HIM 182

Medicare

Medical coverage for people aged 65 or older, along with younger people who have certain disabilities.

Medicare Part B

Medical insurance for physician services

Meditech (Cont'd - 1)

Over 40 years developing, installing, and supporting health care information systems • Founded in 1969 by the developers of MUMPS - A. Neil Pappalardo and Curt W. Marble developed MUMPS technology on a DEC PDP at Mass General Hospital from 1964 to 1968 • Markets: United States, Canada, United Kingdom, Ireland, South Africa, Latin America, Mexico, Spain • 2,200 customers worldwide • 4000 staff members • Revenue (2011): $545.2 million • Privately-held

Tort Law Reform - 2

Periodic payment • Joint-and-several liability reform - More than one defendant - limits amount that can be recovered from each • Caps on non-economic damages - Limit payments for pain and suffering

ATSDR: Agency for Toxic Substances and Disease Registry

Prevents illness/disease from toxic/hazardous substances.

Stark Law

Prohibits physicians from referring Medicare or Medicaid patients to clinical laboratories and certain other services in which they have a financial interest.

Tertiary Care Center

"A tertiary care center is a medical facility that receives referrals from both primary and secondary care levels and usually offers tests, treatments, and procedures that are not available elsewhere. Most tertiary care centers offer a mixture of primary, secondary, and tertiary care services so that it is the specific level of service rendered rather than the facility that determines the designation of care in a given study" (Kane, 2011) 9

Why Implement an EHR?

"Information technology ... holds enormous potential for transforming the health care delivery system"

Licensure

1) Professionals authorized to practice in their occupation by a state. 2) Health care facilities authorized to operate by a state.

Example of an electronic data interchange transaction is

837 transaction for health care claims

NDC: National Drug Codes

A HIPAA standard code set used for reporting retail pharmacy transactions.

CDT: Current Dental Terminology

A HIPAA standard code set used to report dental procedures.

Fee schedule

A list of allowable services and procedures, and the amounts payable for each, provided by a third-party payor.

Data Set

A list of the data elements with uniform definitions for each element.

Blue Cross/Blue Shield

A nationwide association of thirty-nine (39) independently operated companies. Originally, Blue Cross/Blue Shield companies were not-for-profit organizations, but today some of them operate on a for-profit basis.

MPI: Master Patient Index

A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death.

FDA: Federal Drug Administration

A regulatory agency that oversees the safety of food, drugs, medical devices, vaccines, blood and biologic products, animal feed and veterinary drugs, cosmetics, radiation-emitting products, and tobacco products.

Revenue Cycle

A standard set of activities and events that produce revenue or income for a health care organization or provider.

DICOM: Digital Imaging and Communications in Medicine

A standard used for the exchange and storage of images and diagnostic information.

LOINC

A standardized terminology for representing laboratory data in informaton systems.

Illness

A state of poor health.

Which regulation will have highest precedence in enforcing the HIPAA Privacy Rule?

A state-level regulation more stringent than the federal law

CPOE: Computerized Physician Order Entry

A system used for direct entry of one or more types of orders by a provider into a system that transmits those orders electronically to the appropriate department.

Privacy

The individual's right to keep information to himself or herself. It is the right to be left alone.

The third-party payer is:

The insurance company

Meaningful Use Stage 2

The objective of criteria is to advance health care processes with decision support.

Best-of-breed system

The organization chooses multiple vendors and manufacturers for various components of the health IT system.

CMS Form 1450

The paper claim form submitted by institutions.

CMS Form 1500

The paper claim form submitted by physicians.

Hardware can b e defined as:

The physical components that make things work

Epidemiology

The study of the distribution and determinants of health problems in specified populations and the application of this study to control health problems.

Reimbursement

The term used to describe payment by third-party payers to health care organizations for services provided.

Telemedicine

The use of telecommunication technology to provide, enhance, or expedite health care services. The technology is typically used to increase access to clinical expertise to improve the effectiveness of care.

Meaningful Use of Electronic Health Records

The use of these records improves quality, safety, and efficiency of care; engages patietns and families in their care; improves coodination of care, improves population and public healtha nd reduces disparities; and ensures privacy and security protections for all.

Litigation: Parties

Adversary system - Each party presents his or her case - Facts determined by neutral fact-finder • Civil case: plaintiff and defendant • Criminal case: government and defendant

The Health Record as a Legal Record

• Considered the business record for a health care organization • Also a legal record - Admissible in a court of law - Substantiates quality of care provided

Federal Regulation of Private Health Insurance - 2

• Consolidated Omnibus Budget Reconciliation Act (COBRA) 1985 - Amendment to ERISA - Allows continuation of group benefits in certain cases o Voluntary or involuntary job loss o Reduction in hours worked o Transition between jobs o Death of a spouse, divorce, and certain other life events - Individuals may have to pay higher premiums - Not required for companies with >20 employees

Benefits of HIE: Patients

• Consumer Education and Patient Involvement • Improved payment coordination • Improved clinical outcomes • Improved transitions of care • Reduced or eliminated duplicate procedures • Improved visit experience and satisfaction

The Multi-payor U.S. Health Care System

• Contributors - Private sources o Employers and employees Contributions to private health insurance Out of pocket - Public or government sources o Federal, State, and local Payroll and general tax revenues Special tax, e.g. sales tax Pooled into large funds

Messaging (Cont'd - 1)

• Copy chart or lab results to another provider with a note • Telephone message documentation • Patient scheduling • Referral letter or consultation report • Patient follow-up deficiency alerts

HIPAA Security Rule: General Guidelines

• Covered entities must: - Ensure confidentiality, integrity, and availability - Anticipate threats and protect against them - Protect against impermissible uses or disclosures - Ensure workforce compliance

General Provisions

• Covered entities, business associates, and their subcontractors must - Ensure confidentiality, integrity, and availability of electronic PHI that they create, receive, transmit, and maintain - Protect against reasonably anticipated threats and hazards to such information - Protect against reasonably anticipated uses or disclosures not permitted or required by Privacy Rule - Ensure compliance by workforce • HHS (2010) provides guidance on conducting risk assessments and helps determine whether an issue that's addressable should be addressed by the provider

Hospital Systems

• Defined as two or more hospitals owned by a corporation, with a single board of directors • Network - group of hospitals, physicians, and other entities that collaborate to provide care • Example - Greenville Hospital System University Medical Center - Nonprofit in South Carolina - Has multiple locations

Department of Veterans Affairs (VA) Overview

• Department of the federal government • Established in 1930 • Provides medical care, benefits, social support, memorials - Serves veterans and their families - For all branches of military service

Financing Health Care, Part 1 Learning Objectives - 3

• Describe the various roles played by government as policy maker, payor, provider, and regulator of health care. (Lecture d) • Describe the organization and function of Medicare and Medicaid. (Lecture e)

Clinical Terminologies

• Designed for the documentation by providers when delivering clinical care • Allow for the information to be codified and used in EHRs

Dietetics and Nutrition

• Dietetic technician, registered (DTR) - Associate's degree - Registration Examination for Dietetic Technicians - Variable licensure • Registered dietician (RD) - Bachelor's degree - Registration Examination for Dieticians - Most states require licensure, certification or registration

HIT and Workarounds — 1

• Dr. Foxwood creates a new order each time he wants to re-order a medication. • The nurse enters a verbal order to discontinue the previous medication order, so that the medication will be removed from the electronic medication record. • Dr. Foxwood fails to co-sign the discontinuation order because he sees this as an administrative task.

Hospital Setup: ED

• ED is open 24 hours, 7 days a week • Treats various types of injuries - Ranging from ankle sprain to drug overdose - Severity is assessed by a process called triage • Patients are treated completely or sent to other departments

EHR Clients

• EHR systems make medical records available to multiple simultaneous users. • Tablets, laptops, and PCs allow instantaneous access by healthcare staff as they move around health centers. • Clients use application software to securely connect to and pull data from the EHR server to fulfill user requests.

Federal Regulation of Private Health Insurance - 4

• ERISA mandated coverage - Newborns' and Mothers' Health Protection Act 1996 o 48-hour hospital stay following childbirth - Mental Health Parity Act 1996 o Requires equality for coverage of mental illness - Women's Health and Cancer Rights Act 1997 o Provides certain post-mastectomy benefits

Regional Healthcare Information Organizations

• Each RHIO provides backup for other RHIOs. • MPI identifies home RHIO

A reference used with standardized data that contains definitions, principles and guidelines, the values, format and synonyms for each data element is referred to as a

data dictionary

Health Information Exchange

enables the interoperable linkage of healthcare information across organizations within a hospital, an enterprise healthcare system, a region, or a nation. HIE can be the ACT of sharing information (the verb) or it can represent the SYSTEM which facilitates the exchange (the noun)

Interoperability

• "the ability of different information technology systems to communicate, to exchange data accurately, effectively and consistently and to use the information that has been exchanged." • Date of birth formats - 3/22/56 - March 22, 1956 - 22 March 1956

U.K. Private Health Insurance

• 12% of population - Employer sponsored - Self-pay for private insurance • Provides more choices and shorter wait lists - NHS or private hospitals • NHS working to reduce wait times - Hospital specialist : 18 weeks or less

VA Capacity

• 151 Medical Centers • 820 Community-based Outpatient Clinics • 135 Community Living Centers • 103 Domiciliary (Residential) Care Programs • 300 Vet Centers • Home health care

Allscripts: clients

• 180,000 physicians • 45,000 physician offices • 2,500 hospitals • 19,000 post-acute facilities • 100,000 electronic prescribing physicians • 40,000 in-home clinicians

Nurse Anesthetist

• Education - Must have a BSN - Certified registered nurse anesthetist (CRNA) programs are master's degree programs • Training - Most include courses in advanced practice nursing (physical diagnosis, pharmacology, pathophysiology) - Clinical course in anesthesia simulation labs and practicums in clinical anesthesia. • Certification - National certification exam - Must have 40 hours of continuing education every two years to renew • Licensure - Most are licensed by the state board of nursing • Roles - Provide a significant amount of anesthesia care in the United States and usually practice with physicians but are relatively autonomous

TJC History - 2

• 2007: Name simplified to The Joint Commission (TJC); currently accredits and certifies nearly 21,000 organizations and programs in the USA • 1994: Joint Commission International (JCI) offers an international accreditation and has touched more than 90 countries since then.

What Do Other Governments Do?

• 2012 European Commission Directive - Proposed comprehensive reform on data protection rules in the European Union • February, 2016: Finalized the reform of the EU data protection rules - EU-US Umbrella Agreement ensuring data protection for data transfers across the Atlantic (European Commission, 2016)

Specialty Care

• A specialty is a branch of medicine • Physicians train in specific field - Ophthalmology - Radiology • Fellowship - Additional training in more general field - Example: o Trained in General surgery, fellowship as cardiothoracic surgeon

Primary Care Characteristics - 2

• Accessible - Easy for patients to initiate interaction for a health problem with a clinician? - Efforts to eliminate barriers to patient care • Primary care- array of services that are performed by health care professionals for the purpose of promoting, maintaining or restoring health

Primary Care Characteristics - 5

• Accountable care - primary care clinicians and the systems in which they operate are responsible to their patients and communities for - Quality of care - Patient satisfaction - Efficient use of resources - Ethical behavior

Nonclinical Roles of Nursing

• Administration • Research • Education - Nursing school - Continuing nursing education • Case management • Nursing/clinical informatics

Cost Drivers: Administrative Costs and Reimbursement Methods

• Administrative Costs - Billing Procedures o Rules o Process • Reimbursement Methods - Fee-for-service encourage utilization - Disparities within and among insurance plans

Radiology Technician/Technologist

• Education - Certificate, associate's degree, bachelor's degree • Training - Some general studies - Anatomy, physiology, math, physics, radiation technology - Clinical practicums. • Certification - Voluntary certification by the American Registry of Radiologic Technologist (ARRT) - Accredited training program and an exam • Licensure - Varies by state, but most require licensure - ARRT certification is often a requirement. • Role - Help maintain and calibrate equipment - Position and set controls for x-rays - May specialize in a specific type of radiology such as computed tomography and magnetic resonance imaging

Nurses

• Education - Diploma - Associate's degree - Bachelor of science - Bridge programs for RN to BSN • Clinical training - Part of the education process • Additional training programs. • Certification - Certification is not required for licensure, but nurse licensure is required for nurse certification programs - Many specialty certification programs are available • Licensure - Requires successful completion of an accredited nursing school program - NCLEX-RN.

Dentist

• Education - Doctor dental surgery (DDS) or doctor of dental medicine (DMD) - 4 years of college - 4 years of dental school • Training - Preclinical - Clinical. • Licensure - Dental school - Written National Board Dental Examinations - Additional written and practical examinations vary by state • Role - General preventive, restorative, and periodontal care

Physician Assistant

• Education - Most PA applicants have a bachelor of science degree - Associate's, bachelor's, or master's degree • Training - Preclinical - Clinical • Certification - Required to pass the Physician Assistant National Certifying Exam - Maintaining certification requires continuing medical education and recertifying every six years. • Licensure - In most states, licensure is by a medical board - Some states have a specific PA board • Roles - Diagnose and treat patients - Prescribing authority - Hospital and nursing home rounds

EKG Technician

• Education - Often on-the-job training - Certificate programs usually consists of a single course • Training - Basic anatomy, physiology, and electrophysiology of the heart - Technical training on how to use the equipment and verify quality of the tracing. • Certification - Certification exams are available but generally aren't required • License - No state license required • Role - At the most basic level, EKG technicians set up the EKG equipment, run the test, evaluate whether it is an accurate recording, and prepare the recording for interpretation.

State Health Care

• All states have a Department of Health - Organizational structures vary - Responsible for disease treatment, health promotion, care of special groups - State governments partner with HHS • National Academy for State Health Policy - Works with states to improve health care access and quality - Encourages collaboration with federal government, private companies, other states - Example: national health care reform

Concierge Medicine - 1

• Also called direct primary care or retainer practice • Patient pays fee or retainer - Monthly or annual - Receives special service - Enhanced access • Multiple models - Practice size limited - Limited or no insurance billing - Should maintain private health insurance for emergencies

Outpatient Surgical Centers

• Also known as ambulatory surgical centers • Procedures performed in non-hospital location • Patients go home after brief recovery period • Surgical centers do not accommodate overnight or extended stays

"Good Samaritan" Laws

• Apply in emergencies • Protect people who do not have an obligation to help • Rescuer must use common sense • Rescuer must not act beyond expertise and capabilities

Revenue Cycle Overview

• Appointment scheduled • Registration: Demographic and insurance info • Services provided • Charge capture • Coding • Claim submission: paper or electronic • Reimbursement received • Final settlement with patient

Consumer value

• Appropriate care is enhanced by complete set of data about the patient, particularly when combined with decision support • Patient safety is enhanced by complete and timely data at point of care • Effective and appropriate treatment • Patient satisfaction and trust is enhanced by a care giver who knows all about the patient, without the patient having to remember and repeat a full medical history

Administrative Costs

• Approximately 7% of annual U.S. health care expenditures • Administrative costs more than twice average of other western industrialized nations • Estimated excess expense = $91 billion

Prevalent Chronic Diseases

• Asthma • Chronic obstructive pulmonary disease • Chronic renal failure • Congestive heart failure • Coronary artery disease • Diabetes • Mood disorders/senility • Cancer • Hypertension

Information System

• Automated system - Computer hardware and software oReceives data oProcesses data oOutputs data - Supports the functions of the organization

Current Health Care Landscape: Affordable Care Act (ACA)

• Became law on March 23, 2010. • Increases health coverage for children. • Mandates health insurance. • Ends lifetime and most annual limits on care. • Allows young adults under 26 to stay on their parents' health insurance. • Gives patients access to recommended preventive services without cost. • Other benefits: - 50% discounts on brand-name drugs for seniors in the Medicare "donut hole." - Tax credits for small businesses that provide insurance to employees

Common HIT Acronyms

• CIO Chief Information Officer • CMIO Chief Medical Information Officer • CNIO Chief Nursing Information Officer

CONNECT

• CONNECT is an open source software package that implements the NwHIN architecture. • Federal agencies collaborated through the Federal Health Architecture (FHA) to create the CONNECT package.

Quality Reporting for Health Plans

• Called out because of historic role • Health Plan Employer Data and Information Set (HEDIS) by NCQA provides 60 measures that evaluate health plans, particularly health maintenance organizations • NCQA annual reports calculate lives saved saved based on outcomes from adherence

Financing Canada's Health Care

• Canada Health Act 1984 - Increased access - Lowered individual costs - Defined medically necessary services • Financing - Federal income tax distributed to provinces and territories - Province/territory fund a portion

Nursing Homes

• Care for people who cannot live in home or community - May have medical, physical, mental problems - Facilities help with ADLs, provide nursing care - Some are hospital-like, others are home-like - Services include medical, nursing, personal care - Physician draws up a plan of care - Nursing care pertains to medications, acute conditions, rehabilitation, special care units • Facility should be licensed/accredited, although Medicare usually does not pay

Clinical Roles - 1

• Care management coordinator - Helps with referrals, tests, insurance preapprovals • Pharmacist - Acts as a pharmacological resource for patients - Manage medications for chronic illnesses or dosing protocols for blood thinners

Master Patient Index (MPI)

• Centerpiece for all subsequent functionality and software applications - Links to the patient health record - Links to scheduling for appointments, reporting lab, x-ray, pharmacy, patient-related images

Financial and Quality Issues - 1

• Centers for Medicare and Medicaid Services (CMS) - Provides health insurance for older adults, disabled, poor - Covers over 30% of the U.S. population; and nearly all individuals age 65 or older - Reimburses qualifying health care facilities

Pharmacy

• Certification - Six specialty practice areas recognized by the Board of Pharmacy Specialties: o Ambulatory care pharmacy o Nuclear pharmacy o Nutrition support pharmacy o Oncology pharmacy o Pharmacotherapy o Psychiatric pharmacy. • Licensure - Varies by state - North America Pharmacy Licensure Exam (NAPLEX) - Multistate Pharmacy Jurisprudence Exam (MPJE) - Some states require a state exam instead of or in addition to the MPJE • Roles - Dispensing, community and hospital-based - Consulting, usually hospital-based

Critical Access Hospitals

• Certified for reimbursement by Medicare • Typically are licensed acute-care hospitals in rural locations • Sometimes health clinics are eligible - Reimbursement may save the hospital from closing

Concierge Medicine - 5

• Challenges - Health insurance for specialty services, highcost procedures, emergency treatments, and hospitalization. - No data on how model affects overall health care costs - Employers evaluating model for savings - Could exacerbate the shortage of primary care providers

Billing Definitions - 1

• Charge Capture - The process of documenting medical services in preparation of a claim • Charge Description Master - Database of prices for services provided, used by HCOs during the billing process

Two Kinds of Penalties

• Civil law: Exchange of money between the private parties to the lawsuit • Public law: Can result in fines paid to the government and/or imprisonment • The same action can result in both kinds of penalties

Classification of Laws

• Civil or private law - Relationships between people - Relationships between people and organizations - Relationships between organizations - Includes family, property, inheritance, corporate, contract, and tort law • Public law - Relationships between people and the government

Claim Submission - 1

• Claim: - Demographic and insurance information - Diagnosis and procedure codes - Time intervals - Charges - Provider identifiers

Classifications, Terminologies and Vocabularies

• Classification systems - Group similar or related data o ICD-10-CM o ICD-10-PCS

Application Integration 1

• Clinical decision support - Computerized provider order entry • Financial and resource management - Patient profiling

Quality Clinical Documentation to Avoid Fraud and Abuse Accusations

• Clinical documentation improvement programs support high-quality documentation - Train providers • High-quality documentation supports accurate coding and reimbursement • Accurate coding is needed to avert accusations of fraud and abuse

Laboratory Pathology - 3

• Clinical microbiology - study of microorganisms - The lab may use culture methods to grow and identify organisms • Forensic pathology - Specialized laboratory for medical and legal issues • Molecular pathology - Development of molecular and genetic approaches to the diagnosis and classification of human tumors - Design and validation of predictive biomarkers

Primary Care Characteristics - 3

• Clinician - Individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients. • Patient - Individual who interacts with a clinician either because of illness or for health promotion and disease prevention.

Nurse Midwives

• Education - Postgraduate or graduate program - Must have a BSN to become a certified nurse midwife • Training - Most include courses in advanced practice nursing (physical diagnosis, pharmacology, pathophysiology) - Clinical course and practice in ante-, intra-, and postpartum care and care of the newborn. • Certification - Only a few of the nurse midwife programs are post-baccalaureate programs • Licensure - Licensed in all 50 states and the District of Columbia • Role - Provide routine gynecology services and prenatal, delivery, and postnatal care.

Respiratory Therapy

• Education - Usually an associate's degree, but there are bachelor's degrees in respiratory therapy • Training - Preclinical - Clinical • Certification: Two levels - Certified Respiratory Therapist Exam (CRT) - Registered Respiratory Therapist Exam (RRT) - Both exams are offered by the National Board of Respiratory Care. • Licensure - Required in most states - Successful completion of the CRT exam required • Roles - Respiratory assessment - Patient education - Respiratory treatments and medication - Oxygen administration and ventilator support

Case Manager

• Education - Varies greatly to include on-the-job training, associate or certificate programs, nursing degrees, and social service degrees • Training - May include additional training specific for case management • Certification - Certification of case managers is available in specific fields but generally are not required. • Licensure - Depending on education and training • Role - A case manager is required to assess a client's problems and mobilize resources to enable the client to function at his or her best level.

MHS: Education and Research

• Education - Walter Reed National Military Medical Center - Defense Medical Readiness Training Institute - Joint Theater Trauma System (JTTS) Clinical Practice Guidelines - Tactical Combat Casualty Care • Research - Congressionally Directed Medical Research Programs - Military Infectious Diseases Research Program - TriService Nursing Research Program

MHS: Goals of Deployable Medicine

• Effective health care wherever troops go • Specific goals include: - First-responder care - Essential care (life and limb) - Definitive care - Care during transfer to another medical facility - Logistics (supplies, equipment) - Education, training, information technology

National Health Care Quality Report

• Effectiveness • Timeliness • Efficiency • Patient safety • Access to care • Patient centeredness

Common Internal Medicine Specialties and Subspecialties

Cardiology Endocrinology Gastroenterology Geriatric medicine Hematology and oncology Infectious disease Nephrology Pulmonary disease and critical care medicine Rheumatology Genomic specialists

Which of the following describes a decision by an organization choosing to go "best of breed"?

Chooses the best components from several vendors

In which type of documentation of electronic capture of clinical information would include all the medications that have been administered to a patient?

Clinical reports

Summary of inpatient vendors

• Epic • Cerner • Allscripts • MEDITECH • Evident

Assisted Living - 2

• Facilities are licensed in most states • Billing is monthly rent plus fees • Insurance may cover some costs; Medicare does not

EHR Hardware - Clients

• Fixed workstations - Connected to server via wired network - Strategically positioned throughout work environment to facilitate convenient access - Most commonly used and often already in place - Economical

Government-Funded Health Care

• Government-Provided Health Care Services - TRICARE - Veterans Health Administration - Indian Health Service • Government Health Insurance - Medicare - Medicaid - Children's Health Insurance Program

Doctor of Nursing Practice

• Graduate trained • Post-graduate training • Certification examination • Work independently • Benefits - Lower cost for professional development - Lower expenditures

Healthcare Common Procedure Coding System (HCPCS)

• HIPAA standard code set - Level I o Current Procedural Terminology (CPT) codes o Medical services and procedures performed by physicians and other healthcare providers

Healthcare Common Procedure Coding System (HCPCS) (con't)

• HIPAA standard code set - Level II o National Codes o Products, services and supplies o Current Dental Terminology (CDT)

HIPAA Standard Code Sets

• HIPAA standard code sets - International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) - National Drug Codes (NDC) - The CMS Healthcare Common Procedure Coding System (HCPCS) o Current Procedural Terminology, 4th edition (CPT) o Code on Dental Procedures and Nomenclature (CDT)

HIPAA Covered Entities - 3

• Health care clearinghouses - Billing services - Repricing companies - Community health management information systems - Value-added networks and switches that perform clearinghouse functions

EOC: Capitation - 1

• Health care organization receives fixed sum per person enrolled in the plan • Same amount paid regardless of the number of plan patients requiring care, frequency of visits, or severity of illness - PMPM: per member per month • Payor knows costs in advance • Provider assumes some risk, but has guaranteed income

Home Health Care - 2

• Home health care agency is another option - Professional service - May be reimbursed by Medicare - Includes hospice care (end-of-life care)

Ancillary Services - 2

• Hospice care - For terminally ill patients whose life expectancy is not expected to exceed 6 months - Palliative care outside the hospital o At hospice institutions o At home - Multidisciplinary team for care

Hospital & Provider Dichotomy

• Hospitals - Most hospitals public institutions • Providers - Most providers in private practice - Paid fee-for-service

Patient Record System

• IOM (1991): Any "patient record system" includes: - People - Data - Rules and procedures - Processing and storage devices - Communication and support facilities

A New Health System for the 21st Century

• IOM (2001): Six aims for improving health care quality 1. Safe 2. Effective 3. Patient-centered 4. Timely 5. Efficient 6. Equitable

Functions a UPI Must Support

• Identification of an individual • Identification of information • Accurate identification functions • Reduce health care operational cost and enhance the health status of the nation

Agency for Toxic Substances and Disease Registry (ATSDR) - 2

• Identifies exposures, evaluates risk, recommends action • Prepares for emergencies/disasters • Educates about toxicology, environmental medicine, chemical exposures • Issues public health advisories • Example: 9/11/2001

Risks of HIE

• Identity Theft • Hackers • Errors • Complexity • Cost

Early Detection and Prevention

• Increased Preventive Services - Detection o Screening mammograms o Colonoscopy - Prevention o Immunizations

Chronic Disease and Increased Demand for Services

• Increased Utilization of Services - Management/treatment to decrease risk of complications o For example, aggressive treatment of diabetes to avoid such complications as heart disease, kidney failure, or blindness - Early intervention at risk groups o For example, weight loss, smoking cessation

Critical Integration Elements

• Information is available when and where it is needed • Users must have an integrated view • Data must have a consistent interpretation • Adequate security must be in place

Nationwide Health Information Network [NwHIN]

• Initiative of the Office of the National Coordinator for Health Information Technology • Purpose is to tie together health information exchanges (HIEOs) • Assigns OID to participating organizations • Built on Open Source code using Java platform • Public/private venture

Radiology Services - 4

• Interventional radiology - Invasive tests - Angiography • Teleradiology allows radiologists to review images remotely • Picture Archiving and Communication System (PACS) - facilitate archival and retrieval of images • DICOM - Standard for medical images

Emergency Department Overcrowding

• Lack of key clinical staff a driver of overcrowding • Care provided to uninsured and patients with non-urgent conditions not a cause of overcrowding • Evidence links overcrowding to reduced health care quality and patient safety

Authorizations Must Include

• Names of authorized persons making use of disclosure • Description of information • Expiration of date of event • Patient's right to revoke and instructions on how to do so • Purpose of use or disclosure • Signature and date

Key Privacy Compliance Areas

• Notice of privacy practices • Authorization • Business associates and subcontractors • Allowable disclosures • Marketing • Physician and staff training • Penalties

ANA Recommended Standardized Nursing Terminologies (2)

• Nursing Intervention Classification (NIC) - Identifies therapy for the nursing diagnosis • Nursing Outcomes Classification (NOC) - Describes the patient outcomes associated with the intervention

US Governmental Oversight for HITECH

• ONC Office of the National Coordinator for Health Information Technology Health IT Standards Committee Health IT Policy Committee • ACB Authorized Certification Body • ATL Accredited Testing Laboratory

Reform of the US Healthcare System

• Patient Protection & Affordable Care Act of 2010 • CMS Center For Innovations • "Journeys of care, not fragments of care" (Berwick)

Five Principles of the Canada Health Act

• Public administration • Comprehensiveness • Universality • Portability • Accessibility

EHR Hardware - Servers (cont'd - 4)

• Purchase considerations (cont'd) - RAM o e.g. 8 GB - Hard drive configuration o e.g. RAID or network storage - Network card o e.g. 1 GB/second or higher - Accessories: monitor, keyboard, CD/DVD drive, UPS (Uninterruptible Power Supply)

Public Health Benefits of the Canadian System

• Statistics show Canadians benefit from good health care • Life expectancy - 80 years as of 2005 - Among highest in industrialized nations • Infant mortality cut in half from 1979 to 2005

ACA Expansion of Health Insurance Coverage - 1

• Subsidies for those who do not receive employer-provided health insurance up to 400% of U.S. poverty level • Medicaid expansion by the states for those earning up to 133% of poverty level • Coverage for children on adults' policies up to age 26 • Disallows denial for pre-existing conditions or becoming ill

National Drug Codes (NDC)

• Used for reporting retail pharmacy transactions • Owned by the US FDA • Medications o Prescription drugs o Over-the-counter (OTC) drugs o Drugs used by veterinarians • Used for billing and reimbursement • Used for tracking drugs for many purposes

Federally Funded Health Care Institutions

• Veterans Health Administration (VA hospitals) • Military Health System • Indian Health Service

Business Intelligence Applications

Allow for • Data analysis • Correlation • Trending • Reporting of data across multiple sources

Health care spending can be slowed by:

Reducing unnecessary services Reducing care of marginal value Rationing resources

Results review functionality

Refers to the reviewing of results for laboratory tests as well as imaging tests.

• Fragments and fractures • ACA - AHRQ Center for QI and Patient Safety • Telehealth expansion

Reform & HIT

The EMTALA act requires hospitals receiving federal funds to evaluate individuals presenting to the emergency department:

Regardless of their ability to pay

Comparing Court Systems: An Example

U.S. Government State of Ohio City of Cleveland Trial courts U.S. District Court for the Northern District of Ohio Cuyahoga County Court of Common Pleas Cleveland Municipal Court Appellate courts U.S. Sixth Circuit Court of Appeals Ohio Eighth District Court of Appeals Ohio Eighth District Court of Appeals Highest court U.S. Supreme Court Ohio Supreme Court Ohio Supreme Court

Examples in Donabedian Model

Type of Measure Individual Department Organization Structural - Professional certification - Credential review - Staffing analysis - Equipment safety checks - Licensure - Fire safety inspections Process - Peer review - Performance evaluations - Review of performance indicators - Infection surveillance - Review of utilization data Outcome - Practice profiles - Rework required - Error/complication rate analysis - Mortality rates - Quality sanctions

Primary Care Physician

Typically provides routine care, including health maintenance and management of new and chronic disease.

Infodemiology defined

"Infodemiology can be defined as the science of distribution and determinants of information in an electronic medium, specifically the Internet, or in a population, with the ultimate aim to inform public health and public policy." Eysenbach G. (2009)

• Standardized terminologies

- Allow merging data for population health studies - Allow use of decision support - Allow mapping between terminologies for patient-specific information

• Data set

- List of the data elements with uniform definitions

HIPAA Privacy and Security Continued

- Original rule summaries available (ID Experts, 2014; BridgeFront, 2009; Leyva, 2011) - HHS resources such as HIPAA & Health IT - Various HIPAA tool kits - NIH's research entities guides - Employee training resources - HIPAA certificates and training courses - HHS's consumer resources for the public

Patient/consumer

-Anyone seeking preventive care services, wellness services, assistance with self-managed care, or medical services

•Radiology

-Diagnostic -Neuroradiology -Interventional -Pediatric -Radiation oncology -Nuclear radiology

Certification has several meanings

-Education/training certificate program typically 1 year for medical assistants -National health profession organization certification typically requires completion of an accredited program and an exam, such as with radiologic technologists -Physician board certification in a specialty or subspecialty requires an approved residency/fellowship and a board exam. •State licensure is mandatory for many practicing professionals, such as physicians and nurses.

Education

-Formal lecture and learning activities, including simulation and patient contact -Depending on the health profession, may be on-the-job training, a certificate, associate's degree, bachelor's degree, master's degree, or doctoral degree

What percentage of all orders in a hospital setting must be placed using a Compterized Provider Order Entry to be considered being a "meaningful user" of an EHR system?

10%

Specialty

A branch of medicine that focuses on a particular area of expertise.

837 Transaction

A claim "form" submitted through an Electronic Data Interchange (EDI) transaction.

Syndrome

A combination of symptoms and physical findings not easily attributable to a specific cause. An example is carpal tunnel syndrome, which is pain, burning, and numbness in the hand

The health record is:

A communication tool among care providers A tool to improve quality and safety for patients The legal business record of a health care organization

EMTALA: Emergency Medical Treatment and Active Labor Act

A federal law that requires hospitals to provide emergency medical care to patients, regardless of their ability to pay.

Interdisciplinary Team

A group of individuals with diverse training and backgrounds who work together as an identified unit or system.

Master Patient Index (MPI) 1

AHIMA definition "A patient-identifying directory referencing all patients related to an organization and which also serves as a link to the patient record or information, facilitates patient identification, and assists in maintaining a longitudinal patient record from birth to death"

Which of the following standards for the exchange of administrative data includes insurance claims?

ANSI ASCX12N

CMS: Centers for Medicare and Medicaid Services

Administers Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).

The age group associated with the highest medical expenses is:

Adults ages 65 and older

A patient signs a Do Not Resuscitate (DNR) before having surgery. In which type of documentation of electronic capture of clinical information would this order be found?

Advance directives and consents

CMS: Centers for Medicare and Medicaid Services 1

An agency within the U.S. Department of Health and Human Services responsible for the administration of several key federal health care programs. CMS regulates reimbursement for the provision of health care products and services for Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).

Joint Commission

An independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States.

CHIP: Children's Health Insurance Program

An insurance program that serves uninsured children and pregnant women who do not qualify for Medicaid but cannot afford private health care insurance.

CE: Covered Entity

An organization that must comply with the HIPAA rules.

Exclusion Statute

Bans individuals or organizations convicted of certain crimes from being providers in the Medicare and Medicaid programs.

Lack of informed consent can lead to accusation of:

Battery Negligence Malpractice

A major public health agency

CDC

Which of the following HIPAA code sets would be used by dental practices to report dental procedures?

CDT

Organization that must comply with HIPAA rules

CE

How to Achieve Quality Strategy Goals?

CMS will: • Measure and publicly report providers' performance and cost • Provide technical assistance and foster learning networks • Adopt evidence-based National Coverage Determinations • Create incentives for quality and value • Set quality standards for providers • Create processes to evaluate quality improvement

Louisa, a 19-year-old female, goes to a local outpatient clinic to obtain a physical for her college club soccer team. The next day, Louisa's mother calls the clinic to find out the results of Louisa's physical, and the medical assistant at the clinic provides her with some preliminary information. Which of the following principles underlying the HIPAA Privacy Rule has been violated?

Confidentiality

Hospital System

Consists of two or more hospitals or other health care faciliteis that are owned, leased, or managed by an organization such as a corporation. Oversight is provided by a single board of directors.

Mental Health Professionals Roles and Training

Counselor: Directly counsel patients. Cannot prescribe medications. Usually earn master's degree. Licensure required by all states. Certification varies by state. Psychologist: May or may not directly counsel patients. Administer and analyze psychological tests. Cannot prescribe medications. Usually earn doctoral degree (PhD). Licensure required by all state. Certification varies by state. Psychiatrist: Counseling Therapy. Manage medications used to treat. psychological disorders. Can prescribe medications. Must complete medical school and a psychiatry residency. Licensure required by all states by USLME exams Certification usually required for hospital privileges and insurance payment.

Self-funded plans

Created by an employer, an employee organization, or a combination of the two. They operate under the ERISA rules. In this model, the employer assumes the risk of providing health care insurance to its workers and pays for their care directly. The employer may contract with a third-party administrator, which can be an insurance company, to oversee the plan and manage benefits.

ACO: Accountable Care Organizations

Created by the Affordable Care Act (ACA) and refers to physicians, hospitals, other providers, and service suppliers that have agreed to work toegether to coordinate patient care under the original Medicare program.

Meaningful Use Stage 1

Criteria are directed toward capture and sharing data.

Meaningful Use Stage 3

Criteria are targeted at improving outcomes.

Which of the following standards can be used across various healthcare settings to address the capture of data structure and message exchange associated with diagnostic images?

DICOM

Enhancing Equity with HIT

Data capture • Can monitor by population characteristics. • Can uncover health care disparities. Tailor to patient needs • Can enable competencybased patient education. • Can tailor information to educational background and development status. Multi-modal functionality • Can provide various ways for patients to get health information. • Can decrease health care disparity. Decision support • Can provide drug cost information. • Can assist providers in selecting alternatives for low-income patients.

List of data elements with uniform definitions

Dataset

Medical Technicians (EMTs) and Paramedics

EMT • 120 - 150 hours of coursework • CPR • Artificial ventilations • Administer oxygen • Basic airway management • Spinal immobilization • Vital signs • Bandaging and splinting • Transport patients. Advanced EMT • 200 - 400 hours of coursework • In addition to EMT tasks: • Start IV lines • Automated defibrillation. Paramedic • 1,200 - 1,800 hours of coursework • In addition to Advanced EMT tasks: • Administer medications • Advanced airway management • Manual defibrillation

Managed care reimbursements may be paid using which of the following methods:

Either fee-for-service or episode-of-care

2016 and Onward Clinical Quality Measures

Eligible professionals (physicians): Report on 10 objectives • Example—Objective 1: Protect patient health information - Measure: Conduct or review a security risk analysis Eligible hospitals and critical access hospitals: Report on 9 objectives • Example—Objective 2: Clinical decision support - Measure 1: Implement five clinical decision support interventions related to high-priority health conditions - Measure 2: Enable and implement functionality for drug-drug and drug-allergy interaction checks for entire reporting period

FDA: Food and Drug Administration

Ensures the safety and effectiveness of foods, drugs, medical devices, veterinary drugs, and cosmetics. Also regulates tobacco.

Person-centered care

Ensuring that each person and family is engaged as partners in their care.

The Joint Commission (formerly known as JCAHO) accredits:

Entire health care organizations

Equity: Case Review

Event: • One of the greatest challenges to chronic care management in a public housing community is keeping patients engaged in their care. • They are often lost to follow-up care when they do not return for medical visits or refill their prescriptions. • This is especially problematic for vulnerable patients with diabetes.

Evidence-based medicine:

Examines the evidence gathered from scientific research and applies it to clinical decision making

State Medical Practice Acts

Example of Tort Law, • Define the practice of medicine • Regulate how medicine will be practiced within the state • Establish medical board - Set standards - Create process - Investigate complaints

Business Intelligence Applications 1

Examples • Clinical and Financial Analytics and Decision Support • Query and Reporting Tools • Data Mining • Online Scoreboards and Dashboards

Covered entities are not allowed to disclose protected health information (PHI) to public health agencies except in support of treatment, payment, and health care operations (TPO) activities.

False

FDA Overview

Food, Drugs, Medical Devices, vaccines and blood biologics, animal vetranary, cosmetics, radiation admitting products, tabacco products.

ICD-10-PCS

For inpatients, procedures are coded using... which are always seven characters.

CPT-4

For outpatients, procedures are coded with... which are 5 characters.

Anti-Kickback Statute

Forbids asking for or receiving anything of value in exchange for referrals of federal health care program business.

NIH: National Institutes of Health

Funds medical research.

AoA: Administration on Aging

Funds non-medical programs to prolong health and independence.

Health care networks

Groups of hospitals, physicians, other health care providers, insurers, and/or agencies that collaborate to provide many types of health care in a community.

Code set for identifying medical supplies and products

HCPCS

Legislation that supports Health IT

HITECH

Organization that works to establish technical standards for EHRs

HL7

HL7 Messaging Standard

Health Level Seven (HL7) • Content exchange (messaging) standard • Supports clinical practice • Move data in standard formats

Medicare Part A

Hospital insurance

A patient is admitted to the hospital for appendicitis and has an appendectomy. Which of the following would be used to report the diagnoses and procedures?

ICD-10

Which of the following is used for diagnosis coding and reporting on claims, regardless of the provider?

ICD-10

PHI: Protected Health Information

Identifying information about the individual that HIPAA protects.

HRSA: Health Resrouces and Services Administration

Improves access to healthcare.

SAMHSA: Substance Abuse and Mental Health Services Administration

Improves the health of people with mental illness/substance abuse, while reducing healthcare costs and social costs.

IHS: Indian Health Service

Improves the physical, psychological, and spiritual health of American Indians and Alaska natives.

PMS: Practice Management System

In a physician setting, this system provides a combination of financial and administrative functions. It automates a physician office's patient appointment, scheduling, registration, billing, and payroll functions.

Personal Health Records

Initial and ongoing care that is typically provided in a physician's office or in a clinic, and is sometimes provided by non-physician practitioners (or mid-level providers).

Defining Interoperability

Interoperability involves exchanging key pieces of health information securely, with the goal of being to obtain and share the right information in the right context. Meaningful Use data set: http://ccda.sitenv.org/Common+MU+Data+Set • Vocabulary & Code Sets (Snomed, ICD9 or10) • Content Structure • Transport • Security • Services

Healthcare Interoperability: Terms

Interoperability: The ability of diverse systems to work together.Two types of Interoperability 1. Syntactic: The ability of computer systems to communicate and exchange data. 2. Semantic: The ability of computer systems to meaningfully interpret the information exchanged.

If you wish to make comparisons between 2 vendor-specific EHR systems, you would rely on:

KLAS rating system

Patient Safety

Making care safer by reducing harm caused in the delivery of care.

Care Affordability

Making quality care more affordable for individuals, families, employers, and governmetns by developing and spreading new health care delivery models.

Current Health Care Landscape

Meaningful Use Providers show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity. Patient-Centered Medical Home Providers organize care around patients, working in teams, coordinating care, and tracking over time. Accountable Care Organization Provider reimbursements are tied to quality metrics and reductions in the total cost of care for assigned population of patients.

Structural measures

Measure physical attributes, such as the number and qualifications of staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures.

CQM: Eligible Hospital Example Continued

Measure: Stroke 2, ischemic stroke— discharge on antithrombotic therapy Numerator: Number of stroke patients prescribed antithrombotic therapy at hospitals Denominator: Number of ischemic stroke patients

HCPCS level 2

Medical supplies and some Medicare services may be coded with... which are 5 characters, beginning with an alphabetic character and the remainder being numeric.

Medicare Part C

Medicare Advantage, which allows the use of private companies approved by Medicare, or provider organizations.

All of the following are potential differences in the functionality of documentation among different EHR vendor systems EXCEPT for which one?

Medication abbreviation

Which of the following is NOT an option for creating a clinical note that may be supported by an EHR vendor system?

Microsoft Office

OIG: Office of Inspector General

Mission is to prevent fraud and abuse in HHS programs, especially Medicare.

Commercial Health Insurers

Most often owned by stockholders or stock companies (such as Aetna Insurance Company) and also known as privately funded health plans, or simply insurance carriers. Alternatively, these companies can be mutual insurance companies, which are owned by their policyholders.

HL7 Messaging Standards

Move data between systems in standard formats.

Code set for reporting retail pharmacy transactions

NDC

HCPCS Level II

National codes that identify medical supplies and products used.

What is the name of the system that is used to manage digital radiography?

Picture Archiving Communications Systems (PACS)

Which is an example of semi-structured documentation?

Note with structured headings and free-text entry

The following government agency enforces HIPAA:

OCR

Which of the following agencies if responsible for oversight of the HITECH initiatives to promote meaningful use of electronic health records?

ONC

Off-the-shelf system

Off-the-shelf system

Episode-of-care

One payment made for all care provided during an illness or time frame.

Which of the following is an example of the use of a Computerized Provider Order Entry in an EHR system?

Ordering medications Discharge orders Provider referrals

Home-grown system

Organizations develop their own system using system designers and programmers that work for the organization.

FCA: False Claims Act

Prohibits the submission of false or fraudulent claims to the federal government.

Care Coordination

Promoting effective communication and coordination of care.

Health care expenditures

Represents the total value of the servcies delivered during a time period, usually one year. Various methods can be used to examine spending, including category of servcie, contributor, and payor.

CDC: Centers for Disease Control and Prevention

Responsible for health promotion, disease prevention, reduction of injury or disability.

Defensive medicine:

Results in increased health care expendistures Is a practice to safeguard the provider against potential malpractice lawsuits Involves additional testing or valuations that is of marginal value in the treatment and care of an individual

Interoperability & HIE

Review of HIE: • HIE the verb - the Exchange of Health Information • HIE the nouns: - (HIE) Health Information Exchanges - (RHIO) Regional Health Information Organizations - (ACO) Accountable Care Organizations - (PCMH) Patient Centered Medical Homes

Comprehensive terminology used with electronic health records to encode medical information.

SNOMED

Identify the comprehensive controlled terminology that is published in numerous languages and used all over the world designed to capture information in the EHR.

SNOMED CT

Episode-of-care reimbursement types include ALL of the following, EXCEPT:

Self-pay

Fee-for-service

Separate payments are made for each individual service provided.

Ambulatory Services

Services provided to non-hospitalized patients. Also known as outpatient care.

Administrative hearings would be held for:

Social Security Appeals

Negligence

Someone acts carelessly or unreasonably and someone else is harmed as a result.

Ancillary Services

Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests.

What They Did: Self-Management Counseling

System change: • Community volunteers were provided online training on self-management counseling for patients with diabetes. • They created a diabetes registry in the electronic health record to identify and recall patients due for routine diabetes care. • Just prior to the scheduled visit, the community volunteer reminds the patient of the visit and asks him to arrive early for self-management teaching.

Health care financing

Teh collection and pooling of funds used to pay the cost of health care servcies provided by a health care system to individuals and populations. it also involves a method for the distribution of payments for the services provided.

Charge Description Master

Teh database of prices for services provided to patients and used by health care organizations during the billing process.

Charge Capture

Teh process of collecting and noting all services, procedures, and supplies provided during an encounter or patietn care in preparation for submitting a claim to a third party payor.

Which organization developed the National Patient Safety Goals, the Sentinel Event Policy, and the Speak Up Initiative?

The Joint Commission

The Patient-Centered Medical Home (PCMH)

The Patient-Centered Medical Home is "an approach to providing comprehensive primary care for children, youth and adults. The PCMH is a healthcare setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient's family" (Patient-Centered Primary Care Collaborative).

OIG Compliance Program Tips - 2

The Seven Fundamental Elements of an Effective Compliance Program 5. Conducting internal monitoring and auditing 6. Enforcing standards through well-publicized disciplinary guidelines 7. Responding promptly to detected offenses and undertaking corrective action

Security

The activity of protecting personal information. It consists of mechanisms to assure the safety of data and the systems in which the data reside.

Informed Consent

The concept that a patient must be fully informed about the proposed treatment before consenting to or refusing the treatmetn.

Outpatient

The delivery of health care services in a setting where the patient is not hospitalized.

Claim

The health care organization's itemized statement and formal request for paymetn from the third-party payer for the medical services provided to the patient or the insured.

Secondary Care

The specialty care that is provided in the community, such as when a patient is referred for a test to a local specialist or hospitalized in their local community for a test or surgical procedure.

Health

The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

EDI: Electronic Data Interchange

The structured transmission of data between organizations by electronic means.

Diagnosis code

These are ICD-10-CM codes. ICD stands for International Classification of Disease. CM stands for Clinical Modifications. ICD-10-CM codes are used in both inpatient and outpatient settings.

Community Health Clinics

These are community-based health cetners providing care to underserved populations.

Publicly-funded health care

These are government programs, which are funded by income taxes and payroll taxes. These programs start in federal legislation and are voted into law by Congress to help specific population groups that meet eligibility requirements. Some, like Medicare, are run by the federal government, while others, like Medicaid, are federal-state partnerships.

CFR: Code of Federal Regulations

These are rules that are published in the Federal Register

Managed Care Organizations

These companies combine health insurance benefits with the actual delivery of health care services. They impose tight controls on costs and use of services, and some have their own doctors and facilities.

Outcome measures

These measures determine the impact of our changes in teh system. They measure results about a person's health and well-being. Outcome measures can be intermediate or long term.

DRG: Diagnosis-related Group

This is a classification system, based on ICD-10-CM and ICD-10-PCS codes, that determines payment rates for inpatient visits.

SNOMED CT Systemized Nomenclature of Medicine

This is a comprehensive clinical terminology that is used in the EHR to capture the clinical information by assigning codes to terms that represent medical concepts, descriptions of those concepts, and their relationship.

Continuum of Care

This is a concept involving an integrated system of care that guides and tracks the patient over time through a comprehensive array of health services spanning all levels of care intensity. Continuity of health care for an individual from birth to death. It focuses on treating patients at the level of care required and extends from primary care providers to specialists and ancillary providers.

Patient-Centered Medical Home

This is a model for providing comprehensive health care. Hallmarks include: personal physician, physician-directed medical practice, care coordinated or integrated across all elements of the health care system, emphasis on quality and safety, and enhanced access to care.

Intentional Tort

This occurs when someone deliberately causes harm to another person.

HL7

This organization provides a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services.

Jurisdiction

This refers to whether a court has the authority to hear and decide cases.

Legacy systems

Those systems that have been in place and used by the organization for a period of time.

A framework for an electronic system that could be customized by each organization.

Vanilla

Urgent Care Centers

Walk-in clinics that may be staffed by physicians or mid-level providers such as physician assistants and nurse practitioners. These centers may have extended hours and usually provide care for acute illnesses and injuries that are beyond the scope of care of a typical primary care practice.

Healthy Living

Working with communities to promote wide use of best practices to enable healthy living.

Vanilla system

a system that is more of a framework for the organization's own customization.

Biomedical engineers

apply engineering principles in the design, development, and maintenance of IT systems and medical device equipment

After coding...

most claim forms are sent electronically to the insurance company. The payment is made to the provider, along with an explanation of benefits (EOB) or remittance advice (RA).

Health information management (HIM)

professionals manage the patient's medical record for clinical, financial, and legal uses

Community Health Clinic

• "Health centers are community-based and patient-directed organizations that serve populations with limited access to health care" (HRSA, 2011) • Type examples: - Grant-supported federally qualified health centers - Lookalikes - Tribal operated - Others

Systems and Health Care Reform

• "Healthcare reform without attention to the nature and nurture of healthcare as a system is doomed ... It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities experience it" (Berwick, 2009). • "The performance of a system — its achievement of its aims — depends as much on the interactions among elements as on the elements themselves" (Berwick, 2009). • "The improvement of health and healthcare depends on systems thinking and systems redesign ... 'Reform' without systems thinking isn't reform at all" (Berwick, 2009).

Potential Advantages of EHR Systems

• "Legacy" EHR systems have often fallen short for a variety of reasons, but overall potential benefits include: - Better, more accurate documentation - More efficient storage & retrieval of records - Higher quality of care, fewer errors - Lower insurance premiums and operating costs

Early Hospital & Physician Health Plans

• 1929: Dallas school teachers contract with Baylor Hospital - Hospital service plans - Exempt from most state insurance regulations - Later becomes Blue Cross • 1939: Physicians form own associations - Physicians form pre-paid health care services plan - Blue Shield Association

Factors Influencing Development of Commercial Health Insurance

• 1940s - WWII wage controls - IRS favorable tax treatment - Employer sponsored health contracts noncancellable - 1949: Unions may negotiate health insurance benefits as part of wages

Early Commercial Health Insurance

• 1940s: Commercial Insurance - Compete against the Blues - Employer (group) enrollment spread risk and addressed "moral hazard" - Experience rating vs. community rating

How the NHS Began

• 1946 National Health Service Act passed - Authorized NHS - Began covering medical services July 1948 • Goal - Provide free health care for all citizens • Ambitious and controversial project - Health minister Aneurin Bevan - 90% of British doctors joined

Sequoia Project

• A group of federal agencies and nonfederal organizations have created a collaboration, known as the Sequoia Project. • Its mission and purpose is to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange.

Types of Networks

• A network is a system of multiple computers that share information virtually • Information is stored and retrieved from data repositories on computers called servers • Smart terminals • Dumb terminals • Wireless

Electronic Claims Transactions

• American National Standards Institute • Electronic Data Interchange (EDI) - HIPAA privacy rules/Transactions Rule o 837 Health care claims or equivalent encounter information o 835 Health care payment and remittance advice o 270/271 Eligibility for a health plan o 276/277 Health claims status o 278 Referral certification and authorization

Disease

• An impairment of a specific structure or function of the body that produces symptoms and physical findings; usually attributable to a specific cause, such as a specific type of bacteria causing pneumonia

Laboratory Pathology - 1

• Anatomical Pathology - Histopathology: Study of whole tissues - Cytopathology: At the cellular level - Electron microscopic pathology • Surgical Pathology • Chemical pathology (clinical chemistry) - General chemistry - Endocrinology - Immunology - Toxicology

HIPAA Privacy Rule

• Applies to protected health information (PHI) • Applies to all forms or medium • Individually identifiable health information - Name/address - Phone number - E-mail address - SSN - Photograph

Medicaid and CHIP

• Children covered by CHIP, may also qualify for Medicaid • Range of benefits include: - Doctor visits, emergency care, hospital care - Prescription drugs, vision, hearing, dental - Free preventive care, including vaccinations • Low premiums and cost-sharing may be available for other services

Network - Assessing Usage (cont'd - 2)

• Conduct a wireless connectivity survey • Explore remote connectivity options, including VPN (Virtual Private Networks)

Breaches Adversely Impact Organizations

• Costs (Ponemon Institute, 2015) - Estimated cost to the industry: $6 billion - Average cost per breach: $2.1 million - Significant part of cost: "lost business" - Criminal attacks up 125% in healthcare organizations—now number 1 cause of breaches • Attack sources (HIMSS, 2015) - Foreign sources, hacktivist, nation-state actor, malicious insider, hacker, social engineering, online scam artist • Security budgets (HIMSS, 2015) - Health care providers average > than 6% of the IT budget for security - Federal government spends 16% of its IT budget on security, while financial and banking institutions spend 12% to 15% - Information security is a business priority

VA Vet Centers

• Counseling for combat veterans and their families • Every state and territory • Services include help with: - Readjustment to civilian life - Medical problems - Military sexual trauma - Substance abuse - Bereavement

Workarounds

• Defined - Alternative processes that help workers avoid demands placed on them that they perceive to be unrealistic or harmful. - Unanticipated behaviors directly or indirectly caused by the EHR when the system impedes one's work. • Examples - Nurses taking verbal orders rather than prescribers entering the order into CPOE due to workflow timing of event. - Significant events located in multiple locations in the EHR due to lack of standardization of data entry screens.

Artifacts

• Defined - Manmade tools that aid or enhance the worker's thinking abilities. - Developed to meet the demands of an activity. • Examples - Bedside references. - Patient locator boards. - Report sheets. - Documenting on paper then transcribing into electronic record.

In Summary

• Defined HIE and Interoperability • Benefits and Risks of HIE • Basic terminology of interoperability & data exchange • Highlighted the structure of HIE entities • Shared some future expectations for HIE

Marketing

• Defined as "a communication about a product/service that encourages recipients of the communication to purchase/use the product/service" • Using PHI for marketing requires authorization from the individual • Is not marketing for providers if treatment is - Therapy recommendation - Appointment notification - Prescription refill reminder.

Community Hospitals

• Defined as non-federal, short-term, general public hospitals - Provide general or specialty care - Operate on for-profit or nonprofit basis • Advantageous for U.S. health care system - Well-suited for routine illness/surgery - Provide cost-effective and accessible care

Health Maintenance Organization Act of 1973

• Federal grants and loans to encourage HMOs • Required employers offering traditional health plans to offer HMO option • HMOs thought to lower costs - Gave pre-paid health plans access to the employer-based insurance market

CMS - Medicare

• Federally funded health care program for individuals who: - Are over age 65 - Are under age 65 with certain disabilities - Have permanent kidney failure requiring dialysis or transplant

Issues for Shared EHR

• Federated vs centralized • Primary reason for federated is privacy concerns • Centralized features: - Site deals with only one other site for send and receive - Integration and validation of data done only once - Better control of privacy and security - Better reliability - Better quality control - Many HIEs can offer centralized data with federated segregation of data • Natural disasters better managed with centralized control with backup in other region

KLAS

• Mission - To improve health care technology delivery by honestly, accurately, and impartially measuring vendor performance for provider partners • What they do - Help health care providers make informed technology decisions by reporting accurate, honest, and impartial vendor performance

Emergency Department (ED) - 2

• Intended to treat life-threatening emergencies • Large number of visits were not emergencies • 2008 - 11% of ambulatory visits occurred in ED setting • 2010 - 13.7% - 27.1% of cases could have been treated in urgent care

In the End...

• Ongoing breaches of data are worsening, but - Complete security of all health information is impossible - Security is a trade-off with ease of use; a happy medium must be found - Will concerns be tempered when society sees more benefits of health IT? - Would other societal changes lessen the impact of this problem (changes in legal system, health care financing, etc.)?

Technology - 1

• Previously untreatable conditions - Arthritis in hips and knees • New medical and surgical procedures - Angioplasty - Joint repairs/replacements

FFS: Self-pay

• Self-pay - Patient responsible for payment for health care services o Uninsured subset of self-pay - May seek reimbursement afterwards o Self-insured plan: Large employers (ERISA) o Costs possibly higher

Ideal Quality Measures

• Quality measures should be (Landon et al., 2003): - Evidence-based - Agreed-on standards for satisfactory performance - Standardized specifications - Adequate sample size for reliable estimates - Adjustment for confounding patient factors - Care attributable to individual physician - Feasible to collect - Representative of activities of specialty • "In God we trust, all others bring data" - W. Edwards Deming, statistician (1900-1993) • Adage from business management: An organization can 't improve what it cannot measure

Specialty Hospitals, Rehabilitation Care - 1

• Specialty hospitals focus on particular diseases or medical fields - Common examples are cardiology, orthopedics, women's health, and surgery - Less common example: end-stage kidney disease

Reimbursement Methodologies

• Revenue Cycle - Claims submitted and adjusted by payor • Examine different methodologies used by payors to reimburse providers.

Claim Submission - 2

• Submission: - Paper o Physicians - CMS Form 1500 o Facility - CMS Form 1450 - EDI: 837 Transaction

Health Care Accreditation

• The Joint Commission certifies medical care facilities - Oldest and largest health care accrediting body - Independent nonprofit organization - Certifies nearly 21,000 organizations and programs in the U.S. • Organizations must undergo periodic site visits to identify and resolve problems

Home Health

• Wide range of health care services provided in patient's home • Examples: - Wound care - Education - Intravenous and nutrition therapy - Medication administration - Health status monitoring - Physical and rehabilitation therapy

Documentation: potential barriers to implementation

• Workflow implications - Increased documentation time - Overuse of checkboxes may impact cognitive processes o Less opportunity to thinking and synthesizing patient problems than when writing a narrative note o Potential for inaccurate data selections that may persist

Agency for Toxic Substances and Disease Registry (ATSDR) - 1

• Works to prevent illness and disease due to toxic or hazardous substances • Common toxins: arsenic, asbestos, lead, mercury • Locations: environmental pollution, waste sites, disasters • Methods of exposure: breathing, drinking, food, soil exposure, cut

Nonclinical Roles of Physicians

•Administration •Teaching •Research •Public health •Publishing

Clinician

•An individual qualified in the clinical practice of medicine, psychiatry, or psychology as distinguished from one specializing in laboratory or research techniques or in theory

Pathology

•Blood banking/transfusion medicine •Cytopathology •Forensic pathology •Laboratory medicine •Pediatric pathology

Surgical Subspecialties

•Cardiovascular surgery •Colon and rectal (colorectal) surgery •Neurosurgery •Orthopedic surgery •Otolaryngologic surgery •Pediatric surgery •Plastic surgery •Urologic surgery

Nonclinical Roles for Physicians

•Clinical or health informatics -Focused on effective use of clinical systems in patient care delivery processes -Certifications are available in informatics for clinicians -Physicians with an informatics background can serve in a variety of roles

Meaningful Use and QI — 1

"Even hospitals with fully functioning EMRs still make extensive use of digitized scans of manually completed forms and textual checklists. With no forms or screens to capture data in a structured way, hospitals fail to report quality measures as a routine byproduct of the practices, relying instead on a retrospective chart abstracting process" (Holland, 2010).

Primary Care Organization

"Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community" (Donaldson et al., 1996) • Main function is to provide screening, prevention, education, diagnosis, and treatment for acute and chronic health problems • Examples: physician office, health clinics

Quality Health Care

"Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge." (IOM, 2001)

Infodemiology

"The Internet has made measurable what was previously immeasurable: The distribution of health information in a population, tracking (in real time) health information trends over time, and identifying gaps between information supply and demand." Eysenbach G. (2009)

Admission-Discharge-Transfer (ADT)

"The name given to software systems used in healthcare facilities that register and track patients from admission through discharge including transfers; usually interfaced with other systems used throughout a facility such as an electronic health record or lab information system." (AHIMA, 2012)

Training

-Supervised clinical practice; often has increasing level of responsibility with time

Integrated Network

1) An informal association between primary care providers with local hospitals or medical centers. 2)A formal organization in which primary, secondary, and tertiary services are managed by a single organization supporting their community and other targeted geographic locations.

Seven PCMH Principles — 1

1. Personal physician. 2. Physician-directed medical practice. - Collective responsibility. 3. Whole person orientation. - All stages of life, all sites of care. 4. Coordinated and integrated care. - Assures smooth, continuous, and culturally appropriate care.

Seven PCMH Principles — 2

5. Quality and safety. - Optimal patient-centered outcomes, evidence-based practice, CQI, use of CDS, measuring achievement of outcomes, etc. 6. Enhanced access. - Ease of access to providers. 7. Payment. - Recognizes value of the PCMH. Coordination, Health IT, Remote Monitoring, Attention to Case Mix, Physician Share in Cost Savings, Payment for Quality.

Medicaid

A health insurance program targeted at low-income individuals and families who meet specific requirements. The eligibility rules and the services provided vary by state.

Health Information Exchange enables the interoperable linkage of health care information across organizations within a _________.

A hospital An enterprise system A region Across a nation

IPA: Independent Practice Association

A type of group practice where physicians work together to provide services while sharing economic risk.

ACF: Administration for Children and Families

Addresses the economic and social well-being of children and families, especially in vulnerable populations.

Precision Medicine or Personalized Medicine

Approach to disease prevention and treatment that takes into account differences in people's genes, environments, and lifestyles • Example - Demonstrated results in patients with cancer or family cancer history - Improved survival rates with reduced treatment side effects

Integration

Arrangement of an organization's information systems • Efficient and effective communication • Bring together related parts into a single system

CQM: Eligible Professional (Physician) Example

Measure: Appropriate testing for children with pharyngitis (sore throat) CMS eMeasure Identification: CMS146v1 NQF #: 0002 NQS's Priority Domain: Efficient Use of Healthcare Resources Measure Steward: National Committee for Quality Assurance Description: Percentage of children 2-18 years who were diagnosed with pharyngitis, ordered an antibiotic, and received a group A streptococcus (strep) test for episode

CQM: Eligible Hospital Example

Measure: Stroke 2, ischemic stroke—discharge on antithrombotic therapy (drug to prevent blood clots) CMS eMeasure: 104 NQF#: 0435 Version#: 2 Measure Steward: The Joint Commission NQS Priority: Clinical process/effectiveness Description: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

Hospital Services

Medical and surgical services and the supporting laboratories, equipment and personnel that make up the medical and surgical mission of a hospital or hospital system.

In which type of documentation of electronic capture of clinical information would include a patient's heart rate and breathing rate?

Patient assessments

Medicare Part D

Prescription drug coverage

Which of the following is one of the four key components of any EHR system?

Provides "longitudinal health data" on individuals

Confidentiality

The individual's right to keep information about himself or herself from being disclosed to other people.

Fraud is:

The intentional misrepresentation or concealment of relevant facts

TRICARE

The managed health care program of the Department of Defense that serves active-duty service members, retirees, and their families from all seven service branches. Besides immediate family members, survivors and certain former spouses may benefit from TRICARE.

ADT: Admission-Discharge-Transfer

The name given to software systems used in health care facilities that register and track patients from admission through discharge including transfers; usually interfaced with other systems used throughout a facility such as an electronic health record or lab information system.

Health Care

The prevention and treatment of illness.

Clinical Decision Support

The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts.

HIE: Health Information Exchange

The process of sharing health information electronically among two or more organizations, according to nationally recognized standards.

Medical Billing

The process of submitting claims to insurance companies in order to receive payment or reimbursement for services rendered by a health care provider.

Primary Care Characteristics - 1

• Integrated - provision of services that are: - Comprehensive - Coordinated - Continuous - A seamless process of care combining events and information that occur in different settings

The Managed Care Business Model

• Integrates financing and delivery using managed care techniques - Provider reimbursement - Comprehensive quality medical care • Features: - Controlled access to comprehensive care - Reduce costs - Improving quality care • Rationing and quality of care concerns

Messaging

• Internal e-mail • Secure email for patients • EHR-linked automatic text page • Intra-office group communications

Core Elements of an MPI

• Internal patient identification • Person name • Date of birth • Gender • Race • Ethnicity

HIT and Workarounds — 3

• Investigators found increased mortality among children admitted to Children's Hospital in Pittsburgh after CPOE implementation. • Three reasons were cited for this unexpected outcome: 1. CPOE changed the workflow. 2. Order entry required as many as 10 clicks and took as long as two minutes. 3. When the team changed its workflow to accommodate CPOE, faceto-face contact among team members diminished.

Roles of U.S. Government - 2

• Lawmaker role 1: Ensure fair competition - Sherman Anti-Trust Act, 1890 - Clayton Act, 1914 • Lawmaker role 2: Protect the public - Food, Drug, and Cosmetic Act created FDA, 1938 - Hatch-Waxman Act, 1984 - American with Disabilities Act, 1990

The Health Record

• Summarizes a patient's health conditions and care activities • Historically existed on paper but have become increasingly digitized • Serves as a - Communication and quality enhancement tool - Legal record of the care provided

Other Hospital Personnel - 1

• Surgeons - Perform operations - Special types o Orthopedic surgery o Plastic surgery • Anesthesiologists - Monitor patients in the OR - Treat pain o In the ICU o During childbirth

Delivery of Specialty Care Across Settings

• Surgical specialists - See patients in outpatient clinics - Perform surgeries in hospitals or in outpatient surgical centers

Agency for Healthcare Research and Quality (AHRQ) Annual Reports

Annual AHRQ reports on quality and disparities show progress is being made but is still suboptimal

HIPAA Privacy Rule 1

Applies to "covered entities" (CEs)—any entity that bills electronically - Health care providers o Clinicians, hospitals, clinics, etc. - Health plans o HMOs, insurance companies, etc. - Healthcare clearinghouses o Billing services - Business associates • Patient must authorize any disclosure, with the exception of "treatment, payment, or operations" (TPO); does not preclude health care providers from sharing data for patient care, a common misunderstanding (Houser, Houser, & Shewchuk, 2007)

Health Level 7 (HL7)

• ANSI accredited SDO • Used for healthcare information exchange around the world • Standards for - Clinical data exchange - Vocabulary - Document architecture

Informed Consent Process - 1

• Physician or other health care professional explains: - Risks and benefits - Other options, including no treatment • Opportunity to ask questions and get satisfactory, understandable answers

Documentation: multiple disciplines

• Physician • Nurse • Social worker • Physical therapist • Respiratory therapist • Other clinicians

EHR Hardware - Servers (cont'd - 5)

Category Internal External/Hosted Cost Higher initial costs Monthly fees Management Need staff to implement & manage server(s), perform software/hardware maintenance & backup Dependent on vendor for scheduled maintenance Power Capable of utilizing full power of server Often share resources with other institutions Connectivity Control speed & connectivity to server(s) Remote locations, so connectivity may be shared with other customers, reducing speed

Elements of Malpractice

• Duty of reasonable care to the injured party • Did not meet the minimum standard of care or failed to obtain informed consent • Failure to meet the standard of care was the proximate cause of the injury • The injury resulted in damages

Medical Mistakes Today

• Errors can result in medical malpractice lawsuits - 61% of doctors are sued at some point - Medical malpractice payouts totaled over $3 billion dollars in 2014 • Suffering from medical errors: not measurable

Long-term care facilities

Health care organizations that provide assistance to aging adults and to clients with chronic illness.

Health Information Exchange (HIE)

Health care providers and patients can appropriately access and securely share personal vital medical information electronically. Goals: • Avoid readmissions • Avoid medication errors • Improve diagnoses • Decrease duplicate testing

Inpatient Care

Health care that requires admission to a hospital for more than 24 hours.

Tertiary Care

Highly specialized care usually provided by referral to some sort of large medical center. The key is that the patient is away from the primary and secondary care that they've received initially.

Examples

Hospital • Aim: we will reduce the number of ventilator-associated pneumonias (VAP) in the ICU from the current 23% to under 10% in 4 months. • Measures: - Process measure: o Ventilator days o Over-sedation hours o Oral care performed - Outcome measure: Number of VAP - Balancing measure: o Cost of care o Re-intubation rates Ambulatory • Aim: we will reduce the amount of time it takes our patients to get an appointment (request to appointment) from 23 days to 0 days in 6 months. • Measures: - Process measure: o Supply o Demand o No-show rate - Outcome measure: Third next available appointment - Balancing measure: Patient satisfaction

Purpose of the MPI 1

• Establishes a streamlined governance process • Accurately matches persons being registered for care with their existing medical records

Epic: details

• Founded in 1979 • Private and employee-owned • 190 customers • 150,000 physicians (1 in 4 U.S. physicians)

Agency for Healthcare Research and Quality (AHRQ) - 2

• Helps organizations adopt new technology • Areas of research: - Effectiveness of treatments - Quality improvement and patient safety - Illness prevention and care management - Health care value

Procedure Codes

In the outpatient setting, procedures are coded using CPT-4. CPT stands for Current Procedural Terminology. In the inpatient setting, procedures are coded using ICD-10-PCS.

CQM: Eligible Professional (Physician) Example Continued

Measure: Appropriate testing for children with pharyngitis (sore throat) Numerator statement: Children with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis Denominator statement: Children aged 2-18 years who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic ordered on or 3 days after the visit

Effective Treatment

Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.

Health professional

Provides care to the sick and injured in pre-hospital, hospital, outpatient, home, extended-care facilities, and other settings Supports preventive care, wellness services, and patients' self-managed care

AHRQ: Agency for Healthcare Research and Quality

Provides data on healthcare in the U.S.

Purpose of the HHS

Provides essential health care for all Americans • Protects the needy or underserved • State, local, and tribal levels • Structure - Office of the Secretary - 11 operating divisions

Process measures

These measures look at the steps in teh system or processes of recommended care, e.g., in clinical guidelines. Valid measures should influence outcomes and thus should improve before the outcomes measures do.

Innovative Tort Reform

• "Safe harbor" for adherence to practice guidelines based on the latest medical research • More evidence needed to assess newer reform proposals • Affordable Care Act authorizes $50 million in grants for projects that evaluate the effectiveness of newer tort reform proposals

Veterans Health Administration

• "The Veterans Health Administration is home to the United States' largest integrated health care system consisting of 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers, and Domiciliaries" (Department of Veterans Affairs, 2011) - Primary care - Specialty care - Tertiary care

TJC's Mission Statement

• "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value." (The Joint Commission, 2016)

TJC History - 1

• 1910: The forerunner of TJC was called the "end-result" system • 1951: Joint Commission on Accreditation of Hospitals (JCAH) is created and starts accrediting health care organizations • 1987: JCAH changed its name to Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Attributes of Primary Care

• 1978 Institute of Medicine (IOM) definition: - Care that is accessible, comprehensive, coordinated and continuous - From perspective of patient and family • Comprehensive definition - Broaden perspectives to include: o Community o Integrated delivery systems o Ecosystem

Affordable Care Act (ACA) - 2

• 20 million people gained insurance coverage via the Affordable Care Act or "Obamacare" - Expands coverage o Individual mandates o Private insurance that allows young adults to stay on parents' health insurance plans o Medicaid expansion - Requires plans to cover people with pre-existing conditions - Provides free preventive services

HIPAA Privacy and Security

• 2006 HIPAA Rule - Privacy Rule: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary - Security Rule: www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html • 2008 Genetic Information Nondiscrimination Act (GINA) - Genetic information is protected under the HIPAA Privacy Rule - Prohibits most health plans from using/disclosing genetic information for underwriting purposes - www.eeoc.gov/laws/statutes/gina.cfm • 2009 ARRA/HITECH legislation enhanced both rules - http://www.hhs.gov/ocr/privacy • 2013 HIPAA Rule updated - Strengthens privacy protections, new rights for individuals to their health information, strengthens the government's ability to enforce the law - www.hhs.gov/about/news/2013/01/17/new-rule-protects-patient-privacy-secureshealth-information.html

Cerner (Cont'd)

• 21,000 associates worldwide • Cerner solutions are licensed at more than 20,000 facilities in more than 30 countries • 2014 revenues: $3.4 billion • 2014 net earnings: $525.4 million • Ticker symbol: CERN - NASDAQ

Roles of U.S. Government - 1

• 3 key roles: provider, payor, and lawmaker • Provider of health care services - Veterans Health Administration and TRICARE - Indian Health System - Supports research into new models of health care • Payor of third-party services - Outsources health care services, claims paperwork, grants for research

Cost Drivers: Technology

• 50 % of total annual expenditures • Devices advance diagnosis and care - Imaging: CT, MRI - Artificial devices: Hips, knees, pacemakers • New procedures treat the untreatable, minimize risk, improve outcomes - Surgery: da Vinci robot

Is "De-identified" Data More Secure? Not Necessarily

• 87% of US population uniquely identified by five-digit ZIP code, gender, and date of birth (Sweeney, 2002) • Sweeney identified William Weld, governor of Massachusetts, in health insurance database for state employees by purchasing voter registration for Cambridge, Massachusetts, for $20 and linking ZIP code, gender, and date of birth to "deidentified" medical database (Sweeney, 1997) • Genomic data can aid re-identification in clinical research studies (Malin & Sweeney, 2005; Lumley & Rice, 2010) • Social security numbers can be predicted from public data (Acquisti & Gross, 2009)

Corporate Integrity Agreements - 2

• A comprehensive CIA includes requirements to: - Establish a confidential disclosure program - Restrict employment of ineligible persons - Report overpayments, reportable events, and ongoing investigations/legal proceedings - Provide an implementation report and annual reports to OIG on the status of the entity's compliance activities

Corporate Integrity Agreements - 1

• A comprehensive CIA includes requirements to: - Hire a compliance officer/appoint a compliance committee - Develop written standards and policies - Implement a comprehensive employee training program - Retain an independent review organization to conduct annual reviews

Primary Care as a Strategy

• A strategy for organizing the health care system as a whole • Greater emphasis on community-based health care - Less costly - Patients are healthier

Accountable Care Organizations (ACO)

• ACO: providers and suppliers (e.g., hospitals, physicians, and others involved in patient care) work together to coordinate Medicare covered services. • Goal: Medicare beneficiaries receive lower cost, higher quality, and better coordinated care. • Patient-centered care decisions are joint between patient and providers. • Under the proposed rule: - Medicare would continue to cover Medicare services. - Benchmarks developed by CMS for each ACO. - ACO performance measured to determine if they receive shared savings, or held accountable for losses/poor performance.

Professional Organizations Supporting HIT

• AHIMA American Health Information Management Association • AMIA American Medical Informatics Association • HIMSS Healthcare Information and Management Systems Society • EHRA HIMSS Electronic Health Record Association

Medical Identity Theft

• AHIMA reported in 2008 a growing concern of general identity theft • 2015 Medical Identity Fraud Alliance Annual Report - Medical info more valuable than financial - Costly to the victim - Can be complex to solve over a long time • HHS report outlines approaches to prevention, detection, and remediation (ONC & OCR, 2015)

National Agencies Supporting HIT

• AHRQ Agency for Healthcare Research and Quality • HHS Department of Health and Human Services • NIH National Institutes of Health • NLM National Library of Medicine • IOM Institute of Medicine - National Academy of Medicine

Technical Safeguards

• Access control - Unique user identification (R) - Emergency access procedure (R) - Automatic logoff (A) - Encryption and decryption (A) • Audit controls (R) • Integrity—mechanism to authenticate electronic PHI (A) • Person or entity authentication (R) • Transmission security - Integrity controls (A) - Encryption (A)

Regional Center

• Accommodates 3 to 5 million persons • Contains aggregated data for EHR • Is a local ( to the region) database • Available 24/7 • Contains linkages to other centers so patients crossing boundaries of regions can be aggregated • De-identified data available for local or global queries and analysis

Potential Consequences of Poor Security

• According to Rindfleish (1997) - Patients avoid health care - Patients lie - Providers avoid entering sensitive data - Providers devise workarounds • California Health Care Foundation (2005) - 13% of consumers admit to engaging in "privacyprotective" behaviors that might put health at risk, such as o Asking doctor to lie about diagnosis o Paying for a test because they did not want to submit a claim o Avoid seeing their regular doctor

The National Committee for Quality Assurance (NCQA)

• Accreditation body for: - Health plans - Health plan contracting organizations - Accountable Care Organizations - Accreditation process includes assessments of clinical performance and consumer experience o Healthcare Effectiveness Data and Information Set (HEDIS) o Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey

Long Term Hospitals

• Acute-care hospitals that provide prolonged care (for more than 25 days) • Patients may have complex medical problems - May come from intensive care units - May have more than one condition - May need rehabilitation • Medicare covers hospital stay if hospital is certified

Core Elements of a MPI

• Address • Telephone number • Alias/previous/maiden names • Social security number • Facility identification • Universal patient identifier (UPI) • Account/visit number

Administration for Children and Families (ACF)

• Addresses the economic and social wellbeing of children, families, individuals, communities • Vulnerable populations • Programs are both national and regional • Well-known program: Head Start

Workers' Compensation at the State Level

• Administration differs by state - Some operate state fund - Majority provided by private insurance companies

Hospital or Inpatient Care Services

• Admission for more than 24 hours • Range of services - Emergency, trauma services such as accidents, heart attacks - Acute care medical and surgical services such as appendicitis - Highly specialized care services - Chronic care such as diabetes - Mental health care - Ancillary services such as lab and radiology

Long-Term Care

• Adult daycare - Meals and activities limited during the day • Independent living - Retirement community - Per-service options • Assisted living - Apartment or room - Personal care, medication, meals, housekeeping. • Skilled nursing facilities - Full medical care - Assistance with activities of daily living - Meals • Long-term care hospitals (CMS, 2015) - Acute care hospitals - Average stay greater than 25 days - Expect patients to return home

Administration on Aging (AoA)

• Adults 65 years of age and older will be 21.7% of the U.S. population by 2040 • Programs are both home-based and community-based • Funds non-medical programs to prolong health and independence • Multiple needs served: nutritional, logistical, legal, quality of life

Standards for Encryption and Related Functions

• Advanced Encryption Standard (AES): NIST-designated standard for encryption/decryption (Daemen & Rijmen, 2002) • Transport Layer Security (TLS) and predecessor, Secure Sockets Layer (SSL): Cryptographic protocols that provide security for communications over all points on networks (Rescorla, 2001) • Internet Protocol Security (IPsec): Protocol for securing Internet Protocol (IP) communications by authenticating and encrypting each IP packet of a data stream - Part of IPv6 but also added as standalone on top of IPv4 • Secure Hash Algorithm (SHA): Protocols that ensure integrity of transmitted information and documents (NIST, 2002) - Security flaws have been identified in SHA-1, so SHA-2 family of protocols has been developed • For more: - Secure Hash Algorithm https://en.wikipedia.org/wiki/Secure_Hash_Algorithm - NIST's Cryptographic Toolkit http://csrc.nist.gov/groups/ST/toolkit/index.html

Chronic Disease - 2

• Affects 1 of 2 adults in the U.S. • Accounts for 7 of 10 deaths • Daily activity limitations for 1 in 4 with chronic disease • Obesity major concern and contributor - 1 in 3 adults - 1 in 5 children between ages 2 and 19

Examples of Government Health Care Programs - 1

• Affordable Care Act (ACA) • Medicare • Medicaid • Children's Health Insurance Program • Veterans Health Administration • TRICARE • Indian Health Service

Indian Health Service

• Agency within the U.S. Department of Health and Human Services - Provides health services for American Indians and Alaska Natives - Goals are to ensure access to health services and reduce health disparities. • Federal IHS system includes 28 hospitals, 63 health centers, 31 health stations, and 34 urban projects • American Indian tribes and Alaska Native corporations independently administer 17 additional hospitals, 263 health centers, 92 health stations, and 166 Alaska village clinics • Additional services are contracted through private providers

Urgent Care Centers-2

• Also called immediate care centers • For acute illness or injury not serious enough for a hospital emergency department (ED) - Capability is intermediate between retail clinic and ED - Service is available on walk-in basis - Extended hours • Advantageous for U.S. health care system - Provide more health care for more people - Reserve EDs for life-threatening emergencies

EHR Messaging Standards

• Also called • Data exchange standards • Interoperability standards • Supports sharing of data • Safe • Accurate • Protocols • Data definitions

KLAS ratings

• Ambulatory EHRs - Software solutions for clinic and practice management, providing charting, orders, prescriptions, and / or EHR functionality • Divisions of physician organization - Over 100 physicians - 26-100 physicians - 6-25 physicians - 2-5 physicians - 1 physician

Specific Nursing Roles in Other Provider Settings

• Ambulatory care facilities - Similar to hospital-based units • Home health, hospice, patient's medical home - Medication administration, wound care, postoperative care, physical therapy • Long-term care, nursing homes - Provides constant care and assistance with activities of daily living • Public health clinics - Focus on population health with health promotion and disease prevention.

Joint Principles of the PatientCentered Medical Home

• American Academy of Family Physicians (AAFP). • American Academy of Pediatrics (AAP). • American College of Physicians (ACP). • American Osteopathic Association (AOA). • Seven Principles of the PCMH.

Preferred Provider Organization (PPO)

• Any provider - In-network providers o Lower deductibles, copayments, and coinsurance - Out-of-network providers o Higher deductibles and coinsurance for the patient • EPO - Must use in-network providers - No reimbursement for out of network provider services • No gatekeeper for either a PPO or EPO

Vendor Questions to Facilitate HIE

• Are there HIE capabilities within our EHR? • Privacy/security features present / supported • Form(s) of exchange • Cost of upgrading to include HIE • Maintenance costs of including HIE functionality • Timeframe for availability if not available now

CPT Examples

• Auditory System - External Ear o Incision o 69000 Drainage external ear, abscess or hematoma, simple o 69005 Complicated o 69020 Drainage external auditory canal, abscess o 69090 Ear piercing

Authentication and Passwords

• Authentication: Process of gaining access to secure computer • Usual approach is passwords ("what you know"), but secure systems may add physical entities ("what you have") - Biometric devices: Physical characteristic (e.g., thumbprint) - Physical devices: Smart card or some other physical "key" • Ideal password is one you can remember but no one else can guess • Typical Internet user interacts with many sites for which he/she must use password - "single sign-on" is commonly used • Two-factor authentication

Health Care in Other Countries

• Benefits/drawbacks of two public (taxfunded) health care plans • Compare a multi-payor health care system with a single-payor system • The role of private health insurance in each system

National Quality Strategy (NQS) Aims

• Better care: improve overall quality by making health care more patient centered, reliable, accessible, and safe. • Healthy people/healthy communities: improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher quality care. • Affordable care: reduce the cost of quality health care for individuals, families, employers, and government.

Radiology Services - 1

• Branch of medicine that uses imaging technology to diagnose or treat diseases • Radiologists - physicians who specialize in radiology • Outpatient radiology services may be housed within a hospital or may be freestanding

Other Modifications in HITECH

• Breach notification: When 500 or more patients affected, breach must be reported to local media and OCR - www.hhs.gov/hipaa/for-professionals/breachnotification/index.html - Restrictions on disclosures - Information about services paid for out of pocket must be withheld from payers upon request - TPO disclosures must be tracked and records maintained for three years - Covered entities with EHRs must provide or transmit PHI in electronic format as directed by patient • Patients can opt out of fundraising appeals

Tools for Protecting Health Information

• Brought to wider light by IOM report For the Record (Committee on Maintaining Privacy and Security,1997) • Guide to Privacy and Security of Electronic Health Information (ONC & OCR, 2015) • NIST Critical Cybersecurity Infrastructure Framework • SANS • And many more ...

Business Associates 1

• Business associate (BA) - Does work on behalf of a covered entity using or disclosing PHI o Anyone who comes in contact with and uses PHI - Must sign agreement with covered entity - Is directly accountable to HHS for compliance and subject to breach notification rules - Includes all subcontractors to business associates

Other Regulations

• Business associates and subcontractors are required to - Implement safeguards to protect covered entity's PHI - Ensure its agents meet same standards - Report to covered entity any security incident • Documentation of covered entity must be - Maintained for six years - Available to those responsible for implementing - Reviewed and updated periodically • HITECH meaningful use criteria specify use of various encryption standards (e.g., AES, TLS, IPsec, SHA-2)

Other Government HIT Organizations

• CDC Centers for Disease Control and Prevention • CMS Centers for Medicare and Medicaid Services • FDA Food and Drug Administration • HRSA Health Resources and Services Administration

Chronic Disease and Health Risk Behaviors

• CDC: Four health risk behaviors - Lack of physical activity - Poor nutrition and obesity - Tobacco use - Excessive alcohol consumption

Common HIPAA Acronyms

• CE Covered Entity • HIPAA Health Insurance Portability and Accountability Act of 1996 • BA Business Associate • BAA Business Associate Agreemen

Common HIPAA Acronyms 2

• CFR Code of Federal Regulations • IFR Interim Final Rule • NPRM Notice of Proposed Rule Making • OCR Office for Civil Rights • PHI Protected Health Information

EHRs Can Augment Data Used in Quality Measures

• Coded information in EHR - Improves ability to assess diabetes quality measures (Tang, 2007) - Administrative (or "claims") data insufficient to calculate HEDIS measures—EHR data can improve accuracy of calculating HEDIS measures (Pawlson, Scholle, & Powers, 2007) • But some measures are in narrative text that is harder to access - In heart failure, important data inaccessible in clinical notes, especially exclusion data for medications (Baker et al., 2007) - Some data can be extracted by natural language processing (NLP) as effectively as manual abstractors in areas such as smoking cessation advice (Hazlehurst et al., 2005), diabetic foot exam (Pakhomov et al., 2008), and congestive heart failure (CHF) (Pakhomov et al., 2008) • Overall, EHR data quality is mixed for quality measurement; important attributes to improve include are granularity, timeliness, and comparability (Chan, Fowles, & Weiner, 2010)

Clinical Roles - 4

• Coders and billers - Interpret codes that delineate diagnoses and levels of care • Insurance Specialists / Referral Coordinators - Simplify the referrals process • Housekeeping Services - Disposal of sensitive patient-related information and medical wastes

Coding and Code Sets

• Coding: Process of translating the written diagnosis and procedures relating to a patient encounter into a numeric classification or code sets • Code set: Group of numeric or alphanumeric codes used to encode descriptive data elements - Tables of terms, medical concepts, diagnostic codes, or procedure codes - Includes codes and descriptors of the codes

Network

• Collection of computers and devices connected by communication channels • Allows users to communicate and share resources with other users • Important terms - Network Medium; Ethernet; Wireless Access Point (WAP); LAN (Local Area Network); WLAN (Wireless Local Area Network); WiFi; WAN (Wide Area Network); Point-to-point or fractional T1; Bandwidth; VPN (Virtual Private Network); Firewall

State-Licensed Insurance Organizations - 1

• Commercial Health Insurers - Most are owned by stockholders or stock companies - Mutual insurance companies are owned by their policyholders • BlueCross BlueShield - Association of 39 different companies in 50 states - Locally operated; some are for-profit - Largest insurer, covering 1 in 3 Americans

Some Challenges with Passwords

• Common approach to security is password "aging" (i.e., expiration), which is less effective than other measures (Wagner, Allan, & Heiser, 2005) - Session-locking: One or small number of simultaneous logons - Login failure lockout: After 3 to 5 attempts • Password aging may also induce counterproductive behavior (Allan, 2005)

Types of Hospitals

• Community hospitals - "Community hospitals are defined as all nonfederal, short-term general, and other special hospitals" • Teaching hospital (academic hospital) - Usually associated with a university or medical school - Major role in clinical training of health professionals • Specialty hospitals - Focus on a specific population or disease state - Examples include children's hospitals, orthopedic and spine hospitals, and cancer-focused hospitals

Other Long Term Care Options for Older Adults - 1

• Community-based services - Various programs, coordinated by state agencies - State Medicaid may help with costs • In-law apartments - Defined as a separate living space on a property - Subject to local and state laws

Long term care Facilities and Services

• Community-based services • In-home health care • In-law apartments • Housing for aging and disabled individuals • Board and care homes • Assisted living • Continuing care retirement communities • Nursing homes

SNOMED CT

• Compilation of many healthcare terminologies • Comprehensive clinical terminology • Controlled medical terminology • Multilingual • Hierarchical • Captures clinical information in EHR

Affordable Care Act (ACA) - 1

• Comprehensive health care reform • Passed by Congress and signed into law by President Obama on March 23, 2010 • Supreme Court upheld ACA on June 28, 2012 • Health Insurance Marketplace began October 1, 2013 - states had option to use federal site or develop their own

Healthcare Information and Management Systems Society (HIMSS)

• Comprehensive health care stakeholder membership organization • Global leadership for optimal use of information technology (IT) and management systems for health care • Educational, professional development, and advocacy initiatives • Promotes information and management systems' contributions to ensuring quality patient care

Concerns about Security

• Comprehensive overview (Herzig, 2010) • Guide to Privacy and Security of Electronic Health Information (ONC & OCR, 2015) - https://www.youtube.com/watch?v=phrXsdnh E7w • Many points of leakage • A problem for paper records, too • Consequences of poor security • Medical identity theft

CPR vs. EMR vs. EHR

• Computerized Patient Record (CPR): Electronic record with full interoperability within an enterprise (hospital, clinic, practice) • Electronic Medical Record (EMR): Commonly found in ambulatory care and physicians practices • Electronic Health Record (EHR): Designed for interoperability and accessibility across disparate organizations

Change

• Concepts and strategies: decide on the overall changes that will lead to the desired improvement. • Specific changes: - Make them small. - Make them fast. - Make them frequent. • You may need to include additional measures specifically to decide if a change you have tested is worth keeping or did not lead to improvement. • Consider using pre-existing change packages.

Personal Privacy vs. the Common Good

• Concerns expressed in ACLU video Scary Pizza • A spectrum of views: - One end holds that while personal privacy is important, there are some instances when the common good of society outweighs it, such as in biosurveillance (Gostin & Hodge, 2002; Hodge, Gostin, & Jacobson, 1999) - The other end holds that personal privacy trumps all other concerns (Privacy Rights Clearinghouse, 2009; see also video by Deborah Peel, Designing Technology to Restore Privacy, http://www.patientprivacyrights.org) - More "balanced" views? (California Health Care Foundation, 2008; Detmer, 2010; American College of Physicians, 2011) • Where do your views fit?

Technology and National Health Care Expenditures

• Congressional Budget Office Estimates - 40-50% of total expenditures • Technology in health care - Procedures - Equipment - Processes by which medical care is delivered

Network - Assessing Usage (cont'd)

• Considerations - How many users will need simultaneous access to the network? - Bandwidth requirements of the EHR system (per vendor) o Special bandwidth needs of scanning equipment or other medical equipment - Sufficient connectivity between internal and remote resources such as satellite facilities

Standards for Certification of EHR Technology

• Content exchange standards - NCPDP SCRIPT Standard - HL7 Clinical Document Architecture (CDA), C-CDA • Vocabulary standards - SNOMED CT - LOINC • Privacy and security standards - NIST encryption algorithm - NIST hashing algorithm

Contract Law

• Contract elements - Offer - Acceptance - Consideration: something of value given in exchange for a promise • Express contract - Written or oral • Implied contract

KLAS criteria in evaluations

• Contracting experience • Product works as promoted • Money's worth • Avoids nickel and diming • Quality of implementation • Implementation on time • Quality of training • Overall product quality • Delivery of new technology • Ease of use • Product response time • Supports integration goals • Product has needed functionality • Quality of phone / web support • Proactive service • Executive involvement • Lives up to expectations • Keeps promises • Part of long term plans • Overall communication • Recommend to peer / friend • Overall satisfaction • Forecasted overall satisfaction • Would you buy again • Ranked client's best vendor

Medicare-2

• Created by Social Security Act of 1965 - Determines Medicare eligibility - Processes premium payments • FICA - Financed by payroll taxes 1.45% from employee + 1.45% from employer 2.9% deduction - Pays for Medicare Part A (hospital insurance)

Medicare Part D...

• Created in 2003 • Prescription drug coverage • Voluntary enrollment • Pay premium to company approved by Medicare • Patients pay deductible & co-payment - After certain point, may pay up to 50% of drug costs themselves ("doughnut hole")

Personnel Who Provide Serious Acute Care - 2

• Critical care - Specialty - life threatening conditions - Focus is long term care - Sent to ICU or CCU once stabilized

Big Picture: NwHIN Nationwide Health Information Network

• Current pronunciation: "New HIN" - Also known as the NHIN • NwHIN Connect - traditional view of interconnected cells • NHIN Direct - aka Direct Project, considered "NwHIN" lite; idea is ease of adoption • ARRA funded - American Recovery and Reinvestment Act • Syndromic Surveillance - 9/11/2001 as a driving factor

• Metadata

• Data about the data • Characteristics of each data element

Data and Process Integration

• Data integration - Interface engine • Process integration - Operational workflow - Human organizational systems

Systems Integration Strategies

• Data preservation • Separate information management plan components for - Data management - Applications and business logic - User interface

Advantages of Client-Server Model

• Data resides on the server, which generally has safer controls • Easier to manage and update • Less resource-intensive for the client

CPOE: vendor system differences (Cont'd - 1)

• Decision support functionalities - Dosing recommendations and calculations - Customized order sets - Bar coding scanning technology o Medication administration process (pharmacy to administration) o Right patient gets the right drug at the right time - Alerts o Allergy alert o Drug interaction checking o Laboratory alerts

Health Information Rights

• Declaration of Health Data Rights - Right to our own health data - Right to know the source of each health data element - Right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; if data exist in computable form, they must be made available in that form - Right to share our health data with others as we see fit - Read: https://sites.tufts.edu/prep/2009/07/07/declaration-of-health-datarights • AHIMA Health Information Bill of Rights (2009) - http://bok.ahima.org/PdfView?oid=107674 - Slightly more detailed but with similar provisions • HIPAA Privacy Rule Provisions (2016) - www.healthit.gov/patients-families/your-health-information-rights

Primary Care Crisis Contributing Factors - 1

• Decreasing number of physicians practicing primary care • Supply-demand imbalance • Greater dependence on after-hours care • Increased cost of health care delivery

Cost Drivers: Defensive Medicine & Patient Preference

• Defensive medicine - Overutilization of services - Tort reform • Patient preference - Request for specific test or medication - Direct to consumer advertising

Standards to Promote Health Information Exchange Summary

• Define terms related to standardized terminologies • Identify and define HIPAA standard code sets • Identify and define terminologies and vocabularies that represent nursing care • Define and give examples of data interchange standards

Family Practice

• Defined by American Board of Family Practice - Medical specialty that provides continuing and comprehensive health care for the individual and for the family in an outpatient setting. • Integrates biological, clinical and behavioral sciences • Encompasses all ages, both sexes, each organ system and every disease entity

Privacy, Confidentiality, and Security

• Definitions • Concerns - Privacy - Security • Tools for protecting health information • HIPAA - Privacy Rule - Security Rule - Enhancements in HITECH - Implications

Effects of Overcrowding In The ED

• Delays in the treatment of serious medical conditions • Increased waiting times • Reduced promptness and quality of pain management • Hallway boarding of admitted patients • Ambulance diversions • Decreased physician productivity

Dental Health

• Dental Assistant - Education o On the Job o Certificate o Associate's degree - Certification o Certified Dental Assistant Exam - Licensure o Varies by state • Dental Hygienist - Education o Associate's degree o Bachelor's degree - Licensure o National Dental Hygiene Board Exam o State clinical board.

Other Outpatient Facilities

• Dental offices • Medical and diagnostic laboratories • Urgent Care Centers • Mental Health Clinics • Alcohol and Substance Abuse Treatment Center • Outpatient Surgical Centers • Physical and Occupational Therapy Centers • Home Health • Hospice Care

Examples of Medical Specialties

• Dermatology • Pathology • Radiology • Nuclear Medicine • Psychiatry • Emergency Medicine • Preventive Medicine

Financing Health Care, Part 1 Learning Objectives - 2

• Describe models of health care financing in the U.S. and in selected other countries. (Lecture c) • Explain the differences among various types of private health insurance and describe the organization and structure of network-based managed care health insurance programs. (Lecture d)

Financing Health Care, Part 1 Learning Objectives - 1

• Describe the history and role of the health insurance industry in financing health care in the United States, and Federal laws that have influenced the development of the industry. (Lecture a) • Explain the importance of the health care industry to the U.S. economy and the role of financial management in health care. (Lecture b)

Health Care Revenue Collection

• Describe the revenue cycle and the billing process • Review the use of code sets used in the claims process

Technologies to Secure Information

• Deterrents - Alerts - Audit trails • System management precautions - Software management - Analysis of vulnerability • Obstacles - Authentication - Authorization - Integrity management - Digital signatures - Encryption - Firewalls - Rights managemen

Systematized Nomenclature of Medicine Clinical Terms

• Developed by College of American Pathologists • Ownership transferred to International Health Terminology Standards Development Organisation (IHTSDO) • Distributed free in the US by NLM

Logical Observation Identifiers, Names, and Codes

• Developed by the Regenstrief Institute • Provides a standard set of codes and names for the electronic reporting of laboratory results • Expanded to include items related to measurement of clinical observations, such as blood pressure and symptoms

AHRQ: Health IT

• Develops and disseminates information • Toolkits and educational materials are available to capture best practices in the use of technology • Research funding opportunities are also available

Data Entry

• Devices • Central Processing Units (CPU) • Secured Tablets • Slim Clients • Smartphones • Locations • Point-of-care • Nurses' Station • Computers on Wheels (COW) • Workstation on Wheels (WOW)

Coding Examples

• Diagnosis - Upper respiratory infection = J06.9 (ICD-10-CM) • Service, procedure or test - New patient, office visit, level II = 99202 (CPT) - Biopsy of skin, subcutaneous tissue and/or mucous membrane(including simple closure), unless otherwise listed; single lesion = 11100 (CPT) - Immune globulin 10 mg = J1564 (HCPCS Level II)

Radiology Services - 3

• Diagnostic radiology - Computerized Tomography (CT) scans - Magnetic Resonance Imaging (MRI) scans - Positron Emission Tomography (PET) scans - Ultrasound - Mammography - Bone density tests - Nuclear medicine tests

• Data dictionary

• Dictionary of the metadata for a particular data set • Definitions, principles and guidelines for each data element • Specifies values for each element

Clinical Roles - 2

• Dietician / Diabetes educator - Helps patients with specific dietary interventions • Social Worker - Assists with social issues - Goal to enhance human well-being • Counselor - Mental health issues, also assists with patients' psychosocial issues - There is an acute shortage of mental health services

Other Results from McGlynn and Related Data

• Differences between sociodemographic groups much greater than within groups (Asch et al., 2006) • From this and other data, quality of care increases with number of chronic conditions (Higashi et al., 2007) • Similar analysis applied to patients in Veterans Health Administration found overall quality higher than national sample for process measures but not outcomes (Asch et al., 2004; Trivedi et al., 2011) - In light of history of suboptimal care within VA, transformation called "remarkable" and attributed in part to EHR system (Greenfield & Kaplan, 2004; Baker, 2006; Congressional Budget Office, 2009)

Medicare Part C - 2

• Differences in Advantage Plans: - Out-of-pocket costs - Rules for services - Change each year • Part C options include: - Health maintenance organization (HMO) - Preferred provider organization (PPO) - Private fee-for-service plan - Special needs plan

Medicaid - 2

• Differs by State - Eligibility requirements - Co-payments - Counting income and resources • Must provide payments for hospital and physician services • May provide payments for pharmacy, dental, and eye care • Must not provide payments for abortions

Security for Paper Records Is a Significant Problem

• Difficult to audit trail of paper chart • Fax machines, scanners are easily accessible • Records frequently copied for many reasons - New providers, insurance purposes • Records abstracted for variety of purposes - Research - Quality assurance - Insurance fraud → Medical Information Bureau (Rothfeder, 1992)

Digital Communication

• Digital - Electronic health record - Patient sourced information - Personal health record and portals

Legal issues

• Discovery of electronic records for legal purposes - Centers for Medicare and Medicaid and Joint Commission o Accepted standards for Legal Health Record - HIPAA privacy and security rules and Office of Civil Rights o Organizations identify "designated record set" • How the information is used (e.g., was it used to provide patient care?), not where it resides, determines if it is part of the legal record

ICD-10-CM

• Diseases of the circulatory system I00-I99 - I20-I25 Ischemic heart diseases o I20 Angina pectoris o I21 ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction o I22 Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction o I23 Certain current complications following ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction (within the 28 day period) o I24 Other acute ischemic heart diseases o I25 Chronic ischemic heart disease

General Internal Medicine

• Doctors of internal medicine (also known as "internists") • Focus on adult medicine • Special study and training focusing on the prevention and treatment of adult diseases. • Can be called upon to act as consultants to other physicians

Results of Current Approaches

• Does better performance on measures lead to improved patient outcomes? • What problems arise from current approaches? • Results in other countries, such as in England

Example: Traffic Accident

• Drunk driver crashes car, causing serious injury to the driver of the other car • Criminal (public) penalty - State vs. drunk driver • Civil (private) damages - Injured driver vs. drunk driver

Licensed Practical Nurse

• Education - 12 to 18 months of training post-high school • Training - Includes training in medical terminology, introduction to anatomy and physiology, introduction to pharmacology, and practical nursing clinical course • Certification - Usually results in a certificate of attendance. • Licensing - All states and the District of Columbia require a licensing exam - Licensed by the state board of nursing • Role - Provide more direct care - Work under supervision of registered nurse or physician - State laws vary but most allow LPNs to start and administer IV therapy, and many allow LPNs to administer IV medications except IV push

Social Workers

• Education - Bachelor's degree in social work (BSW) - Master's degree or master's of social work (MSW) • Training - BSW focuses on direct service - MSW more clinical and supervisory training • Licensure - All states and the District of Columbia require licensure, certification, or registration. • Roles - BSW o Direct service o Case management Health, housing, relationships, disability - MSW o Counseling o Case management o Supervisory o May specialize in certain areas such as mental health, substance abuse, rehabilitation

HEDIS Categories and Example Measures

• Effectiveness of care - Childhood and adult immunizations - Use of beta blockers after myocardial infarction - Screening for various types of cancer - Comprehensive diabetes care • Access to/availability of care - Access to preventive health services - Availability of primary care providers - Initiation of prenatal care • Satisfaction with care - Member satisfaction surveys • Use of service - Rate trends

Limiting Private Insurance

• Effects include: - Does not improve access to basic services already covered by MEDICARE - Increases the public cost of universal coverage • Some want to expand the role of private insurance to solve these problems • Others want to continue restriction to ensure equal access for all

Measurement Issues

• Elderly patients often have complex comorbidities that render recommendations in guidelines (and performance measures) inappropriate (Boyd et al., 2005) - Experience to date in England (Doran et al., 2008) and US (Persell et al., 2010) show most physician-recorded exceptions appropriate • Medicare patients' care dispersed among many physicians, so it's hard to attribute quality (Pham et al., 2007) • New results in clinical trials can render some measures obsolete (e.g., lowering cholesterol, diabetes) (Krumholz & Lee, 2008) • Some measures have unintended consequences, (e.g., time to first antibiotic dose in pneumonia) (Wachter et al., 2008) • Multiplicity of measures leads to conflict reports (e.g., in stroke care) (Kelly et al., 2008) • Most physicians don't have large enough practice caseloads to reliably measure differences (Scholle et al., 2008; Nyweide et al., 2009) - Need to focus on multiple measures and all payers (Berwick et al., 2009)

Billing Definitions - 2

• Electronic Data Interchange (EDI) - Transmission of data between organizations by electronic means - Transaction set: an electronic model of a paper transaction or form

Electronic Health Information Management 2

• Electronic Health Record (EHR) Management - A process where the management of electronic health data is created or received for legal or business purposes

Benefits of HIE: Providers

• Emergency Care • Public health reporting and monitoring • Improved Care / Fewer Medical Errors • Clinical Decision Support • Tracking Access to Information • Less Redundant of Unnecessary Services • Reduced Costs

EMTALA

• Emergency Medical Treatment and Active Labor Act of 1986 - Legal mandate to offer medical care to all patients regardless of ability to pay - Anyone presenting to an ED must be: o Examined to determine if there is an emergency o Treated until stabilized, discharged to self care or continuing care o Transferred to a facility capable of providing care if the facility is unable to provide the required care

Personnel Who Provide Serious Acute Care - 1

• Emergency Medicine - Encompasses verity of medical problems - Specialty dedicated to life threating problems - Short term care • EMTs and Paramedics - Perform basic care - Paramedics have extra training

Federal Regulation of Private Health Insurance - 1

• Employee Retirement Income Security Act (ERISA) 1974 - Permits and regulates self-insured health plans o Does not require employer plan o Requires plans to meet minimum standards o Requires a grievance and appeals process o Gives participants the right to sue for benefits

VA Strategic Goals

• Empower veterans to improve their wellbeing • Enhance and develop trusted partnerships • Burial and memorial benefits • Public health, emergency readiness, and socioeconomic well-being • Manage and improve VA operations to deliver seamless and integrated support

Penalties

• Enforced by HHS Office for Civil Rights http://www.hhs.gov/ocr/index.html • Penalties higher for "willful neglect" (i.e., offender knew about violation or was recklessly indifferent) • Original HIPAA criticized for modest penalties and minimal prosecutions • HITECH increased severity of penalties: - Tiered penalty structure ranging from $25,000 to $1.5 million per year, with $100 to $50,000 per violation (for each record)

The Uninsured 2014

• Enrollment in ACA coverage corresponds with large declines in the uninsured rate - Uninsured rate dropped from 16.2%, last quarter of 2013 to 12.1%, last quarter of 2014 • Barriers: - 48% coverage too expensive - 12% unemployed or not offered through work - 13% ineligible

Importance of Charge Capture

• Ensures proper reimbursement for services provided • Permits reevaluation of episode of care reimbursement arrangements

Food and Drug Administration (FDA)

• Ensures safety and effectiveness: - Food and drugs - Medical devices - Animal drugs - Cosmetics • Evaluates and approves new drugs • Regulates tobacco manufacture and marketing • 8 centers with oversight by Commissioner

Understanding Information Exchange in HIT Systems - Summary

• Entities that are commonly involved in HIT system data exchange • The need for standards and why they exist • Vocabulary, content exchange, and privacy and security standards • Health information exchange between providers, communities, regions and nation (NHIN, HIEs, NHIN Direct)

Business Associates

• Entities that are engaged to assist covered entities in delivering health care services • Business Associate Agreement (BAA) • Must also comply with HIPAA rules

Pharmaceutical Costs

• Estimated 10% of total health care expenditures - $298 billion in 2014; $40.3 billion 1990 - Average ~12% increase over the last 10 years - Drug costs inflated above Consumer Price Index (CPI)/other health care sectors • Increased availability - Medications for chronic disease o e.g. cholesterol, diabetes • Increased demand - Cancer chemotherapy

Controlling Health Care Costs - 2

• Examine delivery models for reducing health care expenditures - Retail clinics/Urgent care - Extenders/Doctors of Nursing Practice (DNP) - Patient-Centered Medical Home o Direct primary care - Concierge medicine

ORYX: Core Measure Sets - 1

• Examples - Heart attack - Pneumonia - Inpatient psychiatric care - Children's asthma - Stroke

Medicare/Medicaid Fraud and Abuse - 2

• Examples of possible fraud/abuse: - Provider bills for services or equipment that the patient never received - Someone uses another person's Medicare or Medicaid card to get medical care or equipment - Provider bills for home medical equipment after it is returned

NHS Expenditures and Funding

• Expenditures - Per capita spending (2013) $3,595 • Financing - National taxes (76%) - Payroll taxes (18%) - Other sources (6%) o NHS patients o Private patients o Other

HIMSS "products"

• Extensive collection of industry research reports • IT news • Topics and tools - E.g. Tools for EHR professionals - Materials about factors and trends in the use of EHR • Note: Given the mixed membership (providers and vendors), you will not find vendor comparisons and product reviews

Medication Aides

• Extremely variable education/training ranging from 15 to 70 contact hours • Most states require an exam and supervised administration for some period of time • Some states specify training as a certified nursing assistant as a prerequisite • Most states license medication aides • Roles are variable but usually include the administration oral, topical, and nebulized or metered inhaled medication. Many states restrict medication aides to long-term care or assisted living facilities

Fast Healthcare Interoperable Resource

• FHIR combines the best features of: HL7v2, HL7v3, CDA • FHIR leverages latest web service technologies • FHIR utilizes "REST" in contrast to "SOAP" web services • FHIR's modular components bring practical solutions • HL7 International: Draft Standard for Trial Use (DSTU)

Digital Imaging Communications in Medicine (DICOM)

• Facilitates the exchange of images and diagnostic information from manufacturers to vendors to providers • Application is in any area using diagnostic images such as radiology, pathology, dentistry • Standards address - Data structure - Data dictionary - Message exchange - Media storage - Mapping

Retail Clinics

• Facilities usually located in stores or pharmacies, may also be free-standing • Staffed by nurse practitioners - nurses with additional training • Intended to treat common and minor illnesses

Physical Safeguards

• Facility access controls - Contingency operations (A) - Facility security plan (A) - Access control and validation procedures (A) - Maintenance records (A) • Workstation use (R) • Workstation security (R) • Device and media controls - Disposal (R) - Media re-use (R) - Accountability (A) - Data backup and storage (A)

Outpatient Laboratories

• Facility where laboratory tests are performed on clinical specimens • May be associated with a hospital or be freestanding • Testing may be done in a location remote to the location where specimen was obtained

Federal Fraud and Abuse Laws

• False Claims Act • Anti-Kickback Statute • Stark Law • Exclusion Statute • Civil Monetary Penalties Law

Primary Care Medical Specialties

• Family Practice • General Internal Medicine • Pediatrics • Obstetrics and Gynecology (OB/GYN)

Governance of Health Record

• Federal and State Laws, Regulations, and Rules • The Joint Commission and other voluntary accreditation • Medical staff bylaws

The Judicial System: Jurisdiction

• Federal courts - Constitutionality of a federal law - Disputes primarily involving federal law - Disputes between citizens of different states • State courts - Often called courts of common pleas or county courts • City or municipal courts

Workers' Compensation: Federal and State

• Federal government - Provides for non-military federal employees - Administered by Office of Workers' Compensation Programs • State governments - 1949 - all states required some form of Workers' Compensation - Most employers are required to offer - Investigate fraud and abuse

Reimbursement Methodology

• Fee-for-service (FFS) - Traditional retrospective - Self-pay • Episode-of-care (EOC) - Capitation - Prospective payment - Global payment • Managed care may involve either methodology

Radiology Services - 2

• First X-ray - Wilhelm Röntgen in 1895 - Wilhelm's wife's hand • Termed diagnostic radiology when they help diagnose diseases

Public Administration and Comprehensiveness

• First two principles explain how plans are administered - Public administration: o Publicly administered o Non-profit organizations o Accountable to the public - Comprehensiveness: o Must provide all medically necessary services o Each province or territory decides what is medically necessary

Unit 2: EHR Functionality, Summary

• Five important functions of EHRs: - Results review - Computerized Provider Order Entry (CPOE) - Documentation - Messaging - Billing • These functionalities impact clinical workflow, patient safety, information retrieval, legal issues, billing, and communication

Board and Care Homes (Group Homes) - 1

• For people who cannot live alone and need help with ADLs - Residents may o Physical or mental disability o Cognitive impairment o Substance abuse o Elderly

HIMSS

• Founded in 1961 • Offices in Chicago, Washington D.C., Brussels, Singapore, and other U.S. locations • 52,000 individual members, of which more than 2/3 work in health care provider, governmental, and not-for-profit organizations • 600 corporate members and 250 not-for-profit organizations

Medicare/Medicaid Fraud and Abuse - 1

• Fraud - intentional falsification of information or deception of Medicare or Medicaid • Abuse - doctors or suppliers don't follow good medical practices - Unnecessary costs - Improper payment - Services that aren't medically necessary

VA Community-Based Outpatient Clinics

• Freestanding clinics • Routine care • Every state and territory • Accessible and convenient

Tort Reform

• Frivolous lawsuits - No lawsuits for expected complications • Damage caps - Limit punitive awards - Limit attorney fees - Pain and suffering • Binding arbitration

Allscripts: products

• Full suite of health solutions: - Offers health care providers, payers, and life sciences companies globally a complete portfolio of clinical, financial, population health management, transaction and managed IT services, as well as other solutions

Sole Proprietorship Clinic

• Functions as a small private office • Run by a single physician with a small staff • Owner assumes all obligations/liabilities • This type of practice is increasingly rare

Point of Service Plan (POS)

• Gatekeeper - All services through primary care physician - Controls access to all medical services - Referrals generally to in-network providers only - May refer out-of-network • No reimbursement for services to out-ofnetwork providers unless previously authorized by gatekeeper

Cerner

• Global supplier of health care solutions - Makes sure the right people have the right information at the right time - Founded 1979 (Neal Patterson, Cliff Illig, Paul Gorup) • Create a new generation of intelligent medical devices • Leverage clinical and pharmaceutical data for new discoveries • Collaborate with employers to eliminate administrative waste and friction

Hospital Corporate Structure

• Governing board provides oversight • Chief executive officer responsible for daily operations • Administration also includes chief officers, department heads, patient care managers • Medical staff and ancillary personnel provide health care and technical services • Non-medical services are also critical • Business office does paperwork

Examples of Government Health Care Programs - 2

• Government payors: Programs whereby the government pays health care organizations to provide health care services • Government operated delivery systems: Self-contained systems that operate facilities and have government-employed providers

Publically-Funded Health Care

• Government programs, some of them funded through income taxes and payroll taxes • Begin in federal legislation • Voted into law by Congress • Help specific population groups • Run by federal government and federalstate partnerships

National Health Care Spending 2013

• Gross Domestic Product (GDP): 17.35T • National Health Spending: $3.0T - As a percentage of GDP: 17.5% - Per capita cost: $9,255 - Projected spending as a percentage of GDP (2024): 19.6%

MHS: TRICARE Program Overview

• Group of managed care plans - Comprehensive, low-cost options - Network of physicians, hospitals, pharmacies - Active duty, retirees, families; all service branches • Most common coverage plans - TRICARE Prime - TRICARE Standard - TRICARE for Life - TRICARE Reserve Select - Also overseas options, family care

EOC: Capitation - 2

• Group practice agreement with payor - Payor pays the practice $25 per 100 members per month o If costs of care are less than $25 per 100, the practice makes money o If costs of care are greater than $25 per 100, the practice loses money • Provider must balance provision of care with the costs

Required Safeguards

• Grouped into three categories - Administrative: Policies and procedures designed to prevent, detect, contain, and correct security violations - Physical: Protecting facilities, equipment, and media - Technical: Implementing technological policies and procedures • Following slides from Security 101

Delivering Health Care, Part 1 Summary - Lecture a

• HHS - Described organization of health care at federal, state and local levels - Provides oversight through eleven operating divisions • States run their own departments - Accessed locally through private practices, clinics and hospitals • Overall goal - ensure the health of all Americans

Common HIT Acronyms 2

• HIE Health Information Exchange • MU Meaningful Use • VHA Veterans Health Administration • VistA Veterans Health Information Systems and Technology Architecture

Demonstrating Effective Use of Health IT

• HIMSS Davies Award of Excellence winners • HIMSS Analytics EMRAM model • HIMSS Continuity of Care Maturity model • HIMSS IT Value Suite • KLAS Research

Unit 1: Common Commercial Electronic Health Record (EHR) Systems, Summary

• HIMSS is a valuable starting resource to acquire detailed information about features and functions of EHR technology • KLAS is resource that can be used to assist with selecting a specific EHR system • There is wide variation in the corporate history and product offering of commercial EHR system vendors

Current Trends to Establish a UPI

• HIPAA - Requires unique identification numbers o UPI has not been adopted • ONC's Health Information Technology Standards Committee (HITSC) - Patient Matching Power Team o Recommendations

HIPAA Enforcement and Penalties - 2

• HIPAA Omnibus Rule, 2013 - Stringent requirements regarding notification of health information breach to the Department of Health and Human Services - Increased fines and penalties - Enhanced patient control of health information

Compliance Beyond Fraud and Abuse

• HIPAA Privacy and Security Rules - What is the plan for appropriate release of PHI? - How is the tracking of release occurring? - Who is responsible for breach notification? - What training is being done? - Is there a team reviewing policies and procedures?

Health Information Standards

• HIPAA national policy • NCVHS recommendations • National Library of Medicine - Unified Medical Language System (UMLS)

Managed Health Care

• HMO - Prepaid health plan - Physicians are paid per patient - Patient pays co-payments for service, obtains referrals for specialty care • PPO - Physicians are independent - Patient pays fees but does not need referrals • Point-of-Service Plan - Works as a combination of HMO and PPO

Quality Clinical Documentation for Legal Purposes

• Hand-written documentation - Illegibility introduces malpractice risk • Electronic documentation - Mistakes can be made, but the legibility of health record content is improved - More detailed notes • "What isn't documented isn't done"

Hardware and Software

• Hardware - Physical devices or components that make up a computer system. • Software - Computer programs and accompanying data needed to tell the computer what to do and how to behave.

EHR Hardware - Defined

• Hardware is: - the physical components that make up a computer system. - necessary to make the computer work and run properly.

Health Care Financing & Expenditures - 2

• Health Care Expenditures - Represent the total value of the health care services delivered during some time period - Methods for examining spending include: o Category of Service o Contributor o payor

Health Care Financing & Expenditures - 1

• Health Care Financing - The collection and pooling of funds used to pay the cost of health care services provided by a health care system - Includes a method for distributing payment

The Business of Health Care - 2

• Health Care Organizations: - May receive varying amounts from payor to payor for identical services - Receive payment from the government for approximately 47% of all medical services rendered

The Business of Health Care - 1

• Health Care Organizations: - Receive payments from 3rd party - Payment depends on: o Codes entered on bill for type of service provided and diagnosis o Formula determined by payor Formula is rarely transparent

Health Care Financing & Expenditures - 3

• Health Care Services - Hospital, nursing, home health care - Physician, dental, and ancillary services - Prescription medications - Equipment, public health activities, research, administration, and infrastructure

Supporting the Advancement of Health IT

• Health IT certification requirements • Standards development organizations - Example: http://www.HL7.org • Integrating the Healthcare Enterprise (IHE) • Commonwell Health Alliance • Other industry resources

HIE Initiatives

• Health Information Exchange (HIE) - The electronic movement of health-related information among organizations according to nationally recognized standards. • HIO, RHIO • Examples: HealthBridge, Indiana HIE, CareSpark, MedVirginia • NHIN

Health Information Technology

• Health Information Technology for Economic and Clinical Health Act (HITECH) - Reward ($$$) for meaningful use of EHR • EHR Facilitates - Coordination of care - Support providers o Clinical decision support (CDS) o Clinical practice guidelines/EBM o Shared information (health information exchange) o Error avoidance

Federal Regulation of Private Health Insurance - 3

• Health Insurance Portability and Accountability Act (HIPAA) 1996 - Amendment to ERISA - Defines "protected health information" and helps ensure its privacy - Protects participants in group health plans

National Committee on Vital and Health Statistics

• Health Level 7 (HL7) for - Messaging - Clinical encounters • SNOMED CT for - Diagnosis and problem list - Non-laboratory procedures and interventions - Anatomy and nursing data

MCO Models

• Health Maintenance Organization (HMO) - Prototype MCO • Newer MCOs - Preferred Provider Organization (PPO) - Exclusive Provider Organization (EPO) - Point of Service Plan (POS) • Newer MCOs Use: - Mix and match reimbursement methodologies - Greater patient choice - Increased costs

Self-Funded Employer Plans

• Health benefit plans regulated by federal law • Created by employers, employee organizations, or a combination • Employer assumes risk for workers and pays for care directly • Employer may choose to have a thirdparty administrator administer the plan

Patient Information Disclosures

• Health care cybersecurity attacks over the past five years have increased 125% as the industry has become an easy target; personal health information is 50 times more valuable than financial information on the black market (Kutscher, 2016) • Portland, Oregon, thieves broke into a car with back-up disks and tapes containing records of 365,000 patients (Rojas-Burke, 2006) • Several episodes from Virginia, including a laptop with data of more than 1 million veterans, recovered without apparent access (Lee & Goldfarb, 2006) • Hack of Indianapolis-based payer Anthem's IT systems exposed personal data of approximately 80 million customers (Perma, 2015) • Improper disclosure of research participants' PHI results in $3.9 million HIPAA settlement (U.S. Dept. of Health and Human Services [HHS], 2016b) • Hospital pays hackers $17,000 to unlock EHRs frozen in "ransomware" attack (Conn, 2016)

HIPAA Covered Entities - 2

• Health care providers • Health plans - Insurance companies - Health maintenance organizations (HMOs) - Company insurance plans - Government agencies that pay for health care

The Role of Health Care in the U.S. Economy - 1

• Health care spending - Economic impact and gross domestic product - Health care jobs • The History of the U.S. Health Insurance Industry - Historic legislation and factors contributing to the current U.S. system of insurance - Roles of government in health care

Post-2010 NHS Reform

• Health services determined locally, not centrally - Groups of local general practitioners, specialists, nurses, and consumer advocates • Requirements: - Provide urgent and emergency care - Address health and social needs of all users - Protect patients' interests, quality, and efficiency through outcomes

Substance Abuse Treatment Centers

• Help patients overcome drug and/or alcohol abuse • Various facilities - Residential treatment centers - Outpatient programs - Hospitals • Programs may specialize - By drug (for example, cocaine addiction) - By age group (for example, adolescents)

Medicaid - 1

• Helps pay costs for people with limited income and resources - Joint federal and state program - Some Medicare patients qualify for Medicaid - Funded by taxpayers' income tax payments • Administered through CMS at state level - Formulate and administer plan subject to federal regulations and guidelines - Outlines nature and scope of services provided

Laboratory Pathology - 2

• Hematopathology - Diseases of blood cells o Traditional microscopy o Immunohistochemistry o Flow cytometry o Molecular diagnostic tests • Blood banking - Transfusion medicine • Cytogenetics

Example PQRS Measures

• Hemoglobin a1c, poor control in diabetes mellitus - Percentage of patients aged 18 to 75 years with diabetes mellitus whose most recent hemoglobin A1c test was greater than 9.0% • Thoracic surgery: Recording of clinical stage for lung cancer and esophageal cancer resection - Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical TNM staging prior to surgery • Weight assessment and counseling for children and adolescents - Percentage of children 2 to 18 years of age whose weight is classified on basis of BMI percentile for age and gender

Allscripts: history

• History: - 1986: founded - 2008: merged with the health care systems operations of Misys - 2010: Allscripts-Misys merged with Eclipsys - March 2013: Allscripts acquired dbMotion, Ltd., a supplier of community health solutions and Jardogs LLC, a patient engagement solution provider

Ancillary Services - 1

• Home health care - Care provided at the patient's home - Physician house calls - Nurse visits - Home health aides - Help with activities of daily living (ADLs)

Home Health Care - 1

• Home health care is assistance with ADLs and chores inside the home - Family, friends, volunteers may help - Community services may be available - Skilled nursing is needed for medical issues - May be reimbursed by Medicare

Reporting for Inpatient Setting

• Hospital Quality Alliance (HQA) www.hospitalqualityalliance.org - Collaboration among CMS, The Joint Commission, and others to create a starter set of quality measures for various conditions - In Hospital Compare Project, hospitals voluntarily provide quality information that can be accessed via www.hospitalcompare.hhs.gov - Consists of two programs based on reporting to CMS: o Inpatient Quality Reporting (IQR)—for HQA data; nonparticipation = 2% Medicare reimbursement reduction o Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS)—reporting of patient satisfaction at hospitals

Hill-Burton Act

• Hospital Survey and Construction Act, passed in 1946 • Stimulated construction of facilities • Foundation of today's hospitals and health care organizations • Continues to authorize funding • Requires participation in Medicare and Medicaid • Imposes anti-discrimination rules

Medicare Part A...

• Hospital insurance • Inpatient care (including psychiatric hospital) • Hospital outpatient care • Skilled nursing facility or rehabilitation facility • Long-term care facility • Hospice (end-of-life care) • Patient pays deductible • No premiums after 10 years of payments - Can purchase through premiums

Registration

• Hospital management software or practice management software - Demographic information - Health insurance information • Insurance information - Confirm terms of coverage - Determine deductibles, copayments, and coinsurance - Accurate claim identification by third party payor

Specific Nursing Roles in a Hospital Setting

• Hospital medical-surgical nurse - Care for patients with medical and surgical problems - May obtain certification but not always required • Specialized nursing roles - Specific disease or specialty o Diabetic nursing o Emergency nursing o Rehabilitation nursing o Neurosurgery nursing.

Health Insurance in the U.S. - 1

• How does health insurance work • How insurers pay health care providers • Sources of health care funding • Who can offer health insurance • Types of health insurance plans • Managed care • How laws regulate private insurance

General Data and Healthcare

• How might "general data" contribute to health of persons and populations? • Biosurveillance - "Collection and integration of timely health-related information for public health action achieved through the early detection, characterization, and situation awareness of exposures and acute human health events of public health significance." (Fleischauer, Diaz, & Sosin, 2008)

KLAS methodology

• How overall performance rating is calculated with software: - Scores for 25 questions - Rating scale of 1 to 9 (1 = poor and 9 = excellent) and "yes" or "no" - Each question weighted equally - Total score is based on 100-point scale

Vendor billing codes supported

• ICD-10 - ICD-10-CM for diagnosis coding and ICD-10- PCS for inpatient hospital procedure coding o There are over 70,000 ICD-10 codes (up from around 14,000 ICD-9 codes) - Current Procedural Terminology (CPT) codes o Identifies the services rendered rather than the diagnosis on the claim

HIPAA Code Sets

• ICD-10-CM (Diagnosis codes) • ICD-10-PCS (Procedure codes) - NCHS & CMS respectively • Current Procedural Terminology (CPT) - AMA • National Drug Codes (NDC) - FDA and drug manufacturers • Code on Dental Procedures and Nomenclature (CDT) - ADA

Update to ICD-9

• ICD-10-CM - Replaces ICD-9-CM Volumes 1 & 2 - Diagnosis codes increased from 14,025 to 69,823. • ICD-10-PCS - Replaces ICD-9-CM Volume 3 - Procedure codes increased from 11,000 to 87,000 • Compliance was set for October 1, 2015

Hospital Setup: ICU/CCU

• ICUs treat patients with severe disease or injury - Pneumonia - Traumatic injury • CCUs are for cardiac (heart) disease • Patients come from ED, OR, or another hospital • Sophisticated equipment is used

Server Software Elements of the EHR

• IOM: Eight Core Components 1. Health information in database 2. Results management 3. Order entry and management 4. Decision support 5. Electronic communication/connectivity 6. Patient support 7. Administrative processes 8. Reporting and population health management

Informed Consent Process - 2

• If desired, takes time to discuss the situation with others • Opportunity to communicate the decision to physician or treatment team

Health Resources and Services Administration (HRSA) - 1

• Improve access to health care for individuals with: - Low incomes, no insurance - Certain medical issues - Isolated • Six bureaus and thirteen offices • Provides leadership and funding to health care providers

Indian Health Service (IHS)

• Improve physical, mental, social, and spiritual health of American Indians and Alaska Natives - Accessible public health services - Culturally sensitive; recognizes sovereign rights - 567 federally recognized tribes in 35 states • Medical and social issues - Disparities in health and life expectancy - Higher mortality from diseases, social problems

Goals of Meaningful Use

• Improve quality, safety, and efficiency. • Engage patients and their families. • Improve care coordination. • Improve population and public health; reduce disparities. • Ensure privacy and security protections.

Benefits of HIE: Government/Public Health

• Improved understanding of patients' clinical needs • Improves Public Health Reporting /Monitoring • More timely access to public health and population health data • Supports Medicaid in developing programs to improve health of residents

Health Insurance Portability and Accountability Act (HIPAA)

• Improves "portability" of health insurance - Employer plans may not limit coverage due to pre-existing conditions - If health insurance is lost, improves access to a group health plan - Protects from discrimination based on health status • Establishes requirements for the exchange of personally identifiable health information

Substance Abuse and Mental Health Services Administration (SAMHSA)

• Improves the health of people with mental illness and abuse alcohol, tobacco, or drugs • 6 strategic initiatives: - Prevent substance abuse and mental illness - Integrate health systems - Establish a trauma-informed approach in health - Provide recovery support - Promote health information technology and electronic medical records - Promote cultural sensitivity

IOM Definition of Primary Care

• In 1994 - updated definition: - Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Reporting for Outpatient Setting

• In United States, major efforts led by Centers for Medicare and Medicaid Services (CMS: http://www.cms.hhs.gov) in Medicare program • Physician Quality Reporting System (PQRS, formerly PQRI: http://www.cms.hhs.gov/pqri) - - Initially reimbursed extra 1% for reporting on large number of measures - - Also offered 0.5% for maintaining certification - - Penalties for failing to meet objectives began in 2015 • Electronic Prescribing (eRx) Incentive Program (http://www.cms.gov/ERxIncentive) - Reimbursed extra 1% for using eRx (through 2013) - Began penalizing in 2012 for non-use of eRx

Process vs. Outcomes

• In general, want to focus on outcomes - Represents what actually happens to patient - But difficult to measure; confounding factors • Do we know about relationship between process and outcomes? - In acute coronary syndromes, strong correlation between process and outcome measures (Peterson et al., 2006) - In other areas, however, not a strong relationship between satisfaction with care ("global ratings") and its technical quality (Chang et al., 2006) - The science behind care also changes (e.g., recognition that too tight of control [HgbA1C] in diabetes can be detrimental) (Aron & Pogach, 2009) - Consensus not always reached (e.g., "drugs to avoid" in elderly) (Steinman et al., 2009)

Role of IT and Informatics Continued

• In inpatient settings - University HealthSystem Consortium (UHC) sites at HIMSS Analytics Stage 4 or higher adoption have higher scores on quality measures (HIMSS Analytics, 2006) - "Most wired" hospitals more likely to have higher quality measures (Weinstock 2015) • Mixed results in outpatient settings - Presence of EHR not correlated with better quality in treatment of diabetes measures (Crosson et al., 2007) and general ambulatory quality measures (Linder et al., 2007; Romano & Stafford, 2011) - Targeted quality improvement does lead to better outcomes (Cebul et al., 2011) • Better quality "not automatic" and requires substantial effort (Baron, 2007)

Health Information Exchange Summary

• In this lecture we have looked at Health Information Exchanges. We have examined the concept, purposes and value of HIEOs. • We have looked and several different models for realizing HIEOs or RHIOs. • We have looked at several federallyinitiated programs.

"Meaningful Use" and HIT Information Exchange

• Incentive program encourages: - Demonstration of interoperability - Sharing of electronic data with patients - eRx - Quality measures reporting to CMS/States - Drug formulary checks - Medication reconciliation - Summary of care records for transfers/referrals - Immunization reporting to registries - Syndromic surveillance reporting to public health agencies - Lab results reporting to public health agencies - Patient reminders - Direct patient access to his or her record in an EHR

Physician/Hospital Costs

• Increased demand - Utilization o Positron emission tomography (PET) o Magnetic resonance imaging (MRI) - Techniques o Minimally invasive surgery da Vinci robotic surgery o Imaging techniques

Challenges from Proliferation of Technologies and Applications

• Increased technology use by all care providers • Health information exchange and data sharing activities across multiple networks • Cloud computing and third-party outsourcing • Increased use by patients, families, and consumers of their devices (tablets, smartphones, etc.) • New models of care require more care providers to access data across the patient care continuum • Clinicians using their own devices - Personal laptops, tablet devices, smartphones, and so on • Connected medical devices and implantable devices

Increased Demand: Aging

• Increased utilization of services for chronic illness above age 64 • 1946-1964: 66 million children • Medicare eligibility beginning in 2011 - Additional 10 million enrollees by 2018 - Projected costs > $13,000 per capita with comparable increase in Medicare costs

Primary Care In Crisis?

• Increasing number of older patients with complex medical issues • Inadequate coverage of preventive care services • Emphasis on documentation • Complex billing and compensation system

Types of Private Health Insurance

• Indemnity plans - "traditional" plans - Fee for service - Simply provide reimbursement to providers - Less prevalent today • Managed care plans - Offer financial incentives to providers and patients - Integrate financing and delivery of care within a single system

Local Health Care: Private Health Care Agencies

• Independent health care providers - Single-provider practices - Group practices • Corporate health care - Employees, families, retirees • Some agencies operate community health centers • Can have for-profit or nonprofit status

Blue Cross/Blue Shield-1

• Independent, state-licensed organizations • Blue Cross reimburses hospitals • Blue Shield reimburses physicians • Historically set up as not-for-profits under special state laws • Today, some organizations operate as commercial insurers

Definitions Continued

• Individually identifiable health information (IIHI): Any data that can be correlated with an individual - Also called protected health information, or PHI • Consent (in context of privacy): Written or verbal permission to allow use of your IIHI

Individually Identifiable Information

• Information can be used to identify the individual - Physical or mental health condition - Provision of health care - Payment

Threats to Security

• Insider - Accidental disclosure - Curiosity - Malicious/subornation • Outsider - Organized crime - Hacktivists - Cyber thieves

Case Studies, Best Practices, and Education Resources

• Institute for Healthcare Improvement (ihi.org) • American Society for Quality (ASQ.org) • National Heart, Lung, and Blood Institute (NHLBI.org) • National Institutes of Health (NIH.org) • AHRQ: Centers for Excellence and case studies (CAHPS.AHRQ.org)

The Government as Insurance Payor

• Insurance Managed by the Centers for Medicare and Medicaid Services (CMS) - Medicare - Medicaid - Children's Health Insurance Program (CHIP) • Medicaid/Medicare Fraud and Abuse • Workers' Compensation

Hospice Care

• Intended for patients with a terminal illness • Focus is palliative, or comfort care • Care is provided at home, dedicated hospice facility, hospital, assisted living facility, or nursing home • Services available depend on type of program • Home care workers should be licensed/bonded • Contact with family is an important focus

Tort Law

• Intentional torts - Battery - Defamation • Negligence - Does not act with a reasonable amount of care - As a result, someone is injured

Results review

• Laboratory results - Linked to laboratory information system - E.g., bacterial cultures, complete blood count, therapeutic drug levels • Imaging results - Linked to radiology (imaging) information system o Used with Picture Archiving Communications Systems (PACS) which manage digital radiography - E.g., radiology reports, X-rays, CAT scans, MRI images

Teaching/Research Hospitals

• Large institutions affiliated with medical schools - Latest medications, surgical procedures, equipment, technology - Treat complex medical problems, rare diseases - Teach physicians and other health care providers - Support and perform medical research - Offer special services - Accept uninsured patients • Example: - Massachusetts General Hospita

History of Health Care Financing in the U.S.

• Late 19th and early 20th century - Care provided at patient's or doctor's home - Self-pay/charity payment for services - Increasing advancement of medicine - AMA standardizes medical education - Medical care moves - Commercial health insurance not available o Unpredictability of health o Moral hazard

Software

• Legacy • Off-the-shelf/Turnkey • Vanilla systems • Home grown • Best of breed

The Legal System in the U.S.

• Legislative - House of Representatives - Senate • Executive - The president - Depts and agencies • Judicial - Judges - Courts

Sources of Law

• Legislative branch makes statutory laws • Executive branch makes administrative laws • Laws made by the courts are called common law or case law

Fixing a Broken System?

• Limit resource availability - Rationing • Incentives to change utilization - Increase patient cost - Wellness and prevention • Increase in efficiency - Health Information Technology (HIT) - Evidence-based medicine (EBM) - Clinical Practice Guidelines

School-Based Health Centers (School-Based Health Alliance)

• Located in schools • Range of services: - Screening, preventive, and limited acute care - Behavioral care - Counseling • Linkage with other local health care providers

Children's Health Insurance Program (CHIP)

• Low-cost coverage for children - Family doesn't qualify for Medicaid but can't afford private health insurance • Each state has its own program and eligibility criteria - Eligibility is based on child's status, not parents - Example: a child who is U.S. citizen qualifies even if a parent is not a citizen • Low-income pregnant women eligible

HMO Models

• Lowest cost • Various types: - Staff model - Group model - Open-group model - Independent physician association (IPA) - Network model - Mixed model • Reimbursement to HMO providers only

Set an Aim

• Make it specific. - Assign it a number if possible. • Assign it a timeline. • Make it measurable. • Make sure it is challenging but doable.

State-Licensed Insurance Organizations - 2

• Managed Care Organizations - Combine health insurance and health care services - Cost control and utilization control - Some hire their own doctors and have their own facilities - 3 main types: o Health maintenance organizations (HMOs) o Preferred provider organizations (PPOs) o Point-of-service (POS) plans

The "Managed" in Managed Care

• Managed care - Accessibility - Controls costs o Patient and provider incentives - Utilization review o Determine medical necessity of care o Role as gatekeeper - Different types of managed care plans o Plan differences based upon cost and provider choice

Sampling of Current Quality Programs and Measures

• Many sets and acronyms, and they change constantly - Still "early" in the science of quality improvement (Berwick, 2008) - "Science" defined in an IOM report (2006) - Many measurements in use (Damberg, 2011) but still need improvement (Pronovost, 2011) • Many measures have been developed, reflecting various perspectives - AHRQ maintains clearinghouse: www.qualitymeasures.ahrq.gov - Growing consensus that standard sets are needed for each perspective • We view them from following perspectives: - Health plans - Outpatient - Inpatient - Quality measures in HITECH meaningful use program

MHS: Disaster Response

• Mass-casualty violence • Homeland defense • Flu outbreak preparedness • Humanitarian assistance after natural disaster • International health initiatives - North Atlantic Treaty Organization (NATO) - International Committee of Military Medicine

Key Components of Enterprise Integration

• Master person index • Single sign-on with context management • Data warehouse

Secondary Care Organization

• May be known as specialty care organizations • Provides most types of specialty diagnoses and treatment • Examples: freestanding ambulatory facilities, community hospitals, academic medical centers, specialty hospitals, home health services, extended care facilities

Causes of Non-Emergency ED Visits

• May not have primary care providers • Primary care clinicians are over-extended • Lack of insurance • Medicaid patients seek ED care more often • Cost of ED visits more expensive then primary care • Non-emergency visits to ED driving up health care costs

What We Know about Health Care Quality

• McGlynn et al. (2003) and similar studies • NCQA annual reports • Commonwealth Fund scorecards • Agency for Healthcare Research and Quality (AHRQ) annual reports • Other studies

Board and Care Homes (Group Homes) - 2

• Meals are provided, but medical care is not • Services, quality, and fees vary widely • May be paid in part by private insurance, Medicare/Medicaid, other assistance

Problems from Current Approaches

• Measurement issues • Challenges for certain practice environments • Ethical issues

CMS - Medicaid and CHIP

• Medicaid and CHIP provide health care for low income adults and children. - Programs are administered by individual states

Pediatrics

• Medical care of: - Infants - Children - Adolescents • Focus: - Diagnosing, treating and preventing diseases that affect children

Technology - 2

• Medical devices - Computerized Tomography (CT) scanners - MRI imaging - Implantable defibrillators • Health Information Technology (HIT) - Electronic medical records - Telemedicine

Medicare Part B...

• Medical insurance • Coverage - Doctors' services - Outpatient care - Home health services - Some preventive services - Other medical services • Patient pays premium and deductible

Specialty clinics

• Medical specialties - Examples: o Cardiology o Immunology o Gastroenterology • Surgical specialties - Examples: o Orthopedic surgery o Neurosurgery o Plastic surgery

MEDICARE Coverage in Canada

• Medically necessary services - Medical and surgical care - Preventive care - Hospitalization due to illness or injury - Medical Equipment - Dental surgery • Extended health care services - No requirement for coverage - Many areas provide some coverage - Average $580 per year out-of-pocket

Medicare Part C - 1

• Medicare Advantage plans - Offered by private companies approved by Medicare • Provide all Part A and Part B - Vision - Hearing - Dental • Most plans include Part D • Patient pays premium and deductible

Relationship between Expenditures and Quality

• Medicare data: - Great variation in cost among patients but little relationship to quality (Fisher et al., 2003a, 2003b) - Inverse relationship between expenditures per capita and state rank of quality (Baicker & Chandra, 2004) • No association between per capita expenses and perceptions of quality by patients (Fowler et al., 2008)

Medicare and Medicaid Laws: SSA Amendments 1965

• Medicare: Title XVIII - Social Insurance addresses care for elderly - Funded through FICA • Medicaid: Title XIX - Social welfare or social protection - Joint funded through Federal and state tax revenues - Administered through the states - Funded through general tax revenues

CPOE: vendor system differences (Cont'd - 2)

• Medication reconciliation process - Outpatient - Emergency department - Hospital admission - Inpatient course - Hospital discharge

CPOE types of orders

• Medications • Nursing • Laboratory • Radiology / Imaging • Provider referrals • Blood bank • Physical therapy • Occupational therapy • Respiratory therapy • Rehabilitation therapy • Dialysis • Provider consults • Discharge • Transfer

American Board of Medical Specialties (ABMS) - 2

• Member boards certify specialist physicians - Also subspecialists; for example, adolescent medicine is a subspecialty of family medicine

Meditech

• Mission statement: - To provide software that enables physicians, nurses, and other clinicians to orchestrate and deliver patient care in a safe, effective, and efficient manner. Our software is integrated in a manner that fully optimizes the financial and business potential of the health care enterprise • Information is available whenever and wherever clinicians need it • Ensure access to a full electronic record with data from across the continuum

URAC

• Mission: "To promote continuous improvement in the quality and efficiency of healthcare management through processes of accreditation, education, and measurement" • Has more than 30 accreditation and certification programs for various types of health care organizations

American Board of Medical Specialties (ABMS) - 1

• Mission: "to serve the public and the medical profession by improving the quality of health care through setting professional standards for lifelong certification in partnership with Member Boards." • Board certification differs from licensure, which sets minimum competency for physicians

Agency for Healthcare Research and Quality (AHRQ) - 1

• Mission: - produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used • All stakeholders are included - Health care value

Types of Health Care Systems

• Mixed Delivery System - Primarily private health care organizations and providers - Government operated system o Affordable Care Act (ACA) o Veterans Health Administration o Military Health System o Indian Health Service

EHR Hardware - Clients (cont'd - 2)

• Mobile computers (cont'd) - Advantages o Additional mobility compared to workstations o Save time o Can be cheaper if additional infrastructure such as ports are needed - Disadvantages o Typically more expensive than fixed workstations o Subject to theft o Easily broken o Require additional support, cleaning, maintenance

EHR Hardware - Clients (cont'd)

• Mobile computers - Laptops: physical keyboards; input generally via keyboard or mouse/touchpad, no touch option - Tablets: data entry & navigation including touch input, via stylus / electronic pen or finger • Slates • Convertibles • Booklets - Connect wirelessly to the network - Use rechargeable batteries

Defining HIE Verb and Noun

• Mobilization of healthcare information electronically across organizations (Verb) • Entity that facilitates the exchange (Noun) • Goal: facilitate access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care.

Hospice and Palliative Care

• Model for providing quality and compassionate care for those facing a lifelimiting illness or injury • Variety of hospice settings available to patient and families

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

• Modification of the World Health Organization's ICD-10 • ICD-10-CM implemented in 2015 • Numerous purposes - Statistics and research - Reimbursement - Analyzing patterns of care - Strategic planning

Health Resources and Services Administration (HRSA) - 2

• Monitors organ, blood, bone marrow donations • Supports programs that combat bioterrorism • Compensates people for severe vaccination reactions • Maintains medical malpractice and fraud database

Allscripts

• More than 7,000 employees • 20 locations worldwide • 2015 revenues: $1.4 billion • Ticker symbol: MDRX - NASDAQ

Primary Care Crisis Contributing Factors - 2

• More than 80 percent of graduating medical students carry educational debt • Specialists are better compensated than primary care physicians • Fewer U.S. graduates enter family medicine • Recent years have more positive statistics

What Is the Role of Government? Continued

• Most federal agencies actively involved with privacy and security - Including the Office of the Inspector General (OIG), the Office of Civil Rights (OCR), Federal Trade Commission (FTC), Food and Drug Administration (FDA), Federal Communications Commission (FCC), Department of Health and Human Services (HHS), and Department of Justice (DOJ) • The eHealth Exchange, previously the Nationwide Health Information Network, is a "network of exchange partners who securely share clinical information over the Internet across the US, using a standardized approach" - Data Use and Reciprocal Support Agreement (DURSA) ensures secure data exchange—all eHealth Exchange participants required to follow • States are involved in privacy and security policymaking and in creation of new laws

Client-Server Model

• Most of today's EHR systems are based on the client-server model. • Software: the collection of programs and related data that contain the instructions for what the computer should do • Servers: service providers - Servers run "server application" software designed to meet client requests. • Clients: service requesters - Client software is designed to "request" information from a server and then present it to the user in an efficient manner. • A server and client may reside on the same "box" but is generally not recommended.

Network - Assessing Usage

• Must be able to support data requirements of EHR application • Insufficient capabilities will degrade application performance and increase risk of user rejection

Other Aspects of Privacy Practices

• Must be written in plain language • Practices/organizations must state they preserve the right to change NPP • There must be a complaint process • Practices/organizations must designate a privacy official in the office • See Oregon Health & Science University's examples of NPP: http://www.ohsu.edu/xd/about/services/integrity/i ps/npp.cfm

HQA Categories and Examples

• Myocardial infarction - Aspirin at arrival and discharge - Inpatient mortality • Heart failure - Discharge instructions - Evaluation of left ventricular systolic function • Pneumonia - Time to blood cultures and antibiotics - Pneumococcal and influenza vaccinations • Surgical infection prevention - Prophylactic antibiotics - Prophylaxis for deep venous thrombosis • Children's asthma care - Reliever medication while hospitalized - Home Management Plan of Care Document

Identifiers Contained in Protected Health Information (PHI)

• Name • Address (street address, city, county, ZIP code) • Names of relatives • Names of employers • E-mail address • Fax number • Telephone number • Birth date • Finger or voice prints • Photographic images • Social Security number • Internet protocol (IP) address • Any vehicle or device serial number • Medical record number • Health plan beneficiary number • Account number • Certificate/license number • Web URL • Any other unique identifying number, characteristic, or code

Narrow vs. Broad View of Primary Care

• Narrow view - If primary = "first" in time or order - Then primary care = "ground floor" of health care delivery • Broad view: - If primary = "chief" or "main" - Then primary care = "central" to health care

TJC Patient Safety Activities

• National Patient Safety Goals • Universal Protocol • Office of Quality Monitoring • Speak Up™ Program • Sentinel Event Policy

Cost Drivers: Increased Utilization

• Physician and Hospital Utilization - Aging o Increasing number >65 y.o. o Increasing cost >65 y.o. - Chronic disease o Diagnostic tests o Management of disease o Prevention of progression and complications

Additional Resources Continued

• National Quality Measures Clearinghouse (NQMC) • CMS tools and resources: - Clinical Quality Measures Basics • Specialty Reporting Tools: - CMS Hospice Quality reporting program - Hospice Item Set endorsed by the National Quality Foundation

Other Inpatient Quality Initiatives

• National Surgical Quality Improvement Program (NSQIP: http://www.acsnsqip.org) - Effort of American College of Surgeons to measure, risk-adjust, and improve quality of surgical care • University Health System Consortium (UHC: http://www.uhc.edu) - Quality measurements to benchmark academic medical centers - Measured by green and red dots (½ a dot to 2 dots)

American Medical Association (AMA)

• Nearly 225,000 members - Physicians with an MD or DO degree, or a recognized international equivalent - Resident physicians and fellows - Medical students • Major programs - Resources for physicians - Advocacy - Publishing medical journals

American Hospital Association (AHA)

• Nearly 5,000 organizational members • 43,000 individual members • Major programs - Advocacy o Lobbying and media campaigns to influence political and economic policies - Resource center o Database of information on health planning and admin. - Annual survey of U.S. hospitals - Reports and studies

Encryption

• Necessary but not sufficient to ensure security - Is a "safe harbor" under federal and state laws when data loss occurs • Should, however, be used for all communications over public networks, such as the Internet, and with mobile devices • Information is scrambled and unscrambled using a key • Types: Symmetric and asymmetric - Asymmetric, also known as public key encryption, can be used for digital certificates, electronic signatures, and so on

We Achieve a "HighPerformance" Health Care System?

• Need a "learning" health care system (Olsen, Aisner, & McGinnis, 2007) - Must build infrastructure, including informatics, to learn what works (Olsen, 2010; Friedman, 2010) • Should be guided by principles (Shih et al., 2008) - Patients have access to care and information but are also accountable - System must provide coordination of care and aim for continuous learning and improvement • Should we be thinking more of "value" than "quality?" (Porter, 2010; Brook, 2010)

Role of IT and Informatics

• Need electronic data (IT) and means to understand it (informatics) • Series of case studies demonstrate real-world use for quality measurement and improvement (Fowles et al., 2008) • Standards emerging for measures and their reporting - Quality Reporting Document Architecture (QRDA) for quality reports (Alschuler et al., 2007) - Hospital Quality Measures Format (HQMF) for individual measures (http://www.hqmf.org) - eMeasures: Effort to "retool" 113 quality measures easy to extract from EHR data and express in HQMF o http://www.qualityforum.org/Projects/eg/eMeasures/Electronic_Quality_Meas ures.aspx

U.S. Health Care System: How Are We Doing?

• Needs to be improved, especially for the uninsured. • Patient safety and health care-associated infections have shown improvement. • Quality is improving, but pace is slow, especially in preventive care & chronic disease management. • Disparities are common, and lack of insurance is a contributor. • Many disparities are not decreasing; those that warrant increased attention include care for cancer, heart failure, and pneumonia

Ambulatory or Outpatient Service Organizations

• Non-hospital care, outpatient care • Primary care services - Physician offices - Clinics • Specific services - Surgery centers - Rehabilitation - Lab and radiology • Retail clinics • Public health clinics

Accreditation, Regulation, and Professional Associations

• Nonprofit Accrediting Organizations - The Joint Commission (TJC) - URAC (formerly called Utilization Review Accreditation Commission) - National Committee for Quality Assurance (NCQA) • Regulatory Agencies - Food and Drug Administration (FDA) • Professional Associations

Professional Associations - 1

• Nonprofit organizations that support: - A particular profession - The interests of individuals engaged in that profession o Physicians o Hospital administrators - The public interest

American Nurses Association (ANA)

• Nonprofit professional organization that represents the interests of the USA's 3.4 million registered nurses • Focus areas - Fostering high standards of nursing practice - Promoting a safe and ethical work environment - Bolstering the health and wellness of nurses - Advocating for nurses and the public

ANA Recommended Standardized Nursing Terminologies

• North American Nursing Diagnosis Association (NANDA) - Organized around 13 domains - Contains nursing diagnoses for existing or potential problems

Medicare/Medicaid Fraud and Abuse - 3

• Not abuse to complain about quality of care from a physician, hospital, or other provider or facility • Medicare Web site offers options to file: - Inquiries - Complaints - Grievances - Appeals

Privacy Rule Requirements

• Notify patients of rights • Allow patients to see their medical records • Implement and train employees on privacy procedures • Designate individual to be responsible for seeing that procedures are adopted and followed • Keep patient records secure

EHR Systems: Then and Now (cont'd - 2)

• Now - Fast, low-cost PCs, tablets, and systems permeate the workplace, often less than $500 each. - Improved network protocols make updating and maintenance easier and more costeffective. - Ubiquitous, easy to use graphical systems reduce training costs.

EHR Messaging Standards (con't)

• Numerous standards, including - American National Standards Institute, Accredited Standards Committee X12- Insurance Subcommittee (ANSI-ASCX12N) - Digital Imaging and Communications in Medicine (DICOM)

Advanced Practice Nursing

• Nurse practitioner - Education: Usually requires a master's degree in nursing with specific clinical and diagnostic training - Training: Programs include clinical training in physical diagnosis, managing acute and chronic disease, wellness care, and prescribing medication. • Nurse practitioner - Certification: Most states require certification in their area of specialty o Examples: Family nurse practitioner (FNP), pediatric nurse practitioner (PNP), geriatric nurse practitioner (GNP) - Licensure o States vary on the roles allowed to nurse practitioners, including prescription privileges and whether they may practice independently - Roles o Nurse practitioners function most often as primary care providers, including preventive, acute, and chronic care

Ancillary Personnel

• Nursing assistants work under the direction of RNs and LPNs • Technicians help with treatment or diagnosis • Rehabilitation personnel include PTs, OTs, respiratory and speech therapists • Other workers educate and counsel - Dietitians/nutritionists - Diabetes educators - Social workers

Office of the National Coordinator for Health Information Technology (ONC)

• ONC a federal entity within the Department of Health & Human Services • Coordinates nationwide efforts to implement and use electronic health records • Promotes the exchange of electronic health information across care settings

Physician Oaths of Privacy Are Not New

• Oath of Hippocrates, fifth century BC - "All that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and never reveal." • Declaration of Geneva, 20th century - "I will respect the secrets which are confided in me, even after the patient has died."

Obstetrics and Gynecology

• Obstetrics (OB) - Care of women during pregnancy and immediately after childbirth • Gynecology (GYN) - Care of the female reproductive system • Preventive care is an important facet of primary care • Often same clinician provides both services

Occupational Therapy

• Occupational therapy aide - On-the-job training - Not licensed • Occupational therapy assistant - Associate's degree or certificate - Certification o Certified Occupational Therapy Assistant (COTA) - Licensure varies by state • Occupational therapist - Master's or doctoral degree - Certification o Occupational Therapist Registered Exam - Licensure varies by state

Continuing Care Retirement Communities

• Offer different types of housing, depending on the level of assistance needed - Separate homes/apartments for independent living - Assisted living facility for help with ADLs - Nursing home on site • May be accredited or not • Billing is a large entry fee plus monthly payments

Fraud, Waste, and Abuse

• Office of Inspector General (OIG) protects integrity of Medicare, Medicaid, other government programs • Fraud: Intentional misrepresentation or concealment of relevant facts • Waste: Unnecessary costs as a result of poor management practices or controls • Abuse: Excessively or improperly using government resources

VA Domiciliary Care Program

• Oldest element in VA health care system - Called "soldiers' homes" in late 1860s • Residential treatment for veterans with: - Severe medical conditions - Mental illness, substance abuse, psychosocial problems • Operates with the VA's Mental Health Residential Rehabilitation and Treatment Programs • Foster healthy behaviors, improve quality of life, integration into society

Epic: company highlights

• On-time, on-budget track record is one of the best in health care • Quick to implement and easy to use • Information shared in two ways: - Care Everywhere (doctor controls flow of data) - Lucy PHR (patients control their own health information) • Develop, install, and support all applications in-house • Leadership team includes clinicians, developers, and process experts

Clinical Quality Measures and HITECH

• One goal: Improving quality, safety, and efficiency • Meaningful use achieved over multiple stages and years • Quality requirements are closely aligned with other CMS quality reporting programs • There is ongoing discussion regarding implementing new measures or discontinuing meaningful use

Quality for Population at Large (McGlynn et al., 2003)

• One of most widely cited studies • Contacted 17,937 adults in 12 metropolitan areas asking if they would agree to release records for assessment of quality - 6,712 agreed to do so - Records reviewed for 439 indicators of quality of care for 30 acute and chronic diseases and preventive measures (McGlynn et al., 2003) • Percentage receiving recommended care varied for different conditions - Overall 54.9%, varying from atrial fibrillation (24.7%) to senile cataract (78.7%)

A Need for Ongoing Research

• One of the four HITECH Strategic Healthcare IT Advanced Research Projects (SHARP) projects was focused on security: www.sharps.org • Resources provided by ONC on many aspects of privacy and security - Security risk assessments, mobile devices, to name a few • NIST • Many other initiatives

Learn

• One of the most important aspects of QI is to understand how your systems actually perform, under a range of conditions. • Deming's theory of profound knowledge is based on the principle that each organization is composed of a system of interrelated processes and people. • The improvement of the system depends on the capability to organize the balance of each component to enhance the entire system. • Understanding and learning about your system is essential to improve it.

Chronic Disease - 1

• Ongoing, generally incurable, illness or condition - Heart disease - Obesity - Cancer - Diabetes • Preventable/Manageable through: - Early detection - Diet - Exercise - Medical treatment

CPOE: vendor system differences

• Online formularies • e-prescribing - Medication prescriptions in ambulatory setting - Health plan formulary - Transmission of the prescription directly to pharmacy

Military Health System (MHS): Overview

• Operated by the Department of Defense • For U.S. active-duty military personnel and their families • Structure: - Secretary of Defense for Health Affairs - Medical departments of the military branches - Combatant Command surgeons - Providers in the TRICARE health care program (including private companies)

Core EHR Functions: US Government

• Orders for therapies (e.g. medications) • Orders for tests • Reporting of test results • Physician notes

Organization of Primary Care Clinics

• Organization of primary care clinics usually revolves around two axes • The provider - Physician - Nurse practitioner - Physician's assistant • The patient

Physical Therapy

• Physical therapy aide - On-the-job training - Not licensed • Physical therapy assistant - Associate's degree - Licensure varies by state • Physical therapist - Master's or doctoral degree - Licensure o National Physical Therapy Exam (NPTE) o Other exams or requirements

For the Record Best Practices (Committee on Maintaining Privacy and Security, 1997)

• Organizational - Information & security governance - Confidentiality and security policies and committees - Education and training programs - Sanctions - Patient access to audit trails - Management dashboards - Risk management and compliance • Technical - Authentication of users - Audit trails - Physical security and disaster recovery - Protection of remote access points and external communications - Software discipline - Ongoing system vulnerability assessment - Infrastructure management

Concierge Medicine - 3

• Other features - Patient's home or workplace consultations - Wellness and nutrition planning - Mental health counseling - Stress reduction counseling - Smoking cessation support - Coordination of medical needs during travel

Other Hospital Personnel - 2

• Other physician specialties - Internal medicine - Cardiology - Obstetrics/gynecology - Psychiatry • Medical subspecialties - Pediatric cardiology - RNs, LPNs, and PAs may also specialize - Pharmacists evaluate and dispense medications

URAC Privacy & Security Accreditation - 1

• Outlines best practices for maintaining privacy and security of health information • Allows organizations to demonstrate compliance with privacy and security requirements specified by: - Health Insurance Portability and Accountability Act (HIPAA) - Health Information Technology for Economic and Clinical Health Act (HITECH)

Outpatient Care

• Outpatient = not hospitalized • Visits an "outpatient facility" for care • Outpatient facilities - Primary care offices - Specialty care offices - Single specialty or multi-specialty offices • Specialty Offices - Single - All providers have same specialty - Multi-specialty - Providers have different specialties

Evident (Cont'd - 1)

• Over 1,400 technical, health care, medical, and business professionals provide system implementation and continuing support services as part of a comprehensive program • Software solutions: - Evident Community HIS - Evident Patient Care / Clinicals - Evident Patient Management

Urgent Care Centers - 1

• Over 8500 acute care centers in the U.S. • Growing trend since the 1970s • Usually walk-in clinics • May have extended hours • Usually provide care that may be beyond the scope of care of typical primary care practice

Assisted Living - 1

• Own room or apartment in a large complex • Assistance available 24 hours a day • Offers social/recreational activities, housekeeping and laundry • Medical services may be available on site • Service plan is individualized

Hospital Financing

• Ownership may be public or private - Public hospitals are funded by the government, may have limited resources - Private hospitals are run by private entities, may have greater resources (for example, finances, equipment) • Either type of hospital may be for-profit or nonprofit

English Quality and Outcomes Framework (QOF)

• P4P program that ties 25% of pay to 129 quality indicators • Initial assumption In England was 75% achievement, but it ended up being 97%, which increased costs (Doran et al., 2006) - Most quality improvement occurred during pre-evaluation period and has since leveled out (Campbell et al., 2009) • Other findings of note - Ability to exclude patients in measures has not led to "gaming" of system (Doran et al., 2008) - Major "unintended consequence" has been excess focus on EHR and prompts for quality measures (McDonald & Roland, 2009) - Gap for care in more "deprived" areas has been reduced (Ashworth, Medina, & Morgan, 2009)

Agency for Health Care Research and Quality (AHRQ)

• Part of U.S. Department of Health and Human Services. - www.AHRQ.gov • Improve safety and quality of care - Investing in research - Creating tools to put the results into practice - Generating measures and data used by providers and policymakers

Military Medicine

• Part of the U.S. Department of Defense Military Health System - Ensures worldwide delivery of health care - Facilities for each branch of military • TRICARE partnership network ensures accessibility of care - Military facilities - Supplemented by private-sector services

Group Practice Clinic

• Partnership includes 2 or more physicians • Corporate group practice: - Corporation owns the practice - Physicians are employees • Independent Practice Association (IPA) - Practice is a legal entity (e.g., corporation) - Each physician has a separate office - Physicians own the practice - May contract with HMOs to provide health care

Social Security Act

• Passed in 1935 • Established system of old-age benefits • Also created: - Unemployment insurance - Benefits for victims of industrial accidents - Aid for dependent mothers and children, the blind, and the physically handicapped - Social Security Act: Medicare and Medicaid

Federal Regulation of Private Health Insurance - 5

• Patient Protection and Affordable Care Act (PPACA), or Affordable Care Act (ACA) of 2010 - Ends lifetime limits and most annual limits on care - Provides free access to preventive services - 50% discount on brand-name drugs on Medicare - No limit or denial for children under 19 with preexisting conditions - Adults no longer denied due to preexisting condition - Allows children under 26 to stay on parent's plan

How Insurers Pay Providers - 2

• Patient and provider receive explanation of benefits (EOB), also called remittance advice (RA), from payor • Claim can be denied for many reasons: - Coding errors - Insufficient information - Procedure considered experimental or otherwise not covered by the policy • Rejected claims can be appealed

Ethical Issues

• Patient consent - Treat as part of care or like research with human subjects protection (Lynn et al., 2007; Snyder & Neubauer, 2007; Miller & Emanuel, 2008)? • Not paying for preventable complications - Some obvious (e.g., objects left in patients), others less so (e.g., ventilator-associated pneumonia) (Pronovost, Goeschel, & Wachter, 2008) • Tensions between - "Customers" and "purchasers" in US system (Milstein & Lee, 2007) - "Needing to improve care and knowing how to do it" (Auerbach, Landefeld, & Shojania, 2007) - Physician internal motivations—not found to be adversely impacted in one UK study (McDonald et al., 2007)

Reducing Inappropriate ED Visits

• Patient education is key • Establish medical homes • Start a telephone triage system • Improve the availability of after hours care • Increase enrollment in safety net programs • Simplify health information

Notice of Privacy Practices

• Patient has right to - Adequate notice of privacy practices - Uses and disclosures of PHI - Description of individual rights - Covered entities' legal duties • One problem is readability of Notice of Privacy Practices (NPP) forms comparable to medical journal articles and beyond 80% of U.S. adults (Breese & Burman, 2005) • Physicians' requirements for obtaining NPP consent include - "Good faith effort" to obtain acknowledgment during first provision of inperson service - Failure to obtain is not penalized (per Bush administration revision) • Many publicly available industry resources

Application Integration

• Patient management and billing - Patient tracking • Department management - Electronic document management • Care delivery and clinical documentation - Order entry and results reporting

HCIS Components

• Patient management and billing • Department management • Care delivery and clinical documentation • Clinical decision support • Financial and resource management

National Quality Strategy (NQS) Priorities

• Patient safety: making care safer by reducing harm caused in the delivery of care. • Person-centered care: ensuring that each person and family is engaged as partners in their care. • Care coordination: promoting effective communication and coordination of care. • Effective treatment: promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. • Healthy living: working with communities to promote wide use of best practices to enable healthy living. • Care affordability: making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Better Performance on Measures = Better Outcomes? Yes

• Patients choosing top-performing hospital or surgeon had one-half mortality of those who chose one in lowest quartile (Jha & Epstein, 2006) • Participation in HQA associated with lower mortality for MI, pneumonia, and CHF (Jha et al., 2007) • Adopting Leapfrog Group practices associated with better quality and lower mortality for acute MI (Jha et al., 2008)

Legal and Ethical Issues

• Patients may/may not be able to make decisions • Family may not be available; patient may need legal guardian • Patient has right to participate in important decisions • Long term care facilities have ethical/legal obligations

Setting the boundaries

• Patients receive care at multiple sites of care, independent of any geographical or legal boundary. • Even within one family, the members have different geographically boundaries for care. • On the average, an adult person receives their care from 5 different sites.

Mining Data - Looking for Gold

• Pattern detection - What clusters? - Data driven approaches - letting our data speak • Using the patterns to Improve - Evidence versus habit - Product placement - Tradeoffs - Unknown influencers

Other Definitions

• Pay for performance (P4P) (Rowe, 2006) - Often equated with quality assessment but is just one approach (Rosenthal, 2008) - Based on notion that health care providers and organizations should be held accountable financially and otherwise • Value-based purchasing (CMS, 2016) - Application of P4P • Accountable health care (Chassin et al., 2010) - Health care that is accountable to patients, purchasers, and others • Transitions of care • Population health

FFS: Traditional Retrospective - 1

• Payment made after services have been provided - Method used by commercial or indemnity insurance policies - Fee schedule o Developed using historical claims data o Lists allowable services and procedures and amounts payable for each

Diagnosis Related Groups (DRGs)

• Payments to hospitals for inpatient services for Medicare patients • Payments based on: - Diagnosis, procedures, age, sex, comorbidities, complications, and discharge status o Comorbidity: The presence of 2 or more conditions or diseases in the same patient which complicates a patient's hospital stay leading to more resource use or longer length of stay

EOC: Global Payment

• Payor makes one payment for multiple providers treating a single episode of care • Extends the concept of capitation to a larger group

EOC: Prospective Payment Method

• Payors establish reimbursement rates in advance for services to be provided over a specified time • Based upon average resource use required to provide a level of care for a given set of conditions or a disease • Same amount paid regardless of the costs incurred

More consumer value

• People over the age of 65 have on average 3 or more chronic diseases. Disease management means a higher quality of life as well as a longer life. Proper disease management means complete data about the patient as well as having and using the appropriate knowledge about the patient and the disease. • Proper management of health and constant monitoring of health extends independent home living.

Prospective Payment Types

• Per-diem: Fixed payment made for each day of hospitalization - i.e. based on unit of time • Case-based: Fixed amount for providing health services for a condition or disease (case)

ANA Recommended Standardized Nursing Terminologies (3)

• Perioperative Nursing Data Set (PNDS) - Standardized, universal language - Developed by Association of periOperative Registered Nurses (AORN) - Identifies perioperative experience of the patient from preadmission through recovery at home - Includes nursing diagnoses, interventions and outcomes

Consumer value (2)

• Personal health data that is timely and understandable by the consumer • Understanding importance and significance of data • Personal health plans • Understanding treatment options - Tradeoffs between risks of death and quality of life • Manage event flow related to health - Appointments - Drug management - Manage cost of care - Inform and manage expectations of care • Provide encouragement for good health

Concerns about Privacy

• Personal privacy vs. common good • Continued disclosures • Concerns of public • De-identified data

Ancillary Services - 3

• Physical therapy - Maintains function after injury or illness • Occupational therapy - Helps patients maintain occupation • Speech therapy - Helps patients recover from diseases that affect speech • Care provided by ancillary staff

Code Sets by Provider

• Physician: Inpatient and outpatient • Diagnosis: ICD-10-CM • Procedure: CPT • Hospital Facility: inpatient - Diagnosis: ICD-10-CM - Procedure: ICD-10-PCS • Hospital Facility: Outpatient - Diagnosis: ICD-10-CM - Procedure: HCPCS (CPT Level I and HCPCS Level II)

EHR Hardware - Servers (cont'd)

• Picking the right server - Consult your IT staff, hardware & EHR vendor(s), and/or consultant to determine the hardware specs required for your organization. - Important items to consider include: o Reliability o Performance o Scalability

Direct and Connect

• Point to Point • Specifies a simple, secure, scalable, standards-based method to send authenticated, encrypted health information directly to known, trusted recipients over the Internet, using third parties such as DirectTrust http://directproject.org/ • Broader - multiple entities • Open source software gateway that allows health organizations to securely exchange health-related information connecting multiple stakeholders.

Concierge Medicine - 4

• Practice costs lower - Lower staff costs o Fewer patients = fewer administration/nursing - Lower overhead costs o Rent smaller office o Lower utility costs • Perception of improved quality - No difference from traditional primary care

Practice Management

• Practice management system (PMS) - Combination of financial and administrative functions - Patient appointment, scheduling, registration, billing, and payroll functions • PMS and electronic medical records integration

Physician and Staff Training

• Practices/organizations must - Designate a privacy Officer - Develop policies and procedures - Provide privacy training to workforce - Develop a system of sanctions for employees who violate privacy laws

Newer Tort Law Reforms

• Pre-determined non-economic damages • Administrative compensation systems ("health courts") - Neutral expert witnesses - Knowledgeable hearing officers • Disclosure-and-offer programs - Mistakes are admitted - Compensation is offered

Tort Law Reform - 1

• Pre-trial screening panels - Reviews case at early stage and gives opinion about merit • Certificate of merit - From qualified medical expert in order to file a lawsuit • Attorney fee limits - Limits on percentage and/or total amount

Primary Care Characteristics - 6

• Primary Care Clinicians - Diagnose and manage most needs - Have limitations within practice • Due to limitation - May call other practitioners - May include specialists for further evaluation/treatment

Employer-Based Health Clinics

• Primary and urgent care • Occupational health, preventive care and wellness, chronic disease management • Aimed at containing health care costs - Employer retains utilization decisions - Shifts emphasis from illness care to preventive • Trend anticipated to continue for employers to provide clinics for their employees

Patient Medical Home Model for Primary Care Services

• Primary care approach to patient-centered, comprehensive, team-based, coordinated care • Focus on patient care quality and safety • Emphases on patient care - In the right place - At the right time - In manner that best suits patient and family • Primary care physicians are at the center of coordinating care in the medical home model

Where Is Primary Care Delivered?

• Primary care clinic: - Point of delivery - A medical facility • Usually, the conditions seen at a primary care clinic are not serious or life threatening • "Gateway" to health care services

Care Level and Care Setting

• Primary care is an entry point to the health care system • Levels of care - Primary care o Outpatient ambulatory care - Secondary care o Inpatient hospital care - Tertiary care o Inpatient hospital care

What Is Primary Care?

• Primary care medical specialties are - Family medicine - General internal medicine - General pediatrics - Obstetrics and gynecology • Do only physicians provide primary care? - Nurse practitioners - Physician assistants - Other mid-level providers

Definitions

• Privacy - The right to be left alone - The right to keep personal information secret - The right to control personal information • Confidentiality - Sharing or disseminating data only to those with a "need to know" • Security - Mechanisms to assure the safety of data and systems in which the data reside

Patient Information Disclosures Continued

• Privacy Rights Clearinghouse provides searchable Chronology of Data Breaches—not limited to medical - http://www.privacyrights.org/data-breach • HHS (2016a) must post list of breaches of unsecured PHI affecting 500 or more individuals ("wall of shame") - https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf - 2015 top 10 data breaches accounted for just over 111 million records; the top six breaches affected at least 1 million individuals

The Role of Private Insurance

• Private insurance - Available through employers or purchase - Supplement for non-covered Medicare services - Prohibited from paying for medically necessary services • Private insurance payments - 30% of Canada's total health care expenditures

The Role of Health Care in the U.S. Economy - 2

• Privately funded health care • Publically funded health care - Role Important federal laws

Measure

• Process Measure: Are we doing what we must to get the improvement we seek? • Outcome Measure: Are we getting what we expect? • Balancing Measure: Are we causing new problems in other parts of the system?

Better Performance on Measures = Better Outcomes? No

• Process measures in hospitals predict small differences in mortality in MI, CHF, and pneumonia (Werner & Bradlow, 2006) • CHF measures of ACC/AHA have little relationship to mortality or rehospitalization rates (Fonarow et al., 2007) • Participation of hospitals in MI P4P quality effort did not improve quality of care or better outcomes (Glickman et al., 2007) • Smoking cessation quality metric did not correlate with actual smoking cessation (Reeves et al., 2008) • Door-to-balloon measure for acute MI not correlated with other quality measures or mortality (Wang et al., 2009) • CMS heart failure measures not associated with better outcomes (Patterson et al., 2010)

Charge Capture-1

• Process of collecting a list of services, procedures, supplies, and associated costs • Charge description master - Database used by health care facilities - Paper based forms o Superbill, encounter form, or charge ticket - Electronic capture o Automatic - improved accuracy

Professional and hospital billing

• Professional billing (physicians' and nurse practitioners' services) - ICD-10-CM codes o Hospital discharge summary or outpatient visit note - CPT codes o Procedure (e.g., surgery) - CPT codes E / M (Evaluation and Management) o Level of evaluation and management service performed at patient visit • Hospital billing - ICD-10-CM codes o Inpatients billing by hospitals

Local Health Care: Hospitals

• Profit or nonprofit • Government-supported or not • General or specialty - University-affiliated or community-based - Single or chain - Critical-access hospitals get Medicare reimbursement

Medicaid - 3

• Programs have different names in different states • Federal government reimburses states for expenditures • States accepting funding must provide coverage to people who receive: - Temporary Assistance to Needy Families - Supplemental Security Income (SSI)

FDA Mission

• Protect public health - Regulates drugs o Performs drug approvals o Provides drug safety information o Spreads the message about medication errors - Helps speed up product innovations - Helps public obtain accurate, science-based information

What Is Covered?

• Protected health information (PHI) - Collected from patient and created by covered entity - Individually identifiable - Electronically transmitted—in reality, all information • Extends to covered entities and business associates • De-identified information is not covered • Pre-emption - HIPAA trumps state law if state law is less protective of privacy and security, but state laws that go beyond the HIPAA protections are not nullified by HIPAA and must be followed

Office of the Inspector General (OIG)

• Protects the integrity of HHS programs - Performs nationwide audits, investigations - Reports abuses, fraud, or waste - Recommends corrections • "Most-Wanted Health Care Fugitives" - Names and photos - Providers and public encouraged to help

Nursing Roles

• Provide direct patient care and coordinate care activities with other ancillary/allied health professionals based on physician orders and the patient's plan of care • Continuous patient assessment, monitoring, and planning of care • Diagnostic tests and treatments • Medication administration • Patient and family education • Emotional support.

Day Hospitals

• Provide mental health treatment during the day • Considered an alternative to outpatient care • Most facilities are hospitals or community centers • Provide individual/group therapy, other treatments • Goal is for patient to function within community

School-Based Health Centers

• Provide physical and behavioral health care - Certified medical providers and counselors - Further medical or hospital services are arranged as needed - Parental consent is required • Not all health centers are located inside schools - Mobile Health Centers - Off-site center serving more than one school

Community Health Centers

• Provide primary care for disadvantaged persons - Treat those who cannot pay and/or have no insurance - Found in all 50 states and territories - Usually rely on public financing • Advantageous for U.S. health care system - Improve health care access for all - Reserve EDs for true emergencies • Community mental health centers also exist

Community Mental Health Centers

• Provide treatment for elderly, adults, or children • Patients have chronic mental illness or recent hospital discharge • Services include outpatient care, emergency care, partial hospitalization, rehabilitation • May be reimbursed by Medicare

The Patient Experience - 3

• Provider - Physician, physician assistants or nurse practitioner who address the patient's clinical issues o Providers typically have a predetermined schedule of appointments for their day o May visit hospitalized patients o Have additional work that is not patient facing

How Insurers Pay Providers - 1

• Provider submits claim - Uses two kinds of codes o Diagnosis code = ICD-10-CM o Procedure code = CPT code or DRG code • Medical claims examiner or adjuster processes claim - Determines "usual and customary" charge o Deducts portion patient is responsible for o Deducts contractual provider discount o Reimburses remainder

Authorizations

• Providers must obtain authorization before using PHI for purposes other than TPO • They may not condition treatment on an individual's authorization • Covered entities must make "reasonable safeguards" to limit the use or disclosure of PHI to the minimum amount necessary - Non-treatment disclosure governed by "Minimum Necessary" standard (HHS, 2003)

Integrated Health Care Delivery

• Provides a full range of care • Informal association between practitioners, ambulatory facilities, hospitals, and academic medical center • Formal organizations that provide facilities under a single management structure to manage primary, secondary, and tertiary care services

The Medical Home

• Provides comprehensive medical care - Personal physician = director - Practice team o Collective responsibility - Enhanced access o Same day appointments

Workers' Compensation

• Provides fixed monetary awards to employees who are injured or become sick while at work - Regardless of who was at fault - Employee gives up the right to sue their employer for negligence • Is not: - Disability insurance - Unemployment income

Centers for Medicare and Medicaid Services (CMS)

• Provides insurance for 1 in 4 Americans • Medicare - Largest health insurer in the U.S. - For people 65+ or disabled people - Insured person pays premiums • Medicaid - For low-income patients and families - Specific guidelines are determined by each state - Insured person generally does not pay • Children's Health Insurance Program

Core EHR Functions: IOM

• Provides longitudinal health data on individuals • Provides immediate, yet secure, electronic access • Provides knowledge to enhance quality, safety, and efficiency of care • Supports efficient processes of care

Purpose of the MPI

• Provides the index, location of, and access to a patient's EHR in an enterprise • Facilitates intraoperability and the accurate creation of a longitudinal record • Ensures accurate and complete linking of EHRs for HIE

The Health Record as Tool for Patient Safety

• Providing care based on a full understanding of a patient's current and past conditions is a key element of safe care • Information in the health record is monitored for accuracy and completeness • The health record is used to manage risk and improve care

Psychiatric Hospitals

• Psychiatric care has evolved - Hospitalization is voluntary in most cases • Many types of care exist - Open units - Crisis stabilization units - Medium-term units - Juvenile wards - Long term care psychiatric hospitals • Some psychiatric hospitals specialize in certain illnesses or addictions

Public vs. Private Insurance

• Public - Government run - Medicare - Medicaid - Children's Health Insurance Program (CHIP) • Private - Individual organizations - State-licensed companies - Self-insured employer plan o ERISA regulates o Third-party administrator

EHR Hardware - Servers (cont'd - 3)

• Purchase considerations - Brand o e.g. Dell vs. "white box" - Operating system (OS) o e.g. Windows 8 or 10 or Linux - Processors o e.g. Intel® Core™ i7-7700 Processor (8M Cache, up to 4.20 GHz)

Pre-trial Litigation: Discovery

• Purpose is to fully develop the facts • Depositions are one kind of discovery - Sworn testimony recorded by court reporter - Parties - Witnesses - Expert witnesses

Moving data: Push/Pull

• Push: secure sending of information between two known entities - Direct Project • Pull: secure accessing of information that involves a query and a response - CONNECT

Additional Resources

• Quality Improvement Organizations (QIOs) Program • HCI3's Bridges to Excellence • Pharmacy Quality Alliance (PQA) • Quality Enhancement Research Initiative (QUERI) • National Committee for Quality Assurance (NCQA) • National Association for Healthcare Quality (NAHQ) • National Quality Forum (NQF) • The Joint Commission

KLAS methodology (Cont'd - 1)

• Questions allow health care providers to rate the product / vendor in the areas of: - Sales and contracting - Implementation and training - Functionality and upgrades - Service and support - General

What Else We Know: Providers

• Rate of deaths from treatable conditions ("amenable to healthcare") has declined much more slowly in US than in other developed countries (Nolte & McKee, 2008) • Physicians who score better on maintenance of certification exams have higher rates of quality based on process measures (Holmboe et al., 2008) • Use of hospitalists associated with better performance on quality indicators in hospitals (López et al., 2009) • In primary care, visit duration (Chen, Farwell, & Jha, 2009) and patient "connectedness" (Atlas et al., 2009) associated with quality • Underinsured, minority, disabled, and/or non-English-speaking patients associated with lower-quality rankings for primary care physicians (Hong et al., 2010)

Benefits of ACA

• Rate of uninsurance has fallen from 18% to 11% (Gallup, 2016) • Continued slowing of spending growth; amount due to ACA unknown (Martin, 2016) • No change in employment or reported hours worked (Moriya, 2015) • Increased economic growth, especially in states expanding Medicaid (ASPE, 2015) • Reduced uncompensated care (ASPE, 2015)

HIPAA Security Rule 1

• Readable overview in Security 101 for Covered Entities (CMS, 2007) • Aligned with terminology of Privacy Rule • Aims to minimize specificity to allow scalability, flexibility, and changes in technology • For covered entities, business associates, and subcontractors, rules are either - Required: Must be implemented - Addressable: If reasonable and appropriate to implement • As with HIPAA Privacy Rule, modifications under HITECH and other legislative actions • State laws are instrumental

These views must serve

• Real-time connectivity to provide appropriate and controlled access to aggregated patient data. • Disease registries permit the monitoring and assurance of high quality care. • Research databases are derived for specific purposes and for specific periods of time. • Reimbursement is derived from clinical data, ideally in real time. • Accreditation, credentialing and statistical reporting are derived products. • The data warehouse contains all data for legal and archiving purposes. • Support consumer driven healthcare • Mandatory reporting such as immunizations, HAI, etc.

The Uninsured

• Receive - Less preventive care - Diagnosed at more advanced disease states - Once diagnosed, received less therapeutic care - Have higher mortality rates • Cost of care is twice as much for uninsured vs. insured

Regional Health Information Organizations

• Regional collaboration of multi-stakeholder organizations working together to connect healthcare communities with the goal of improving quality of care, safety and efficiency • Typical objectives - Develop community-wide health information exchange - Create healthcare portal with interoperable applications - Create a training and support infrastructure to ensure adoption of applications - Engaging payers in programs that align incentives appropriately

Employee Retirement Income Security Act of 1974 (ERISA)

• Regulates employer self-insured health plans - Employer not required to establish plan • Requires plans to meet certain standards - Establishes standards of conduct for plan administrators - Requires a grievance and appeals process - Allows employees the right to sue for benefits

Patient Safety - 1

• Regulation is an important mechanism used to improve patient safety • Landmark 1999 report (To Err is Human) - 44,000 to 98,000 people die in hospitals each year as a result of preventable medical mistakes - Mistakes cost hospitals $17 billion to $29 billion yearly

Specialty Hospitals, Rehabilitation Care - 2

• Rehabilitation hospitals - Stand-alone hospitals or units within a hospital - Provide intensive daily rehabilitation • Outpatient rehabilitation is also available through agencies, clinics

Managed Care Reimbursement

• Reimbursement - Contract with providers to limit fees o Fee-for-service: Discounted fee schedules o Episode-of-care: Prospective payment • Patient utilization control through - Financial incentives to use network resources o Offer lower in-network costs o Increase out-of-pocket expenses for non-network use

3rd Party reimbursement

• Reimbursement Methodology - Fee-for-service (FFS): Separate payments made for each individual service provided - Episode-of-care: Payment of one sum for providing all services or care during a illness or time frame • Example: - Patient with cough and fever is treated at urgent care

Remittance

• Reimbursement received - Reduced amount due to coinsurance, copayments, or contract - Challenges o Non-payment by payor o Incorrect reimbursement • Final settlement with patient - coinsurance

Reimbursement & Claims

• Reimbursement: Compensation or payment for health care services already provided - Fee-For-Service - Episode-of-Care • Claim: Itemized statement and request for payment of the costs of health care services rendered by a health care provider or organization sent to third-party payor

Informed Consent 1

• Requirement that patient be fully informed and give consent to treatment • Process of communication between doctor and patient • Required legally and ethically • Absence can result in liability - Battery - Negligence

HIPAA Security Rule

• Requires covered entities to use security measures to protect health information • Does not specify which technology must be used • Establishes minimum federal standards - State laws may require more rigorous safeguards

Allowable Non-TPO Disclosures

• Research - Overview: HHS, 2004 - Authorization by patient is generally required - Authorization waiver can be provided by an institutional review board (IRB) or privacy board approval o Must involve "no more than a minimal risk" o Research could not be practically conducted without waiver and without access to PHI • Public Health - Can be disclosed to public health agencies for public health activities - Also allowed for child abuse reporting, exposure to communicable diseases, and workforce surveillance • Other - Law enforcement - Decedents - Cadaveric tissue donation.

FFS: Traditional Retrospective - 2

• Resource-Based Relative Value Scale (RBRVS) - Used by Medicare and other third-party payors - Payments are based on cost of services in terms of effort, overhead, and malpractice insurance

Centers for Disease Control and Prevention (CDC) - 1

• Responsible for public health - Protect America from health, safety and security threats, both foreign and domestic • Activities: - Health promotion - Disease prevention - Reduction of injury and disability - Public Preparedness • Numerous centers, institutes and offices

Tort Law Reform - 3

• Results Considered: - Costs - Frequency of malpractice claims - Supply of health care services, - Quality of care - Need for physicians to practice so-called defensive medicine • The only tort reform that significantly improved these results was the cap on noneconomic damages

The Revenue Cycle and Medical Billing

• Revenue Cycle: Standard set of activities and events that produce revenue or income for a health care provider. • Medical Billing: Part of revenue cycle. The process of submitting claims to insurance companies in order to receive payment or reimbursement for services rendered by a health care provider.

System Integration Example

• Revenue cycle - Administrative functions - Clinical functions • Revenue cycle management

What's Driving the High Cost of Health Care in the U.S.

• Review U.S. health care expenditures and medical inflation • Examine the factors contributing to the increase in health care expenditures in the United States • Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) • Discuss the cost of care to the uninsured

Controlling Health Care Costs - 1

• Review some potential methods of controlling rising costs in medicine - Examine the role of health information technology in reducing and limiting costs o Use of electronic health records and evidencebased medicine (EBM) o Clinical decision support o Clinical practice guidelines

Does HIPAA Privacy Rule Protect Privacy?

• Reviews by GAO (2004) and NCVHS (Kanaan, 2007) found adherence less problematic than anticipated • Major concerns relate to difficulty in performing clinical research - Finding and accessing patients for research more difficult (Armstrong et al., 2005) - Two-thirds of researchers surveyed reported more difficulty in work; only one-quarter believed privacy enhanced (Ness, 2007) - Reports from AAHC (Steinberg, & Rubin, 2009) and Institute of Medicine (2009) argue for revision to make research easier • Also concerns with implications for public health (Kamoie & Hodge, 2004) • Another view calls for less emphasis on consent and more on a framework that makes for easier sharing of TPO (with some modifications of "O") with more rigorous restrictions on other uses, such as marketing (McGraw, 2009; McGraw et al., 2009)

Employer Pre-paid Plans

• Ross-Loos Medical Group - Believed to be first HMO in U.S. • 1930s: Surgeon Dr. Sidney Garfield - Organizes employer pre-paid plan - Fixed payment per employee per month - Formed Permanente Health Plan o Open to the public o Union support boosted growth

Informed Consent with Shared Decision Making (SDM)

• SDM: Informed discussion between providers and patient to help patient decide among multiple acceptable health care choices. Discussion must include patient's priorities and values. • Decision aids facilitate SDM. Include information on options, risks, benefits, and can include a priority-setting activity and coaching.

Organizations Supporting HIT Standards 2

• SDO Standards Development Organization • HITSP Health Information Technology Standards Panel • HL7 Health Level 7 • NIST National Institute for Standards and Technology • ISO International Organization for Standardization

KLAS research focus

• Software - Ratings for making the best possible purchasing and negotiating decisions (since 1997) • Services firms - Reports on services markets including implementation, planning and assessment, vendor selection, technical consulting, IT outsourcing, and business process outsourcing (since 2004) • Medical equipment - Gathering research on medical equipment, including CR / DR and MRI scanners (since 2005)

Administrative Safeguards Continued

• Security awareness and training - Security reminders (A) - Protection from malicious software (A) - Log-in monitoring (A) - Password management (A) • Security incident procedures—response & reporting (R) • Contingency plan - Data back-up plan (R) - Disaster recovery plan (R) - Emergency mode operation plan (R) - Testing and revision procedures (A) - Application and data criticality analysis (A) • Evaluation (R) • Business association contracts, subcontractors, and other arrangements (R

Health Care Organizations Are Not Well Prepared for Security

• Security budgets are not keeping pace with complex IT environments and the growing risk of attacks (HIMSS, 2015) • Growing sophistication of attacks and number of threats make it hard to keep up • There is a need for innovative, advanced security tools and in-depth approaches to address threats and vulnerabilities (HIMSS, 2015) • There is not enough highly skilled, security expertise (Ponemon Institute, 2015) • Paper security breaches remain an issue (Ponemon Institute, 2015) • Data leakage is a primary threat - Identity and access management is a top priority • Chief information security officers (CISO) are not in all organizations

Administrative Safeguards

• Security management process - Risk analysis (R) - Risk management (R) - Sanction policy (R) - Information system activity review (R) • Assigned security responsibility (R) • Workforce security - Authorization and/or supervision (A) - Workforce clearance procedure (A) - Termination procedures (A) • Information access management - Isolating healthcare clearinghouse functions (R) - Access authorization (A) - Access establishment and modification (A) R = required A = addressable.

Methods of Fighting Medicare/Medicaid Fraud

• Senior Medicare Patrols (SMP) • Health and Human Services Online brochure (stopmedicarefraud.gov) • HEAT law enforcement activities

The Joint Commission Safety Initiatives - 1

• Sentinel Event Policy - Unexpected death, unexpected serious physical or psychological injury, or the risk of such an event • Patient Safety Advisory Group - Panel of experts who recommend National Patient Safety Goals - Also address newly developing safety issues

Balance of Power

• Separation of powers - Three branches of government - Designed to prevent any one branch from becoming too powerful • Checks and balances - Legislative branch makes laws - Executive branch enforces laws - Judicial branch interprets laws

EHR Hardware - Most Common

• Servers • Workstations • Laptops • Tablets • PDAs/smartphones • Flat-panel monitors • Scanners • Printers • Storage and backup • Shredders • Medical diagnostic and treatment items

NHS Patient Fees

• Services free until the early 1950s • 2007 out-of-pocket average cost - U.K. $343 in U.S. dollars - U.S. $890 in U.S. dollars • Help keep health care affordable: - Fixed rate for prescriptions - Fee exemptions - Caps on cost of dental procedures

Professional Associations - 2

• Sets requirements: - For entry into the profession o May require license or certificate - For maintaining membership in the profession • Members generally have a significant amount of education, training, or experience

Solving The Primary Care Crisis

• Shift in training focus • Increased funding • International Medical Graduates • Recruitment • Loan forgiveness and other financial inducements

VA Community Living Centers

• Similar to nursing homes • Skilled nursing facilities • Veterans with special concerns - Chronic health conditions - Need for rehabilitation - End-of-life care

The Canadian Health Care System (MEDICARE)

• Similar to the NHS - Taxpayer-funded - Universal coverage • Different from the NHS - Nationwide and regional funding - Federal government cannot run regional health care plans - Limitations on private health insurance

Evident

• Since 1979, as CPSI, developing, installing, and supporting health care information systems for rural communities • CPSI is a leading provider of health care information / EHR solutions for community hospitals

VA Hospitals

• Single hospitals • Health care systems - Groups of medical centers, clinics - Share resources; improve efficiency - Examples o VA Pittsburgh Healthcare System o VA Puget Sound Healthcare System

2016 CMS Quality Strategy Goals

• Six priority goals - Safer care - Patient/family engagement - Communication across care coordination - Effective prevention and treatment of chronic disease - Healthy living best practices - Affordable care

Home Health Care

• Skilled home health care services - Short term care - Homebound - Live in remote location • Homemaker/Home Health Aide services • Home Telehealth services

ACA Expansion of Health Insurance Coverage - 2

• Small business tax credits • Requirement for larger (>50) employers to offer health insurance coverage • Close Medicare "donut hole" • Individual mandate for health insurance

Challenges for Certain Practice Environments

• Small numbers in small hospitals can inflate performance relative to large hospitals (O'Brien, DeLong, & Peterson, 2008) • "Safety-net" hospitals—ongoing funding and staffing issues impact ability to provide quality care. Mission could be adversely affected by P4P (Werner, Goldman, & Dudley, 2008) and worsen already existing disparities (Casalino et al., 2007) • Small practices have limited time, multiple payers, and low capital investment (Landon & Normand, 2008) - Is it overly burdensome? (Vonnegut, 2007)

EHR Hardware - PDAs and Smart Phones

• Smart phones & Personal Digital Assistants (PDAs) combine computing and networking / cellular features into a personalized unit. - Like tablets, mostly pen-based, using stylus for input rather than keyboard - Allow users to access patient data remotely, from any location with network connectivity - Similar advantages & disadvantages as laptops & tablets - May require additional hardware/infrastructure resources

Administrative Hearing Example

• Social Security Administration (SSA) - Hearing officers - Social Security Appeals Council - Decisions of the SSA appeals board can be further appealed to the U.S. District Court

Epic

• Software for mid-size and large medical groups, hospitals, and integrated health care organizations • Customers: - Community hospitals - Academic facilities - Children's organizations - Safety net providers - Multi-hospital systems • Spans clinical, access, and revenue functions and extends into the home

KLAS ratings for acute care EHR

• Software products that provide core inpatient functionality: - Clinical data repository (CDR) - Order entry including computerized provider order entry (CPOE) - Results reporting - Clinical charting and documentation • Large: over 200 beds • Small: 200 or less beds

Administrative Hearings

• Sometimes an administrative agency has a system of hearings that is outside the normal court system • The agency may or may not have an appellate level • Usually reviewable in a court of law

Ancillary Roles

• Specialized ancillary staff - Radiology and laboratory technicians - Nuclear medicine technicians - Sonographers • Other ancillary service providers o Physical and occupational therapists o Speech therapists o Emergency medical technicians and paramedics

ORYX: Core Measure Sets - 2

• Specific performance measures are associated with each core measure set - For example, the TJC looks at whether children with asthma received certain drugs in the hospital and were sent home with a management plan

Health IT in the Future Summary

• Speculate on the relationship between HIT and health reform • Suggest alternative designs • Hypothesize how HIT may intersect with publicly available data to improve health (i.e. Point of Sale, Weather, GIS, foods, etc.) • Predict avenues of future innovations in HIT

Health Insurance

• Spreads risk over a large pool of people - 5% of people account for about 50% of spending • Cost influenced by: - Prescription costs - Technology - Aging population - Chronic conditions - Government subsidies - Administrative costs

Interoperability (con't)

• Standardized terminologies / ontologies - Patient diagnoses, interventions, outcomes • Semantic Interoperability - Data means same thing to different users

Key Components of Enterprise Integration 1

• Standards - Structure and content o Identifier - Vocabulary o SNOMED CT - Content exchange o HL7 Clinical Document Architecture o HL7 Consolidated Clinical Document Architecture (C-CDA) - Privacy and security o NIST encryption algorithm

What is behind this model?

• Standards • Infrastructure to support aggregation of data into a single patient record which requires ... • Infrastructure to support a regional network • Infrastructure and linkage of regional networks to provide a virtual national network • A business case based on supported facts and includes a financial model that balances rewards with costs • A workable process that permits us to reach the destination in doable chunks • Understanding and creating the necessary linkages among stakeholders • State efforts blended into a common process that will support interoperability among states

Patient Consent

• State and federal law decides if patents have the option to opt in or out of exchange: • Opt-in State - None of your data is shared unless you opt-in to the program • Opt-out State - Patient's data automatically is available to the HIE unless they opt-out

Regulation of Private Health Insurance

• States control the legal structure and monitor their finances - Ensure the company can meet its obligations • Private insurance companies are also regulated by federal laws

EHR Hardware - Servers (cont'd - 2)

• Storage requirements depend on EHR/PM application, volume of scanned documents - Check with your EHR vendor. - Rule of thumb: 5 GB/year/provider

Hospital Clinical Structure: Overview

• Structured according to type and level of care - Similar inpatients - wards - Specialized areas o Emergency department o Operating room o Intensive Care Units (ICU) Cardiac Care Unit (CCU) • Care provided by physicians and nurses - May have specializations - Assisted by ancillary personnel

Other Long Term Care Options for Older Adults - 2

• Subsidized housing - Provide residence for older adults/disabled/poor, other services - Federal or state agency funds the program - Billing is a percentage of monthly income

Hospital Setup: OR

• Surgery is done in the OR - Sterile environment is required - Surgical team includes a variety of health care workers - Contains surgical instruments, monitoring equipment, emergency equipment • Surgery centers - Freestanding, not part of a hospital - Perform operations on outpatient basis - Subject to Joint Commission certification

Primary Care Characteristics - 4

• Sustained partnership: - First visit - relationship established - Expectation of continuation - Develop trust, responsibility and respect

Prospective Payment System (PPS)

• System for reimbursing providers - Controls costs - Pays predetermined, fixed dollar rate regardless of services provided - The rate depends on the patient's diagnosisrelated group (DRG) o Age o Gender o Principal diagnosis o Other conditions o Surgical procedures

Computerized provider order entry (CPOE)

• System used for direct entry of one or more types of orders by a provider into a system that transmits those orders electronically to the appropriate department - (Armstrong, 2000)

Evidence-Based Medicine

• Systematic Review of Published Research • Clinical Practice Guidelines • Standard of Care - Lower costs - End defensive medicine - Cookbook medicine? • Evaluating Technology

Effect of Public Reporting of Quality

• Systematic review finds scant evidence for documented benefit in quality of care (Fung et al., 2008) • Combining public reporting with P4P improves performance on measures, whereas reporting alone does not (Lindenauer et al., 2007) • US general internists support financial incentives for quality, although they have concerns about public reporting, especially its impact on incentive to care for sicker or more complex patients (Casalino et al., 2007) • Public report cards in Canada did not improve indicators for MI or heart failure (Tu et al., 2009) • Patients have difficulty understanding; better approach consists of a framework and plain language (Hibbard, Greene, & Daniel, 2010)

Resources for Quality-Related Activities

• Systems and Tools - Source systems: Clinical systems, EHRs, and so on - Decision support systems - Data warehousing, analytics, and reporting tools • Organizational and executive support - Data governance - Quality activities • Staffing - All staff - Information technology o Analysts, application support, etc. - Informatics: CNIO, CMIO - Training and education of quality program and use of systems

Financial and Resource Management

• Systems that support business functions - Example oAccounts Payable System - Supporting technology oClaims administration • Houses financial and employee data

Patient Management and Billing

• Systems that support the management of the patient - Example Patient identification - Supporting technology Master patient index ▪ Patient-identifying directory ▪ Links to the patient record ▪ Facilitates patient identification ▪ Assists in maintaining a longitudinal patient record

Patient Management and Billing 1

• Systems that support the management of the patient - Example o Patient identification - Supporting technology o Master patient index

TJC Accreditation - 1

• TJC accreditation signifies an organization meets TJC's standards for patient care • Accreditation is earned by an entire health care organization (hospital, nursing home, office-based surgery practice, etc.) • Procedure manual: emergency management, environment of care, HR, infection prevention and control

TJC Certification

• TJC-accredited organizations and providers of health care staffing services can also earn certification for specific programs or services - For chronic diseases and conditions o Examples: asthma, diabetes, heart failure programs - Programs can be within the medical center or in the communit

Factors Contributing to High Health Care Expenditures

• Technology • Increased demand and utilization - Chronic disease - Aging population • Administrative costs - 7% of health care expenditures in the U.S. - Twice the average of other industrialized countries

Documentation: note creation options

• Templates - Clinical discipline - Specialty - Type of note • Macros - Combination of keys generate a user predefined text set • Voice recognition software / embedded dictation • Copy and paste • Structured documentation - Tailored assessments

EHR Systems: Then and Now (cont'd)

• The 1990s - Improvements in computing power and connectivity spurred progress. - EMRs began to be adopted by some practices. - Rapid progression of technology meant technology was outdated almost as soon as it was installed.

Patient Safety - 2

• The 1999 To Err is Human Report: - Individual errors are not the main problem - Faulty systems, processes, and other conditions lead to preventable errors

What Is the Role of Government?

• The American Recovery and Reinvestment Act of 2009 (ARRA) provided creation of the HIT Policy Committee and an HIT Standards Committee under the auspices of the Federal Advisory Committee Act (FACA). Groups under these two committees include - Privacy and Security Workgroup: Focus on policy issues and opportunities to ensure electronic data captured and exchanged is protected and shared consistent with consumer needs and expectations - API Task Force: Identifies privacy and security concerns that are barriers to widespread adoption of open APIs in health care • ONC's Federal Advisory Committee Process: https://www.healthit.gov/facas/sites/faca/files/developrecommendations-SOP.pdf • 2015 Precision Medicine Initiative: ONC was funded $5 million to support development of interoperability standards and requirements addressing privacy and enabling secure data exchange

Meaningful Use and QI — 2

• The American Reinvestment and Recovery Act (ARRA) of 2009 "authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming 'meaningful users' of certified electronic health record technology." • The Health Information Technology for Economic and Clinical Health Act (HITECH) establishes programs under CMS in coordination with the Office of the National Coordinator to accomplish this charge.

The Patient Experience - 2

• The Clinical Team - Medical Assistant - certified health care assistant who performs minor clinical or clerical work o First clinical point of contact for patients in outpatient offices o Takes patients to exam room o Obtains the vital signs and chief complaint

The DIRECT Project

• The DIRECT project specifies a simple, secure, scalable, standard-based implementation guide for users to send authenticated, encrypted health data directly to known, trusted recipients over the Internet. • DIRECT Project is a collaborative whose stakeholders represent over 50 provider, state, HIE, and HIT vendor organizations. • DIRECT accomplishes this using familiar protocols, such as SMTP (email) with S/MIME (encryption). • DIRECT is an excellent option for secure communication between providers, particularly those who are not connected to an HIE via CONNECT.

NHS Governance & Responsibilities

• The Department of Health - Administers and provides funds - Responsible for NHS o Public o Parliament - Improving public health o Environmental health hazards o Medication safety o National policies o Health education

The Patient Experience - 1

• The Front Office - Receptionist: First point of contact - Greeter: help patients find the appropriate area - Scheduler: Makes appointments - Patient Navigator: helps navigate medical care - Clinic Manager: administrator for the office - Clinic Supervisors: help run the clinic

Financial and Quality Issues - 2

• The Joint Commission - Independent nonprofit agency - Performs on-site visits - Health care facilities volunteer for certification

Nonprofit Accrediting Organizations

• The Joint Commission • URAC, formerly the Utilization Review Accreditation Commission

HIPAA Enforcement and Penalties - 1

• The Office of Civil Rights within the U.S. Department of Health and Human Services enforces HIPAA compliance • The HITECH Act extends privacy and security rules, provides for enhanced enforcement

OIG Compliance Program Tips - 1

• The Seven Fundamental Elements of an Effective Compliance Program 1. Implementing written policies, procedures and standards of conduct 2. Designating a compliance officer and compliance committee 3. Conducting effective training and education. 4. Developing effective lines of communication

State HIEs

• The State Health Information Exchange Cooperative Agreement Program was designed to promote HIE and advance information sharing across the health care system. • Long term goal was to enable a nationwide HIE and interoperability. • In total, 56 states, eligible territories and State Designated Entities received awards. • Program ended in 2014

Five Single-Payor Systems in the United Kingdom

• The U.K. Department of Health: - Funds the National Health Service (NHS) - Ten regional health authorities - Primary Care Trusts (PCTs) o Salary o Fee-for-service o Capitation

EHR Systems: Then and Now

• The early years - Earlier EHR systems required extremely expensive computer hardware. - Core components usually ran on UNIX and often incurred high training costs. - Rapid progression of technology meant technology was outdated almost as soon as it was installed.

Universality, Portability, and Accessibility

• The last three principles protect patient rights - Universality o Right to health care - Portability o Provides coverage between regions or travels outside of Canada - Accessibility o Provided regardless of health, age, or income

Affordable Care Act

• The most major recent health care insurance legislation is the Patient Protection and Affordable Care Act (PPACA), also known as - The Affordable Care Act (ACA) - Obamacare • The ACA has two major goals - Expansion of health insurance coverage - Improving quality of care while reducing cost

EHR Hardware - Servers

• The server(s) are the "home base" of the core EHR system, with components including: - Storage of patient database (index) - Real-time, dynamic compilation of patient information from varied sources - Modules for parsing user requests - User management tools - Customization tools

HIT and Optimizing Equity

• There are few stroke specialists in rural areas, so people at risk for stroke in these areas have unequal access to quality care. • Physicians in Arizona set up a hub-andspoke service using telemedicine (audiovideo) to decrease health disparities. (hub=urban stroke center; spoke=outlying rural hospitals)

URAC Privacy & Security Accreditation - 2

• These health care organizations must comply with HIPAA: - Health plans: Health insurance companies, employer-funded health plans, and government programs that pay for health care, such as Medicare or Medicaid - Health care providers that conduct certain tasks electronically - Health care clearinghouses (organizations that process health information)

Donabedian Model of Quality (2002)

• Three categories: - Structural: Factors that make it easier or harder to deliver high-quality care (e.g., hospital location, volume, association with teaching hospital) - Process: Factors describing health care content and activities (e.g., adherence to screening, guidelines) - Outcomes: Changes attributable to care (e.g., mortality, morbidity, functional status) • Implemented and measured at different levels at an institution (e.g., individual, department, organization)

Statute of Limitations

• Time limit for filing a lawsuit - Short as 6 months - Long as 4 years • Discovery rule - Time limit starts when the malpractice is discovered, rather than when it was allegedly committed

Benefits of HIE- Rural

• Timely real-time access to health information • Decreased travel time for patients /families • Extended access to remote clinicians, pharmacists • Efficient transfer for services not offered locally • Efficient local care after intense care in a tertiary hospital

Nationwide Healthcare Information Network (NwHIN)

• To provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare. • E-health information to follow the consumer, be available for clinical decision making, and support appropriate use of healthcare information beyond direct patient care so as to improve health • De-identified regional data can be analyzed nationally in aggregate. There is a proposed national MPI which would permit authenticated and authorized access to RHIOs for legal health-related purposes, but patient matching algorithms are the industry standard. • Security and privacy are top priorities.

TJC Accreditation - 2

• Tools TJC uses to measure performance - Integrated Survey Process (ISP): An in-person visit to evaluate performance across an organization - Outcome Research Yields Excellence (ORYX): System for health care organizations to report information to TJC about patients with certain conditions (core measure sets) o The core measure sets reported depend on the type and size of the organization

What Else We Know: Organizations

• Training at an organization associated with a "best doctor" rating for bypass surgeons did not lower adjusted mortality rates (Hartz, Kuhn, & Pulido, 1999) • Being US News & World Report "Best Hospitals" associated with lower 30- day mortality from acute MI, but some best hospitals had worse mortality (Wang et al., 2007) • Organizations with direct leadership, accountability for quality and safety, and culture of collaboration have measurable differences (Keroack et al., 2007) • Higher quality seen in larger (more integrated) subspecialty medical groups (Weeks et al., 2010) • Resources available to compare organizations - http://www.hospitalcompare.hhs.gov - Hospital Compare from the Hospital Quality Alliance (HQA) - Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Interface Engine

• Translates functions from different systems and protocols • Outcome is a common format • Facilitates information sharing • Controls data flow between applications • Central connecting point for all interfaces

Clinical Roles - 3

• Triage Nurse - Takes phone calls - Problem-solves issues - Refers complex issues to physician - Arrange referrals • Back-office Medical Assistants - Telephone triage - Referral coordination - Point-of-care procedures

The Judicial System: Courts

• Trial court - Hears evidence and hands down verdicts - Can be federal, state, or local • Appellate court - Losing party can appeal - Court usually does not hear new evidence - Reviews case to determine if the law was properly applied to the facts as determined by the trial court

Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)

• Two components: - The Merit-Based Incentive Payment System (MIPS) o Combines programs into a single system - The Alternative Payment Models (APMs): o New models for provider reimbursement such as accountable care organizations and patientcentered medical homes • Applies to Medicaid patients • 2020 targeted timeframe

Typical Server Elements

• Types of servers: - Application server: computer on which the EHR/PM (Practice Management) application resides - Database server: computer on which the database software resides - Citrix or terminal server: computer that supports thin client network • Application, database, and terminal services may reside on the same computer for small installations (<10 users)

Concierge Medicine - 2

• Typical features - Same day urgent care appointments - Next day non-urgent care appointments - 24-hour telephone access - Extended office visits - Preventive care physicals/screenings

Medical Staff

• Typically has an elected chief of staff • Chief of staff and CMO manage - Physician privileges - Medical polices - Governance of medical staff - Continuing medical education - Quality and patient safety initiatives • VP of quality & patient safety

Urgent Care Centers - 2

• Typically have laboratory and/or X-ray facilities on-site • Some may have more advanced diagnostic equipment • Not intended to treat life-threatening emergencies

The U.S. Health Care Industry

• U.S. Health Care - Fifth largest sector of the economy by sales - 11.8 million employees o More than any other sector - 10 of 20 fastest growing occupations o 3.2 million new jobs by 2018

The U.S. Multipayor System

• U.S. Health Care Financing - History of U.S. health insurance - Role of Government - Private payors vs. Government (Public) payors

Some Technologies Can Worsen the Problem

• USB ("thumb") drives run programs when plugged into USB port; can be modified to extract data from computer (Wright & Sittig, 2007a, 2007b) • Personal health records, other systems, may lack encryption and be easily compromised • 10% of hard drives sold by a second-hand retailer in Canada had remnants of personal health information (El Emam, Neri, & Jonker, 2007) • Peer-to-peer (P2P) file sharing—0.5% of all U.S. IP addresses have PHI (El Emam et al., 2010) • Digital photocopiers store all copies made (Keteyian, 2010); scanners may also store copies Restrict physical access where possible, always encrypt!

Centers for Medicare & Medicaid Services (CMS)

• Under U.S. Department of Health & Human Services • CMS regulates reimbursement for health care products and services, including: - Medicare - Medicaid - Children's Health Insurance Program (CHIP)

Regulatory Agencies

• Under the authority of Congress, federal agencies enforce standards in a specific field in the private sector • Agencies create regulations, known as "rules", to carry out public policy • The goal is consumer protection. Example: Food and Drug Administration (FDA)

How providers use KLAS findings

• Understand products' and vendors' strengths and weaknesses • Screen prospective vendors • Create influential proposals with KLAS research that supports your buying decision • Manage risk and exposure: be informed on price, contract issues, and common complaints • Set realistic expectations for your organization and your vendor • Save research time and money

ED Utilization and Uninsured

• Uninsured care cause for ED overcrowding? - 2008, Weber examined ED use o Percent of uninsured using the ED did not change over 10 years o Non-poor insured with PCP accounted for most increase in ED visits

Single vs. Multi-Payor Systems

• United Kingdom - Public payor o Public funded o Provides basic services - Private payor o Employer plans • Canada - Single public payor in each province or territory - Limited or no private payor

Public Health Care in the United Kingdom and Canada

• United Kingdom: National Health Service - Department of Health funds 5 regional health care plans throughout the country • Canada: MEDICARE - Provincial/Territorial Single Payor - Medicare funds provinces and territories, which run their own health plans

The Joint Commission Safety Initiatives - 2

• Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery - Pre-surgery verification - Site marking - "Time out" before an incision is made • The Speak Up Initiative - Encourages patients to participate in their care - Free patient education materials

What the NHS Provides

• Universal coverage for all U.K. residents • Primary care, specialists, hospital care, long-term care, and preventive care • Mental health, rehabilitation, dental, and eye care

Commonwealth Fund National Scorecard (Schoen, 2011)

• Up to 84,000 fewer Americans would die prematurely from causes amenable to health care if United States achieved lower mortality rate of three other leading countries • Reducing insurance administrative costs to comparable costs of other best countries would save $114 billion per year • Medicare could save $4.2 billion per year by reducing hospitalizations for preventable conditions

Why So Many ED Visits?

• Upstate New York - 45% of potentially unnecessary ER cases were seen between 9 am and 5 pm • Hours of operation not necessarily an issue • Could this be a consequence of the primary care crisis?

Alternative Delivery Methods

• Urgent Care - Low cost alternative o Incentives to avoid the high cost of the ED - X-ray and lab on site - Extended hours • Retail Clinics - Located in non-traditional provider locations o Pharmacy and large retail locations o Staffed by nurse practitioners and physicians o Minimal x-ray and laboratory services

Unique Patient Identifier (UPI)

• Value permanently assigned to an individual for identification purposes • Unique across the entire national health care system • Not shared with any other individual

Medical Assistants

• Variable education: One year (certificate) to two years (associate's degree) • Most receive training in medical terminology, office administration, coding and reimbursement, laboratory procedures, office patient care, medications • Not licensed • Role includes routine administrative and clinical duties.

Cost vs. Provider Choice

• Various plans are defined by choices in what providers the patient can use • Fewer choices = lower premiums and outof-pocket costs • Types of plans: - Health maintenance organization (HMO) - Preferred provider organization (PPO) o Exclusive Provider Organization (EPO) - Point-of-service plan (POS)

Results review (Cont'd - 1)

• Vendor system of differences - Critical results notification - Viewing formats o Table / flowsheet format o Graph for display of trends - Workflow configurations o Interfaces with other systems, such as labs and imaging

HIMSS (Cont'd - 1)

• Vision - Advance the best use of information and management systems for the betterment of health care • Mission - To lead health care transformation through the effective use of health information technology

Emergency Department (ED) - 1

• Visits increasing over time - 2006 - over 119 million visits - 2011 - over 136 million visits • Visits resulting in admission - 2006 - 12.8% - 2011 - 11.9% • Majority of patients waited 15 - 59 minutes to see a provider

Types of Standards

• Vocabulary, content exchange, and privacy and security standards (including transport standards) - Vocabulary: code sets, ICD-10-CM, SNOMED CT, LOINC - Content exchange: HL7 CDA R2 CCD, ASTM CCR - Privacy/security: AES encryption, IPsec, TLS Transport: SOAP, REST

Benefits of Workers' Compensation Plans

• Wage replacement (form of disability insurance) • Compensation for economic loss (past and future) • Medical benefits (form of health insurance) • Benefits to survivors of employees killed in work-related accidents (form of life insurance)

Additional Provider Activities

• What do physicians do when they are not seeing patients? - Reviewing charts - Fielding telephone calls - Reviewing test results, correspondence - Answering questions from staff about patient care - Consulting with other physicians about patients - Completing forms - Other work

Definitions and Operationalization

• What is health care quality? Different views... - Donabedian, 1988: "That kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts" (in Blumenthal, 1996) - Lohr, IOM, 1990: The "degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge" (in Blumenthal, 1996) • In an era of rising costs and concerns about quality, physicians and the health care system must have public accountability (Chassin et al., 2010, Chassin & Loeb, 2011) • Value based reimbursement models

HIT and Workarounds — 2

• When a barcoding medication system interfered with their workflow, nurses devised workarounds, such as removing the armband from the patient and attaching it to the bed because the barcode reader failed to interpret bar codes when the bracelet curved tightly around a small arm.

Alternative Designs for HIT (cont'd)

• Where might alternative designs take us? - I-phone like apps - Advanced smart phones - Robots

Alternative Designs for HIT

• Where might alternative designs take us? - Wearable computers - Implantable chips - Mobile solutions for mobile clinicians

Related Issues for Medical Privacy

• Who " owns " medical information? - Complex; varies from state to state (http://www.healthinfolaw.org/comparativeanalysis/who-owns-medical-records-50-state-comparison) - May have economic value, which should be shared back to patient (Hall & Shulman, 2009; Rodwin, 2009) • "Compelled" disclosures (Rothstein & Talbott, 2006) - We are often compelled to disclose information for nonclinical care reasons • Ultimate "personal identifier" may be individual's genome (McGuire & Gibbs, 2006) - Even "de-identified" data may compromise privacy (Malin & Sweeney, 2005) - Genome of family members can identify siblings (Cassa et al., 2008) - Data from genome-wide association studies can reveal individual-level information (Lumley & Rice, 2010)

Other Issues to Ponder

• Who owns information? • How is informed consent implemented? • When does public good exceed personal privacy? - e.g., public health, research, law enforcement • What conflicts are there with business interests? • How do we let individuals "opt out" of systems? - What are the costs? When do we override?

Centers for Disease Control and Prevention (CDC) - 2

• Works with partners to monitor and investigate threats to health • Enacts prevention strategies, develops public health policies, advocates for healthy behaviors. • Educates health care providers, consumers

National Institutes of Health (NIH)

• World's largest source of funding for medical research • Funds universities, research institutions, its own laboratories • 27 institutes and centers: - Diseases - Specific patient groups - Research issues

Electronic Health Information Management

• eHIM® - A term and trademark used by AHIMA to identify the transition from paper based health information management to electronic health information management (eHIM)