Introduction to Healthcare and Public Health in the US

1. Introduction to Healthcareand Public Health in the US Regulating Healthcare Lecture d This material (Comp1_Unit6d was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

2. Regulating HealthcareLearning Objectives • Describe the role of accreditation, regulatory bodies, and professional associations in healthcare in the US. (Lecture a) •  Describe the basic concepts of law in the United States: the legal system, sources of law, classification of laws, the court system, and the trial process.  (Lecture b) • Describe legal aspects of medicine involving the Affordable Care Act, professional standards in healthcare, medical malpractice, Tort reform, and Medicare and Medicaid Fraud and Abuse (Lecture c) • Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and current issues of privacy and patient safety in the US (Lecture d) • Discuss the need for quality clinical documentation for the use of the health record as a legal document, communication tool and  a key to prove compliance for healthcare organizations. (Lecture e) Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

3. Health Insurance Portability and Accountability Act • Improves “portability” of health insurance • New employer plan may not limit coverage due to pre-existing condition • If health insurance is lost, improves access to group health plan • Protects from discrimination based on health status • Combats fraud, abuse, and waste in healthcare • Promotes use of health savings accounts • Improves access to long-term care • Simplifies the administration of medical insurance Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

4. HIPAA Privacy & Security Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d • Privacy requirements • What health information must be protected • http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html • Security requirements • How to protect the information • http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html

5. HIPAA Covered Entities 6.7 Figure: Flowchart for determining whether an entity is a HIPAA covered health provider or not. (CMS.gov, nd.) Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

6. HIPAA CoveredEntities (cont’d) Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d • Health plans • Insurance companies • Health maintenance organizations (HMOs) • Company insurance plans • Government agencies that pay for healthcare • Health care clearinghouses • Billing services • Repricing companies • Community health management information systems • Value-added networks that perform clearinghouse functions

7. HIPAA Privacy Rule Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d • Applies to protected health information • All individually identifiable health information is protected • Held or transmitted by a covered entity or its business associates • In any form or medium, whether electronic, paper, or oral

8. Individually Identifiable Information Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d • Physical or mental health condition • Provision of healthcare • Payment and • Identifies the individual, or there is a reasonable basis to believe the information can be used to identify the individual

9. Privacy Rule Requirements Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d Notify patients of privacy rights Allow patients to see their medical records Implement privacy procedures Train employees  Designate an individual to be responsible for seeing that privacy procedures are adopted and followed Keep patient records secure

10. HIPAA Security Rule Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d • Requires covered entities to use security measures to protect health information • Does not require use of any specific technology • Establishes minimum standards • If state laws require more rigorous safeguards, the state law must be followed

11. HIPAA Security Rule:General Guidelines Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d Ensure the confidentiality, integrity, and availability of health information Anticipate threats to the security and integrity of the information, and protect against them Protect against reasonably anticipated, impermissible uses or disclosures of health information Ensure compliance by the workforce

12. HIPAA Enforcementand Penalties Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d • Enforced by Office of Civil Rights of the US Department of Health and Human Services Violations can result in civil fines and criminal penalties • $4.3 million civil penalty in 2010 • $1.3 million for failure to give patients access to medical records • $3 million for failure to cooperate with investigation

13. Patient Safety • To Err is Human (Institute of Medicine, 1999) • Reported that: • 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 • Individual errors are not the main problem • Faulty systems, processes, and other conditions lead to preventable errors Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

14. Medical Mistakes Today Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d • Affected 1 in 3 hospital patients in one study • In 2008, harms to patients from medical errors cost $17.1 billion • Errors can result in medical malpractice lawsuits • 42% of doctors are sued at some point • Hospital malpractice suits alone could top $8.6 billion in 2011 • Suffering from medical errors: not measurable

15. The Joint CommissionSafety Initiatives • 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 Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

16. The Joint CommissionSafety Initiatives (cont’d) • 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 Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

17. Agency for HealthcareResearch and Quality (AHRQ) 6.8 Table: The bottom of the AHRQ home page, which can be found at AHRQ dot gov. (AHRQ.gov, nd.) Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture c

18. National Healthcare Quality Report • Effectiveness • Timeliness • Efficiency • Patient safety • Access to care • Patient centeredness • 6.9 Table : Listing the attributes of Quality & Patient Safety. (AHRQ, nd.) Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture c

19. AHRQ: Health IT 6.10 Figure (left). Menu from the AHRQ web page on Health It Technology, Best Practices Transforming Quality, Safety, and Efficiency (AHRQ,gov, ND) 6.11 Figure (right). Menu of articles on background information and the latest evidence on key topics from the field of health IT. (AHRQ.gov, nd.) Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

20. Regulating HealthcareSummary – Lecture d • Patient privacy and safety are high priorities for all people employed in the healthcare industry • HIPAA has rules for the privacy and security of patient health information • The Joint Commission supports initiatives for reducing medical errors • The Agency for Healthcare Research and Quality is an important source of information about how to keep patients safe and maintain the privacy of their health information Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

21. Regulating HealthcareReferences – Lecture d References Agency for Healthcare Research and Quality. 2010 National Healthcare Quality Report. Publication No. 11-0004. February 2011. http://www.ahrq.gov/qual/nhqr10/nhqr10.pdf. Accessed April 13, 2011. Agency for Healthcare Research and Quality. Health information technology [portal]. http://healthit.ahrq.gov/portal/server.pt?open=514&objID=5664&parentname=CommunityPage&parentid=50&mode=2. Accessed April 13, 2011. American Medical Association. Understanding the HIPAA standard transactions: the HIPAA Transactions and Code Set Rule. 2009. http://www.ama-assn.org/resources/doc/psa/hipaa-tcs.pdf. Accessed April 12, 2011. Centers for Medicare and Medicaid Services. Are you a covered entity? http://www.cms.gov/HIPAAGenInfo/06_AreYouaCoveredEntity.asp. Accessed April 13, 2011. Gamble M. Frequency, severity of medical malpractice claims to rise in 2011. Becker’s Hospital Review. October 13, 2010. http://www.beckershospitalreview.com/hospital-financial-and-business-news/frequency-severity-of-medical-malpractice-claims-to-rise-in-2011.html. Accessed April 13, 2011. Institute of Medicine. To Err is Human: Building a Safer Health System. November 1, 1999. http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx. Accessed April 13, 2011. Kane CK. Medical liability claim frequency: a 2007–2008 snapshot of physicians. American Medical Association. 2010. http://www.ama-assn.org/ama1/pub/upload/mm/363/prp-201001-claim-freq.pdf. Accessed April 13, 2011. Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d

22. Regulating HealthcareReferences – Lecture d (continued) References Reinberg S. Hospital errors may be far more common than suspected. HealthDay. April 7, 2011. http://www.usnews.com/mobile/articles_mobile/report-hospital-errors-may-be-far-more-common-than-suspected. Accessed April 13, 2011. The Joint Commission. http://www.jointcommission.org. Accessed April 13, 2011. US Department of Health and Human Resources. HHS imposes a $4.3 million civil money penalty for violations of the HIPAA Privacy Rule. February 22, 2011. http://www.hhs.gov/news/press/2011pres/02/20110222a.html. Accessed April 12, 2011. US Department of Health and Human Resources. Understanding health information privacy. http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html. Accessed April 12, 2011. Charts, Tables, Figures 6.7 Figure: Adapted from http://www.cms.gov/HIPAAGenInfo/Downloads/CoveredEntitycharts.pdf. CMS (nd.) Acquired from http://www.cms.gov. Last accessed Jan. 2012. 6.8 Table: The bottom of the AHRQ home page, which can be found at http://www.ahrq.gov/ AHRQ (nd.). Last accessed Jan. 2012. 6.9 Table: Listing the attributes of Quality & Patient Safety. AHRQ.gov (nd.). From the bottom of the AHRQ home page, which can be found at http://www.ahrq.gov/. Last accessed Jan. 2012. 6.10 Figure (left): AHRQ.gov (nd.) http://healthit.ahrq.gov/portal/server.pt?open=514&objID=5664&parentname=CommunityPage&parentid=50&mode=2. From the AHRQ website, http://www.ahrq.gov/ . Last accessed Jan. 2012. 6.11 Figure (right). Menu of articles on background information and the latest evidence on key topics from the field of health IT. http://healthit.ahrq.gov/portal/server.pt/community/knowledge_library/653/key_topics/5664. From the AHRQ website, http://www.ahrq.gov/ . Last accessed Jan. 2012. Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture d