Chapter 1 – Comparative Health Information Management

a voluntary process in which facilities agree to follow a set of standards and receive recognition for having met those standards
administrative simplification
provisions of Health Insurance Portability and Accountability Act (HIPAA) that addressed standardization of electronic data interchange, privacy of health information, and security of health data
American College of Surgeons (ACS)
a professional organization founded in 1913 to “improve the quality of care for the surgical patient by setting high standards for surgical education and practice” (ACS, 2003, p.1); in the early twentieth century, the ACS established a hospital standardization program that was the forerunner of today’s accreditation organizations
American Recovery and Reinvestment Act (ARRA)
Also known as the “Stimulus Act” or the “Recovery Act”, ARRA was enacted in 2009; its main purpose was to create jobs and stimulate economic growth; however, it contains many provisions for health care, including billions of dollars for health information technology; Title XIII of ARRA is Health Information Technology for Economic and Clinical Health (HITECH) that addresses many of the health information and technology requirements, including privacy
business associate (BA)
partner or contractor performing a job or service on behalf of a covered entity; the original HIPAA legislation required covered entities to have a business associate
a method of payment for health care in which the health care provider receives a monthly payment based on the number of persons the provider has agreed to treat, regardless of the number of persons actually treated or the amount of service rendered
Centers for Medicare & Medicaid Services
a federal agency within the Department of Health and Human Services; its main focus is to administer the Medicare and Medicaid programs
Children’s Health Insurance Program (CHIP)
allows states to offer health insurance plans for children, up to age 19, who are not already insured; CHIP affords families who earn too much to qualify for Medicaid an opportunity to obtain health insurance for their children
clinical documentation improvement (CDI) program
a locally implemented program focused upon improving the quality of clinical documentation to “facilitate an accurate representation of health care services through complete and accurate reporting of diagnosis and procedures”; accurate clinical documentation can positively affect reimbursement, severity of illness and mortality risk assessment, and reporting of quality an pay-for-performance measures
covered entity (CE)
under HIPAA, a health plan, a health care clearinghouse, or any health care provider that transmits health information in electronic form
deemed status
the status of a health care provider that is deemed to meet federal Conditions of Participation by virtue of accreditation by a federally approved voluntary accrediting organization; with deemed status, the health care provider’s accreditation satisfies the Conditions of Participation, routine surveys by the state agency are unnecessary
electronic health record (EHR)
a system in which a health care provider maintains individual patient health records electronically; fully developed EHRs include capabilities such as generating clinical alerts and reminders and providing readily available decision support
a method of payment for health care in which the health care provider charges and is paid for each item of service provided
Flexner Report
a report published in 1910, examining the state of medical education in the US and Canada; the Flexnor Report resulted in sweeping changes in the way North American physicians were educated
health information exchange (HIE)
a process defined as “the electronic movement of health-related information among organizations according to nationally recognized standards (contrast with HIE organization)
health information technology (HIT)
electronic health records and related information systems to manage health care processes; the major focus of the HITECH Act of 2009 is to promote adoption of HIT in an effort to improve the quality, efficiency, and safety of health care delivery while reducing costs and minimizing medical errors
Health Information Technology for Economic and Clinical Health (HITECH)
The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology; amends HIPAA privacy and security rules by introducing additional privacy regulations, breach notification rules, and stiffer civil and criminal penalties for security violations
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
provisions include the portability of health care benefits, prevention of fraud and abuse in health care, and simplification of the electronic interchange of health care data, while improving the privacy and security of health information
health record banking
a concept analogous to online financial banking, where the patient controls access to the health record “account”; deposits and withdrawals may be made by authorized individuals; an alternative to a personal health record (PHR), while achieving similar goals
HIE organization
an entity that “oversees and governs the exchange of health-related information among organizations according to nationally recognized standards”; often used synonymously with regional health information organization (RHIO), which focuses more on HIE within a specific region; contrast with health information exchange, which is a process rather than an entity
Hill-Burton Act
the “Hospital Survey and Construction Act” enacted by Congress in 1946; this legislation provided federal money to determine the need for more hospitals and to pay for their construction
Hospital Inpatient Quality Reporting (IQR)
a national quality initiative implemented by CMS; IQR requires hospitals to submit data for certain quality measures, which are made pubicly available to consumers via the Hospital Compare Web site; while program participation is voluntary, hospitals that do not participate receive a reduced Medicare Annual Payment Update
Hospital Outpatient Quality Data Reporting Program (HQP QDRP)
a national quality program implemented by CMS that is modeled after the hospital IQR initiative; hospitals must report data for standardized quality measures for outpatient hospital services, which are made publically available to consumers via the Hospital Compare Web site; participation is required in order to receive the full annual update to the Outpatient Prospective Payment System (OPPS) payment rate
United States’ clinical modification of the World Health Organization’s diagnostic disease classification (International Classification of Diseases, 10th Revision, Clinical Modification); effective 10/1/13, ICD-10-CM is the diagnosis code set required by HIPAA
United States’ procedural coding system for inpatient, acute care settings (International classification of Diseases, 10th Revision, Procedural Coding System); effective 10/1/13
Institute of Medicine (IM)
health division of the National Academy of Sciences; it is an independent, nonprofit organization that serves as a national adviser on matters related to health improvement
a governmental process in which a facility must meet certain regulations, set by the state, in order to provide care
longitudinal patient record
a record documenting a patient’s health status, conditions, and treatments throughout their life and across multiple facilities, providers, and health care encounters
meaningful use
a concept called for by ARRA; in order for health care providers to become eligible for reimbursement incentives and eventually avoid financial penalties through Medicare and Medicaid, they must demonstrate meaningful use of certified electronic health record (EHR) technology; on 1/13/10, an interim final rule was published that specified an initial set of standards, implementation specifications, and certification criteria for EHR technology; concept refers to a set of criteria and measures, rather than a single definition, and is being implemented in three phases through a series of published rules
Title XIX of the 1965 Amendments to the Social Security Act, Medicaid is jointly funded by federal and state governments and provides medical assistance to lower-income individuals and families
Medicaid Integrity Program (MIP)
a national strategy created as a result of the Deficit Reduction Act of 2005 to detect and prevent Medicaid fraud, waste, and abuse; it uses contracted reviewers to audit the accuracy of Medicaid payments made to health care providers
Title XVIII of the 1965 Amendments to the Social security Act, Medicare provides health benefits for Social Security recipients and other qualified individuals
Medicare certification
process in which a state agency determines that a health care organization meets the standards set forth in the relevant Conditions of Participation or Conditions of Coverage and is therefore eligible for participation in the Medicare program
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
made significant revisions to the Medicare program by calling for the creation of Part D, e-prescribing for prescription drug plans, revision of claims processing, and a Medicare payment recovery demonstration project that ultimately resulted int eh Recovery Audit Contractor (RAC) initiative
National Patient Safety Goals (NPSG)
program created by the Joint Commission in 2002 to help accredited health care institutions focus upon specific patient safety concerns; in an effort to focus on the most critical patient safety issues, NPSGs are updated annually based upon review of literature and available databases
National Quality Forum (NQF)
a private, nonprofit, membership organizational focused upon improving the quality of care through national goal setting, development and endorsement of performance measurement standards, and educational initiatives; NQF collaborated with CMS to develop measures for the Physician Quality Reporting Initiative (PQRI); through a contact with the US Department of Health and Human Services, NQF continues to provide support for improved quality of health care services
Nationwide Health Information Network (NHIN)
“a set of standards, services and policies that enable secure health information exchange over the Internet; the NHIN will provide a foundation for the exchange of health IT across diverse entities, within communities and across the country, helping to achieve the goals of the HITECH Act; this critical part of the national health IT agenda will enable health information to follow the consumer, be available for clinical decision making, and support appropriate sue of health care information beyond direct patient care so as to improve population health”
Office of the National Coordinator for Health Information Technology (ONC)
“the principal Federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information; the position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009”
patient-centered medical home model
a care model in which the primary care physician act as a “gatekeeper” to coordinate the patient’s care across providers; it addresses preventative, acute, and chronic care needs and also provides patients with access to electronic tools such as provider-patient e-mail, online appointment scheduling applications, and electronic health record data; the Patient Protection and Affordable Care Act (PPACA or Health Reform) calls for use of the medical home model to improve health outcomes
Patient Protection and Affordable Care Act (PPACA or Health Reform)
a federal statute that contains a number of health care provisions, most notably an expansion of Medicaid eligibility requirements; Health Reform Act also increases quality reporting requirements for health care providers
patient safety organizations (PSOs)
“organization that can work with clinicians and health care organizations to identify, analyze, and reduce the risks and hazards associated with patient care”; Patient Safety and Quality Improvement Act of 2005 called for development of PSOs to help determine the root causes, risks, and harms of health care safety issues
pay-for-performance (P4P)
emerging inventive-based reimbursement programs that reward or penalize providers based upon their ability to meed preestablished quality and performance targets for delivery of health care services
per diem
per day; a per diem payment is a payment rendered to an institution based on the number of days of service provided
personal health record (PHR)
“an Internet-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it”
Physician Quality Reporting Initiative (PQRI)
voluntary, incentive-based quality reporting system for eligible professionals who report data on quality measures for covered professional services provided to Medicare beneficiaries; it was established as a requirement by the 2006 Tax Relief and Health Care Act (TRHCA) and is implemented yearly by CMS through an annual rule-making process; therefore, program requirements and measures may vary from year to year
prospective payment system (PPS)
a payment system in which payment levels for health care services are determined before the services are rendered; in a prospective payment system, the unit of payment is not based solely on the individual services provided, but on the payment units that represent general groupings of patient encounters, hospital stays, or episodes of care
protected health information (PHI)
individually identifiable health information
quality improvement organization (QIO)
“private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints about he quality of care and to implement improvements in the quality of care available throughout the spectrum of care; QIO contracts are 3 years in length”
Recovery Audit Contractor (RAC)
a 3rd-party entity working under the direction of CMS to detect improper Medicare payments through review of providers’ medical records an Medicare claims data
Regional Extension Center (RECs)
nonprofit organizations called for by ARRA and initially funded by federal grants to provide health information technology support to providers; RECs offer technical assistance, guidance, and support to help providers become meaningful uses of certified electronic health record technology; an additional goal for the REC program is to create HIT jobs
regional health information organization (RHIO)
“health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community”; often uses synonymously with HIE organization, which is a broader term that encompasses the use of nationally recognized standards and is not limited by geographic boundaries
state agency
the agency of the state government responsible for administering the federal requirements for participation in Medicare and Medicaid programs; the state agency is ordinarily also charged with administering applicable licensure requirements for the state
“such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit patient data for monitoring and interpretation”
the practice of medicine in which electronic signals are utilized to transmit clinical information from one site to another; generally, the patient is in a remote location from the physician, and medical information, which may include images and video, is transmitted back and forth between with 2 locations electronically
the use of robotic technology to assist with or perform procedures remotely
Zone Program Integrity Contractor (ZPIC) program
program implemented by CMS to identify and investigate malicious fraudulent claims activity within Medicare’s 7 geographic regions (zones)
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