Chapter 1 Health Care Information Systems: A Practical Approach for Health Care Management 2nd...

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Introduction to Health Care Information

Chapter 1

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Learning ObjectivesTo be able to compare and contrast the various

definitions of health care information.To be able to describe the major types of health

care information (internal and external) that are captured or used, or both, in health care organizations.

To be able to cite specific examples of the major types of health care information.

To be able to understand the content and uses of patient records.

To be able to follow a patient’s or client’s health information throughout a typical encounter or process.

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

OutlineTypes of Health Care InformationPatient Encounter DataPatient Specific Information

Clinical Administrative Combined

Aggregate Information Clinical Administrative Combined

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Outline (cont.)Comparative InformationExpert of Knowledge-based Information

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Types of Health Care Information

Definitions vary HIPAA National Alliance for Health

Information Technology Joint Commission

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Types of Health Care Information

Framework Internal Data/Information Patient Encounter

Patient specific Aggregate Comparative

General Operations

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Types of Health Care Information

Framework External Data and Information Comparative Expert/Knowledge-based

Patient Encounter DataPrimary PurposeType

Clinical Administrative

Patient-Specific

Those items generally included as a part of the patient medical record are in italics

Identification SheetProblem ListMedication RecordHistoryPhysicalProgress NotesConsultationsPhysicians’ OrdersImaging and X-ray resultsLab resultsImmunization RecordOperative ReportPathology ReportDischarge SummaryDiagnoses CodesProcedure Codes

Identification SheetConsentsAuthorizationsPre-authorization SchedulingAdmission/RegistrationInsurance EligibilityBillingDiagnoses CodesProcedure Codes

Aggregate Disease IndexesSpecialized RegistersOutcomes DataStatistical ReportsTrend AnalysisAd hoc Reports

Cost ReportsClaims Denial AnalysisStaffing AnalysisReferral AnalysisStatistical ReportsTrend AnalysisAd hoc Reports

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific—Clinical

Purpose of Patient Records Patient care Communication Legal documentation Billing and Reimbursement Research and Quality Management

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific—Clinical

Content of Patient Records (myPHR, 2008)

Identification Sheet Problem List Medication Record History and Physical Progress Notes Consultation

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific--Clinical

Content of Patient Records (myPHR, 2008)

Imaging and X-ray reports Laboratory reports Consent and authorization forms Operative Reports Pathology Reports Discharge Summary Other

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific—Clinical

Overview of Inpatient Encounter

Scheduling Preadmission Admission/Registration Treatment Medical Nursing Ancillary

Discharge

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Inpatient Encounter

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific—Clinical

Physician’s Office Patient Flow Check In Move to Exam Room Examination Check Out Later activities

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Office Visit Encounter

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific—Administrative

Data Needed for Reimbursement

UB 04 CMS 1500

Other Uniform Data Sets ACDS UHDDS MDS

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Uniform Hospital Discharge Data Set Elements Journal of AHIMA 72, no.10 (2001).

UHDDS elements as adopted in 1986 are:

1.    Personal identification2.    Sex3.    Race4.    Ethnicity5.    Residence6.    Hospital identification7-8.  Admission and discharge dates9-10.  Attending physician and operating

physician11.    Diagnoses: Principal diagnosis &

Other diagnoses 12.    Procedure and date13.    Disposition of patient14.    Expected payer

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific—Combined

Coding Systems ICD-9-CM National Center for Health Statistics Inpatient and Outpatient Diagnoses Inpatient Procedures

CPT American Medical Association Outpatient Procedures

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient Specific—Combined

Coding Standards Compliance Issues Fraud & Abuse Issues

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Aggregate—ClinicalDisease and Procedure IndexesSpecialized Registers

Emergency Room Operating Room Trauma Tumor Other

Ad hoc Reports

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Sample Diabetes Query

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Aggregate—Administrative

Limitless Ad hoc ReportsSpecific Examples

Medicare Cost Reports Health Care Statistics Census Discharge

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Aggregate—CombinedAd hoc Reports

Trend analysis Statistical reports Quality improvement

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

ComparativeOutcome Measures

Benchmarking Balanced Scorecards Clinical Value Compass

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Sources for Comparative Data

Kelly, 2007

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Expert of Knowledge-based

Clinical, scientific and management print literature

On-line resources

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

SummaryTypes of Health Care InformationInternal

Patient Specific Information Clinical Administrative Combined

Aggregate Information Clinical Administrative Combined

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Summary (cont.)External

Comparative Information Expert of Knowledge-based

Information