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Transcript of 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