Health Information Management Technology PDF

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 2: Healthcare Delivery Systems ahima.org ahima.org © 2020 AHIMA United States Healthcare System Covers a wide range of services Preventive care: immunizations Complex procedures: heart transplants Individual contact...

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 2: Healthcare Delivery Systems ahima.org ahima.org © 2020 AHIMA United States Healthcare System Covers a wide range of services Preventive care: immunizations Complex procedures: heart transplants Individual contact with the healthcare system Begins at birth; continues through death Employs an estimated 16 million workers ahima.org © 2020 AHIMA Medical Practice “Doctor” refers to a graduate degree Examples of doctors who are practitioners: Chiropractor (DC) Dentist (DDS or DMD) Medical (MD)—most prevalent in US Optometry (OD) Osteopath (DO) Podiatrist (DPM) ahima.org © 2020 AHIMA Medical Practice Sample medical specialties o Internal medicine o Pediatrics o Family practice o Cardiology Sample surgical specialties o Anesthesiology o Orthopedics o Cardiovascular surgery ahima.org © 2020 AHIMA Nursing Practice Licensed practical nurses (LPN) Registered nurses (RN) o Associate degree o Bachelor degree Nurse practitioner o RN plus postgraduate education ahima.org © 2020 AHIMA Nursing Practice Nursing specialization o Surgery o Psychiatry o Intensive care o Nurse-midwives ahima.org © 2020 AHIMA Allied Health Professions Support physicians, nurses, and physician assistants Receive certificate or higher in healthcare-related science All 50 states require licensure for some allied health professions Significant shortages in many allied health professions are expected to reach up to 2.5 million by 2020 ahima.org © 2020 AHIMA Examples of Allied Health Professions Clinical laboratory science Diagnostic imaging technology Dietetics Emergency medical technology Health information management Occupational therapy Physical therapy Respiratory therapy Speech-language pathology and audiology ahima.org © 2020 AHIMA Health Occupations ahima.org © 2020 AHIMA Organization and Operation of Modern Hospitals Integrated delivery system (IDS) Second curve of healthcare Continuum of care Integrated delivery network (IDN) Health expenditures Approximately $3.5 trillion 17.9 % of the total American economy ahima.org © 2020 AHIMA Organization and Operation of Modern Hospitals Hospital o Has organized medical staff o Provides permanent medical staff o Offers around-the-clock nursing service o Provides diagnostic and therapeutic services Acute care o Short-term care provided to diagnose or treat illness or injury ahima.org © 2020 AHIMA Organization and Operation of Modern Hospitals Hospital Has an organized medical staff Provides permanent inpatient beds Offers around-the clock nursing services Provides diagnostic and therapeutic services Acute-care hospital Average length of stay is 25 days or less Includes long term acute care hospitals Inpatient and outpatient care ahima.org © 2020 AHIMA Hospital Classification Number of beds o Bed capacity (licensed or staffed) o Adult and pediatric Types of services provided o Rehabilitation o Psychiatric o General o Specialty ahima.org © 2020 AHIMA Hospital Classification Types of patients served For-profit or not-for-profit status Type of ownership o Government-owned o Proprietary o Voluntary ahima.org © 2020 AHIMA Hospital Classification Safety net hospital Highest number of inpatient stays that were paid by Medicaid or uninsured More likely to be a teaching hospital Large number of inpatient beds 27% located in large metropolitan areas ahima.org © 2020 AHIMA Hospital Classification Critical access hospital Part of Balanced Budget Act of 1997 If specific criteria are met, CAH are allowed a separate payment system not subject to IPPS or OPPS, and pays 101% of reasonable costs Criteria to qualify: Located in a state that accepted a grant under the Medicare Rural Hospital Flexibility Program Located in a rural area Furnish 24-hour emergency care services Maintain no more than 25 inpatient beds Have an ALOS of 96 hours or less per patient Be located more than 35-miles from any other hospital Be certified as a CAH prior to January 1, 2006 ahima.org © 2020 AHIMA Organization of Hospital Services Board of directors Professional medical staff Executive administrative staff Medical and surgical services Patient care (nursing) services Diagnostic services Rehabilitation services Support services ahima.org © 2020 AHIMA Organization of Hospital Services Board of Directors or Trustees Chief of Medical Staff Medical Staff Chief Executive Officer Chief Finanical Officer © 2020 AHIMA Chief Nursing Officer Chief Operating Officer Business Office Health Information Management Nursing Units Plant Operations Revenue Cycle Management Information Systems Labor & Delivery Human Resources Materials Patient Registration Ambulatory Surgery Environmental Services Management ahima.org Chief Information Officer Board of Directors Primary responsibility for setting direction of hospital o Strategic direction o Mission o Values o Establish bylaws based on legal and licensing requirements o Select qualified administrator o Approve organization and makeup of clinical staff o Monitoring quality of care ahima.org © 2020 AHIMA Medical Staff (Physicians) Diagnose and treat patients Clinical privileges Medical staff classification Officers Medical staff bylaws ahima.org © 2020 AHIMA Administrative Staff Chief executive officer (CEO) Chief nursing officer (CNO) Chief operating officer (COO) Chief information officer (CIO) Chief financial officer (CFO) ahima.org © 2020 AHIMA Organization of Hospital Services ahima.org © 2020 AHIMA Patient Care Services Most care provided by nurses Nursing services Case management Patient assessments Care plans Evaluate appropriate of treatment Evaluate effectiveness of care Chief nursing officer (CNO) ahima.org © 2020 AHIMA Diagnostic Services Allied health professionals Clinical laboratory services Radiology Nuclear medicine and radiation therapy ahima.org © 2020 AHIMA Rehabilitation Services Dedicated to eliminate a patient’s disability as fully as possible. Include: Physicians Nurses Occupational therapists Physical therapists Respiratory therapists Speech therapists ahima.org © 2020 AHIMA Ancillary Support Services Pharmaceutical services Food and nutrition services Health information management Social work and social services Patient advocacy services Environmental services Purchasing, central supply, and materials management Engineering and plan operations ahima.org © 2020 AHIMA Administrative Support Services Admissions and central registration Claims and billing Accounting Information services Human resources Public relations Fund development Marketing ahima.org © 2020 AHIMA Managed Care A generic term for a healthcare reimbursement system that manages cost, quality, and access to services Types Health maintenance organizations Preferred provider organization Point-of-service plans Control costs, access, and promote high quality Negotiate fees and control access Premium ahima.org © 2020 AHIMA Accountable Care Organizations Partnership between hospitals and physicians Three models Medicare Shared Savings program that gives Medicare fee-for-service providers an opportunity to become an ACO Advance Payment ACO model designed as a supplementary incentive program for selected participants Pioneer ACO model created for early adopters of coordinate care, though CMS is no longer accepting applications for this model ahima.org © 2020 AHIMA Other Types of Healthcare Services Private Medical practices Primary care Medical or surgical specialty care Freestanding office setting Medical home Model of primary care Patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety ahima.org © 2020 AHIMA Other Types of Healthcare Services Hospital-based ambulatory care services Emergency services and trauma care Outpatient surgical services Outpatient diagnostic and therapeutic services Community-based ambulatory care services o Freestanding ambulatory care centers o Freestanding ambulatory surgery centers ahima.org © 2020 AHIMA Other Types of Healthcare Services Public health services HHS is the principal federal agency that ensures health and provides essential human services Two units in the office of the secretary of HHS are important to public health Office of the Surgeon General of the United States Office of Disease Prevention and Health Promotion (ODPHP) ahima.org © 2020 AHIMA Other Types of Healthcare Services Home care services Fastest-growing sector to offer services for Medicare recipients Voluntary agencies Provide healthcare and healthcare planning services, usually at the local level and to low-income patients Example: Community health center Subacute care Offers patients access to constant nursing care while recovering at home ahima.org © 2020 AHIMA Long-Term Care Care rendered in nonacute-care facility to patients needing inpatient nursing and related services for more than 30 consecutive days Types of long-term care o Skilled nursing facilities o Nursing homes o Rehabilitation hospitals Mainly rehabilitative and supportive—not curative ahima.org © 2020 AHIMA Long-Term Care in the Continuum of Care People are living longer Baby boomers Typical continuum of care o Primary care provider in hospital o Home care o Skilled nursing facility ahima.org © 2020 AHIMA Delivery of Long-Term Care Services Skilled nursing facilities and nursing homes Residential care facilities Hospice programs Provided to patients with terminal illness with a limited life expectancy of six months or less Palliative care Adult daycare programs ahima.org © 2020 AHIMA Behavioral Health Services Traditional long-stay state institutions were used Current programs o Long-stay state institutions o Residential treatment centers Inpatient services to children until 18 o Day-hospital Alternative to inpatient care Transition from inpatient to outpatient ahima.org © 2020 AHIMA Behavioral Health Services Insurance coverage lagged behind other care o Non-parity o Usually many restrictions such as number of outpatient visits ahima.org © 2020 AHIMA Biomedical and Technological Advances in Medicine National Institutes of Health created a “roadmap” program to: o Accelerate biomedical advances o Create effective prevention strategies and new treatments o Bridge knowledge gaps ahima.org © 2020 AHIMA Biomedical and Technological Advances in Medicine Telehealth Use of electronic information and telecommunications technologies to support and promote long-distance clinical health care Electronic health records & health data Tremendous impact on the delivery of health care Big data: large amounts of data collected from sources that are then processed and used for analytics Data utilized to develop new treatments for common health problems Increased need for security and data protection ahima.org © 2020 AHIMA Healthy People 2020 Formerly Institute of Medicine (IOM) “A society in which all people live long, healthy lives.” Goals: Attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death Achieve health equity, eliminate disparities, and improve the health of all groups Create social and physical environments that promote good health for all Promote quality of life, healthy development, and heathy behaviors across all life stages Social determinants of health Conditions in the environments and age that impact a wide range of health, functioning, and quality-of-life outcomes and risks ahima.org © 2020 AHIMA National Academy of Medicine Reports Formerly Institute of Medicine (IOM) To Err is Human Crossing the Quality Chasm Envisioning a National Health Care Quality Report Leadership by Example Priority Areas for National Action Health IT and Patient Safety ahima.org © 2020 AHIMA Centers for Disease Control and Prevention The leading federal agency charged with: Protecting the public health and safety through the control and prevention of disease, injury, and disability. ahima.org © 2020 AHIMA Local, State, and Federal Policies Local Community medical and mental health services State How to allocate state dollars for multiple healthcare services Federal 6 agencies provide healthcare for over 100 million Americans Medicare, Medicaid, SCHIP, VHA, TRICARE, IHS ahima.org © 2020 AHIMA Patient-Centered Outcomes Research Institute Created from PPACA Mandated to improve the quality and applicability of evidence available to help all stakeholders to make knowledgeable healthcare choices. Uses Comparative Effectiveness Research (CER) ahima.org © 2020 AHIMA Social Security Act of 1935 “Old-age and unemployment programs” ahima.org © 2020 AHIMA Public Law 89-97 of 1965 Amendment to Social Security Act Medicare originally designed for people 65 years of age and older Medicare expanded to include: Those willing to pay premium Disabled Those with chronic kidney disease Medicaid originally designed for the indigent ahima.org © 2020 AHIMA Public Law 89-97 of 1965 Medicaid expanded to include: o Poor children o Disabled o Pregnant women o Very poor adults Medicaid joint program with state and federal governments ahima.org © 2020 AHIMA Medicaid Provides Inpatient and outpatient services Laboratory and x-ray services Physician services Nursing facility care for those over 21 years of age Family planning 31 optional programs ahima.org © 2020 AHIMA Public Law 92-603 of 1972 Mandated utilization review for Medicare patients at: o Hospitals o Extended care facilities Now includes Medicaid Established professional standards review organizations (PSRO) o Perform professional review o Evaluate patient care for necessity, quality and costeffectiveness ahima.org © 2020 AHIMA Utilization Review Act of 1977 Mandated continued stay reviews for Medicare and Medicaid patients Reviews determine whether it is medically necessary for a patient to remain hospitalized ahima.org © 2020 AHIMA Peer Review Improvement Act of 1982 PSRO changed to Peer Review Organizations Looked at medical necessity and appropriateness of certain admissions prior to admission Name changed to Quality Improvement Organizations (QIOs) ahima.org © 2020 AHIMA Tax Equity and Fiscal Responsibility Act of 1982 Called for gradual implementation of prospective payment system for Medicare reimbursement Prospective payment system A predetermined level of reimbursement is established before the service is provided ahima.org © 2020 AHIMA Prospective Payment Act (1982)/Public Law 9821 of 1983 Created diagnostic related groups (DRG) for inpatient hospital care Each case is assigned to a DRG based on the patient’s diagnosis at the time of discharge ahima.org © 2020 AHIMA Health Insurance Portability and Accountability Act of 1996 Portability of health insurance after leaving employment National standards for electronic transactions National identifiers for providers, health plans, and employers Privacy Security Healthcare Integrity and Protection Database ahima.org © 2020 AHIMA American Recovery and Reinvestment Act of 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act Nationwide health information exchange Use of health information Implementation of electronic health records Government involvement in standard development for exchange of health information Strengthened privacy and security standards Made Office of the National Coordinator for Health information Technology a permanent office ahima.org © 2020 AHIMA Patient Protection and Affordable Care Act of 2010 Also known as “Obamacare” Provisions include: Medicaid expansion Creation of health insurance exchanges Regulations to prevent health insurers from denying coverage Requirement for health insurance with tax penalties for those without insurance Penalties to employers that do not offer affordable coverage; excludes small employers ahima.org © 2020 AHIMA