Proposal – Information Collection and Legal Considerations for Quality-of-Care Study

Proposal – Information Collection and Legal Considerations for Quality-of-Care Study

This proposal outlines the steps and processes to be carried out to measure the quality of care extended by a physician group to patients diagnosed with diabetes. Diabetes is one of the major prevalent chronic diseases of millions worldwide; therefore, the challenges in tackling this disease call for significant public health action. It is a disease requiring consistent management over the long term, and hence, for improvement in patient outcomes, there is an inherent need to understand the quality of provided care. The reason for the focus on diabetes is due to its increasing prevalence and the complications arising from poorly managing it, which creates admission, amputation, and sometimes death. The physician group is interested in knowing how well it is managing that condition in its patients by reviewing the quality of care that has been delivered.

Information Collection

Patient Population

The patient population in this study will include all diabetic patients treated by the physician group in the past five years. This will help ensure that the treatment patterns and outcomes observed are representative of and relevant to current practice and that the findings of the study will be applicable to current treatment protocols and guidelines. The population will include adult patients 18 years and older without restriction to gender, ethnicity, or socioeconomic background.

Information Systems

Several information systems will be employed to capture the relevant data.

Electronic Health Record (EHR)

In the office, the EHR system will act as the central point for storing patient information (Epizitone et al., 2023). It contains all the substantial details of every patient’s visit, from their laboratory results to their medication and treatment descriptions.

Pharmacy System

This will provide data on medication prescribed and actually dispensed to the patients. This shall be very important in determining adherence to the guidelines in the management of diabetes, more so on drug compliance.

Results Management System

This will help retrieve lab results; for instance, hemoglobin A1c is a critical marker of diabetes control and can be used as a benchmark against which quality of care can be assessed.

Point of Care (POC) System

This system will be used to collect real-time data during patient visits, including vital signs, blood glucose readings, and other relevant measurements. It will provide immediate, actionable information for clinicians and contribute to the overall assessment of care quality.

Computerized Physician Order Entry (CPOE) System

The CPOE system will be utilized to track and analyze physician orders for medications, tests, and procedures. This will help in evaluating adherence to clinical guidelines and identifying patterns in care delivery.

These systems collectively represent a mix of clinical and administrative systems. The EHR, POC, and Results Management systems are primarily clinical, while the Pharmacy and CPOE systems have both clinical and administrative components.

Specific Documentation

Types of documentation to review for comprehensive evaluation of the quality of care include:

History and Physical [H&P]

This will give an idea about the initial diagnosis, the risk factors, and the comorbid conditions of the patient, which is very important in assessing his starting point of care.

Progress Notes

These will allow for monitoring of patient visits, the progression of their condition, and the physician’s continued management in regard to diabetes, including medication changes or treatment plans.

Lab Results

Certain indicators such as hemoglobin A1c levels, blood glucose levels, and lipid profiles will be reviewed for control in patients with diabetes.

Medication Records

A review of medications prescribed and dispensed will help you understand the treatment guidelines regarding medication compliance in living with diabetes.

Radiology

Any relevant imaging studies, including those for diabetic-related complications of the foot or eye, will be reviewed to determine management as it relates to complications from diabetes.

The patients will be drawn from the physician group, and records of all hospitalizations or emergency department encounters for diabetic complications will also be incorporated into the study.

Information Life Cycle

Collection and Documentation

Data collection will be done in the office through the Health Information Management (HIM) system under the supervision of the office manager. Our proposed data sources include the EHRs, the pharmacy, the results management system and information from the health care centers pharmacy department. The particular records that will be taken out by the HIM team will coincide with the inclusion criteria of patients diagnosed with diabetes in the previous five years (Weng, 2019).

Storage

The information will be gathered and afterward archived in a database of Health information in our office Electronic Health Record System. This information shall only be provided to only and directly involved persons in this research and only those who have the necessary role-based privileges such that privacy and confidentiality might be observed and assured whenever required.

 Access Control

The data collected here shall not be made available to third parties and any data kept in computers shall be encrypted and password protected. Only the office manager and the HIM team and the involved physicians shall only have an access thereto. Audit trails in the system shall track who has accessed what data and what action is taken with it to ensure accountability and security.

Interoperability Standards

The physician group will ensure the documentation is interoperable, working under the guidelines of Health Level 7 (HL7), which enables the exchange, integration, and sharing of electronic health information across different health systems. This will provide easy integration in the future with Health Information Exchanges (HIEs), making the data interoperable and meeting national standards.

Integration with HIE

Sharing the office’s information with the HIE confers advantages. It facilitates coordination of care and access to integrated records. However, it also has its challenges: it requires standardization of data formats and may introduce security risks. So, such challenges have to be balanced for smooth integration.

Challenges in Standardization of Health Information

There are many obstacles in the way of standardized health information, which can seriously impede development. The disparity in data formats is one of the main challenges. Different healthcare systems use different data formats, which makes cross-platform information integration and comparison more difficult. Since many systems may show the same information differently, this fragmentation makes it difficult to develop a cohesive picture of patient data.

Destruction

Data will be destroyed in compliance with federal and state regulations after the study. Once retention periods expire, electronic data will be securely deleted, and paper records will be shredded. The office will follow Health Insurance Portability and Accountability Act (HIPAA) guidelines for proper data disposal.

Legal Considerations

Conflicting Privacy, Confidentiality, and Security

This research project will be collecting protected health information. Privacy, confidentiality, and security of this information are crucial. Confidentiality, in this aspect, refers to the duty of the professional to safeguard the patient information from unauthorized access, while privacy concerns individual rights to control access to health information (Haddad & Geiger, 2023; Olejarczyk & Young, 2024; Tulane, 2023). On the other hand, security is the physical and technical steps to protect health information from breach, theft, or loss. All three will be discussed in an effort to have the physician group comply with legal and ethical standards.

HIPAA Compliance

The Health Insurance Portability and Accountability Act specifies the confidentiality, privacy, and security framework for PHI. As a result, this proposal would be required to provide the physician group with HIPAA-compliant policies and procedures, including encryption, access controls, study data auditing, etc. All personnel participating in this study are oriented toward HIPAA guidelines to make them aware of their responsibilities in protecting patient data by maintaining confidentiality and security.

Use of PHI

The data to be extracted will include PHI, as the research covers patients with diabetes. PHI shall be utilized only to review the quality of care delivered. The information shall be de-linked when possible; privacy risks are minimal. No knowledge about the patients shall be disclosed outside the physician group except with express consent from the patient or when legally indicated.

Conclusion

Documentation reviews associated with diabetes care will allow the physician group to gain valuable lessons about the quality of care being reviewed. Collection and analyses of patient data will provide the group the means to determine areas for improvement and may institute changes that will be needed to better the outcomes for their patients. Under HIPAA, there is a need to manage health information securely throughout its lifecycle in order to ensure the success of this study.

References

Epizitone, A., Moyane, S. P., & Agbehadji, I. E. (2023). A Systematic Literature Review of Health Information Systems for Healthcare. Healthcare, 11(7), 959. https://doi.org/10.3390/healthcare11070959

Haddad, L. M., & Geiger, R. A. (2023). Nursing ethical considerations. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054/

Olejarczyk, J., & Young, M. (2024, May 6). Patient rights and ethics. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538279/

Tulane. (2023). Ethics in health care: Improving patient outcomes. Tulane University School of Public Health and Tropical Medicine. https://publichealth.tulane.edu/blog/ethics-in-healthcare/

Weng, C. (2019). Clinical data quality: a data life cycle perspective. Biostatistics & Epidemiology, 1–9. https://doi.org/10.1080/24709360.2019.1572344

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

Develop a section (3–5 pages) of a proposal to study whether a group of physicians provided quality of care related to an identified disease or condition and population. Include a plan to manage the information from collection to destruction and an analysis of legal considerations.

Expand All
Introduction
For this assessment and others in this course, you will assume the role of an office manager for a physician group. In most fields—whether it’s manufacturing, the service industry, or health care—organizations are looking for ways to improve the quality of service they provide to their customers. Keeping an eye on quality helps them remain competitive in the marketplace and stay in business. Otherwise, their customers will go elsewhere. This is especially true in the health care field, where people’s health and lives are at stake.

Preparation
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.

Instructions
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.

Additional Requirements
Your assessment should meet the following requirements:

Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.
Title page: Develop a descriptive title of approximately 5–15 words. It should stir interest yet maintain professional decorum.
References: Include a minimum of two citations of peer-reviewed sources in APA format.
Length: 3–5 typed, double-spaced pages, not including the title page and references page.
Font and font size: Times New Roman, 12 point.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Determine stages of the information lifecycle embedded within health information management technology functions.
Apply steps of the health care information life cycle.
Competency 2: Apply laws governing health information confidentiality, privacy, and security.
Differentiate between required confidentiality and security measures.
Apply laws governing health information confidentiality, privacy, and security.
Competency 3: Assess system applications used to operationalize health information.
Evaluate which information system or systems best provide needed information.
Competency 6: Communicate in a manner that is scholarly, professional, respectful of the diversity, dignity, and integrity of others, and is consistent with the expectations for healthcare professionals.
Write clearly, with correct spelling, grammar, and syntax, and good organization.
Apply proper APA formatting and style to references and citations.