HSA 3111 Final Exam Study Guide
Meaningful use
"the use of certified electronic health record by healthcare providers to improve the safety, efficiency, and quality of care. It includes the: Use of certified EHR technology in a meaningful manner (e.g., e-prescribing). Use of certified EHR technology in a manner that provides for electronic exchange of health information to improve the quality of care. Use of certified EHR technology to submit clinical quality measures (CQM) and other measures." (Henricks, 2011)
Value-based contracting models ranked in order by level of risk
1. Capitation 2. Accountable Care Organizations 3. Bundled Payments 4. Shared Savings 5. Pay for Quality & Pay for Performance
Descriptions of the types of value-based contracting
1. Capitation - a way of paying healthcare providers or organizations in which they receive a predictable, upfront, set amount of money to cover the predicted cost of all or some of the healthcare services for a specific patient over a certain period of time 2. Accountable Care Organizations - provider groups that accept payment risk for their attributed populations in return for the opportunity to share savings when costs are reduced below an adjusted benchmark 3. Bundled Payments - Payment rewards the quantity of services offered by providers rather than the quality of care furnished. "Research has shown that bundled payments can align incentives for providers - hospitals, post-acute care providers, physicians, and other practitioners - allowing them to work closely together across all specialties and settings" 4. Shared Savings - Insurers that purchased disease management programs from vendors needed assurance that the programs would reduce medical costs. Lacking convincing randomized studies, vendors and payers contracted around a financial outcome; initially, vendors put a portion of their fees at risk of a favorable financial outcome. Later models allowed vendors to share in actual savings generated (i.e., gain-sharing) to the extent that the vendor reduced costs below a target 5. Pay for Quality & Pay for Performance - In the fee-for-service (FFS) reimbursement model, each time the patient received a service from a physician, hospital, or pharmacist, a bill was generated and then paid by the patient or the payer (or both). As this system began to impose a financial strain on payers, different models evolved, beginning with payment for quality
Affordable Care Act (ACA)
A federal law passed in 2010, which prohibits insurers from denying coverage to individuals with pre-existing conditions, sets minimum standards for health insurance policies, includes an individual mandate for individuals to have a health insurance policy, and expands Medicaid eligibility for many individuals and families.
Encryption
A method of converting an original message of regular text into encoded text. The text is encrypted using an algorithm (a type of formula). If information is encrypted, there is a low probability that anyone other than the receiving party with the key to the code or access could decrypt (translate) the text and convert it into plain, comprehensible text
They types of insurance using the ACO value-based contracting model
ACO arrangements exist among all payers and payer types, including commercial insurers, traditional Medicare, and Medicai
The impact of price competition on a firm's initial incentive to do research and development
Although price competition may be valued from a consumer's point of view, it destroys the initial incentives a firm has to undertake for research and development. Therefore, governments provide patent protection for a period of time to induce firms to make substantial investments in research and development.
Magnet Recognition Program
American Nurses Credentialing Center award that recognizes organizational commitment to nursing excellence. "The Magnet Recognition Program designates organizations worldwide where nursing leaders successfully align their nursing strategic goals to improve the organization's patient outcomes
Details of the medical-loss ratio requirement in the ACA
An ACA provision requires insurers to spend a minimum of 80% (for individuals in the small group markets) and 85% (for those in the large group market) of sales revenue from premiums on medical care for policyholders and quality improvement Refers to the fact that money spent on medical care, rather than administration, represents a 'loss' to insurers. The MLR encourages health insurance companies to "eliminate wasteful administrative spending and increase the value consumers receive for their premium dollars"
The agency responsible for funding the ACA Medicaid expansion
Because the funding for Medicaid expansion was largely the federal government's responsibility, states had the incentive to participate.
DMADV
Define, Measure, Analyze, Design, Verify
DMAIC
Define, Measure, Analyze, Improve, Control
Digital health
Digital health is a broad, overarching term that includes categories such as eHealth, mHealth, HIT, wearable devices, telehealth and telemedicine, and personalized medicine (U.S. Food & Drug Administration, 2020). Digital health technologies use computing platforms, connectivity, software, and sensors for health care and related uses
Home Under Observation
For some, it sounds like a dystopic surveillance society. But for others, there are great opportunities to prevent hospital admissions among the elderly. The technology has huge potential. For example, pneumonia and urinary tract infections in the elderly can be traced in their everyday rhythms
Existing HIPAA compliance with most telehealth video conferencing platforms
Fortunately, most telehealth video conferencing platforms are HIPAA compliant.
How healthcare differs from other industries that rely on labor
Healthcare differs from other industries that rely on labor in that it is more difficult to achieve increased productivity. Effective performance improvement methodologies in healthcare have been slow to adapt. Healthcare providers are increasingly challenged to provide improved patient services at a faster pace
Barriers that prevent or limit access to healthcare services
Lack of health insurance, Limited availability of healthcare resources, Inconvenient or unreliable transportation, economic, social, cultural, and geographic barriers
Outcomes of access to primary care
Offer a usual source of care, early detection and treatment of disease, chronic disease management, and preventive care Patients with a usual source of care are more likely to receive recommended preventive services such as flu shots, blood pressure screenings, and cancer screenings
NAM Domains
Safe: Avoiding harm to patients from the care intended to help them. Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (i.e., avoiding underuse and misuse). Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who provide care. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
Plan-Do-Study-Act (PDSA)
Since quality improvement projects are typically team-based, PDSA places great emphasis on including the right people for success (Langley et al., 2009). Planning can be the most important part of a successful project. Change should be monitored and adjusted as needed. The cycle of PDSA allows for refinement of the change to implementation on a broader scale after successful changes have been identified
Descriptions (and the difference between) telehealth and telemedicine
TH: provides non-clinical services such as provider training and medical education. It also supports the ability to send and receive secure messages and exchange files with a healthcare provider TM: uses telecommunication technologies such as a computer, tablet, or smartphone over the Internet to let a patient talk to their doctor live either by phone or video chat
The impact of the Patient Protection and Affordable Care Act (ACA) on access to care
Technologically, the ACA created an open market and access to it through an online portal, or health exchange, where Americans could purchase insurance The law also extended coverage by allowing those up to the age of 26 to remain on their parent's healthcare plans. In addition, it expanded Medicaid coverage to include those with incomes 133% or less of the national poverty level. It also prevented health insurance companies from kicking people out of their plans for pre-existing conditions. The ACA requires health insurers to sell policies to all those seeking to purchase them (guaranteed issue) at a fixed rate for each age category and tobacco use within a specific family size and regional area (community rating). The most significant of these is the one regarding age, where the legislation required that premiums charged to older adults be no more than three times those of younger adults. In addition, discrimination based on gender or health status (an individual's health history) is prohibited for plans sold on the ACA insurance markets. An annual ceiling of approximately $7,900 for out-of-pocket (OOP) costs (i.e., deductibles, copayments, and coinsurance) for individuals and $15,800 for families was also required by the ACA in 2019. In 2014, minimum standards as to what must be included in all health insurance plans went into effect, addressing the problem of the "underinsured", which are those people with less than adequate coverage
Measures included in the ACA to improve the quality of care
The ACA contains measures to improve the quality of care at both the individual patient level and for the population in general by encouraging primary care, prevention, new models of integrated care, the use of comparative effectiveness information by providers, quality measurement, the reporting of information about quality to consumers, and improved medical care
The ACA roll-out of state health insurance marketplaces and the strategy used when states chose to not participate
The ACA included the mandatory creation of state health insurance marketplaces - online markets where insurers compete to sell state and/or federally compliant policies to individuals and small businesses. If states chose not to implement an ACA marketplace, the federal government was mandated to step in and make a federal ACA marketplace available to the residents of these states. Up to half the states partnered with the federal government to organize and implement an ACA marketplace (Mercer, 2013). States that partnered were permitted to alter these decisions and take over the responsibility at any time.
The impact of the ACA nursing home transparency regulations
The ACA includes nursing home transparency regulations designed to improve protective services for elderly residents through closer oversight, which could result in better quality nursing home care if consumers and their representatives are vigilant and monitor the information available to them. Unfortunately, many health plans do not do a sufficient job of monitoring the quality of the nursing homes in their network (Graham et al., 2018). The ACA gave nursing home patients broader rights to internal and external appeal of decisions by insurers, including coverage denials. In addition, Medicare obtained the right to collect and distribute data about nursing home staffing levels. The success of these measures depends in part on the appropriation of adequate funds; such funds are not assured.
Iron Triangle
The Triple Aim concept was a proposed solution to an existing model first introduced in William Kissick's book, Medicine's Dilemmas: Infinite Needs Versus Finite Resources in 1994. This first model, known as The Iron Triangle (Fig. 4-1), focused on three key aims of healthcare delivery: access, quality, and cost
Triple Aim of Healthcare
The Triple Aim has the following three pillars (Berwick et al., 2008): Improving the patient experience of care Improving the health of populations Reducing the per capita cost of healthcare The Institute for Healthcare Improvement (IHI) intended for this new model to change the dynamics of healthcare from one focused on an individual to one encompassing population and society at large. It also wanted to shift our thinking from a healthcare system utilized to cure each illness that arises for individuals on a case-by-case basis to one that encompasses the maintenance of the health and wellness of populations. This new model would include treating chronic conditions (i.e., those that develop over time and are ongoing) rather than acute conditions (i.e., those that develop suddenly and are limited in duration).
The benefits of EMRs
The accuracy of data used in patient care and treatment is critical as a foundation for better clinical outcomes, accuracy in billing, and timely reimbursements of healthcare services. The EHR design is to provide complete and accurate medical documentation on each patient. This data accessed at the point of care, without the difficulties of reading an illegible paper record, is critical for efficient and effective clinical decision-making. By sharing patient information outside of the healthcare organization or physician practice with other authorized healthcare providers, organizations can reduce the costs of duplicate testing, saving time and money for patients and providers. The coordination of care includes many stakeholders (e.g., care teams, the patient) in the management of the patient's health. Streamlining administrative and business processes helps improve the value of these systems as well as increase patient safety and satisfaction.
Benefits of robotic surgery
The advantage is that robotic surgery can be performed without an incision, and the patient can leave the hospital earlier than with open surgery (UC Health, 2019). At the same time, the robot can see the body in 3-D; it is more flexible and has more precision. The result is less blood loss, fewer infections, less scarring, shorter hospitalization, and less pain
Reasons for renaming the Meaningful Use Incentive Program
The change moved the program's focus beyond the requirements of Meaningful Use to the interoperability of EHRs to improve data collection and submission, and patient access to health information
Health information technology (HIT)
The processing, storage, and exchange of health information in an electronic environment
Unintended consequences of the EMTLA
Treating the uninsured is an inefficient way for a hospital to treat people. One consequence is that the uninsured are incentivized to seek routine care in hospital emergency rooms, even though this is an expensive place to provide care. Suppose hospitals could commit to only serving those with health insurance to ensure they are paid for the delivery of care. In that case, some of the uninsured might be induced to purchase health insurance instead of relying on emergency departments for routine care. However, hospitals cannot make such a commitment, and it would run counter to the Hippocratic Oath.
Relationship between HIPAA and covered entities
Under HIPAA, only a covered entity is required to be HIPAA-compliant and responsible for data breaches.
Lean Six Sigma
Using the two initiatives together has resulted in superior results to what either program could have achieved alone. Lean creates value by minimizing waste, while Six Sigma reduces defects through effective problem-solving. In addition, Lean can accelerate the Six Sigma process, making it more efficient.
machine learning
a branch of artificial intelligence (AI) and computer science which focuses on the use of data and algorithms to imitate the way that humans learn, gradually improving its accuracy
blockchain
a digital ledger of transactions and is likely an important component of the next-generation Internet - the Decentralized Web or Web 3 (Walkweltech, 2019). Simply put, blockchain is a database technology (or digital ledger) that enables the secure storing and sharing of information
Provisions of HIPAA
a federal law requiring the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge sets national standards for protecting the confidentiality, integrity, and availability of electronically protected health information (Privacy Rule) sets national standards for protecting the confidentiality, integrity, and availability of electronically protected health information (Security Rule)
Cloud computing
a layered architecture composed of the hardware, storage infrastructure, platform composed of the software framework, and web service applications
Value stream mapping
a lean tool that employs a flowchart documenting every step in the process. Many Lean practitioners see VSM as a fundamental tool to identify waste, reduce process cycle times, and implement process improvement
artificial intelligence
a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments
Six Sigma
a measurement-based strategy for process improvement and problem reduction applied to improvement projects. The term Six Sigma derives from the Greek letter σ (sigma), used to denote standard deviation from the mean or how far something deviates from perfection. By definition, six sigma is the equivalent of 3.4 defects or errors per million
Robotic surgery
a method of performing surgery using very small tools attached to a robotic arm. The surgeon controls the robotic arm with a computer. Nowadays, robots are used for surgeries such as gastric bypass, uterus, kidney, bladder, prostate, and colon
Accreditation
a review process that determines if an agency meets the defined standards of quality determined by the accrediting body. The quality standards vary depending on the accrediting organization, but they all share common goals to improve efficiency, equity, and delivery of high-quality care. The main accrediting organizations for healthcare are as follows: The Joint Commission National Committee for Quality Assurance American Medical Accreditation Program American Accreditation Healthcare Commission
eHealth
a set of technologies applied with the help of the internet, in which healthcare services are provided to improve quality of life and facilitate healthcare delivery medical informatics
Lean
a tool to reduce waste, including unnecessary work due to errors, poor organization, or communication. The core principle of Lean is to reduce and eliminate non-value-adding activities and waste
EHR
allows access in real-time to patient information to authorized providers since it contains each patient's medical history, diagnoses, medications, immunizations, and allergies
Remote patient monitoring modality
allows direct transmission of a patient's clinical measurements to their healthcare provider from a distance (which may or may not be in real-time)
Robotic process automation (RPA)
also known as software robotics, uses automation technologies to mimic back-office tasks of human workers, such as extracting data, filling in forms, moving files, et cetera
Existing HIPAA compliance with blockchain
blockchain in its current form is not HIPAA compliant. However, it could be developed to accommodate that requirement.
Physical safeguards
define user access, training, disaster planning, backup, facility inventory, safeguards for unauthorized physical access or tampering, and contingency plans
Interoperability
defined as the ability of two or more systems to exchange health information and use the information once it is received
Covered entities
defined in the HIPAA rules as (1) health plans that provide or pay the cost of medical care, (2) health care clearinghouses such as a billing system or health management information system, and (3) health care providers
Administrative safeguards
demonstrate appropriate written policies, procedures, and job descriptions, including sanctions for violations, so staff are aware and can be properly trained
The Internet of Things
describes a system in which everyday objects are connected to the internet and in turn are able to communicate information throughout an interconnected system user or industrial devices that are connected to the internet including sensors, controllers, and household appliances
The purpose of each type of health information technology
eHealth, mHealth, telehealth, and telemedicine are modern HIT-enabled tools aiming to provide better, more efficient, and more effective care services to the patient.
Social determinants of health (SDOH)
economic stability, education, social + community context, health and healthcare, neighborhood and built environment
Market failures in healthcare that require government policy
externalities, commitment, adverse selection and moral hazards, drug quality and doctor quality, patents, market power, & equity and fairness
The most common reimbursement method used in Medicaid
fee-for-service
How to select a change agent for a quality improvement team
he best change agent can be the provider or employee with the strongest opposition. Gaining their trust, respect, and buy-in can be the biggest asset. For example, several senior physicians in a medical practice opposed the rollout of a new EHR system. Getting the strongest opposition on board by explaining that the success of this rollout would weigh heavily on the administrator's job performance was critical.
Technical safeguards
include unique user-identified password policies, user access allowed, automatic log-off, email policies, encryption, and data transmission protocols
Asynchronous modality
includes "store and forward" technology, where messages, images, or data are collected at one point in time and interpreted or responded to later. Patient portals can facilitate this type of communication between provider and patient through secure messaging
Protected health information (PHI)
individually identifiable health information that is transmitted or maintained in any form or medium (electronic, oral, or paper) by a covered entity or its business associates, excluding certain educational and employment records
Population Health Management (PHM)
is the process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models
Healthy People (HP) 2030
lists 355 core objectives ranging from reducing chronic diseases to mitigating the contagious disease that reached a pandemic stage, COVID-19. This expansive document not only provides evidence-supported objectives but also identifies metrics to help track them
mobile health
mHealthis a component of eHealth. The Global Observatory for eHealth defines mHealth as medical and public health practice supported by mobile applications, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices (Martinez-Pérez et al., 2013). Health and fitness apps are generally intended for daily individual use and are related to monitoring or informing about a variety of healthy activities such as calorie counting or exercise
Synchronous modality
real-time telephone or live audio-video interaction, typically with a patient using a smartphone, tablet, or computer
The Internet of Medical Things
refers to the use of mobile computing, medical sensors, and cloud computing to monitor patients' vital signs in real-time and the use of communication technologies to relay data to a Cloud computing framework
Wearables
small devices using computers and other advanced technology designed to be worn in clothing or directly against the body. These devices are usually used for entertainment and other tasks like monitoring physical activity. Wearable technology typically uses low-powered radiofrequency transmitters to send and receive data from smartphones or the Internet. smartwatches
The various ways the government intervenes in healthcare
taxes and subsides, regulation, and provision of insurance and information
Types of emerging health information technology and examples of each
telemedicine, robotic surgery, game technology, the home under observation, wearables, and usability
The difference between the U.S. and other high-income countries in terms of how much is spent on healthcare (% of GDP) and the outcomes
the United States (U.S.) spends more per capita on healthcare than any other comparable high-income country and continues to spend more on healthcare at an unsustainable rate high-quality care is at least in part a luxury good - something that we spend relatively more on as our income increases Differences in both the quality and cost of healthcare mean that, perhaps surprisingly, people travel to other countries to obtain treatments that are unavailable in their home countries aging population, increased cost of medical technology and prescriptions, ACA, social determinants of health affect costs
Game technology
the application of game design elements (conceptual building blocks integral to building successful games) to traditionally nongame contexts
Cybersecurity
the art of protecting networks, devices, and data from unauthorized access or criminal use and the practice of ensuring confidentiality, integrity, and availability of information
Personal health literacy
the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Examples of personal health literacy include understanding prescription drug instructions, understanding doctor's directions and consent forms, and the ability to navigate the complex healthcare system
Organizational health literacy
the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Examples of organizational health literacy include simplifying the process to schedule appointments, using the Teach-Back method to ensure patient comprehension, and providing communications in the appropriate language, reading level and format
Usability
the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use user interface
Population health
the health outcomes of a group of individuals, including the distribution of such outcomes within the group recognizes the range of social, economic, and physical environmental factors that contribute to health
Primary care
the provision of integrated, accessible healthcare services by clinicians accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community
The group of people most impacted by the ACA minimum standards
the uninsured
Access to healthcare
timely use of personal health services to achieve the best possible health outcomes
Value-based reimbursement models
use financial incentives to reward quality healthcare and positive patient outcomes. For example, Medicare no longer reimburses hospitals to treat patients who acquire certain preventable conditions during their hospital stay, such as pressure injuries or urinary tract infections associated with the use of catheters
Medical tourism
when a patient intentionally crosses a border to seek medical care that will typically require out-of-pocket payment for services
