Electronic Health Record And Applications

I.     Course Prefix/Number: HIT 194

       Course Name: Electronic Health Record And Applications

       Credits: 3 (3 lecture; 0 lab)

II.    Prerequisite

Recommended: Hands-on computer experience using software in Windows, i.e., Word, Excel, Access and PowerPoint.

III.   Course (Catalog) Description

Course covers health information systems used in health care delivery systems including terminology and essential concepts of health information systems. An overview of administrative and clinical information systems is given. Course covers phases of system development life cycle and structure of electronic health record (EHR). Content includes overview of health care industry’s transitioning to electronic health record systems, components of EHR, certified EHR technology, benefits of EHR, along with privacy and security issues affecting access to and use of patient information. Students are introduced to data analytics and healthcare informatics. Course also covers database design, standards for HIT, and health information exchange. Students practice with software applications common to a healthcare setting.

IV.   Learning Objectives

Upon successful completion of this course the student will be able to:

  1. Identify and discuss the impact and the history of computers on healthcare.
  2. Compare and contrast the similarities and differences among the Internet, intranet, and extranet used in healthcare.
  3. Differentiate between data analytics, health informatics, data mining, and consumer informatics.
  4. Identify the information systems needed to support efficient operations in the health information management department.
  5. Differentiate between the various software products used in the HIM department.
  6. Identify the multiple uses of electronic health record in the healthcare setting.
  7. Create a planning, design, implementation, and maintenance phase for an electronic health record in the healthcare setting.
  8. Identify the various data sources that populate the EHR and the need for the multiple information systems required to support EHR.
  9. Perform health data operations utilizing Virtual Lab software.
  10. Create a database structure using MS Access software, data dictionaries, and data models.
  11. List and give an example of each of the American Health Information Management Association data quality management model characteristics.
  12. Make recommendations to address data quality and data integrity issues.
  13. Differentiate between a data repository and a data warehouse.
  14. Analyze the healthcare facility needs for clinical and administrative information systems.
  15. Explain the concept of interoperability and its importance in healthcare.
  16. Compare and contrast the benefits and barriers of the health information exchange (HIE); the models and methods of HIE; information governance with data governance.
  17. Explain the requirements of Meaningful Use and the necessity for standards in health information technology.
  18. Compare and contrast data content standards, vocabulary standards, and messaging standards.
  19. Apply health data privacy and security practices that protect health data and meet compliance standards.
  20. List the key Information Governance Principles for Healthcare (IGPHC).

V.    Academic Integrity and Student Conduct

Students and employees at Oakton Community College are required to demonstrate academic integrity and follow Oakton's Code of Academic Conduct. This code prohibits:

• cheating,
• plagiarism (turning in work not written by you, or lacking proper citation),
• falsification and fabrication (lying or distorting the truth),
• helping others to cheat,
• unauthorized changes on official documents,
• pretending to be someone else or having someone else pretend to be you,
• making or accepting bribes, special favors, or threats, and
• any other behavior that violates academic integrity.

There are serious consequences to violations of the academic integrity policy. Oakton's policies and procedures provide students a fair hearing if a complaint is made against you. If you are found to have violated the policy, the minimum penalty is failure on the assignment and, a disciplinary record will be established and kept on file in the office of the Vice President for Student Affairs for a period of 3 years.

Please review the Code of Academic Conduct and the Code of Student Conduct, both located online at

VI.   Sequence of Topics

  1. History of Computers in Healthcare
    1. Early Information Systems
    2. Modern Information Systems
  2. Impact of Computers on Healthcare
    1. Impact of Technology on Patient Care
      1. Patient Safety
      2. Evidence-Based Medicine
    2. Impact on the HIM Profession
  3. Introduction to Health Informatics and Data Analytics
  4. Data Sources
    1. Primary Data Sources
    2. Secondary Data Sources
  5. Screen Design
  6. Data Capture
    1. Direct Data Entry
      1. Unstructured Data Fields
      2. Structured Data Fields
    2. Template-Based Data Entry
    3. Speech Recognition
      1. Natural Language Processing
  7. Data Integrity
    1. Required Fields
    2. Edit Check
  8. Data Quality Management
    1. Data Accessibility
    2. Data Accuracy
    3. Data Comprehensiveness
    4. Data Consistency
    5. Data Currency
    6. Data Definition
    7. Data Granularity
    8. Data Precision
    9. Data Relevancy
    10. Data Timeliness
  9. Data Integrity Issues
    1. Data Cleansing
    2. Data Mapping
    3. Documentation Integrity Errors
      1. Patient Identification
      2. Authorship
      3. Dictation Errors Without Validation
      4. Copying and Pasting
      5. Amendments to the Health Records
    4. Data Quality Measure
  10. Database Management System
    1. Natural Language Queries
    2. Query by Example
    3. Structured Query Language
    4. Data Dictionary
    5. Data Standards
  11. Data Modeling
    1. Data Modeling Tools
    2. Common Database Models
      1. Relational Database Model
      2. Hierarchical
      3. Network Database Model
      4. Object-Oriented Database Model
  12. Data Repository and Data Warehouse
  13. Data Mining
    1. Online Analytical Processing
    2. Common Uses and Examples in Healthcare and Health Information Management
  14. Planning and Analysis Phase of the System Development Life Cycle(SDLC)
    1. Planning
      1. Conducting a Feasibility Study
      2. Setting the Budget
      3. Goals and Objectives
      4. Identifying the Project Manager and Project Team
      5. Obtaining Buy-in from Management and Users
    2. Organization of the Project
      1. Project Team
    3. Defining Scope of Project
      1. Project Plan
      2. Project Management Tools
    4. Systems Analysis
  15. Design Phase of the SDLC
    1. Determining Who Will Build and Maintain the System
    2. Choosing Between Integrated and Interfaced Information Systems
    3. System Selection
      1. Request for Information and Proposal
        1. Letter of Introduction
        2. Information for Potential Vendors
        3. Description of the Proposed System
      2. Evaluation of proposed systems
        1. Onsite Demonstrations
        2. Site Visits
        3. Reviewing RFP Responses
        4. Reference Checks
      3. Selection of an Information System
      4. Contract Negotiation
  16. System Implementation of the SDLC
    1. Site and space preparation
    2. User Preparation
    3. Installing Hardware and Software
    4. Programming and Customization
    5. User Configurations and Settings
    6. Screen Design
    7. Reengineering Processes
    8. Policy and Procedure Development and Documentation
    9. Testing Plan
      1. Types of Testing
      2. Test Plan
      3. Testing Documentation
    10. Training
      1. Planning for Training
        1. Contents of the Plan
        2. Selecting the Training Location
        3. Scheduling the Training
        4. Resources Needed
        5. Train the Trainer
      2. Conducting the Training
      3. Evaluating the Training
      4. Additional and Ongoing Training
      5. Computer-Assisted Instruction
      6. Documenting the Training
    11. Conversation
    12. Go-Live
      1. Go-Live Models
        1. Phased Approach
        2. Pilot Method
        3. Big Bang Method
        4. Parallel Processing
        5. Straight Turnover
      2. Planning for Go-Live
        1. Initial Support
        2. Ongoing Support
    13. System Evaluation
  17. Computers in Health Information Management: Functionality and Reporting
    1. Release of Information and Disclosure Management
    2. Encoder and Grouper
    3. Cancer and Other Registries
    4. Chart Locator
    5. Chart Deficiency
    6. Dictation and Transcription Systems
    7. Computer-Assisted Coding
    8. Clinical Documentation Improvement
  18. Administrative Information Systems: Functionality and Impact on HIM
    1. Financial Information System
    2. Human Resources Information System
    3. Decision Support System
    4. Master Patient Index
    5. Patient Registration (Registration - Admission, Discharge, Transfer)
    6. Scheduling System
    7. Practice Management
    8. Materials Management
    9. Facilities Management
  19. Clinical Information Systems
    1. Document Management System (DMS)
      1. Components of a Document Management System
        1. Scanner
        2. Scanning Workstation
        3. Abstracting and Quality Control Workstation
        4. File Server
        5. Retrieval Workstation
        6. Printers
        7. Annotation
      2. Advantages and Disadvantages
      3. Implementation
        1. Justification of Cost of System
        2. Forms
        3. Staffing Changes
        4. Process Redesign
      4. Retrieval of Images
      5. Future of Document Management System Imaging Process
    2. Radiology Information Systems (RIS)
      1. Picture Archival Communication System (PACS)
    3. Laboratory Information Systems (LIS)
    4. Nursing Information Systems
    5. Pharmacy Information Systems (PIS)
    6. Interdisciplinary Charting System
    7. Emergency Department System
    8. Anesthesia Information System
    9. Patient Monitoring Systems
  20. Telehealth and Smart Cards
  21. Electronic Health Record
    1. Purpose and Components of the EHR
    2. Status of the EHR
      1. Certified EHR Technology
      2. Stark Law Exception
    3. Components of EHR
      1. Registration-Admission, Discharge, Transfer
      2. Patient Financial Services
      3. Order Communication/Results Retrieval
      4. Ancillary, Clinical, and Department Applications
      5. Patient Monitoring
      6. Document Management System
      7. Clinical Messaging and Provider-Patient Ports
      8. Results Management
      9. Point-of-Care Charting
      10. Computerized Physician or Provider Order Entry System
      11. Electronic Medication Administration Record
      12. Clinical Decision Support System
      13. Health Information Exchange
    4. Benefits of the EHR
    5. Barriers to the EHR
    6. Signatures and Copy and Paste Concerns for the EHR
    7. EHR Tools
      1. Data Retrieval
      2. Graphical User Interface
      3. Color and Icons
      4. Data Entry
        1. Unstructured Data Entry
        2. Structured Data Entry
        3. Template-based Entry
      5. Natural Language Processing
    8. Legal Issues
    9. Interoperability
    10. Transition period – Hybrid Record
    11. Impact on HIM
  22. Consumer Informatics
    1. Health Literacy
    2. Consumer Health Applications
    3. Consumer Informatics Applications
      1. Patient Portals
      2. Personal Health Record
      3. Social Media
  23. Health Information Exchange
    1. History of Health Information Exchange
    2. Benefits and Barriers to Health Information Exchange
    3. Meaningful Use
    4. Models of Health Information Exchange
      1. Consolidated or Centralized Model
      2. Federated or Decentralized Model
      3. Hybrid Model
    5. Methods of Health Information Exchange
      1. Directed Exchange
      2. Query-Based Exchange
      3. Consumer-Mediated Exchange
    6. Health Information Exchange Privacy Concerns
  24. Standards in Healthcare
    1. Standards Development Organizations
      1. American National Standards Institute
      2. ASTM International
    2. Data Content Standards
    3. Vocabulary Standards
      1. Systematized Nomenclature of Medicine (SNOMED)
      2. Logical Observation Identifiers Names and Codes (LOINC)
      3. RxNorm
      4. Unified Medical Language System (UMLS)
      5. National Drug Codes
      6. Current Dental Terminology
      7. MEDCIN
      8. Diagnostic and Statistical Manual of Mental Disorders
      9. Mapping
    4. Messaging Standards
      1. Health Level 7 (HL7)
      2. Digital Imaging in Communications in Medicine
      3. ANSI Accredited Standards Committee X12N
      4. National Council for Prescription Drug Programs
  25. Health Insurance Portability and Accountability Act of 1996
    1. Transaction and Code Sets Rule
    2. Privacy Rule
    3. Security Rule
  26. American Recovery and Reinvestment Act of 2009
  27. Security Threats and Safeguards
    1. Administrative Safeguards and the Security Management Process
      1. Risk Analysis
      2. Risk Management
      3. Sanction Policy
      4. Assigned Security Responsibility
      5. Workforce Security
        1. Managing a Security Incident
        2. Ongoing Security Procedure Evaluation
      6. Contingency and Business Continuity Planning
        1. Data Recovery
  28. Business Associate Contracts or Other Arrangements
    1. Technical Safeguards
      1. Access Control Systems and Authentication
        1. Types of Authentication
        2. User Authentication Methods
      2. Audit Controls
        1. Integrity
    2. Malicious Software
      1. Virus
      2. Worms
      3. Trojans
      4. Bots
      5. Spyware
      6. Phishing
      7. Ransomware
    3. Physical Safeguards
      1. Facility Access Controls
      2. Workstation Use
      3. Device and Media Controls
      4. Mobile Security
      5. Fire and Natural Disasters
  29. Data and Information Governance
    1. Data Governance in Health Information Management (HIM)
      1. Impact of Data Governance in HIM
      2. Issues to Consider
        1. Metadata
        2. Data Mapping
    2. Information Governance in HIM
      1. Valued Strategic Asset
      2. Issues to Consider
        1. Importance of Data Quality
        2. Business Intelligence
        3. IG Steering Committee
        4. Leadership
        5. IG Charter
        6. IG Plan
        7. SBAR in IG
        8. Information Asset Inventory
      3. Strategic Alignment
      4. Information governance Principles of Healthcare
      5. Information Technology Governance
    3. Enterprise Information Management
      1. Building Blocks of Enterprise Information Management
      2. Importance and Impact of Enterprise Information Management on HIM
    4. Information Governance Adoption Model
    5. Roles for the HIM Professional in Data Governance and Information
      1. Data Steward
      2. Clinical Documentation Improvement Coordinator
      3. Health Data Analyst
      4. Future of Data and Information Governance in HIM
  30. Role of HIM Professionals in Information Systems

VII.  Methods of Instruction

Students will complete case studies and participate in online discussions about administrative and clinical information systems.  Class time will include some lecture relating to information systems in HIM, electronic health record, standards in health information technology, system development life cycle and lab activities regarding data modeling, database design, and the EHR selection process. Students will use both textbooks and the Virtual Lab software for the completion of their assignments.

Course may be taught as face-to-face, hybrid or online course.

VIII. Course Practices Required

Students are required to use class D2L website; do all required readings, utilize VLab resources, MS Office and VISIO software to complete the course assignments; participate in online discussions and small group activities; complete assigned projects, and take quizzes and exams. Participation in small groups and online discussions are required, as well as use of Internet and VLab resources.

IX.   Instructional Materials

Note: Current textbook information for each course and section is available on Oakton's Schedule of Classes.

Required Textbook:

Information Systems for Health Information Technology, Third Edition, Nanette B. Sayles and Lauralyn Kavanaugh-Burke.

Optional Textbook:

Health IT and EHRs, Sixth Edition, Margaret K. Amatayakul

Supplemental handouts provided by the instructor.

X.    Methods of Evaluating Student Progress

Evaluation methods include examinations, chapter quizzes, online discussions, VLab activities, research-based project and homework assignments.
Grades will be determined on a cumulative point basis:

A=  94%
B=   88%
C=   82%
D=   76%
F=    Below 76%

XI.   Other Course Information

Class Policy on:

Attendance: Class attendance is required.  Students are expected to be in class and on time for all scheduled classes.  Absences should be reported to the instructor prior to the beginning of the class, through an email.  It is the student responsibility to contact the instructor to obtain copies of any missed course material covered while absent.  It is not the responsibility of the instructor to ensure the student receives any material missed. Two or more absences will result in a 5% reduction of the student’s course grade.

Make-up of Exams: Only one make-up exam is allowed, and only when the student contacts the instructor prior to the exam being given.  Make-up exams must be taken before the next class session.

Incomplete Grades: It is the student’s responsibility to initiate requests for an incomplete grade, to complete all of the required assignments/materials/exams, and to follow through with the procedures to remove the incomplete grade.

Late Assignments:  It is expected that assignments will be turned in on the due date.  If a late assignment is accepted by the instructor, it must be turned in prior to the next class session.  The grade on late assignments will be reduced by 7%. No late assignments will be accepted after the next class session.

Assignments: Written assignments should be typed utilizing the Times New Roman font in size 12. Points will be deducted for handwritten assignments or corrections.

Reading Assignments: All reading assignments are expected to be completed prior to the class session.

Cell Phones and Texting: Cell phones may not be used in the classroom. They must be turned off while the class is in session.  Texting is also not permitted while the class is in session.

Oakton Computer, Printer Use, and Personal Laptop Computers: Oakton computers and printers in the HIT lab are only to be used for class assigned projects and assignments.  Computers are not permitted to be on during a lecture. Personal laptop computers are also not permitted to be used while the class is in session.

Recording Devices: Recording devices are not allowed during class unless special permission is granted.

If you have a documented learning, psychological, or physical disability you may be entitled to reasonable academic accommodations or services. To request accommodations or services, contact the Access and Disability Resource Center at the Des Plaines or Skokie campus. All students are expected to fulfill essential course requirements. The College will not waive any essential skill or requirement of a course or degree program.

Oakton Community College is committed to maintaining a campus environment emphasizing the dignity and worth of all members of the community, and complies with all federal and state Title IX requirements.

Resources and support for
  • pregnancy-related and parenting accommodations; and
  • victims of sexual misconduct
can be found at www.oakton.edu/title9/.

Resources and support for LGBTQ+ students can be found at www.oakton.edu/lgbtq.

Electronic video and/or audio recording is not permitted during class unless the student obtains written permission from the instructor. In cases where recordings are allowed, such content is restricted to personal use only. Any distribution of such recordings is strictly prohibited. Personal use is defined as use by an individual student for the purpose of studying or completing course assignments.

For students who have been approved for audio and/or video recording of lectures and other classroom activities as a reasonable accommodation by Oakton’s Access Disabilities Resource Center (ADRC), applicable federal law requires instructors to permit those recordings. Such recordings are also limited to personal use. Any distribution of such recordings is strictly prohibited.

Violation of this policy will result in disciplinary action through the Code of Student Conduct.