Introduction to Health Care Information

1. Introduction to Health Care Information Chapter 1 Managing Health Care Information Systems

2. Outline Types of Health Care Information • Patient Encounter Data • Patient Specific Information • Clinical • Administrative • Combined • Aggregate Information • Clinical • Administrative • Combined • Comparative Information • Expert Knowledge based Information

3. Types of Health Care Information • Definitions vary • HIPAA defines health information as verbal or written information created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse that relates to the physical or mental health of an individual, or payment for provision of health care. HIPAA specifically refers to this type of information as protected health information, or PHI. • JCAHO urges health care leaders to take “responsibility for managing information, just as they do for ... human, material, and financial resources.”

4. Types of Health Care Information • Framework • Internal Data/Information • Patient Encounter • Patient specific • Aggregate • Comparative • General Operations • External Data/Information • Comparative • Expert/Knowledge-based

5. Patient Encounter Data

6. Patient Specific—Clinical • Purpose of Patient Records • Patient care • Communication • Legal documentation • Billing and Reimbursement • Research and Quality Management

7. Patient Specific—Clinical • Content of Patient Records • Identification Sheet • Problem List • Medication Record • History and Physical • Progress Notes • Consultation

8. Patient Specific--Clinical • Content of Patient Records • Imaging and X-ray reports • Laboratory reports • Consent and authorization forms • Operative Reports • Pathology Reports • Discharge Summary • Other

9. Patient Specific—Clinical • Overview of Inpatient Encounter • Scheduling • Preadmission • Admission/Registration • Treatment • Medical • Nursing • Ancillary • Discharge

11. Patient Specific—Clinical • Physician’s Office Patient Flow • Check In • Move to Exam Room • Examination • Check Out • Later activities

13. Patient Specific—Administrative • Data Needed for Reimbursement • UB 92 • CMS 1500 • Other Uniform Data Sets • ACDS • UHDDS

14. Uniform Hospital Discharge Data Set Elements Journal of AHIMA 72, no.10 (2001). • UHDDS elements as adopted in 1986 are: 1.    Personal identification 2.    Sex 3.    Race 4.    Ethnicity 5.    Residence 6.    Hospital identification 7-8.  Admission and discharge dates 9-10.  Attending physician and operating physician 11.    Diagnoses: Principal diagnosis & Other diagnoses 12.    Procedure and date 13.    Disposition of patient 14.   Expected payer

15. 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

16. Patient Specific—Combined • Coding Standards • Compliance Issues • Fraud & Abuse Issues

17. Aggregate—Clinical • Disease and Procedure Indexes • Specialized Registers • Emergency Room • Operating Room • Trauma • Tumor • Other • Ad hoc Reports

18. Aggregate—Administrative • Limitless Ad hoc Reports • Specific Examples • Medicare Cost Reports • Health Care Statistics • Census • Discharge

19. Aggregate—Combined • Ad hoc Reports • Trend analysis • Statistical reports • Quality improvement

20. Comparative • Outcome Measures • Benchmarking • Balanced Scorecards • Clinical Value Compass

21. Sources for Comparative DataKelly, 2003

22. Comparative • Health Care Data Sets • HEDIS • NCQA • ORYNX • JCAHO • CMS • Leapfrog Group

23. Expert of Knowledge-based • Clinical, scientific and management print literature • On-line resources

24. Summary • Types of Health Care Information • Internal • Patient Specific Information • Clinical • Administrative • Combined • Aggregate Information • Clinical • Administrative • Combined

25. Summary (cont.) • External • Comparative Information • Expert of Knowledge-based Information