and medical errors

 · Improve healthcare and population health through meaningful use of health information technology and support of the health information exchange

All three hospitals within the organization are currently using different data-capture techniques and technologies. Mercy Healthcare, the smallest of the three hospitals, has not yet advanced from paper to electronic medical records. It uses manual extraction and document-imaging technologies, such as scanners and barcodes, to feed indexing information into an electronic database. Examples of indexing information include patient names; medical record numbers; and ICD-10-CM diagnosis codes. Mercy Healthcare applies the subjective, objective, assessment, plan (SOAP) format, which is commonly used by paper-based institutions to help organize its documents.

Hope Healthcare, the second largest hospital in the network, uses a partial electronic health record (EHR) system for data capture, while still maintaining some use of structured paper-based forms. These documents are standardized patient assessment instruments and contain structured data definitions known as common data elements (CDEs). However, some patient records are incomplete, as clinicians and coders have, at times, neglected to fill in all the CDEs displayed on a form. Hope Healthcare also uses optical character recognition/intelligent character recognition technology, which is incorporated in document and data-capture software applications to automatically capture information like names, dates, and patient identification numbers rather than requiring manual extraction and entry. Hope Healthcare applies ICD-10-CM and current procedural terminology codes as terminology standards for internal sharing of information.

Grace Healthcare is the largest of the three medical centers. Like Hope Healthcare, Grace Healthcare has been utilizing a partial EHR system and has employed structured formats for its few paper-based documents that remain. Grace Healthcare’s system is currently set up to use Health Level Seven (HL7) as a conceptual standard for describing clinical data and the Systemized Nomenclature of Medicine (SNOMED) as its terminology for clinical terms.

Quality Regional Healthcare LLC would eventually like to carry out a new system-wide implementation to enable better coordinated care across the associated medical centers. For that to happen, the hospitals must share common data and integrate clinical care. They will need to ensure that they are not duplicating patient records. They must also ensure that staff members are able to find and access needed data that accessible data does not take a long time to obtain, and that staff members are granted the appropriate access for requesting and reviewing data. Clinicians who are a part of the patient-care continuum will need to access patient records. All other requests to access patient records will be determined on a case-by-case basis in order to maintain the integrity and privacy of the patient.

Due to the varying collection, maintenance, and retention practices used by the three hospitals in the organization, data fields in patient records may be incomplete or inaccurate. There is also variation in the classification and coding schemes that were being used by each hospital, making the sharing of information and coordination of care difficult. Lastly, because each hospital was initially operating as a separate legal entity, each was adhering to its own internal privacy and security regulations. The formulation of Quality Regional Healthcare LLC has led to the need to standardize interoperability, security, and privacy policies across the new organization.

 In light of these issues, the chief information officer has tasked the health information manager with developing a training manual on information governance to provide guidance to the medical coders and clinical professionals of the new hospital system

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