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Health Information Chapter 12

Healthcare Delivery Systems
Integrated delivery system (IDS):
A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care; See integrated provider organization (IPO)
Integrated provider organization (IPO):
An organization that manages the delivery of healthcare services provided by hospitals, physicians (employees of the IPO), and other health care organizations (for example, nursing facilities); See integrated delivery system
What do integrated delivery systems offer?
•Full range of healthcare services along a continuum of care to ensure that patients get the right care at the right time from the right provider
•The continuum extends from primary care providers to specialist and ancillary providers
What is the goal of IDSs?
To deliver high-quality, cost-effective care in the most appropriate settings
Continuum of care
The range of healthcare services provided to patients, from routine ambulatory care to intensive acute care
How are most hospitals integrated into their communities?
•Through ties with physicians and other healthcare providers
•Ties with clinics and outpatient facilities and other practitioners
•Almost half the nation's hospitals also are tied to larger orginizational entities such as multihospital and integrated healthcare systems (IHCSs), IDNs, and alliances
What is an IDN?
An IDN comprises a group of hospitals, physicians, other providers, insurers, and/or community agencies that work together to deliver health services.
Integrated Delivery Network (IDN)
See integrated delivery system
A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care; See integrated provider organization
In 2008, what was the total percentage of community hospitals were in IDNs? What do multihospital systems include?
•In 2008, 1,490 community hospitals (29 percent of the total) were in IDNs (AHA 2009).
•Multihospital systems include two or more hospitals owned, leased, sponsored, or contract managed by a central organization.
What percentage of hospitals were in systems in 1985, and what was the change from that time to 2008?
•In 1985, 27.5 percent of hospitals were system members, which rose to 57 percent by 2008 (AHA 2009)
What is an alliance? How many hospitals were in group-purchasing orgs by 2000?
An alliance is defined as a formal organization, usually owned by shareholders/members, that works on behalf of its individual members in the provision of services and products and in the promotion of activities and ventures (AHA 1999)
•In 2000, 3,344 hospitals were in group-purchasing organizations (the dominant kind of alliance)
•The same hospitals can be registered in more than one category (AHA 2004)
What pressures were put on hospitals in the 1990's?
U.S. hospitals really begin to feel pressure to contain costs, improve quality and demonstrate their contributions to the health of the communities they serve
How did hospitals adapt to these pressures in the 1990's?
•Merged with or bought out other hospitals and healthcare organizations
•Created IDSs to provide a full range of healthcare services along the continuum of care, from ambulatory care to inpatient care to long-term care
•Concentrated on improving the care they provided by focusing on patients as customers
•Many hospitals responded to local competition by quickly entering into affiliations and other risk-sharing agreements with acute and nonacute care providers, physicians' groups, and managed care organizations (MCOs)
Managed care organization (MCO):
A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, and/or limiting access to care
At the close of the first decade of 2000, what stressors did healthcare organizations face?
•Challenges of a stressed economy
•High unemployment rates
•More uninsured individuals
What was the result of the stressors found in healthcare organizations by the end of the year 2000? And how was it handled?
•Hospital reimbursement payments continued to shrink
•Hospitals reached out for opportunities to control costs, streamline operations, implement efficient information technologies, engage in quality initiatives, and pursue joint ventures and consolidation
How much did the U.S. spend on healthcare associated with rising costs at the end of 2000? What did the government initiate as a response?
Associated with escalating costs the United States spent about $2.2 trillion on healthcare, representing 16 percent of the total economy
•Government initiated steps for reforming healthcare by:
-Instituting temporary measures to
make healthcare coverage more
-Providing incentives for
computerizing health records, and
-Investing in wellness and disease
What did congress pass regarding healthcare in 2010?
In 2010, Congress passed health care insurance reform legislation with the goals of reducing healthcare costs, protecting and increasing consumers' choices, and guaranteeing access to quality, affordable healthcare for all Americans
In what history is modern Western medicine rooted?
•Ancient Greeks developed surgical procedures, documented clinical cases, and created medical books
Before modern times, what was folk medicine based on?
•European, African, and Native American cultures all had traditions of folk medicine based on spiritual healing and herbal cures
•The first hospitals were created by religious orders in medieval Europe to provide care and respite to religious pilgrims traveling back and forth from the Holy Land
It was not until the late 1800s that medicine became?
•A scientific discipline
•More progress and change occurred in the 20th century than during the preceding 2,000 years
•The past few decades have seen dramatic developments in the way diseases are diagnosed and treated and in the way healthcare is delivered
Before the advent of modern Western medicine, epidemics and plagues were common:
•Smallpox, measles, yellow fever, influenza, scarlet fever, and diphtheria killed millions of people. •Bubonic plague spread periodically through Europe and killed millions more
•Disease was carried by rodents and insects as well as by the travelers who moved along intercontinental trade routes
The medical knowledge that had been gained by ancient Greek scholars such as Hippocrates was _____ during the middle ages
Lost during the Middle Ages
What did The European Renaissance, a historical period beginning in the 14th century revive?
•Interest in the classical arts, literature, and philosophy as well as the scientific study of nature
•This period also was characterized by economic growth and concern for the welfare of workers at all levels of society
What came with the concept of concern for welfare of workers at all levels of society?
With this concept came a growing awareness that a healthy population promoted economic growth.
How did North America's first hospitals arise? And what need was recognized regarding new immigrants?
•Early settlers in the British colonies of North America appointed commissions to care for the sick, to provide for orphans, and to bury the dead
•During the mid-1700s, the citizens of Philadelphia recognized the need for a place to provide relief to the sick and injured
•They also recognized the need to isolate newly arrived immigrants who had caught communicable diseases on the long voyage from Europe
What did Benjamin Franklin and other colonists persuade the legislature to develop for the community?
•Benjamin Franklin and other colonists persuaded the legislature to develop a hospital for the community
•The Pennsylvania Hospital was established in Philadelphia in 1752, the first hospital in the British colonies
•(Almost 200 years earlier, Cortez established the first hospital in Mexico and it still serves patients today.)
In its first 150 years, the Pennsylvania Hospital was? What were the two subsequent hospitals?
•Was a model for the organization of hospitals in other communities
•The New York Hospital opened in 1771 and started its first register of patients in 1791
•Boston's Massachusetts General Hospital opened in 1821
Human anatomy and physiology and the causes of disease were not well understood before the 20th century. At one time, what was believed to determine a person's temperament? What were treatments as a result?
•It was believed that four basic fluids, called humors, determined a person's temperament and health, and that imbalances in the proportion of humors in the body caused disease. •Therapeutic bleeding of patients was practiced until the early 20th century
•Early physicians also treated patients by administering a variety of substances with no scientific basis for their effectiveness
Early medical education
•Early medical education consisted of serving as an apprentice to an established practitioner
•Just about anyone could hang out a shingle and call himself a physician
What did the medical profession soon recognize about medical training? What happened as a result?
•The medical profession recognized that some of its members achieved better results than others, and •Leaders in the profession attempted to regulate the practice of medicine in the late 1700s
•The first attempts at regulation took the form of licensure
•The first licenses to practice medicine were issued in New York in 1760
•By the mid-1800s, however, efforts to license physicians were denounced as being undemocratic and penalties for practicing medicine without a license were removed in most states
At what point did the demand for medical practitioners exceed supply? What happened as a result?
•As the U. S. population grew and settlers moved westward
•To staff new hospitals and serve a growing population, private medical schools began to appear
•By 1869, there were 72 medical schools in the United States
What was a mistake made by the first medical schools?
•These schools did not follow an established course of study and some graduated students with as little as six months of training
•The result was an oversupply of poorly trained physicians
American Medical Association (AMA):
The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters
When and why was the AMA established? Who was it dominated by, and what lead to its reform?
•The American Medical Association (AMA) was established in 1847 to represent the interests of physicians across the country
•The AMA was dominated by members who had strong ties to the medical schools and the status quo. •Its ability to lead a reform of the profession was limited until it broke its ties with the medical schools in 1874
•At that time, the association encouraged the creation of independent state licensing boards
American Association of Medical Colleges (AAMC):
The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians
Which organizations campaigned for medical licensing? By the 1890s, was was established?
The AMA and AAMC
By the 1890s, 35 states had established or reestablished what?
•By the 1890s, 35 states had established or reestablished a system of licensure for physicians
•At that time, 14 states decided to grant licenses only to graduates of reputable medical schools
•The state licensing boards discouraged the worst medical schools, but the criteria for licensing continued to vary from state to state and were not fully enforced
What had become apparent by the early 20th century? What organization was divided on this issue, and how were they divided?
•That improving the quality of American medicine required regulation through curriculum reform as well as licensure
•Members of AMA were divided
•Conservative members continued to believe that the association should stay out of the area of regulation whereas progressive members supporte continued development of state licensure systems and creation of a standardized model for medical education
The division of AMA attracted the attention of who? What was offered as a response, and who undertook it?
•Carnegie Foundation for the Advancement of Teaching
•The president of the foundation offered to sponsor and fund an independent review of the medical colleges then operating in the United States
•Abraham Flexner, an educator from Louisville, Kentucky, undertook the review in 1906
Abraham Flexner
•1906 - over the next 4 years, Flexner visited every medical college in the country and carefully documented his findings
1910 report by Abraham Flexner: what was found? what was most important, and what was recommended?
•Given to the Carnegie foundation the AMA, and the AAMC
•Described the poor quality of the training being provided in the colleges
•Noted that medical school applicants often lacked knowledge of the basic sciences
•How the absence of hospital-based training limited the clinical skills of medical school graduates
•Most important-reported that huge numbers of graduates were being produced every year and that most of them had unacceptable levels of medical skill
•Recommended closing most of the existing medical schools to address the problem of oversupply
Reform initiatives that grew out of Flexner's report and from recommendations made by the AMA's Committee on Medical Education:
•Required medical school applicants to hold a college degree
•Required that medical training be founded in the basic sciences •Required that medical students receive practical, hospital-based training in addition to classroom work
How were the reforms from Flexner's report carried out?
•These reforms were carried out in the decade following Flexner's report, but only about half the medical schools actually closed
•By 1920, most of the medical colleges in the United States had met rigorous academic standards and were approved by the AAMC
Today, medical school graduates must pass a test before they can obtain a license to practice medicine. Who administers? What else is required?
•The licensure tests are administered by state medical boards
•Many states now use a standardized licensure test developed in 1968 by the Federation of State Medical Boards of the United States
•However, passing scores for the test vary by state
•Most physicians also complete several years of residency training in addition to medical school
What must specialty physicians complete? What is required?
•Specialty physicians also complete extensive postgraduate medical education
•Board certification for the various specialties requires the completion of postgraduate training as well as a passing score on a standardized examination
The most common medical specialties include the following:
•Internal medicine
•Family practice
The most common surgical specialties include:
•Cardiovascular surgery
•Plastic and reconstructive surgery
•Some medical and surgical specialists undergo further graduate training to qualify to practice
the subspecialties of internal medicine include endocrinology, pulmonary medicine, rheumatology, geriatrics, and hematology
Physicians also may limit their practices to the treatment of specific illnesses:
•For example, an endocrinologist may limit his or her practice to the treatment of diabetes
•Surgeons can work as general surgeons or as specialists or subspecialists
•For example, an orthopedic surgeon may limit his practice to surgery of the hand, surgery of the knee, surgery of the ankle, or surgery of the spine
Some physicians and healthcare organizations employ physician assistants (PAs) and/or surgeon assistants (SAs) to help them carry out their clinical responsibilities
•Such assistants may perform routine clinical assessments, provide patient education and counseling, and perform simple therapeutic procedures
•Most PAs work in primary care settings, and most SAs work in hospitals and ambulatory surgery clinics
•PAs and SAs always work under the supervision of licensed physicians and surgeons
Religious organizations:
In the 19th century and the first part of the 20th century, they sponsored more than half the hospitals in the United States
•Members of religious orders often provided nursing care in these organizations
•As the U.S. population grew and more towns and cities were established, new hospitals were built •Older cities also grew, and city hospitals became more and more crowded
Nursing in the late 1800s:
•In the late 1800s, nurses received no formal education and little training
•Nursing staff for the hospitals was often recruited from the surrounding community, and many poor women who had no other skills became nurses
•The nature of nursing care at that time was unsophisticated
•Lack of basic hygiene often promoted disease
•Many patients died from infections contracted while hospitalized for surgery, maternity care, and other illnesses
Beginnings of nurse training:
•In 1868, the AMA called the medical profession's attention to the need for trained nurses
•The public also began to call for better nursing care in hospitals
•The first general training school for nurses was opened at the New England Hospital for Women and Children in 1872
•It became a model for other institutions throughout the country. •As hospital after hospital struggled to find competent nursing staff, many institutions and their medical staffs developed their own nurse training programs
Nursing responsibilities in the late 19th and early 20th centuries:
•Housekeeping duties
•Cooked meals for patients in kitchens attached to each ward
•Direct patient care duties included giving baths, changing dressings, monitoring vital signs, administering medications, and assisting physicians
•During this time, nurses were not required to hold a license to practice
American Nurses Association (ANA):
•The national professional membership association of nurses •Works for the improvement of health standards and the availability of healthcare services, fosters high professional standards for the nursing profession, and advances the economic and general welfare of nurses
Founded in 1897 by a group of nurses attending the annual meeting of the American Society of Superintendents of Training Schools for Nursing
•Founded the Nurses Associated Alumnae of the United States and Canada
•In 1911, the organization was renamed the American Nurses Association (ANA)
•During the early meetings of the association, members established a nursing code of ethics and discussed the need for nursing licensure and for publications devoted to the practice of nursing
State nursing associations to advocate for the registration of nurses:
•At the turn of the 20th century, nurses also began to organize state nursing associations to advocate for the registration of nurses
•Their goal was to increase the level of competence among nurses nationwide
What was the opposition to nursing education, and what was passed despite this?
•Despite opposition from many physicians who believed that nurses did not need formal education or licensure, North Carolina passed legislation requiring the registration of nurses in 1903
•Today, all 50 states have laws that spell out the requirements for the registration and licensure of nursing professionals
Modern registered nursing requirements:
•Modern registered nurses must have either a two-year associate's degree or a four-year bachelor's degree from a state-approved nursing school. •Nurse practitioners, researchers, educators, and administrators generally have a four-year degree in nursing and additional postgraduate education in nursing
•The postgraduate degree may be a master's of science or a doctorate in nursing
Nonacademic training and nondegreed nursing personnel:
•Nurses who graduate from nonacademic training programs are called licensed practical nurses (LPNs) or licensed vocational nurses (LVNs). •Nondegreed nursing personnel work under the direct supervision of registered nurses. Nurses in all 50 states must pass an exam to obtain a license to practice
Nursing specialties and training:
Surgery, psychiatry, and intensive care
•Nurse-midwives complete advanced training and are certified by the American College of Nurse-Midwives. •Nurse-anesthetists are certified by the Council on Certification/Council on Recertification of Nurse Anesthetists
•Nurse practitioners receive advanced training at the master's level that qualifies them to provide primary care services to patients
•They are certified by several organizations (for example, the National Board of Pediatric Nurse Practitioners) to practice in the area of their specialty.
The need for registered nurses is expected to rise over the next decade.
•Hospitals in the United States report continued vacancies for registered nurses
•The Department of Health and Human Services estimates that over one million more nurses over the projected supply will be needed by 2020
1910, Dr. Franklin H. Martin
•Suggested that the surgical area of medical practice needed to become more concerned with patient outcomes
•Was introduced to this concept in discussions with Dr. Ernest Codman
Dr. Ernest Codman:
•Codman was a British physician who believed that hospital practitioners should track their patients for a significant amount of time after treatment to determine whether the end result had been positive or negative
•Codman also supported the use of outcome information to identify the practices that led to the best results for patients
Concern of Martin and other American physicians at this time (1910):
•They were concerned about the conditions in U. S. hospitals
•Many observers felt that part of the problem was related to the lack of organization in medical staffs and to lax professional standards. In the early 20th century, before the development of antibiotics and other pharmaceuticals, hospitals were used mainly by physicians who needed facilities in which to perform surgery •Most nonsurgical medical care was still provided in the home
•It was natural, then, for the force behind improved hospital care to come from surgeons
Push for hospital reforms:
•Led to formation of the American College of Surgeons in 1913
American College of Surgeons in 1913:
•The organization faced a difficult task. In 1917, the leaders of the college asked the Carnegie
•Foundation for funding to plan and develop a hospital standardization program
•The college then formed a committee to develop a set of minimum standards for hospital care
•It published the formal standards under the title of the Minimum Standards
During 1918 and part of 1919, American College of Surgeons:
•The college examined the hospitals in the United States and Canada just as Flexner had reviewed the medical colleges a decade earlier
•The performance of 692 hospitals was compared to the college's Minimum Standards
•Only 89 of the hospitals fully met the college's standards, and some of the best-known hospitals in the country failed to meet them.
The adoption of the Minimum Standards was the basis of:
•The Hospital Standardization Program and marked the beginning of the modern accreditation process for healthcare organizations
•Accreditation standards are developed to reflect reasonable quality standards
•The performance of each participating organization is evaluated against the standards
•The accreditation process is voluntary; healthcare organizations choose to participate in order to improve the care they provide to their patients
American Hospital Association (AHA):
The national trade organization that provides education, conducts research, and represents the hospital industry's interests in national legislative matters; membership includes individual healthcare organizations as well as individual healthcare professionals working in specialized areas of hospitals, such as risk management
Early 1950s accreditation:
•The American College of Surgeons continued to sponsor the hospital accreditation program until the early 1950s
•At that time, four professional associations from the U. S. and Canada joined forces with the college to create a new accreditation organization called the Joint Commission on Accreditation of Hospitals
•The associations were the American College of Physicians, the AMA, the American Hospital Association (AHA), and the Canadian Medical Association
•The new organization was formally incorporated in 1952 and began to perform accreditation surveys in 1953.
The Joint Commission (TJC) continues to survey several different types of healthcare organizations today, including:
•Acute care hospitals
•Long-term carefacilities
•Ambulatory care facilities
•Psychiatric facilities
•Home health agencies
Several other organizations also perform accreditation of healthcare organizations, including:
•The American Osteopathic Association (AOA)
•The Commission on Accreditation of Rehabilitation Facilities (CARF), and •The Accreditation Association for Ambulatory Healthcare (AAAHC)
After the First World War, many roles previously played by nurses and nonclinical personnel began to change.
With the advent of modern diagnostic and therapeutic technology in the mid-twentieth century, the complex skills needed by ancillary medical personnel fostered the growth of specialized training programs and professional accreditation and licensure.
According to the AMA, allied health incorporates:
The healthcare-related professions that function to assist, facilitate, and/or complement the work of physicians and other clinical specialists.
The Health Professions Education Amendment of 1991 describes:
•Allied health professionals as health professionals (other than registered nurses, physicians, and physician assistants) who have received either a certificate, an associate's degree, a bachelor's degree, a master's degree, a doctorate, or postdoctoral training in a healthcare-related science
•Such individuals share responsibility for the delivery of healthcare services with clinicians (physicians, nurses, and physician assistants)
Allied health occupations and growth:
•Allied health occupations are among the fastest growing in healthcare
•The number of allied health professionals is difficult to estimate and depends on the definition of allied health
•Unlike the case in medicine, women dominate most of the allied health professions, representing between 75 and 95 percent in most of the occupations
•All 50 states require licensure for some allied health professions (physical therapy, for example). P•ractitioners in other allied health professions (occupational therapy, for example) may be licensed in some states but not in others
•Significant shortages of personnel in many of the allied health disciplines are projected into the next decade
Some of the major occupations usually considered to be allied health professions: Audiology
•Audiology: Audiology is the branch of science that studies hearing, balance, and related disorders
•Audiologists treat those with hearing loss and proactively prevent related damage
•According to the American Speech-Language-Hearing Association, audiologists provide comprehensive diagnostic and treatment/rehabilitative services for auditory, vestibular, and related impairments
•These services are provided to individuals across the entire age span from birth through adulthood; to individuals from diverse language, ethnic, cultural, and socioeconomic backgrounds; and to individuals who have multiple disabilities
Some of the major occupations usually considered to be allied health professions: Clinical laboratory science:
•Originally referred to as medical laboratory technology, this field is now more appropriately referred to as clinical laboratory science
•Clinical laboratory technicians perform a wide array of tests on body fluids, tissues, and cells to assist in the detection, diagnosis, and treatment of diseases and illnesses
Some of the major occupations usually considered to be allied health professions: Diagnostic medical sonography/imaging technology:
•Originally referred to as x-ray technology and then radiologic technology, this field is now more appropriately referred to as diagnostic imaging
•The field continues to expand to include nuclear medicine, radiation therapy, and echocardiography
•These services are provided by physician specialists and technologists including radiation therapists, cardiosonographers (ultrasound technologists), and magnetic resonance technologists.
Some of the major occupations usually considered to be allied health professions: Dietetics and nutrition:
•Dietitians (also clinical nutritionists) are trained in nutrition
•They are responsible for providing nutritional care to individuals and for overseeing nutrition and food services in a variety of settings, ranging from hospitals to schools.
Some of the major occupations usually considered to be allied health professions: Emergency medical technology:
Emergency medical technicians (EMTs) and paramedics provide a wide range of services on an emergency basis for cases of traumatic injury and other emergency situations and in the transport of emergency patients to a medical facility.
Some of the major occupations usually considered to be allied health professions: Health information management:
•Health information management (HIM) professionals (formerly called medical record administration) oversee health record systems and manage health-related information to ensure that it meets relevant medical, administrative, and legal requirements
•Health records are the responsibility of registered health information administrators (RHIAs) and registered health information technicians (RHITs)
Some of the major occupations usually considered to be allied health professions: Occupational therapy:
Occupational therapists (OTs) evaluate and treat patients whose illnesses or injuries have resulted in significant psychological, physical, or work-related impairment.
Some of the major occupations usually considered to be allied health professions: Optometry:
•Optometry is a health profession focused on eyes and related structures, as well as vision, visual systems, and vision information processing in humans
•Optometrists provide treatments such as contact lenses and corrective and low vision devices, and are authorized to use diagnostic and therapeutic pharmaceutical agents to treat anterior segment disease, glaucoma, and ocular hypertension
•As primary eye care practitioners, optometrists often are the first ones to detect such potentially serious conditions as diabetes, hypertension, and arteriosclerosis.
Some of the major occupations usually considered to be allied health professions: Pharmacy:
•The scope of pharmacy practice includes traditional roles such as compounding and dispensing medications, as well as modern services including reviewing medications for safety and efficacy, and providing drug information to physicians and patients
•Pharmacists are the experts on drug therapy and are the primary health professionals who optimize medication use to provide patients with positive health outcomes.
Some of the major occupations usually considered to be allied health professions: Physical therapy:
•Physical therapists (PTs) evaluate and treat patients to improve functional mobility, reduce pain, maintain cardiopulmonary function, and limit disability
•PTs treat movement dysfunction resulting from accidents, trauma, stroke, fractures, multiple sclerosis, cerebral palsy, arthritis, and heart and respiratory illness
•Physical therapy assistants work under the direction of PTs and help carry out the treatment plans developed by PTs
Some of the major occupations usually considered to be allied health professions: Respiratory therapy:
•Respiratory therapists (RTs) evaluate, treat, and care for patients with breathing disorders
•They work under the direction of qualified physicians and provide services such as emergency care for stroke, heart failure, and shock, and treat patients with emphysema and asthma.
Some of the major occupations usually considered to be allied health professions: Speech-language pathology and audiology:
Speech-language pathologists and audiologists identify, assess, and provide treatment for individuals with speech, language, or hearing problems.
Some of the major occupations usually considered to be allied health professions: Surgical technologist:
•Provide surgical care to patients in a variety of settings; the majority are hospital operating rooms
•Surgical technologists work under medical supervision to facilitate the safe and effective conduct of invasive surgical procedures
Check your understanding 12.1:
1. What healthcare professional assists physicians in clinical assessments and patient education?
D. Physician assistants
Check your understanding 12.1:
2. Licensure tests to practice medicine are administered by:
D. State licensure boards
Check your understanding 12.1:
3. Which of the following statements is true about registered nurses?
B. Nurses are required to have a license in the state in which they practice
4. Which of the following professions is generally considered to be an allied health career?
A. Clinical laboratory science
5. To become board-certified in pediatrics, which of the following would an internal medicine physician need to do?
B. Complete graduate training in pediatric medicine and pass a national examination
6. The adoption of the Minimum Standards marked the beginning of what modern practice for healthcare organizations?
A. Accreditation
7. According to the AMA, which of the following incorporates the healthcare-related professions that function to assist, facilitate, and/or complement the work of physicians and other clinical specialists?
D. Allied health
Instructions: Indicate whether the statements below are true or false (T or F).
8. __F__ Respiratory therapists treat patients with limited mobility.
9. _F___ Physical therapy assistants develop treatment plans.
10.__T__ Cardiosonography is a specialization of diagnostic imaging technologists
Where was most healthcare provided until the Second World War? Quality in healthcare services at this time was considered a product of?
•In the home
•Appropriate medical practice and oversight by physicians and surgeons
•Even the Minimum Standards used to evaluate the performance of hospitals were based on factors directly related to the composition and skills of the hospital medical staff
20th century tremendous change
•Advances in medical science promised better outcomes and increased the demand for healthcare services
•Medical care has never been free
•Even in the best economic times, many Americans have been unable to take full advantage of what medicine has to offer because they cannot afford it
Concern over access to healthcare:
•Especially evident during the Great Depression of the 1930s
•Concern over access to healthcare was During the Depression, America's leaders were forced to consider how the poor and disadvantaged could receive the care they needed.
Medical care for poor and elderly: Healthcare at a cost in the 1930s
•Before the Depression, medical care for the poor and elderly had been handled as a function of social welfare agencies
•During the 1930s, however, few people were able to pay for medical care
•The problem of how to pay for the healthcare needs of millions of Americans became a public and governmental concern
•Working Americans turned to prepaid health plans to help them pay for healthcare, but the unemployed and the unemployable needed help from a different source
Prepaid healthcare or health insurance; blue cross
•Began with the financial problems of one hospital, Baylor University Hospital in Dallas, Texas
•In 1929, the administrator of the hospital arranged to provide hospital services to Dallas's schoolteachers for 50 cents per person per month
•Before that time, a few large employers had set up company clinics and hired company physicians to care for their workers, but the idea of a prepaid health plan that could be purchased by individuals had never been tried before.
•The idea caught on quickly, and new prepaid plans appeared across the country
•Eventually, these plans became known as Blue Cross plans when the blue cross symbol used by some of the new plans was adopted officially as the trademark for all the plans in 1939
Blue Shield plan
•Another type of prepaid plan, called the Blue Shield plan, was subsequently developed to cover the cost of physicians' services
•The idea for the Blue Shield plans grew out of the medical service bureaus created by large lumber and mining companies in the Northwest
•In 1939, the first formal Blue Shield plan was founded in California.
•Growth in the number of Blue Cross/Blue Shield (BC/BS) plans continued through the Depression and boomed during the Second World War •During the war-related labor shortages, employers began to pay for their employees' memberships in the Blues as a way to attract and keep scarce workers
Public funding for healthcare services:
•The idea of public funding for healthcare services also goes back to the Great Depression
•The decline in family income during the 1930s curtailed the use of medical services by the poor
•In 10 working-class communities studied between 1929 and 1933, the proportion of families with incomes under $150 per capita had increased from 10 to 43 percent
A 1938 Gallup poll asked people whether they had put off seeing a physician because of the cost.
The results showed that 68 percent of lower-income respondents had put off medical care, compared with 24 percent of respondents in upper-income brackets
The depression, incomes for physicians and hospitals and demand for free services:
•The decreased use of medical services and the inability of many patients to pay meant lower incomes for physicians
•Hospitals were in similar trouble
•Beds were empty, bills went unpaid, and contributions to hospital fundraising efforts tumbled
•As a result, private physicians and charities could no longer meet the demand for free services
•For the first time, physicians and hospitals asked state welfare departments to pay for the treatment of people on relief
The Depression posed a severe test for the AMA
•It was no easy matter to maintain a common front against government intervention when physicians themselves were facing economic difficulties
•Because of the economic hardships, many physicians were willing to accept government-sponsored health insurance
In 1935, the California Medical Association endorsed the concept of:
•Compulsory health insurance
•Because health insurance promised to stimulate the use of physicians' services and help patients pay their bills
What was the AMA's response to the economic crisis
•The AMA's response to the economic crisis emphasized restricting the supply of physicians, rather than increasing the demand for their services, by instituting mandatory health insurance
•The AMA reacted by pushing for the closure of medical schools and reductions in the number of new medical students.
How did the AMA adjust its position on health insurance?
•By the mid-1930s, however, the AMA began to adjust its position on health insurance
•Instead of opposing all insurance, voluntary or compulsory, it began to define the terms on which voluntary programs might be acceptable •Although accepting health insurance plans in principle, the AMA did nothing to support or encourage their development
The push for government-sponsored health insurance continued in the late 1930s during the administration of President Franklin D. Roosevelt
•However, compulsory health insurance stood on the margins of national politics throughout the New Deal era
•It was not made part of the new Social Security program, and it was never fully supported by President Roosevelt
Truman's health care plan:
What did compulsory health insurance become entangled with America's fears of?
•After WWII, the issue of healthcare access finally moved to the center of national politics
•In the late 1940s, President Harry S. Truman expressed unreserved support for a national health insurance program
•However, the issue of compulsory health insurance became entangled with America's fear of communism
•Opponents of Truman's healthcare program labeled it "socialized medicine," and the program failed to win legislative support.
When did the idea of national health insurance resurface?
The idea of national health insurance did not resurface until the administration of Lyndon Johnson and the Great Society legislation of the 1960s.
What was legislated in 1965 to pay the cost of providing healthcare services to the elderly and the poor? When was healthcare reform and national health insurance again given priority?
•The Medicare and Medicaid programs •The issues of healthcare reform and national health insurance were again given priority during the first four years of President Bill Clinton's administration in the 1990s
•However, the complexity of American healthcare issues at the end of the 20th century doomed reform efforts
•In 2010, Congress passed health insurance reform legislation that was signed into law by President Barack Obama
During the 20th century, Congress passed pieces of legislation w/a significant impact on the delivery of healthcare services in the United States:
•Biologics Control Act of 1902
•Social Security Act of 1935
•Hospital Survey and Construction Act of 1946
•Public Law 89-97 of 1965
•Public Law 92-603 of 1972
•Health Planning and Resources •Development Act of 1974
•Utilization Review Act of 1977
•Peer Review Improvement Act of 1982
•Tax Equity and Fiscal Responsibility Act of 1982
•Prospective Payment Act (1982)/Public Law 98-21 of 1983
•Consolidated Omnibus Budget •Reconciliation Act of 1985
•Omnibus Budget Reconciliation Act of 1986
•Healthcare Quality Improvement Act of 1986
•Omnibus Budget Reconciliation Act of 1990
•Mental Health Parity Act of 1996
•Health Insurance Portability and Accountability Act of 1996
•American Recovery and Reinvestment Act of 2009
Biologics Control Act of 1902
•Direct federal sponsorship of medical research began with early research on methods for controlling epidemics of infectious disease
•The Marine Hospital Service performed the first research
•In 1887, a young physician, Joseph Kinyoun, set up a bacteriological laboratory in the Marine Hospital at Staten Island, NY
•Four years later, the Hygienic Laboratory was moved to Washington, DC
•It was given authority to test and improve biological products in 1902 when Congress passed the Biologics Control Act
•This act regulated the vaccines and sera sold via interstate commerce
•That same year, the Hygienic Laboratory added divisions in chemistry, pharmacology, and zoology
National Institutes of Health (NIH):
Federal agency of the Department of Health and Human Services comprising a number of institutes that carry out research and programs related to certain types of diseases, such as cancer
The organization has played a vital role in recent clinical research on the treatment of the following diseases:
•Heart disease and stroke
•Depression andschizophrenia
•Spinal cord injuries
U.S. Public Health Service:
•In 1912, the service, by then called the U. S. Public Health Service, was authorized to study chronic as well as infectious diseases
•In 1930, reorganized under the Randsdell Act, the Hygienic Laboratory became the National Institutes of Health (NIH)
•In 1938, the NIH moved to a large, privately donated estate in Bethesda, Maryland (Starr 1982, 340)
What is the mission of the NIH today?
•Today, the mission of the NIH is to uncover new medical knowledge that can lead to health improvements for everyone
•The NIH accomplishes its mission by conducting and supporting medical research, fostering communication of up-to-date medical information, and training research investigators
The NIH organization has played a vital role in recent clinical research on the treatment of the following diseases:
•Heart disease and stroke
•Depression andschizophrenia
•Spinal cord injuries
Social Security Act of 1935:
•The Great Depression revived the dormant social reform movement in the United States as well as more radical currents in American politics
•Unionization increased, and the American Federation of Labor (AF of L) abandoned its long-standing opposition to social insurance programs
•The Depression also brought to power a Democratic administration
•The administration of Franklin D. Roosevelt was more willing than any previous administration to involve the federal government in the management of economic and social welfare
Social Security Act and FDR:
•Even before Roosevelt took office in 1933, a steady movement toward some sort of social insurance program had been growing
•By 1931, nine states had passed legislation creating old-age pension programs
•As governor of New York State, Roosevelt endorsed unemployment insurance in 1930
Who was the first state to adopt unemployment insurance?
•Wisconsin became the first state to adopt such a measure early in 1932
Roosevelt, unemployment insurance and the committee on economic security:
•Although old-age pension and unemployment insurance bills were introduced into Congress soon after his election, Roosevelt refused to give them his strong support
•Instead, he created a program of his own
•On June 8, 1934, he announced that he would appoint a committee on economic security to study the issue comprehensively and report to Congress in January 1935
•The committee consisted of four members of the cabinet and the federal relief administrator. It was headed by the secretary of labor, Frances Perkins
Committee on economic security: what did the committee include that was not addressed in Roosevelt's message?
Although Roosevelt indicated in his June message that he was especially interested in old-age and unemployment programs, the committee included medical care and health insurance in its research.
In the outset, what was the prevailing sentiment on the committee?
•Was that health insurance would have to wait
•Abraham Epstein was the founder of the American Association for Social Security and a leading figure in the social insurance movement
•In an article published in October 1934, he warned the administration that opposition to health insurance was strong.
Abraham Epstein was the founder of the American Association for Social Security and a leading figure in the social insurance movement, what did he advise?
•He advised the administration to be politically realistic and go slow on health insurance.
•Sentiment in favor of health insurance was strong among members of the Committee on Economic Security
•However, many members of the committee were convinced that adding a health insurance amendment would spell defeat for the entire Social Security legislation
•Ultimately, the Social Security bill included only one reference to health insurance as a subject that the new Social Security Board might study
•The Social Security Act was passed in 1935
What were the Social Security Acts conservative features?
•The omission of health insurance from the legislation
•It relied on a regressive tax and gave no coverage to some of the nation's poorest people, such as farmers and domestic workers
•However, the act did extend the federal government's role in public health through several provisions unrelated to social insurance
•It gave the states funds on a matching basis for maternal and infant care, rehabilitation of crippled children, general public health work, and aid for dependent children under the age of 16
Hospital Survey and Construction Act of 1946:
•Passage of the Hill-Burton Act was another important development in American healthcare delivery
•Enacted in 1946 as the Hospital Survey and Construction Act, this legislation authorized grants for states to construct new hospitals and, later, to modernize old ones
•The fund expansion of the hospital system was to achieve a goal for 4.5 beds per 1,000 persons
Hill-Burton Act:
The federal legislation enacted in 1946 as the Hospital Survey and Construction Act to authorize grants for states to construct new hospitals and, later, to modernize old ones
What created a boom in hospital construction during the 1950s?
•The availability of federal financing created a boom in hospital construction during the 1950s
•The hospital system grew from 6,000 hospitals in 1946 to a high of approximately 7,200 acute care hospitals
Growth in Number of Hospitals
•The number of hospitals in the United States increased from 178 in 1873 to 4,300 in 1909
•In 1946, at the close of the Second World War, there were 6,000 American hospitals, with 3.2 beds available for every 1,000 persons
•In 2002, there were 4,927 hospitals in the United States, with a total of 821,000 beds. Of the $1.4 trillion spent on healthcare in 2001, hospital costs totaled $415 billion, or 32 percent
•Most U. S. hospitals are nonprofit or owned by local, state, or federal governments
Decline in Number of Hospitals: what caused procedures to move outpatient?
•During the 1980s, medical advances and cost-containment measures caused many procedures that once required inpatient hospitalization to be performed on an outpatient basis
•Outpatient hospital visits increased by 40 percent with a resultant decrease in hospital admissions
•Fewer patient admissions and shortened lengths of stay (LOS) resulted in a significant reduction in the number of hospitals and hospital beds
Healthcare reform efforts and the acceptance of managed care as the major medical practice style of U. S. healthcare resulted in:
Enough hospital closings and mergers to reduce the number of government and community-based hospitals in the United States to approximately 5,000 (Sultz and Young 2004, 68).
The advent of diagnosis-related groups (DRGs)
In the mid-1980s resulted in the closure of many rural healthcare facilities
Public Law 89-97 of 1965
•In 1965, passage of a number of amendments to the Social Security Act brought Medicare and Medicaid into existence
•The two programs have greatly changed how healthcare organizations are reimbursed
•Recent attempts to curtail Medicare/Medicaid spending continue to affect healthcare organizations.
Medicare (Title XVIII of the Social Security Act)
•A federal program that provides healthcare benefits for people 65 years old and older who are covered by Social Security
•The program was inaugurated on July 1, 1966
•Over the years, amendments have extended coverage to individuals who are not covered by Social Security but are willing to pay a premium for coverage, to the disabled, and to those suffering from end-stage renal disease (ESRD).
The companion program, Medicaid, Title XIX of the Social Security Act:
•Was established at the same time to support medical and hospital care for persons classified as medically indigent
•Originally targeted recipients of public assistance (primarily single-parent families and the aged, blind, and disabled)
•Medicaid has expanded to additional groups so that it now targets poor children, the disabled, pregnant women, and very poor adults (including 65 and over)
The only exception to the medicaid expansions:
Was passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public law 104-193), which changed eligibility for legal/illegal immigrants
Today, Medicaid is a federally mandated program that provides healthcare benefits to low-income people and their children. Who administers medicaid, and how did it work?
•Medicaid programs are administered and partially paid for by individual states
•Medicaid is an umbrella for 50 different state programs designed specifically to serve the poor
•Beginning in January 1967, Medicaid provided federal funds to states on a cost-sharing basis to ensure that welfare recipients would be guaranteed medical services
For Medicare, coverage of four types of care was required:
•Inpatient and outpatient services
•Other laboratory and x-ray services
•Physician services, and
•Nursing facility care for persons over 21 years of age
Many enhancements have been made in the years since Medicaid was enacted.
•Services now include family planning and 31 other optional services such as prescription drugs and dental services
•With few exceptions, recipients of cash assistance are automatically eligible for Medicaid
•Medicaid also pays the Medicare premium, deductible, and coinsurance costs for some low-income Medicare beneficiaries
How many people are enrolled in medicaid?
•Four million individuals were enrolled in Medicaid in 1966, its first year of implementation
•By 2006, 54 million people were enrolled in Medicaid programs
•In 2007, the states and the federal government expended $319.6 billion on Medicaid
•Elderly and disabled participants comprised about 65% of the expenditures (Kaiser Family Foundation 2009).
Extended care facility:
A healthcare facility licensed by applicable state or local law to offer room and board, skilled nursing by a full-time registered nurse, intermediate care, or a combination of levels on a 24-hour basis over a long period of time
Public Law 92-603 of 1972:
•Utilization review (UR) was a mandatory component of the original Medicare legislation
•Medicare required hospitals and extended care facilities to establish a plan for UR as well as a permanent utilization review committee
•The goal of the UR process was to ensure that the services provided to Medicare beneficiaries were medically necessary.
Public Law 92-603 of 1972: In an effort to curtail Medicare and Medicaid spending, additional amendments to the Social Security Act were instituted in 1972.
•Public Law 92-603 required concurrent review for Medicare and Medicaid patients
•It also established the professional standards review organization (PSRO) program to implement concurrent review
•PSROs performed professional review and evaluated patient care services for necessity, quality, and cost-effectiveness
Public Law 92-603 of 1972: Three major eras occurred in healthcare policy from 1975 to 2000. Like an archeological site, these eras have accumulated mostly on top of one another, rather than fully replacing what has come before. The four health policy eras can be identified as the following:
•Age of Traditional Insurance (1965-1982), which began with the enactment of Medicare and Medicaid and which was based on open-ended, fee-for-service health insurance;
•Age of Regulated Prices for Government Programs (1983-1992), which was launched with the enactment of the Medicare DRG system; and
•Age of Markets, Purchasing, and Managed Care (1993-2000), the era that has seen the population move to managed care plans in both the private and public coverage programs (Etheredge 2001).
•Information Age (2000-present), an era focused on the use of information technology and enhancing information management within and among institutions to improve the delivery of healthcare (Siegel and Channin 2001)
Health systems agency (HSA):
A type of organization called for by the Health Planning and Resources Development Act of 1974 to have broad representation of healthcare providers and consumers on governing boards and committees
What did the Health Planning and Resources Development Act of 1974 call for?
•The Health Planning and Resources Development Act of 1974 called for a new type of organization, the health systems agency (HSA), to have broad representation of healthcare providers and consumers on governing boards and committees
•Although the governance structure required participation by consumers, interested parties from the provider groups dominated the discussions.
HSAs were unsuccessful in what way? What were attempts to achieve consensus based on?
•HSAs were fundamentally unsuccessful in materially influencing decisions about service or technology expansion
•Their decisions became undeniably political and attempts to achieve consensus based on real service needs were counterbalanced by community interests in economic and employment expansions
What legislative initiatives concurrent with attempts to slow cost increases through a planning approach, were related to concerns over?
•A number of other legislative initiatives took shape that were directly related to concerns over Medicare costs and service quality
•The legislation that created the HSAs or nationwide system of local health planning agencies was repealed in 1986
Utilization Review Act:
The federal legislation that requires hospitals to conduct continued-stay reviews for Medicare and Medicaid patients
Utilization Review Act of 1977
•In 1977, the Utilization Review Act made it a requirement that hospitals conduct continued-stay reviews for Medicare and Medicaid patients •Continued-stay reviews determine whether it is medically necessary for a patient to remain hospitalized
•This legislation also included fraud and abuse regulations
Peer review organization (PRO):
Until 2002, a medical organization that performs a professional review of medical necessity, quality, and appropriateness of healthcare services provided to Medicare beneficiaries; now called quality improvement organization (QIO)
Quality improvement organization (QIO):
An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room; until 2002, called peer review organization
Peer Review Improvement Act of 1982:
•In 1982, the Peer Review Improvement Act redesigned the PSRO program and renamed the agencies peer review organizations (PROs)
•At this time, hospitals began to review the medical necessity and appropriateness of certain admissions even before patients were admitted
•PROs were given a new name in 2002 and now are called quality improvement organizations (QIOs). •They currently emphasize quality improvement processes
•Each state and territory, as well as the District of Columbia, now has its own QIO
•The mission of the QIOs is to ensure the quality, efficiency, and cost-effectiveness of the healthcare services provided to Medicare beneficiaries in its locale
Tax Equity and Fiscal Responsibility Act of 1982:
•In 1982, Congress passed the Tax Equity and Fiscal Responsibility Act (TEFRA)
•TEFRA required extensive changes in the Medicare program
•Its purpose was to control the rising cost of providing healthcare services to Medicare beneficiaries.
Before the Tax Equity and Fiscal Responsibility Act of 1982 was passed:
•Healthcare services provided to Medicare beneficiaries were reimbursed on a retrospective, or fee-based, payment system
•TEFRA required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement

In a retrospective payment system, a service is provided, a claim for payment for the service is made, and the healthcare provider is reimbursed for the cost of delivering the service. In a PPS, a predetermined level of reimbursement is established before the service is provided
Retrospective payment system
•In a retrospective payment system, a service is provided, a claim for payment for the service is made, and the healthcare provider is reimbursed for the cost of delivering the service.
•In a PPS, a predetermined level of reimbursement is established before the service is provided
Prospective Payment Act (1982)/Public Law 98-21 of 1983:
•The PPS for acute hospital care (inpatient) services was implemented on October 1, 1983, according to Public Law 98-21
•Under the inpatient PPS, reimbursement for hospital care provided to Medicare patients is based on diagnosis-related groups (DRGs)
PPS for other healthcare services implementation:
•PPSs for other healthcare services provided to Medicare beneficiaries have been gradually implemented in the years since 1983
•Implementation of the ambulatory payment classification system for hospital outpatient services, for example, began in the year 2000
What are cases assigned based on?
•Each case is assigned to a DRG based on the patient's diagnosis at the time of discharge
•For example, under inpatient PPS, all cases of viral pneumonia would be reimbursed at the same predetermined level of reimbursement no matter how long the patients stayed in the hospital or how many services they received
Consolidated Omnibus Budget Reconciliation Act of 1985:
The Consolidated Omnibus Budget Reconciliation Act made it possible for the Centers for Medicare and Medicaid Services (CMS) to deny reimbursement for substandard healthcare services provided to Medicare and Medicaid beneficiaries.
National Practitioner Data Bank (NPDB):
A data bank established by the federal government through the 1986 Health Care Quality Improvement Act that contains information on professional review actions taken against physicians and other licensed healthcare practitioners, which healthcare organizations are required to check as part of the credentialing process
Omnibus Budget Reconciliation Act of 1986:
The Omnibus Budget Reconciliation Act of 1986 requires PROs to report instances of substandard care to relevant licensing and certification agencies.
Healthcare Quality Improvement Act of 1986:
•The Healthcare Quality Improvement Act established the National Practitioner Data Bank (NPDB)
•The purpose of the NPDB is to provide a clearinghouse for information about medical practitioners who have a history of malpractice suits and other quality problems
•Hospitals are required to consult the NPDB before granting medical staff privileges to healthcare practitioners
•The legislation also established immunity from legal actions for practitioners involved in some peer review activities
Omnibus Budget Reconciliation Act of 1989:
•The Omnibus Budget Reconciliation Act of 1989 instituted the Agency for Healthcare Policy and Research
•The mission of this agency is to develop outcome measures to evaluate the quality of healthcare services.
Omnibus Budget Reconciliation Act of 1990:
The Omnibus Budget Reconciliation Act of 1990 requires PROs to report actions taken against physicians to state medical boards and licensing agencies
Mental Health Parity Act of 1996 (MHPA):
•The Mental Health Parity Act of 1996 (MHPA) is a federal law that may apply to large group self-funded group plans or large group fully insured group health plans
What is the purpose of the Mental Health Parity Act of 1996 (MHPA) law?
•The purpose of the law is to provide equality (parity) for mental health benefits with medical/surgical benefits when applying aggregate lifetime and annual dollar limits under a group health plan
•For example, if a health plan has $500,000 lifetime limit on medical and surgical benefits, then it cannot apply a lower limit on mental health benefits
•The law does not require group health plans to include mental health benefits in their plans and does not apply to employers who have less than 50 employees
•Changes in the law occurred when the Mental Health Parity and Addiction Equity Act (MHPAEA) was signed into law in 2008
Health Insurance Portability and Accountability Act of 1996:
•(HIPAA) addresses:
•Issues related to the portability of health insurance after leaving employment, •Establishment of national standards for electronic healthcare transactions, and •National identifiers for providers, health plans, and employers
•A portion of HIPAA addressed the security and privacy of health information by establishing privacy standards to protect health information and security standards for electronic healthcare information
•HIPAA privacy and security standards are covered in chapters 14 and 17. Other provision of HIPAA:
•Another provision of HIPAA was the creation of the Healthcare Integrity and Protection Data Bank (HIPDB) to combat fraud and abuse in health insurance and healthcare delivery
What is the purpose of the Healthcare integrity and protection data bank (HIPD)?
•A purpose of the HIPDB is to inform federal and state agencies about potential quality problems with clinicians and with suppliers and providers of healthcare services
•The American Recovery and Reinvestment Act (ARRA) discussed below includes important changes in HIPAA privacy and security standards that are discussed in chapters 14 and 17
American Recovery and Reinvestment Act of 2009:
çIn February 2009, President Barack Obama signed the American Recovery and Reinvestment Act (ARRA), one of the single largest health information technology laws in recent history
•It provided stimulus funds to the U. S. economy in the midst of a major economic downturn.
Title XIII of the American Recovery and Reinvestment Act of 2009:
•Is a substantial portion of the bill
•Entitled the Health Information Technology for Economic and Clinical Health (HITECH) Act, allocates funds for implementation of nationwide health information exchange, use of health information, and implementation of electronic health records
•The bill provides for investment of billions of dollars in health information technology and incentives to encourage doctors and hospitals to use information technology; $19.2 billion dollars was dedicated to implementing and supporting health information technology
What does the ARRA require of the government?
•ARRA requires the government to take a leadership role in developing standards for exchange of health information nationwide, strengthens Federal privacy and security standards and establishes the Office of the National Coordinator for Health Information Technology (ONC) as a permanent office (Rode 2009). See table 12.1 for a implementation date timeline for specific ARRA initiatives
Table 12.1: ARRA implementation timeline 1-8
1. Issue: Issue regulations to define Meaningful Use
Implementation Date: December 31, 2009
2. Issue: Grants to standards and Indian tribes for development of loan programs to facilitate adoption of certified EHR technology
Implementation date: After January 1, 2010
3. Issue: Issue regulations to modify the HIPAA Enforcement Rule to implement revised penalty structure
Implementation date: February 18, 2010
4. Issue: Issue regulations to extend certain HIPAA Security Rule provisions to business associates
Implementation date: February 18, 2010
5. Issue: Issue guidance on technical safeguards to carry out security
Implementation date: February 18, 2010
6. Issue: Report to Congress on breaches for which notice was provided to the Secretary
Implementation date: February 18, 2010
7. Issue: Issue regulations to extend certain HIPAA Privacy Rule provisions to business associates
Implementation date: February 18, 2010
8. Issue regulations to modify the HIPAA Privacy Rule's provisions regarding right to request restrictions, minimum necessary, access
Implementation date: February 18, 2010
Table 12.1: ARRA implementation timeline
9. Issue: Deadline (issue regulations) to modify the HIPAA Privacy Rules provisions regarding covered entity/business associate compliance with new marketing and fundraising
Implementation Date: February 18, 2010
10. Issue: Issue regulations to clarify that certain entities are HIPAA business associates
Implementation Date: February 18, 2010
11. Issue: HHS/FTC report on application of privacy/security requirements for non-HIPAA covered entities
Implementation Date: February 18, 2010
12. Issue: Study and report to Congress on privacy and security requirements for entities that are not HIPAA covered entities or business associates
Implementation Date: February 18, 2010
13. Issue: HHS guidance on requirements for de-identification of PHI
Implementation Date: February 18, 2010
14. Issue: GAO report for best practices for treatment disclosures
Implementation Date: February 18, 2010
15. Issue: Study the HIPAA Privacy Rule's definition of "psychotherapy notes" with regard to including certain test data and mental health evaluations
Implementation Date: February 18, 2010
16. Issue: Issue regulations to modify the HIPAA Privacy Rule's accounting of disclosures provisions
Implementation Date: June 18, 2010
17. Issue: HHS guidance on "minimum necessary" health information (data) under the HIPAA Privacy Rule
Implementation Date: August 18, 2010
18. Issue: Issue regulations to modify the HIPAA Privacy Rule to generally prohibit exchanging health information for remuneration without individual authorization
Implementation Date: August 18, 2010
19. Issue: Issue regulations to modify the HIPAA Enforcement Rule to implement willful neglect provisions
Implementation Date: August 18, 2010
20. Study and report to Congress on current availability of open source HIT systems to federal safety net providers and recommendations for legislative or administrative action
Implementation Date: October 1, 2010
21. Issue: State grants to promote HIT (implementation grants to facilitate and expand health information exchange, including required matches)
Implementation Date: After October 1, 2010
22. Issue: Initial deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired after January 1, 2009
Implementation date: By 2011
23. Issue: HHS report on reimbursement incentives for federally qualified health centers, rural health clinics, and free clinics
Implementation Date: February 11, 2011
24. Issue: Clarification of ability to pursue civil penalties when criminal penalties are not pursued
Implementation date: February 17, 2011
25. Issue: Issue regulations to modify the HIPAA Enforcement Rule to implement willful neglect provisions for sharing civil money penalties or settlements with harmed individuals
Implementation date: February 18, 2012
26. Issue: Extended deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired after January 1, 2009
Implementation date: By 2013
27. Issue: GAO will report on the impact of ARRA
Implementation date: By 2014
28. Issue: Initial deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired before January 1, 2009
Implementation date: By 2014
29. Issue: Extended deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired before Implementation date: January 1, 2009
2006 Commonwealth Fund Commission on a High Performance Health System:
•Developed a comprehensive method to measure and monitor various aspects of the healthcare system in the United States
•The findings of the Commission's analysis are documented in an annual report called the National Scorecard on U.S. Health System Performance.
The 2008 National Scorecard looked at five dimensions of health system performance including healthy lives, quality, access, efficiency, and equity. What were findings from the scorecard?
T•he average performance of U. S. healthcare was evaluated against benchmarks from top-performing health providers in the United States and other top-performing countries. •Findings from the Scorecard showed that out of a possible score of 100 the United States achieved an overall score of 65 and that performance had not improved from 2006 to 2008
•Specifically, the Scorecard found that access to healthcare significantly declined and health system efficiency remained low
•On a brighter side, quality metrics used in the Scorecard that had been the focus of national campaigns or public reporting efforts showed some significant gains
Poor healthcare system performance impacts individuals as well the nation as a whole. According to the 2008 Scorecard, what is anticipated in the next decade?
•According to the 2008 Scorecard, expenditures on healthcare in the next decade are expected to increase to 20 percent of the national income
•It is also anticipated that there will be an increase in the population of uninsured individuals.
What are the results of improved health system performance?
•Fewer people would die prematurely
•More people would have access to primary care providers and receive preventative care, •Cost savings could be realized in federal programs such as Medicare by reducing hospital readmissions and hospitalizations for preventable conditions
Providing better primary care and care coordination would entail?
•Increasing patients' access to round-the-clock care
•Managing chronic conditions, and promoting efficient use of specialized and expensive resources are ways recommended to improve the healthcare system
•Improvement in mental healthcare
•Adoption of interoperable health information technology, and
•New payment policies are also among the suggestions of the 2008 Scorecard report for improving healthcare system performance
Biomedical and Technological Advances in Medicine: 19th-century advances
•Rapid progress in medical science and technology during the late 19th and 20th centuries revolutionized the way healthcare was provided. •The most important scientific advancement was the discovery of bacteria as the cause of infectious disease
•The most important technological development was the use of anesthesia for surgical procedures.
What did the 19-century advances lay the basis for?
These 19th-century advances laid the basis for the •Development of antibiotics and other pharmaceuticals and
•The application of sophisticated surgical procedures in the 20th century
What did the National Institutes of Health (NIH) do to further medical advances in the 21st century?
The NIH sought the input of more than 300 recognized leaders in academia, industry, government, and the public to create a "Roadmap" program to accelerate biomedical advances, create effective prevention strategies and new treatments, and bridge knowledge gaps.
The NIH Roadmap program, which involves a plethora of NIH institutes and centers, has three main strategic initiatives:
1. New Pathways to Discovery, which includes a comprehensive understanding of building blocks of the body's cells and tissues and how complex biological systems operate, structural biology, molecular libraries and imaging, nanotechnology, bioinformatics, and computational biology;
2. Research Teams of the Future, including interdisciplinary research, high-risk research, and public-private partnerships; and
3. Re-engineering the Clinical Research Enterprise
Through these efforts, NIH will boost the resources and technologies needed for 21st century biomedical science. Figure 12.1 offers a time line of key biological and technological advances at a glance.
Key biological and technological advances in medicine:
1842 - First recorded use of ether as an anesthetic
1860s - Louis Pasteur laid the foundation for modern bacteriology
1865 - Joseph Lister was the first to apply Pasteur's research to the treatment of infected wounds
1880s-1890s - Steam first used in physical sterilization
1898 - Introduction of rubber surgical gloves, sterilization, and antisepsis
1895 - Wilhelm Roentgen made observations that led to the development of x-ray technology
1940 - Studies of prothrombin time first made available
1941-1946 - Studies of electrolytes; development of major pharmaceuticals
1957 - Studies of blood gas
1961 - Studies of creatine phosphokinase
1970s - Surgical advances in cardiac bypass surgery, surgery for joint replacements, and organ transplantation
1971 - Computed tomography first used in England
1974 - Introduction of whole-body scanners
1980s - Introduction of magnetic resonance imaging
1990s - Further technological advances in pharmaceuticals and genetics; Human Genome Project
2000s - NIH creates roadmap to accelerate biomedical advances, create effective prevention strategies and new treatments, and bridge knowledge gaps in the 21st century
Surgical procedures and anesthesia:
•Surgical procedures were performed before the development of anesthesia, so surgeons had to work quickly on conscious patients to minimize risk and pain
•The availability of anesthesia made it possible for surgeons to develop more advanced surgical techniques
•The use of ether as an anesthetic was first recorded in 1842
•At about the same time, nitrous oxide was introduced for use during dental procedures, and chloroform was used to reduce the pain of labor. •By the 1860s, the physicians who treated the casualties of the American Civil War on both sides had access to anesthetic and pain-killing drugs
Louis Pasteur
•In the 1860s, Louis Pasteur began studying a condition in wine that made it sour and unpalatable
•He discovered that the wine was being spoiled by bacterial growths
•His research proved that tiny, living organisms (called bacteria) increase through reproduction and cause infectious disease
•Pasteur also demonstrated that heat and certain chemicals such as alcohol could destroy bacteria. •In doing so, he laid the foundation for modern bacteriology
•After 20 years of research into the biology of microorganisms, Pasteur began studying human diseases
•In 1885, he developed a vaccine that prevented rabies
The importance of cleanliness: role of microorganisms
•The importance of cleanliness had been known since early times, the role that microorganisms played in disease was not understood until Pasteur conducted his research
•In 1865, Joseph Lister was the first to apply Pasteur's research to the treatment of infected wounds
•Lister began by protecting open fractures from infection by treating the wounds with carbolic acid (a disinfectant)
•His discovery was called the antiseptic principle. •Antisepsis reduced the mortality rate in Lister's hospital after 1865 from 45 to 12 percent. He published his results in 1868, and soon carbolic acid was being used to prevent bacterial contamination during surgery.
What technological advance had a major impact on surgery and in other areas throughout the hospital during the 1880s and 1890s?
•During the 1880s and 1890s, physical sterilization using steam was developed
•The sterile operative technique was further advanced through the introduction of rubber surgical gloves in 1898
•Other advances included the use of sterile gowns, masks, and antibiotics and other drugs
Wilhelm Roentgen:
•In 1895, the well-known physicist Wilhelm Roentgen made observations that led to the development of x-ray technology
•He found that he could create images of the bones in his hand by passing x-rays through his hand and onto a photographic plate
•Radiographic technology is used extensively to diagnose illnesses and injuries today
Many advances in laboratory testing occurred during the 20th century.
•Equipment that allows the rapid laboratory processing of diagnostic and prognostic examinations was developed, and the number of diagnostic laboratory procedures increased dramatically
•For example, studies of prothrombin time were first made available in 1940, electrolytes in the period 1941-1946, blood gas in 1957, creatine phosphokinase in 1961, serum hepatitis in 1970, and carcinoembryonic antigen (the first cancer-screening test) in 1974
Diagnostic radiology and radiation therapy have undergone huge advances in the past 50 years: what was the enormous advance first used in 1971?
•An enormous advance first used in 1971 in England is an imaging modality called computed tomography (CT)
•The first CT scanners were used to create images of the skull
•Whole-body scanners were introduced in 1974
•In the 1980s, another powerful diagnostic tool was added—magnetic resonance imaging (MRI). •MRI is a noninvasive technique that uses magnetic and radio-frequency fields to record images of soft tissues
Surgical advances since the 1970s:
•Cardiac bypass surgery was developed in the 1970s, as were the techniques for joint replacement
•Organs are now successfully transplanted, and artificial organs are being tested
•New surgical techniques have included the use of lasers in ophthalmology, gynecology, and urology. •Microsurgery is now a common tool in the reconstruction of damaged nerves and blood vessels
•The use of robotics in surgery holds great promise for the future
Today, what is happening in the health care world that promises to change the healthcare paradigm?
•Today, it is human genetics and progress toward sequencing the human genome that promise to change the healthcare paradigm
•New research on cellular and molecular changes underlying disease processes will necessitate new approaches to diagnosis and treatment
What is the current paradigm for treating disease?
The current paradigm for treating disease is to •Meet with the patient
•Diagnose the patient's symptoms, and
•Prescribe therapy to treat them
What is the hope that genetic medicine will enable?
The hope is that genetic medicine will enable the provider to
•Identify gene patterns that underlie the process of cellular dysfunction that leads to injury before even meeting with the patient
•Thus, diseases will be diagnosed much earlier, enabling physicians to provide treatment to stop or slow down the disease process
The study of cell-based technologies is particularly controversial. Cell-based technologies include:
•Tissue engineering, which involves the use of biomaterials to develop new tissue and even whole organs with or without transplanting cells
•Human embryonic stem cells and/or adult stem cells used for transplantation and in regenerative medicine
•Gene therapy/cell transplantation
•Advances in cell-based technologies such as cell-signaling pathways, growth factors, and the human genome project are encouraging ongoing research in these areas (ElÇin 2003)
Human Genome Project (HGP): what are the three principal goals?
The year 2003 saw completion of the Human Genome Project (HGP), a 13-year-long international effort with three principal goals: to
1. Determine the sequence of the three billion DNA subunits
2. To identify all human genes, and
3. To enable genes to be used in further biological study
Human Genome Project (HGP): Parallel sequencing
•A process called parallel sequencing was used on selected model organisms to help develop the technology and interpret gene function
•The U.S. Human Genome Project was a joint venture of the Department of Energy's HGP and the NIH's National Human Genome Research Institute.
12.2 Check your understanding:
1. Which of the following laws created the Healthcare Integrity and Protection Data Bank?
A. Health Information Portability and Accountability Act
12.2 Check your understanding:
2. What government agency supports medical research?
D. National Institutes of Health
12.2 Check your understanding:
3. A HIT student has asked you why Medicare reimburses healthcare providers through prospective payment systems. Which of the following pieces of legislation would you use as your explanation?
C. Tax Equity and Fiscal Responsibility Act of 1982
12.2 Check your understanding:
4. A friend and I are debating cell-based technologies. Which of the following is a reason why I might argue for this technology?
B. Diseases could be diagnosed earlier
12.2 Check your understanding:
5. Which of the following best describes Medicaid?
B. Federally mandated healthcare program for low-income people
12.2 Check your understanding: 6-10. Instructions: Match the descriptions with the appropriate legislation:
6. Healthcare Quality Improvement Act of 1986
c. Established the National Practitioner Data Bank
7. Omnibus Budget Reconciliation Act of 1990
d. Required PROs to report actions taken against physicians to state medical boards and licensing agencies
8. Public Law 92-603 of 1972
b. Required concurrent review of Medicare and Medicaid patients
9. Omnibus Budget Reconciliation Act of 1989
e. Instituted and Researched the Agency for Healthcare Policy
10. Hill-Burton Act
a. Authorized grants for states to construct new hospitals
A number of trade and professional associations currently influence the practice of medicine and the delivery of healthcare services in the United States. Descriptions of a few of these associations: AMA
American Medical Association (AMA)
•The AMA was founded in 1847 as a national voluntary service organization
•Today, its membership totals approximately 815,000 physicians from every area of medicine. •The organization is headquartered in Chicago
The AMAs mission and key objectives are:
•Its mission is to promote the science and art of medicine and to improve public health
•Its key objectives are:
1. To become the world leader in obtaining, synthesizing, integrating, and disseminating information on health and medical practice
2. To remain the acknowledged leader in promoting professionalism in medicine and setting standards for medical ethics, practice, and education
3. To continue to be an authoritative voice and influential advocate for patients and physicians
4. To continue to be a sound organization that provides value to its members, related organizations, and employees
The AMA acts as an accreditation body for:
•In addition, the AMA acts as an accreditation body for medical schools and residency programs. It also maintains and publishes the Current Procedural Terminology (CPT) coding system
•CPT codes are the basis of reimbursement systems for physician's services and other types of healthcare services provided on an ambulatory basis
Trade and professional associations-American Hospital Association (AHA):
•The AHA was founded in 1899
•At its first meeting, eight hospital superintendents gathered in Cleveland, OH, to exchange ideas, compare methods of hospital management, discuss economics, and explore common interests and new trends
•Originally called the Association of Hospital Superintendents, its mission was "to facilitate the interchange of ideas, comparing and contrasting methods of management, the discussion of hospital economics, the inspection of hospitals, suggestions of better plans for operating them, and such other matters as may affect the general interest of the membership"
What did the AHA adopt and change in 1906?
•The association adopted a new constitution in 1906 and a new name, the American Hospital Association
•At that time, it had 234 members. Its major concerns were developing hospital standards and building the management skills of its members
What is the mission of the AHA today?
•Today, the mission of the AHA is to advance the health of individuals and communities
•The association's current membership includes approximately 5,000 hospitals and healthcare institutions, 600 associate member organizations, and 40,000 individual executives active in the healthcare field. Its headquarters are located in Chicago.
•The AHA publishes Coding Clinic, which provides official ICD-9-CM coding advice
Trade and professional associations-The Joint Commission (TJC):
•Since 1952, the Joint Commission has continually evolved to meet the changing needs of healthcare organizations
•The organization changed its name from the Joint Commission on Accreditation of Hospitals (JCAH) to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in the late 1980s and more recently in 2009 to the Joint Commission (TJC). It is the nation's oldest and largest healthcare standards-setting body.
What does The Joint Commission (TJC) conduct in more than 17,000 healthcare organizations and programs? Who is included in these orgs and programs?
•It conducts accreditation surveys in more than 17,000 healthcare organizations and programs, including:
•Ambulatory care facilities
•Long-term care facilities
•Behavioral health facilities
•Healthcare networks, and
•In addition to acute care hospitals
What must be demonstrated to earn and maintain the Joint Commission's Gold Seal of Approval?
An organization must demonstrate compliance with TJC standards by successfully undergoing an on-site survey at least every three years and laboratories must be surveyed every two years
What types of healthcare organizations does TJC accredits?
•General, psychiatric, children's, and rehabilitation hospitals
•Critical access hospitals
•Home care organizations, including medical equipment services, hospice services
•Nursing homes and other long-term care facilities
•Behavioral healthcare organizations, addiction services
•Ambulatory care providers, including group practices and office-based surgery practices
•Independent or freestanding clinical laboratories
Who governs the TJC? Who are their corporate members? Where is the TJC's central office located?
•A board of commissioners made up of clinicians, administrators, educators, and others governs the organization
•TJC's corporate members are the American College of Physicians, the American College of Surgeons, the American Dental Association, the American Hospital Association, and the American Medical Association
•TJC's central office is located in Oakbrook Terrace, IL
TJC sets standards to aid organizations in providing safe and high-quality healthcare. How are standards developed? What do the standards set expectations for?
•Standards are developed in consultation with a variety of healthcare experts and updated periodically
•The standards set expectations for performance that affect the safety and quality of patient care. •About 50 percent of standards relate to patient safety.
In addition, TJC has instituted a number of patient safety programs including (Joint Commission 2009b):
•National Patient Safety Goals: Annually addresses specific patient safety concerns.
•Sentinel Event Policy: Designed to identify and prevent the occurrence of events that lead to unexpected deaths or events leading to or potentially leading to serious physical injuries. When a sentinel event occurs, a root cause analysis and identification of improvements to risks must be undertaken.
•Sentinel Event Alert: A newsletter that provides important information on specific types of sentinel events such as medication and blood transfusion errors and how to prevent their occurrences.
•Universal Protocol: Provides a protocol to prevent surgical mishaps such as procedures performed on the wrong person and wrong site.
In the late 1990s, what did TJC move away from to begin to emphasize? What initiative reflected the new approach, and what was it's goal?
•In the late 1990s, TJC moved away from traditional quality assessment processes and began emphasizing performance and quality improvement
•The ORYX initiative reflected the new approach. •The goal of the ORYX initiative was to incorporate the ongoing collection of quality and performance data into the accreditation process.
What do outcome measures document?
•Outcome measures document the results of care for individual patients as well as for specific types of patients grouped by diagnostic category
•For example, an acute care hospital's overall rate of post-surgical infection would be considered an outcome measure
•Outcome measures must be reported to TJC via software from vendors that have been approved by TJC for this purpose
Blue Cross and Blue Shield Association: What was the forerunner of the BCBS Association? When were ties broken? Who did BCBS merge with in 1982?
•The forerunner of the Blue Cross and Blue Shield Association was a commission instituted by the AHA in 1929
•In 1960, the commission was replaced by the Blue Cross Association and ties to the AHA were broken
•In 1982, the Blue Cross Association merged with the National Association of Blue Shield Plans to become the Blue Cross and Blue Shield Association, often referred to as "the Blues."
•The Blue Cross and Blue Shield Association (BCBSA) is a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively employ over 150,000 people nationwide
As the nation's oldest and largest family of health benefits companies, the Blue Cross and Blue Shield Association prides itself on what?
•Being the most recognized brand in the health insurance industry along with many other celebrated milestones
•More than 90 percent of hospitals and 80 percent of physicians contract with BCBS companies in the United States, which is more than any other commercial insurer
The purpose of the Blue Cross and Blue Shield plans:
"The purpose of Blue Cross and Blue Shield plans is to coordinate the activities of the local plans throughout the United States. More than 80 percent of hospitals and nearly 90 percent of physicians contract directly with Blue Cross and Blue Shield plans"
American College of Healthcare Executives (ACHE):
The national professional organization of healthcare administrators that provides certification services for its members and promotes excellence in the field
The American College of Healthcare Executives (ACHE) is an organization for healthcare administrators.
•The American College of Healthcare Executives (ACHE) is an organization for healthcare administrators
•Like most of the organizations already discussed, it is headquartered in Chicago
•Its mission is to serve as "the professional membership society for healthcare executives; to meet members' professional, educational, and leadership needs; to promote high ethical standards and conduct; and to enhance healthcare leadership and management excellence"
•ACHE has nearly 30,000 members internationally. •It also publishes books and textbooks on healthcare services management.
American Nurses Association:
•The ANA was founded in 1897 and is headquartered in Washington, DC
•It is a professional association as well as the strongest labor union active in the nursing profession, representing the interests of the nation's 2.6 million registered nurses
•The ANA's mission is to work for the improvement of health standards and the availability of healthcare services, to foster high professional standards for nurses, to stimulate and promote the professional development of nurses, and to advance the economic and general welfare of its members
American Health Information Management Association (AHIMA):
•Professional membership organization for managers of health record services and healthcare information
•It was founded in 1928 under the name of the Association of Record Librarians of North America. •In 1929, the association adopted a constitution and bylaws
•The name of the association was changed to the American Medical Record Association in 1970 and then to the American Health Information Management Association in 1991
Where is AHIMA headquartered, and what is it's mission?
•Headquartered in Chicago, the association currently has more than 56,000 members
•Its mission is "to be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing"
•The association's vision is "quality healthcare through quality information"
Commission on Accreditation of Rehabilitation Facilities (CARF):
A private, not-for-profit organization that develops customer-focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards
Commission on Certification of Health Informatics and Information Management (CHIIM):
An independent body within AHIMA that serves the public and the profession by establishing and enforcing standards for the initial certification and certification maintenance of health informatics and information management professionals
Who is AHIMA the sponsoring organization for?
AHIMA is the sponsoring organization for the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM):
•CAHIIM is an independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality accreditation standards for health informatics (HI) and health information management (HIM) educational programs
•CAHIIM accredits associate and baccalaureate programs in health information management and is currently developing accreditation standards for graduate-level educational programs in health information management and health informatics
What process does AHIMA also sponsor?
AHIMA also sponsors an approval process for certificate programs for coding specialists through a special program called the Coding Education Program Approval (CEPA)
The Commission on Certification for Health Informatics and Information Management (CCHIIM) is an AHIMA commission dedicated to assuring the competency of professionals practicing HIIM.
•CCHIIM serves the public by establishing, implementing, and enforcing standards and procedures for certification and recertification of HIIM professionals
•Through certification, CCHIIM assures the competency of professionals practicing health informatics and information management worldwide
•CCHIIM offers a variety of credentials in the areas of health information management, coding, health data analytics, and healthcare privacy and security
Certification Commission for Health Information Technology (CCHIT):
•Founded in 2004, the Certification Commission for Health Information Technology (CCHIT) is a nonprofit organization whose mission is to accelerate the adoption of health information technology
•The Commission is recognized by the federal government as a certifying body
What does the CCHIT offer?
•The Commission offers a CCHIT Certified Comprehensive certification program that inspects health information technology products against criteria for functionality, interoperability, privacy, and security
•Certification is offered for ambulatory, inpatient, and emergency electronic health records and e-prescribing and health information exchange
•More than 200 EHR products were certified by mid-2009, representing over 75% of the marketplace
CCHIT's second certification program:
•In October 2009 CCHIT launched a second certification program called the Preliminary ARRA 2001 Certification
•This program is a modular certification program for applications that address one or more of the meaningful use objectives of the American Recovery and Reinvestment Act (ARRA)
CCHIT offers numerous venues for participation.
Of particular importance to the HIM professional, are the opportunities to volunteer on a CCHIT work group which drive the development of certification criteria and test scripts that are used in the vendor inspection process
Other Healthcare-related Associations: Many other healthcare-related associations serve their professional members by providing educational, certification, and accreditation services. The best known include:
•The American Osteopathic Association
•The American Dental Association
•The American College of Surgeons
•The American League for Nursing
•The American Society of Clinical Pathologists
•The American Dietetic Association
•The Commission on Accreditation of Rehabilitation Facilities
•The American Association of Nurse Anesthetists
Check your understanding: 12.3
1. What organization has the mission of promoting the science and art of medicine and to improve public health?
B. American Medical Association
Check your understanding: 12.3
2. Which organization certifies the EHR?
B. Commission of Certification of Health Information Technology
Check your understanding: 12.3
3. A college wants to start a new HIT program. Who should the staff contact for program accreditation information?
C. Commission on Accreditation for Health Informatics and Information Management Education
Check your understanding: 12.3
4. At our hospital, a patient died in childbirth. As this is a sentinel event, what do we need to do?
D. Perform a root cause analysis
Check your understanding: 12.3
5. I need to order the Coding Clinic for our coders. Who should I contact?
C. American Hospital Association
Check your understanding: 12.3
6-10. Instructions: Match each organization with the description that best describes it.
6. The Joint Commission
d. This organization developed the National Patient Safety Guidelines.
7. Commission on Certification of Health Information Technology
c. This organization's mission is to certify electronic health records
8. American Nurses Association
b. Part of this organization's mission is to work for the improvement of health standards and the availability of healthcare services.
9. American Medical Association
e. This organization shares information on health and medical practices
10. American Health Information Management Association
a. This association was founded in 1928 under the name of the Association of Record Librarians of North America
Organization and Operation of Modern Hospitals. The term hospital can be applied to any healthcare facility that:
•Has an organized medical staff
•Provides permanent inpatient beds
•Offers around-the-clock nursing services
•Provides diagnostic and therapeutic services
What do most hospitals provide? Who are inpatients?
•Most hospitals provide acute care services to inpatients
•Acute care is the short-term care provided to diagnose and/or treat an illness or injury
•The individuals who receive acute care services in hospitals are considered inpatients
•Inpatients receive room-and-board services in addition to continuous nursing services
•Generally, patients who spend more than 24 hours in a hospital are considered inpatients.
What is the average length of stay (ALOS) in an acute care hospital? After 30 days, what is it considered?
•The average length of stay (ALOS) in an acute care hospital is 30 days or less
•Hospitals that have ALOSs longer than 30 days are considered long-term care facilities
What are the main reasons that the ALOS in hospitals has decreased in recent years?
•With recent advances in surgical technology, anesthesia, and pharmacology, the ALOS in an acute care hospital is much shorter today than it was only a few years ago. In addition, many diagnostic and therapeutic procedures that once required inpatient care now can be performed on an outpatient basis.
•For example, before the development of laparoscopic surgical techniques, a patient might be hospitalized for 10 days after a routine appendectomy (surgical removal of the appendix). •Today, a patient undergoing a laparoscopic appendectomy might spend only a few hours in the hospital's outpatient surgery department and go home the same day
•The influence of managed care and the emphasis on cost control in the Medicare/Medicaid programs also have resulted in shorter hospital stays
What activities are carried out in large acute care hospitals?
•In large acute care hospitals, hundreds of clinicians, administrators, managers, and support staff must work closely together to provide effective and efficient diagnostic and therapeutic services
•Most hospitals provide services to both inpatients and outpatients
•A hospital outpatient is a patient who receives hospital services without being admitted for inpatient (overnight) clinical care
•Outpatient care is considered a kind of ambulatory care
•Much of the clinical training for physicians, nurses, and allied health professionals is conducted in hospitals
•Medical research is another activity carried out in hospitals
Growth in Numbers of Hospitals
•The number of hospitals in the United States increased from 178 in 1873 to 4,300 in 1909
•In 1946, at the close of the Second World War, there were 6,000 hospitals, with 3.2 beds available for every 1,000 persons
•By 2008, the number of registered hospitals in the United States had reached 5,815, with a total of 951,045 beds
•Most hospitals in the United States are nonprofit or owned by local, state, or federal governments (Jonas and Kovner 2005, 224)
•Expenditures on healthcare in 2008 totaled $2.4 trillion
•In 2008 hospital costs totaled about 33 percent of the total healthcare spending
Rise and Fall in Numbers of Hospitals:
•During the 1980s, medical advances and cost-containment measures enabled many procedures that once required inpatient hospitalization to be performed on an outpatient basis
•Outpatient hospital visits increased by 40 percent, resulting in a decrease in hospital admissions
•Fewer admissions and shortened lengths of stay for patients resulted in a significant reduction in the number of hospitals and hospital beds. •Healthcare reform efforts and the rise of managed care resulted in enough hospital closings and mergers to reduce the number of governmental and community-based hospitals in the United States to approximately 5,000 (Sultz and Young 2004, 68)
•In 2008 the number of hospitals in the United States reached 5,815. This figure includes, among others, community, federal, nonfederal psychiatric, and nonfederal long-term care hospitals
Types of Hospitals, Hospitals can be classified in many different ways, including by:
•Number of beds
•Types of services provided
•Types of patients served
•For-profit or not-for-profit status
•Type of ownership
Number of Beds
•A hospital's number of beds refers to the number of beds that are equipped and staffed for patient care
•The term bed capacity sometimes is used to reflect the maximum number of inpatients the hospital can care for
•Hospitals with fewer than 100 beds are usually considered small. Most U.S. hospitals fall into this category
•Some large, urban hospitals may have more than 500 beds
•The number of beds is usually broken down by adult beds and pediatric beds
•The number of maternity beds and other special categories may be listed separately
•Hospitals also can be categorized according to the number of outpatient visits per year
Types of Services Provided, Some hospitals specialize in certain types of service and treat specific illnesses. For example:
•Rehabilitation hospitals generally provide long-term care services to patients recuperating from debilitating or chronic illnesses and injuries such as strokes, head and spine injuries, and gunshot wounds. Patients often stay in rehabilitation hospitals for several months.
•Psychiatric hospitals provide inpatient care for patients with mental and developmental disorders. In the past, the ALOS for psychiatric inpatients was longer than it is today. Rather than months or years, most patients now spend only a few days or weeks per stay. However, many patients require repeated hospitalization for chronic psychiatric illnesses
•General hospitals provide a wide range of medical and surgical services to diagnose and treat most illnesses and injuries.
•Specialty hospitals provide diagnostic and therapeutic services for a limited range of conditions such as burns, cancer, tuberculosis, or obstetrics/gynecology
Types of Patients Served:
Some hospitals specialize in serving specific types of patients. For example, children's hospitals provide specialized pediatric services in a number of medical specialties
For-Profit or Not-for-Profit Status
•Hospitals also can be classified based on their ownership and profitability status
•Not-for-profit healthcare organizations use excess funds to improve their services and to finance educational programs and community services
•For-profit healthcare organizations are privately owned
•Excess funds are paid back to the managers, owners, and investors in the form of bonuses and dividends
Type of Ownership, The most common ownership types for hospitals and other kinds of healthcare organizations in the United States include:
1. Government-owned hospitals
2. Proprietary hospitals
3. Organization of Hospital Services
Government-owned hospitals
•Are operated by a specific branch of federal, state, or local government as not-for-profit organizations. •(Government-owned hospitals sometimes are called public hospitals.)
•They are supported, at least in part, by tax dollars
•Examples of federally owned and operated hospitals include those operated by the •Department of Veterans Affairs to serve retired military personnel
•The Department of Defense operates facilities for active military personnel and their dependents. •Many states own and operate psychiatric hospitals
•County and city governments often operate public hospitals to serve the healthcare needs of their communities, especially those residents who are unable to pay for their care.
Proprietary hospitals
•May be owned by private foundations, partnerships, or investor-owned corporations Large corporations may own a number of for-profit hospitals, and the stock of several large U.S. hospital chains is publicly traded
Voluntary hospitals:
•Not-for-profit hospitals owned by universities, churches, charities, religious orders, unions, and other not-for-profit entities
•They often provide free care to patients who otherwise would not have access to healthcare services.
The organizational structure of every hospital is designed to meet its specific needs, for example:
Most acute care hospitals are made up of a board of directors, a professional medical staff, an executive administrative staff, medical and surgical services, patient care (nursing) services, diagnostic and laboratory services, and support services (for example, nutritional services, environmental safety, and HIM services) (see figure 12.2)
Board of Directors: primary responsibility?
•The board of directors has primary responsibility for setting the overall direction of the hospital
•(In some hospitals, the board of directors is called the governing board or board of trustees.) •The board works with the chief executive officer (CEO) and the leaders of the organization's medical staff to develop the hospital's strategic direction as well as its mission (statement of the organization's purpose and the customers it serves), vision (description of the organization's ideal future), and values (descriptive list of the organization's fundamental principles or beliefs).
Other specific responsibilities of the board of directors include:
1. Establishing bylaws in accordance with the organization's legal and licensing requirements
2. Selecting qualified administrators
3. Approving the organization and makeup of the clinical staff
4. Monitoring the quality of care
The board's members:
•Elected or appointed for specific terms of service (for example, five years)
•Most boards also elect officers, commonly a chairman, vice-chairman, president, secretary, and treasurer
•The size of the board varies considerably. •Individual board members are called directors, board members, or trustees. Individuals serve on one or more standing committees such as the executive committee, joint conference committee, finance committee, strategic planning committee, and building committee.
The makeup of the board:
•Depends on the type of hospital and the form of ownership
•For example, the board of a community hospital is likely to include local business leaders, representatives of community organizations, and other people interested in the welfare of the community
•The board of a teaching hospital, on the other hand, is likely to include medical school alumni and university administrators, among others.
What has made the governing of hospitals especially difficult in the past two decades?
•Increased competition among healthcare providers and limits on managed care and Medicare/Medicaid reimbursement have
•In the future, boards of directors will continue to face strict accountability in terms of cost containment, performance management, and integration of services to maintain fiscal stability and to ensure the delivery of high-quality patient care
Medical Staff, who does it consist of? What is the staffs primary objective?
•The medical staff consists of physicians who have received extensive training in various medical disciplines (internal medicine, pediatrics, cardiology, gynecology/obstetrics, orthopedics, surgery, and so on)
•The medical staff's primary objective is to provide high-quality patient care to the patients who come to the hospital
•The physicians on the hospital's medical staff diagnose illnesses and develop patient-centered treatment regimens
•Moreover, they may serve on the hospital's governing board, where they provide critical insight relevant to strategic and operational planning and policy making.
The medical staff is the aggregate of physicians who have been granted permission to provide clinical services in the hospital. What is this permission called?
•This permission is called clinical privileges
•An individual physician's privileges are limited to a specific scope of practice. For example, an internal medicine physician would be permitted to diagnose and treat a patient with pneumonia, but not to perform a surgical procedure
•Most members of the medical staff are not actually employees of the hospital, although many hospitals do directly employ radiologists, anesthesiologists, and critical care specialists.
Medical staff classification refers to:
•Medical staff classification refers to the organization of physicians according to clinical assignment •Depending on the size of the hospital and on the credentials and clinical privileges of its physicians, the medical staff may be separated into departments such as medicine, surgery, obstetrics, pediatrics, and other specialty services
•Typical medical staff classifications include active, provisional, honorary, consulting, courtesy, and medical resident assignments
Officers of the medical staff usually include who? Who authorizes these offices?
•A president or chief of staff
•A vice-president or chief of staff-elect, and
•A secretary
•These offices are authorized by a vote of the entire active medical staff. •The president presides over all regular meetings of the medical staff and is an ex officio member of all medical staff committees
•The secretary ensures that accurate and complete minutes of the meetings are kept and that correspondence is handled appropriately
The medical staff operates according to a predetermined set of policies called the medical staff bylaws:
•The bylaws spell out the specific qualifications that physicians must demonstrate before they can practice medicine in the hospital
•They are considered legally binding. Any changes to the bylaws must be approved by a vote of the medical staff and the hospital's governing body
Clinical privileges:
The authorization granted by a healthcare organization's governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits
Medical staff classifications:
The organization of physicians in a healthcare facility; typical medical staff classifications include active, provisional, honorary, consulting, courtesy, and medical resident assignments
Medical staff bylaws:
A collection of guidelines adopted by a hospital's medical staff to govern its business conduct and the rights and responsibilities of its members
Chief privacy officer:
A position that (1) oversees activities related to the development, implementation, and maintenance of, and adherence to, organizational policies and procedures regarding the privacy of and access to patient-specific information and (2) ensures compliance with federal, state, and accrediting body rules and regulations concerning the confidentiality and privacy of health-related information
Chief information officer (CIO):
The senior manager responsible for the overall management of information resources in an organization
CEO or chief administrator
•The leader of the administrative staff is the CEO or chief administrator
•The CEO is responsible for implementing the policies and strategic direction set by the hospital's board of directors
•He or she also is responsible for building an effective executive management team and coordinating the hospital's services
Today's healthcare organizations commonly designate which positions as members of the executive management team?
Today's healthcare organizations commonly designate a chief financial officer (CFO), a chief operating officer (COO), and a chief information officer (CIO) as members of the executive management team
What is the executive management team responsible for?
The executive management team is responsible for managing the hospital's finances and ensuring that the hospital complies with the federal, state, and local rules, standards, and laws that govern the delivery of healthcare services.
Depending on the size of the hospital, the CEO's staff may include:
•Healthcare administrators with job titles such as vice-president, associate administrator, department director or manager, or administrative assistant. •Department-level administrators manage and coordinate the activities of the highly specialized and multidisciplinary units that perform clinical, administrative, and support services in the hospital
Healthcare administrators:
•Healthcare administrators may hold advanced degrees in healthcare administration, nursing, public health, or business management
•A growing number of hospitals are hiring physician executives to lead their executive management teams. •Many healthcare administrators are fellows of ACHE
Case management:
1. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient
2. A process that integrates and coordinates patient care over time and across multiple sites and providers, especially in complex and high-cost cases
3. The process of developing a specific care plan for a patient that serves as a communication tool to improve quality of care and reduce cost
Chief nursing officer (CNO):
The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services
Patient Care Services: most direct patient care delivered in hospitals is provided by? What does modern nursing require? What does patient care services constitute in almost every hospital?
•Most direct patient care delivered in hospitals is provided by professional nurses. •Modern nursing requires a diverse skill set, advanced clinical competencies, and postgraduate education
•In almost every hospital, patient care services constitutes the largest clinical department in terms of staffing, budget, specialized services offered, and clinical expertise required.
The quantity and quality of nursing care available to patients are influenced by what factors? What is also a critical component of quality?
•Nurses are responsible for providing continuous, around-the-clock treatment and support for hospital inpatients.
•The nursing staff's educational preparation and specialization, experience, and skill level
•The level of patient care staffing also is a critical component of quality
How do today's nurses play a wider role in treatment planning and case management?
•Traditionally, physicians alone determined the type of treatment each patient would receive
•However, today's nurses are playing a wider role in treatment planning and case management
•They identify timely and effective interventions in response to a wide range of problems related to the patients' treatment, comfort, and safety
•Their responsibilities include performing patient assessments, creating care plans, evaluating the appropriateness of treatment, and evaluating the effectiveness of care
•At the same time that they provide technical care, effective nursing professionals also offer personal care that recognizes the concerns and emotional needs of patients and their families
What type of nurse usually administers patient care services? What is this role referred to as?
•A registered nurse qualified by advanced education and clinical and management experience usually administers patient care services
•Although the title may vary, this role is usually referred to as the chief nursing officer (CNO) or vice-president of nursing or patient care
•The CNO is a member of the hospital's executive management team and usually reports directly to the CEO.
In any nursing organizational structure, several types of relationships can be identified, including:
1. Line relationships identify the positions of superiors and subordinates and indicate the levels of authority and responsibility vested with each position. For example, a supervisor in a postop surgical unit would have authority to direct the work of several nurses
2. Lateral relationships define the connections among various positions in which a hierarchy of authority is not involved. For example, the supervisors of preop and postop surgical units would have parallel positions in the structure and would need to coordinate the work they perform.
3. Functional relationships refer to duties that are divided according to function. In such arrangements, individuals exercise authority in one particular area by virtue of their special knowledge and expertise
Diagnostic and Therapeutic Services:
•The services provided to patients in hospitals go beyond the clinical services provided directly by the medical and nursing staff
•Many diagnostic and therapeutic services involve the work of allied health professionals
•Allied health professionals receive specialized education and training, and their qualifications are registered or certified by a number of specialty organizations
•Diagnostic and therapeutic services are critical to the success of every patient care delivery system
•Diagnostic services include clinical laboratory, radiology, and nuclear medicine
•Therapeutic services include radiation therapy, occupational therapy, and physical therapy
Clinical Laboratory Services; The clinical laboratory is divided into two sections:
•Anatomic pathology and clinical pathology •Anatomic pathology deals with human tissues and provides surgical pathology, autopsy, and cytology services
•Clinical pathology deals mainly with the analysis of body fluids—principally blood, but also urine, gastric contents, and cerebrospinal fluid.
Pathologists / Lab techs.
•Physicians who specialize in performing and interpreting the results of pathology tests are called pathologists
•Laboratory technicians are allied health professionals trained to operate laboratory equipment and perform laboratory tests under the supervision of a pathologist.
•Radiology involves the use of radioactive isotopes, fluoroscopic and radiographic equipment, and CT and MRI equipment to diagnose disease
•Physicians who specialize in radiology are called radiologists
•They are experts in the medical use of radiant energy, radioactive isotopes, radium, cesium, and cobalt as well as x-rays, radium, and radioactive materials. They also are experts in interpreting x-ray, MRI, and CT diagnostic images.
Radiology technicians
Radiology technicians are allied health professionals trained to operate radiological equipment and perform radiological tests under the supervision of a radiologist
Nuclear Medicine and Radiation Therapy; Radiologists:
•Radiologists also may specialize in nuclear medicine and radiation therapy
•Nuclear medicine involves the use of ionizing radiation and small amounts of short-lived radioactive tracers to treat disease, specifically neoplastic disease (that is, nonmalignant tumors and malignant cancers)
•Based on the mathematics and physics of tracer methodology, nuclear medicine is widely applied in clinical medicine
•However, most authorities agree that medical science has only scratched the surface in terms of nuclear medicine's potential capabilities
Radiation therapy:
•Radiation therapy uses high-energy x-rays, cobalt, electrons, and other sources of radiation to treat human disease
•In current practice, radiation therapy is used alone or in combination with surgery or chemotherapy (drugs) to treat many types of cancer
•In addition to external beam therapy, radioactive implants (as well as therapy performed with heat—hyperthermia) are available
Occupational Therapy:
•Occupational therapy is the medically directed use of work and play activities to improve patients' independent functioning, enhance their development, and prevent or decrease their level of disability
•The individuals who perform occupational therapy are credentialed allied health professionals called occupational therapists •They work under the direction of physicians
•Occupational therapy is made available in acute care hospitals, clinics, and rehabilitation centers
Providing occupational therapy services begins with what?
•Providing occupational therapy services begins with an evaluation of the patient and the selection of therapeutic goals. •Occupational therapy activities may involve the adaptation of tasks or the environment to achieve maximum independence and to enhance the patient's quality of life.
What does an occupational therapist treat?
•An occupational therapist may treat developmental deficits, birth defects, learning disabilities, traumatic injuries, burns, neurological conditions, orthopedic conditions, mental deficiencies, and psychiatric disorders
•Within the healthcare system, occupational therapy plays various roles
•These roles include promoting health, preventing disability, developing or restoring functional capacity, guiding adaptation within physical and mental parameters, and teaching creative problem solving to increase independent function
Rehabilitation services:
Health services provided to assist patients in achieving and maintaining their optimal level of function, self-care, and independence after some type of disability
Physical Therapy and Rehabilitation:
•Physical therapy and rehabilitation have expanded into many medical specialties •Physical therapy can be applied in most disciplines of medicine, especially in neurology, neurosurgery, orthopedics, geriatrics, rheumatology, internal medicine, cardiovascular medicine, cardiopulmonary medicine, psychiatry, sports medicine, burn and wound care, and chronic pain management
•It also plays a role in community health education
•Credentialed allied health professionals administer physical therapy under the direction of physicians.
Medical rehabilitation services involve the entire healthcare team:
•Physicians, nurses, social workers, occupational therapists, physical therapists, and other healthcare personnel
•The objective is to either eliminate the patients' disability or alleviate it as fully as possible
•Physical therapy can be used to improve the cognitive, social, and physical abilities of patients impaired by chronic disease or injury
What is the primary purpose of physical therapy rehabilitation?
•The primary purpose of physical therapy in rehabilitation is to promote optimal health and function by applying scientific principles
•Treatment modalities include therapeutic exercise, therapeutic massage, biofeedback, and applications of heat, low-energy lasers, cold, water, electricity, and ultrasound
Respiratory therapy:
•Respiratory therapy involves the diagnosis and treatment of patients who have acute and/or chronic lung disorders
•Under the direction of qualified physicians and surgeons, respiratory therapists provide services such as emergency care for stroke, heart failure, and shock patients
•They also treat patients with chronic respiratory diseases such as emphysema and asthma.
Respiratory treatments include:
•Respiratory treatments include the administration of oxygen and inhalants such as bronchodilators
•The therapists set up and monitor ventilator equipment and provide physiotherapy to improve breathing.
Ancillary Support Services:
The ancillary units of the hospital provide vital clinical and administrative support services to patients, medical staff, visitors, and employees
The clinical support units provide the following services:
•Pharmaceutical services (provided by registered pharmacists and pharmacy technologists)
•Food and nutrition services (managed by registered dietitians who develop general and special-diet menus and nutritional plans for individual patients)
•HIM (health record) services (managed by RHIAs and RHITs)
•Social work and social services (provided by licensed social workers and licensed clinical social workers)
•Patient advocacy services (provided by several types of healthcare professionals, most commonly registered nurses and licensed social workers)
•Environmental (housekeeping) services
•Purchasing, central supply, and materials management services
•Engineering and plant operations
Administrative Support Services; In addition to clinical support services, hospitals need administrative support services to operate effectively. Administrative support services provide business management and clerical services in several key areas, including:
•Admissions andcentral registration
•Claims and billing (business office)
•Information services
•Human resources
•Public relations
•Fund development
Check your understanding 12.4
1. Which of the following is an example of a voluntary hospital?
D. A not-for-profit hospital owned by a church
Check your understanding 12.4
2. I have been asked who has the primary responsibility to guide the direction of the hospital. My response should be:
A. Board of directors
Check your understanding 12.4
3. The HIM Department is considered to be what type of department?
D. Clinical support services
Check your understanding 12.4
4. What service uses work and play to help the patient improve independent functioning?
A. Occupational therapy
Check your understanding 12.4
5. Dr. Smith has been granted permission by Community hospital to perform cardiac catheterizations. This permission is called:
A. Clinical privileges
Check your understanding 12.4
6-10. Instructions: Indicate whether the statements below are true or false (T or F).
6. _F___ Ambulatory care is the short-term care provided to diagnose and/or treat an illness.
7. __T__ A registered nurse qualified by advanced education and clinical management experience usually administers patient care services.
8. __T__ Healthcare reform results in closing of some hospitals.
9. __F__ The average length of stay for an acute care hospital is 21 days or less.
10. __F__ Rehabilitation services include only physical therapy and occupational therapy
Forces Affecting Healthcare Delivery:
A number of recent developments in healthcare delivery have had far-reaching effects on the operation of hospitals and other healthcare delivery facilities and services in the United States
Growth of Subacute Care:
•Subacute care represents a new movement in healthcare
•In the past, the term was used in reference to the services provided to hospitalized patients who did not meet the medical criteria for needing acute care
•Today, it refers to the level of skilled care needed by patients with complex medical conditions, typically Medicare patients with multiple medical problems
Who traditionally provided subacute care?
•Traditionally, nursing homes, home care providers, and rehabilitation facilities have provided subacute care
•Now some hospitals are developing subacute units in response to changing demographics that make it a cost-effective alternative to inpatient acute care
Development of Peer Review and Quality Improvement Programs:
•The goal of high-quality patient care is to promote, preserve, and restore health. •High-quality care is delivered in an appropriate setting in a manner that is satisfying to patients
•It is achieved when the patient's health status is improved as much as possible
Quality has several components, including:
•Appropriateness (the right care is provided at the right time)
•Technical excellence (the right care is provided in the right manner)
•Accessibility (the right care can be obtained when it is needed)
•Acceptability (patients are satisfied)
Peer Review: What happens in peer review? What has it traditionally been at the center of? What have the medical profession's peer review efforts emphasized? What are among the measures of quality that have been used?
•In peer review, a member of a profession assesses the work of colleagues within that same profession
•Peer review traditionally has been at the center of quality assessment and assurance efforts
•The medical profession's peer review efforts have emphasized the scientific aspects of quality
•Appropriate use of pharmaceuticals, postoperative infection rates, and accuracy of diagnosis are among the measures of quality that have been used.
•Peer review is a requirement of both CMS and TJC
Quality Improvement:
•Quality improvement (QI) programs have been in place in hospitals for years and have been required by the Medicare/Medicaid programs and accreditation standards
•QI programs have covered medical staff as well as nursing and other departments or processes
What level do efforts to encourage delivery of high-quality care take place? What are these efforts geared toward?
•Efforts to encourage the delivery of high-quality care take place at the local and national levels
•Such efforts are geared toward assessing the efforts of both individuals and institutions
Who plays a role in trying to promote high-quality care?
•Currently, professional associations, healthcare organizations, government agencies, private external quality review associations, consumer groups, MCOs, and group purchasers of care all play a role in trying to promote high-quality care
Growth of Managed Care: what is managed care? How do they provide healthcare?
•Managed care is a generic term for a healthcare reimbursement system that manages cost, quality, and access to services
•Most managed care plans do not provide healthcare directly
•Instead, they enter into service contracts with the physicians, hospitals, and other healthcare providers who provide medical services to enrollees in the plans
How do managed care systems control costs?
Managed care systems control costs primarily by presetting payment amounts and restricting patient access to healthcare services through precertification and utilization review processes.
Managed care delivery systems also attempt to manage cost and quality by:
•Implementing various forms of financial incentives for providers
•Promoting healthy lifestyles
•Identifying risk factors and illnesses early in the disease process
•Providing patient education
What do most recent studies suggest about managed care? Why may these findings be limited? What is known about long-term care?
•Although the most recent studies suggest that managed care results in lower costs with equal or better quality, most are limited because they have focused on short-term health outcomes
•Very little is known about the long-term effects of specific reimbursement or organizational arrangements on quality of care
•Further, recent evidence indicates that the quality of care provided under managed care systems may differ across population groups.
Efforts at Healthcare Reengineering
•During the 1980s, healthcare organizations adopted continuous quality improvement (CQI) processes
•Lessons learned from other areas of business were applied to healthcare settings
•Reengineering came in many varieties, such as focused process improvement, major business process improvement and business process innovation, total quality management, and CQI
•Regardless of approach, every healthcare organization attempted to look inside and to practice "process" as opposed to traditional "department" thinking
•Healthcare organizations formed cross-functional teams that collaborated to solve organizational problems
What also happened while healthcare organizations formed cross-functional teams that collaborated to solve organizational problems, at the same time:
•TJC reengineered the accreditation process to increase its focus on process and systems analysis
•Gone were the days of thinking in a "silo."
•All the silos were turned over, and healthcare teams learned from each other. •The drivers of reengineering included cost reduction, staff shortages, and implementation of technology
Emphasis on Patient-focused Care:
•Patient-focused care is a concept developed to contain hospital inpatient costs and improve quality by restructuring services so that more of them take place in the nursing units (patient floors) and not in specialized units in dispersed hospital locations
•The emphasis is on cross-training staff in the nursing units to perform a variety of functions for a small group of patients rather than one set of functions for a large number of patients
How have some organizations achieved patient-focused care? What has been the experience with this type of worker?
•Some organizations have achieved patient-focused care by assigning multiskilled workers to serve food, clean patients' rooms, and assist in nursing care
•However, some organizations have experienced low patient satisfaction with this type of worker because the patients are confused and do not know who to ask to do what
Hospital staff spend most of their time performing activities in the following nine categories:
•Medical, technical, and clinical procedures
•Patient services
•Medical documentation
•Institutional documentation
•Scheduling and coordination
•Patient transportation
•Staff transportation
•Management and supervision
•Ready-for-action activities
A study at Lakeland Regional Medical Center, a 750-bed hospital in central Florida, found:
•That medical, technical, and clinical activity consumed one-sixth of the center's personnel-related costs
•The study also showed that almost twice that amount of time was spent writing things down
•Scheduling and coordination took as much time as medical activity, and ready-for-action activities consumed even more.
The Lakeland Regional Medical Center study suggested:
•The study suggested that restructuring services at Lakeland would reduce the number of staff required for patient care activities from 2,200 to 1,200 and improve care
•The amount of physical space allotted to each unit would be sufficient to contain a minilab, diagnostic radiology rooms, linen and general supply, stockrooms, and so on. •If such changes were carried out, medical documentation could be reduced by almost two-thirds, scheduling and coordination service by more than two-thirds, and ready-for-action time by two-thirds
What are the reasons hospitals have had difficulty in fully and rapidly implementing patient-focused care?
Hospitals have had difficulty in fully and rapidly implementing patient-focused care for the following reasons:
•The high cost of conversion
•The extensive physical renovations required
•Resistance from functional departments
•Other priorities for management, such as mergers and considering potential mergers
Evidenced-based (medicine) Best Practices and Outcomes: What is evidence-based medicine? What does the practice mean integrating? What does it mean to practice this kind of medicine?
•Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients
•The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research •Practicing evidenced-based medicine means that healthcare providers combine their individual experience and knowledge with clinically based research to make diagnoses and decisions about an individual's patient care.
Integrating individual expertise with clinically based research for making healthcare decisions is not a new concept.
•However, formalizing the use of clinically based research in day-to-day practice has received more attention during the past decade
•For example, the Agency for Healthcare Research and Quality (AHRQ) in 1997 launched an initiative to promote evidence-based practice in everyday care •The goal of this initiative is to improve the quality of healthcare by facilitating the use of evidence-based research findings in everyday healthcare practice
What did the AHRQ establish?
•The AHRQ established 12 evidence-based practice centers (EPCs)
•Each of the EPCs develops evidence reports related to healthcare delivery issues that are common, expensive, and/or significant for the Medicare and Medicaid populations •These reports are used by federal and state agencies, private sector professional societies, health delivery systems, providers, payers, and others to develop evidenced base guidelines
Evidence-based guidelines suggest diagnostic or therapeutic interventions that a healthcare practitioner may use. For example:
•Improvement of the palliative care of pain is a guideline that suggests clinicians monitor pain regularly and use therapies of proven effectiveness to manage pain
•The purpose of such guidelines is to improve the quality of healthcare and patient's chances of getting as well as possible
Using evidence-based guidelines provide the following benefits when used for (National Institutes for Health and Clinical Excellence 2009):
•Recommendations for the treatment •Developing standards to assess the clinical practice of individual health professionals
•Education and training of health professionals
•Helping patients to make informed decisions
•Improving communication between patient and health professional
Skilled nursing facility (SNF):
A long-term care facility with an organized professional staff and permanent facilities (including inpatient beds) that provides continuous nursing and other health-related, psychosocial, and personal services to patients who are not in an acute phase of illness but who primarily require continued care on an inpatient basis
Development of Integrated Healthcare Delivery Systems; what is an IDS?
•An IDS (also referred to as an Integrated Delivery Network or IDN) is a healthcare provider made up of a number of associated medical facilities that furnish coordinated healthcare services
•Most IDSs include a number of facilities that provide services along the continuum of care (ambulatory surgery centers, physician office practices, outpatient clinics, acute care hospitals, skilled nursing facilities [SNFs], MCOs, and so on).
What is the purpose of an IDS?
•The purpose of an IDS is to organize the continuum of care, maximize effectiveness, and reduce costs
•The continuum of care includes services for patients at different levels of the healthcare system. In an IDS arrangement, the focus is on holistic care rather than on fragmented care among specialists
Examples of different levels of care across the continuum are:
•Health promotion and disease prevention
•Primary care
•Acute care
•Tertiary care
•Long-term care
•Hospice care
Integrated healthcare information systems are needed to manage the continuum of care:
•The electronic health record (EHR) is essential for meeting IDS goals of effectively managing and delivering high-quality care •Timely, accurate, and accessible information is needed to manage care across all the different continuum of care levels
Licensure, Certification, and Accreditation of Healthcare Facilities:
•Licensure, certification, and accreditation have had an enormous impact on the standardization and quality of healthcare services in the United States
•Such programs require that high-performance standards be met in the provision of medical care and in the construction, maintenance, and management of the healthcare facility
State Licensure:
•Licensure is a "process by which a governmental authority grants permission to an individual practitioner or healthcare organization to operate or to engage in an occupation or profession"
•State legislatures usually grant authority to a state agency to license healthcare facilities
•For example, hospitals, nursing homes, home health agencies, ambulatory surgical facilities, and adult day-care/health facilities are usually licensed by state agencies.
What may standards that are set by licensing agencies for healthcare facilities address?
•Licensing agencies set standards that healthcare facilities must meet before being granted a license to operate
•The standards are designed to promote the health, welfare, and safety of patients
•Such standards may address staff levels, coordination of services, patient rights, quality assurance, safety of the environment, and adequacy of the physical plant
•The licensing agency monitors compliance with the standards, usually through surveys and on-site inspections
•The types of facilities licensed and the standards for licensure vary from state to state
Although licensure requirements vary, healthcare facilities must meet basic criteria determined by who? What do these standards address?
•Although licensure requirements vary, healthcare facilities must meet certain basic criteria determined by state regulatory agencies
•These standards address concerns such as adequacy of staffing, physical aspects of the facility (equipment, buildings), and services provided, including the maintenance of health records. Most licensing agencies perform reviews annually
Certification for Medicare Participation: what is certification? What must providers do to receive Medicare and Medicaid reimbursement? What are these conditions called, and who sets them?
•Certification is the procedure conducted by an authorized body in evaluating and recognizing whether an individual or institution meets predetermined requirements
•To receive Medicare and Medicaid reimbursement, providers must prove that they follow the rules and regulations for participating in the Medicare program. •Called the Medicare Conditions of Participation, these rules are set forth by CMS
•Facilities that must meet the standards in the Conditions of Participation include hospitals, home health agencies, ambulatory surgical centers, and hospices
Certification for Medicare reimbursement is the responsibility of:
•Certification for Medicare reimbursement is the responsibility of the states
•However, the Medicare act specifies that those facilities accredited by TJC and the AOA are "deemed" to be in compliance with the Conditions of Participation and do not have to undergo a separate certification process
•Most recently, in late 2009 DNV Healthcare, Inc., was granted deeming authority by CMS in addition to TJC and the AOA
Voluntary Accreditation:
Accreditation is a voluntary system of institutional or organizational review performed by an independent body that has developed standards to measure and ensure the quality of healthcare services. Examples of accrediting organizations are TJC and the AOA.
TJC is a private, nonprofit organization that does what?
TJC is a private, nonprofit organization that establishes guidelines and standards for the operation and management of healthcare facilities to ensure the quality and safety of care.
TJC operates how?
It operates voluntary accreditation programs for hospitals, non-hospital-based psychiatric and substance abuse organizations, long-term care organizations, home care organizations, ambulatory care organizations, and organization-based pathology and clinical laboratory services
Most state governments recognize Joint Commission accreditation as a condition of?
•Most state governments recognize Joint Commission accreditation as a condition of licensure and receiving Medicaid reimbursement
•Typically, organizations are inspected every three years with accreditation and survey findings made available to the public
•When an organization is found to be in substantial compliance with TJC standards, accreditation may be awarded for up to three years
What does the AOA sponsor? What is its purpose?
•The AOA sponsors a voluntary accreditation program for osteopathic healthcare facilities and medical schools. Its purpose is to advance the philosophy and practice of osteopathy
•The AOA has developed accreditation requirements for osteopathic hospitals, ambulatory care/surgery, mental health, substance abuse, and physical rehabilitation medicine facilities
•Like Joint Commission-accredited facilities, AOA- and now DNV Healthcare, Inc.-accredited facilities are considered to have "deemed" status and qualify to receive Medicare reimbursement
Check Your Understanding 12.5
1. I have been asked to describe quality of healthcare. Which of the following would I include in my definition?
B. The right care is provided at the right time
Check Your Understanding 12.5
2. I work for an organization that owns a hospital, a skilled nursing facility, and physician practices. I work for what type of organization?
D. An integrated delivery system
Check Your Understanding 12.5
3. Which of the following is true regarding Medicare certification of hospitals?
C. Must be in compliance with the Conditions of Participation
Check Your Understanding 12.5
4. I have been asked what is the purpose of evidence-based guidelines. How would I respond?
B. They help to improve the quality of patient care
Check Your Understanding 12.5
5. At our facility, our staff in the nursing units are cross-trained to perform many tasks for a small group of patients. This concept is called:
D. Patient-focused care
Check Your Understanding 12.5
6. A Medicare patient needs intermittent skilled nursing care and speech therapy. Which of the following is the best service for this patient?
C. Home care
Check Your Understanding 12.5
7. Quality has several components, including appropriateness, technical excellence, acceptability, and:
D. Accessibility
Check Your Understanding 12.5
8. What type of program has been in place in hospitals for years and is required by the Medicare and Medicaid programs as well as accreditation standards?
A. Quality improvement
Check Your Understanding 12.5
9. Which of the following is a true statement about peer review?
C. Involves assessment of the work of colleagues by those in the same profession
Check Your Understanding 12.5
10. What program attempts to contain hospital inpatient costs and improve quality by restructuring services so that more is done in nursing unit?
B. Patient-focused care
Other Types of Healthcare Services:
•Healthcare delivery is more than hospital-related care
•It can be viewed as a continuum of services that cuts across care settings, including ambulatory, acute, subacute, long-term, and residential care, among others
•Continuum of care has also been defined as "the totality of healthcare services provided to a patient and his or her family in all settings from the least extensive to the most extensive"
Integrated Delivery Network/System:
•In an IDN/IDS, providers strive to meet every healthcare consumer's needs
•This can be described as a full-service model of meeting patient needs from the cradle to the grave
•IDNs develop a full continuum of care model, including acute care inpatient and outpatient services, a home health agency, a long-term care facility, and hospital-based durable medical equipment (DME) services
Ambulatory Care:
•Ambulatory care may be defined as the preventive and/or corrective healthcare provided in a practitioner's office, a clinic, or a hospital on a nonresident (outpatient) basis
•The term usually implies that patients go to locations outside their homes to obtain healthcare services and return the same day
What does ambulatory care encompass? What services are included?
•It encompasses all the health services provided to individual patients who are not residents in a healthcare facility
•Such services include the educational services provided by community health clinics and public health departments •Primary care, emergency care, and ambulatory specialty care (which includes ambulatory surgery) all may be considered ambulatory care
•Ambulatory care services are provided in a variety of settings, including urgent care centers, school-based clinics, public health clinics, and neighborhood and community health centers
What does current medical practice emphasize in performing healthcare services? What has this change in thinking led to?
•Current medical practice emphasizes performing healthcare services in the least costly setting possible
•This change in thinking has led to decreased utilization of emergency services, increased utilization of nonemergency ambulatory facilities, decreased hospital admissions, and shorter hospital stays
•The need to reduce the cost of healthcare also has led primary care physicians to treat conditions they once would have referred to specialists.
Physicians who provide ambulatory care services fall into two major categories:
•Physicians working in private practice and •Physicians working for ambulatory care organizations
•Physicians in private practice are self-employed: They work in solo, partnership, and group practices set up as for-profit organizations.
•Alternatively, physicians who work for ambulatory care organizations are employees of those organizations
What do ambulatory care organizations include?
•Ambulatory care organizations include •Health maintenance organizations (HMOs), •Hospital-based ambulatory clinics
•Walk-in and emergency clinics •Hospital-owned group practices and health promotion centers
•Feestanding surgery centers
•Freestanding urgent care centers
•Freestanding emergency care centers •Health department clinics
•Neighborhood clinics
•Home care agencies
•Community mental health centers
•School and workplace health services, and •Prison health services
What else do ambulatory care organizations employ?
Ambulatory care organizations also employ other healthcare providers, including nurses, laboratory technicians, podiatrists, chiropractors, physical therapists, radiology technicians, psychologists, and social workers
Private Medical Practice
•Private medical practices are physician-owned entities that provide primary care or medical/surgical specialty care services in a freestanding office setting
•The physicians have medical privileges at local hospitals and surgical centers but are not employees of the other healthcare entities
Hospital-based Ambulatory Care Services:
In addition to providing inpatient services, many acute care hospitals provide various ambulatory care services
Emergency Services and Trauma Care:
•More than 90 percent of community hospitals in the United States provide emergency services
•Hospital-based emergency departments provide specialized care for victims of traumatic accidents and life-threatening illnesses
•In urban areas, many also provide walk-in services for patients with minor illnesses and injuries who do not have access to regular primary care physicians
•Many physicians on the hospital staff also use the emergency care department as a setting to assess patients with problems that may either lead to an inpatient admission or require equipment or diagnostic imaging facilities not available in a private office or nursing home
•Emergency services function as a major source of unscheduled admissions to the hospital
Outpatient Surgical Services:
•Generally, the term ambulatory surgery refers to any surgical procedure that does not require an overnight stay in a hospital
•It can be performed in the outpatient surgery department of a hospital and in a freestanding ambulatory surgery center •During the 1980s and 1990s, the percentage of surgeries done on an outpatient basis rose dramatically and this trend continues today
•The increased number of procedures performed in an ambulatory setting can be attributed to improvements in surgical technology and anesthesia and the utilization management demands of third-party payers
Outpatient Diagnostic and Therapeutic Services:
•Outpatient diagnostic and therapeutic services are provided in a hospital or one of its satellite facilities
•Diagnostic services are those services performed by a physician to identify the disease or condition from which the patient is suffering
•Therapeutic services are those services performed by a physician to treat the disease or condition that has been identified
Hospital outpatients fall into different classifications according to the type of service they receive and the location of the service, for example:
•Emergency outpatients are treated in the hospital's emergency or trauma care department for conditions that require immediate care
•Clinic outpatients are treated in one of the hospital's clinical departments on an ambulatory basis
•Referral outpatients receive special diagnostic or therapeutic services in the hospital on an ambulatory basis, but responsibility for their care remains with the referring physician
Community-based Ambulatory Care Services:
•Community-based ambulatory care services are those services provided in freestanding facilities that are not owned by or affiliated with a hospital
•Such facilities can range in size from a small medical practice with a single physician to a large clinic with an organized medical staff
What are among the organizations that provide ambulatory care services?
•Specialized treatment facilities
•Examples of these facilities include birthing centers, cancer treatment centers, renal dialysis centers, and rehabilitation centers
Freestanding Ambulatory Care Centers:
•Freestanding ambulatory care centers provide emergency services and urgent care for walk-in patients
•Urgent care centers (sometimes called emergicenters) provide diagnostic and therapeutic care for patients with minor illnesses and injuries
•They do not serve seriously ill patients, and most do not accept ambulance cases
Which Two groups of patients find freestanding Ambulatory Care Centers attractive?
•The first group consists of patients seeking the convenience and access of emergency services without the delays and other forms of negative feedback associated with using hospital services for nonurgent problems. •The second group consists of patients whose insurance treats urgent care centers preferentially compared with physicians' offices
What has happened as freestanding ambulatory centers have increased in number and become familiar to more patients?
As they have increased in number and become familiar to more patients, many free-standing ambulatory care centers now offer a combination of walk-in and appointment services
Freestanding Ambulatory Surgery Centers:
•Freestanding ambulatory surgery centers generally provide surgical procedures that take anywhere from 5 to 90 minutes to perform and require less than a 4-hour recovery period
•Patients must schedule their surgeries in advance and be prepared to return home on the same day
•Patients who experience surgical complications are sent to an inpatient facility for care
•Most ambulatory surgery centers are for-profit entities
•Individual physicians, MCOs, or entrepreneurs may own them
•Generally, ambulatory care centers can provide surgical services at lower cost than hospitals can because their overhead expenses are lower
Public Health Services; who has constitutional authority to implement public health? Who is the federal agency who ensures health and provides essential human services?
•The states have constitutional authority to implement public health, and many of them are assisted by a wide variety of federal programs and laws
•The Department of Health and Human Services (HHS) is the principal federal agency that ensures health and provides essential human services
•All HHS agencies have some responsibility for prevention
•Through its 10 regional offices, HHS coordinates closely with state and local government agencies and many HHS-funded services are provided by these agencies as well as by private-sector and nonprofit organizations
Two units in the Office of the Secretary of HHS are important to public health:
•The Office of the Surgeon General of the United States and the Office of Disease Prevention and Health Promotion (ODPHP) •ODPHP has an analysis and leadership role for health promotion and disease prevention
Who provides leadership and recommendations about the public's health? How are they appointment?
•The surgeon general is appointed by the president of the United States and provides leadership and authoritative, science-based recommendations about the public's health •He or she has responsibility for the public health service (PHS) workforce
Home Care Services: what is the primary reason for home healthcare to grow so fast?
•Home healthcare is the fastest-growing sector to offer services for Medicare recipients
•The primary reason for this is increased economic pressure from third-party payers. •In other words, third-party payers want patients released from the hospital more quickly than they were in the past. •Moreover, patients generally prefer to be cared for in their own homes
•In fact, most patients prefer home care, no matter how complex their medical problems
What does research indicate about medical outcomes of home care?
Research indicates that the medical outcomes of home care patients are similar to those of patients treated in SNFs for similar conditions.
Rules for home care services: who is eligible to receive?
•In 1989, Medicare rules for home care services were clarified to make it easier for Medicare beneficiaries to receive them. •Patients are eligible to receive home health services from a qualified Medicare provider when they are homebound, when they are under the care of a specified physician who will establish a home health plan, and when they need physical or occupational therapy, speech therapy, or intermittent skilled nursing care.
Skilled nursing care, how is it defined? What is intermittent care? What are hospitals doing in the realm of home healthcare?
•Skilled nursing care is defined as both technical procedures, such as tube feedings and catheter care, and skilled nursing observations
•Intermittent is defined as up to 28 hours per week for nursing care and 35 hours per week for home health aide care
•Many hospitals have formed their own home healthcare agencies to increase revenues and at the same time to enable them to discharge patients from the hospital earlier
Voluntary Agencies: what do they provide? how are they funded?
•Voluntary agencies provide healthcare and healthcare planning services, usually at the local level and to low-income patients
•Their services range from giving free immunizations to offering family planning counseling
•Funds to operate such agencies come from a variety of sources, including local or state health departments, private grants, and funds from different federal bureaus
What is an example of a voluntary agency? What are they sometimes called? How are fees handled?
•One common example of a voluntary agency is the community health center •Sometimes called neighborhood health centers, community health centers offer comprehensive, primary healthcare services to patients who otherwise would not have access to them
•Often patients pay for these services on a sliding scale based on income or according to a flat rate, discounted fee schedule supplemented by public funding
What are some specialized voluntary agencies?
•Some voluntary agencies offer specialized services such as counseling for battered and abused women
•Typically, these are set up within local communities
•An example of a voluntary agency that offers services on a much larger scale is the Red Cross
Subacute Care: Who is eligible to receive? What does subacute care offer patients?
•Patients needing ongoing rehabilitative care and/or treatments using advanced technology sometimes are eligible to receive subacute care
•Subacute care offers patients access to constant nursing care while recovering at home
•In the past, patients could receive comprehensive rehabilitative care only while in the hospital
What does subacute care now allow that it didn't used to? What does this care emphasize? What kinds of patients are considered appropriate for subacute care?
•Today, however, the availability of subacute care services allows patients to optimize their functional gain in a familiar and more comfortable environment
•In essence, subacute care in most IDNs emphasizes patient independence
•The patient is given an individualized care plan developed by a highly trained team of healthcare professionals
•Patients considered appropriate for subacute care are those recovering from stroke, cardiac surgery, serious injury, amputation, joint replacement, or chronic wounds
Long-term Care, what is it?
•Generally speaking, long-term care is the healthcare rendered in a nonacute care facility to patients who require inpatient nursing and related services for more than 30 consecutive days.
Which facilities provide long-term care?
•SNFs, nursing homes, and rehabilitation hospitals are the principal facilities that provide long-term care
•Rehabilitation hospitals provide recuperative services for patients who have suffered strokes and traumatic injuries as well as other serious illnesses
•Specialized long-term care facilities serve patients with chronic respiratory disease, permanent cognitive impairment, and other incapacitating conditions
What services does long-term care encompass? Who are people that may need long-term care?
•Long-term care encompasses a range of health, personal care, social, and housing services provided to people of all ages with health conditions that limit their ability to carry out normal daily activities without assistance
•People who need long-term care have many different types of physical and mental disabilities
•Moreover, their need for the mix and intensity of long-term care services can change over time
What is the goal of long-term care? Who can provide this care, and where is it done? What is needed to provide long-term care?
•Long-term care is mainly rehabilitative and supportive rather than curative
•Moreover, healthcare workers other than physicians can provide long-term care in the home or in residential or institutional settings
•For the most part, long-term care requires little or no technology
Long-term Care in the Continuum of Care: Why is availability of this care so important in the U.S. today?
•The availability of long-term care is one of the most important health issues in the United States today
•There are two principal reasons for this:
1. First, thanks to advances in medicine and healthcare practices, people are living longer today than they did in the past
•The number of people who survive previously fatal conditions has been growing, and more and more people with chronic medical problems are able to live reasonably normal lives
2. Second, there was an explosion in birth rate after the Second World War
•Children born during that period, the so-called baby-boomer generation, are today in or entering their 50s
•These factors combined mean that the need for long-term care will only increase in the years to come
As discussed earlier, healthcare is now viewed as a continuum of care, what does this mean?
•That is, patients are provided care by different caregivers at several different levels of the healthcare system
•In the case of long-term care, the patient's continuum of care may have begun with a primary provider in a hospital and then continued with home care and eventually care in an SNF
•The patient's care is coordinated from one care setting to the next
What is happening to the roles of the different care providers along the patient's continuum of care? What role do health information managers play in long-term care?
•Moreover, the roles of the different care providers along the patient's continuum of care are continuing to evolve
•Health information managers play a key part in providing consultation services to long-term care facilities with regard to developing systems to manage information from a diverse number of healthcare providers
Delivery of Long-term Care Services:
Long-term care services are delivered in a variety of settings, including
•Skilled nursing facilities/nursing homes, •Residential care facilities,
•Hospice programs, and
•Adult day-care programs
Skilled Nursing Facilities and Nursing Homes / long-term care facility:
•The most important providers of formal, long-term care services are nursing homes. •SNFs, or nursing homes, provide medical, nursing, and/or rehabilitative care, in some cases, around the clock
•Most SNF residents are over age 65 and often are classified as the frail elderly.
Who owns many nursing homes? Who else may they be owned by? What has happened to the number of nursing homes in recent years?
•Many nursing homes are owned by for-profit organizations
•However, SNFs also may be owned by not-for-profit groups as well as local, state, and federal governments
•In recent years, there has been a decline in the total number of nursing homes in the United States, but an increase in the number of nursing home beds
What factors play a role in determining which type of long-term care facility is best for a particular patient?
•Nursing homes are no longer the only option for patients needing long-term care. •Various factors play a role in determining which type of long-term care facility is best for a particular patient, including cost, access to services, and individual needs.
Residential Care Facilities: what are they? What growing role do they play?
•New living environments that are more homelike and less institutional are the focus of much attention in the current long-term care market
•Residential care facilities now play a growing role in the continuum of long-term care services
•Having affordable and appropriate housing available for elderly and disabled people can reduce the level of need for institutional long-term care services in the community
What can be postponed or prevented by the availability of residential care facilities?
Institutionalization can be postponed or prevented when the elderly and disabled live in safe, accessible settings where assistance with daily activities is available.
Hospice Programs: where is it provided, and who uses it? What philosophy is it based on?
•Hospice care is provided mainly in the home to the terminally ill and their families. •Hospice is based on a philosophy of care imported from England and Canada that holds that during the course of terminal illness, the patient should be able to live life as fully and as comfortably as possible, but without artificial or mechanical efforts to prolong life
Who is the unit of treatment in hospice care? Who provides the the care? What are the main goals of hospice?
•In the hospice approach, the family is the
unit of treatment
•An interdisciplinary team provides medical, nursing, psychological, therapeutic, pharmacological, and spiritual support during the final stages of illness, at the time of death, and during bereavement
•The main goals are to control pain, maintain independence, and minimize the stress and trauma of death.
Hospice services have gained acceptance as an alternative to what kind of care? What is the outlook for hospice?
•Hospice services have gained acceptance as an alternative to hospital care for the terminally ill
•The number of hospices is likely to continue to grow because this philosophy of care for people at the end of life has become a model for the nation
Adult Day-Care Programs: what do they offer? Who do they target? What are the goals?
•Adult day-care programs offer a wide range of health and social services to elderly persons during the daytime hours
•Adult day-care services are usually targeted to elderly members of families in which the regular caregivers work during the day
•Many elderly people who live alone also benefit from leaving their homes every day to participate in programs designed to keep them active
•The goals of adult day-care programs are to delay the need for institutionalization and to provide respite for caregivers.
Data on adult day-care programs; what do they offer?
•Data on adult day-care programs are still limited, but there were about 3,000 programs in 2000
•Most adult day-care programs offer social services, crafts, current events discussions, family counseling, reminiscence therapy, nursing assessment, physical exercise, activities of daily living, rehabilitation, psychiatric assessment, and medical care
Behavioral Health Services: How did it begin, and what changes have occurred?
•From the mid-19th century to the mid-20th century, psychiatric services in the United States were based primarily in long-stay institutions supported by state governments and patterns of practice were relatively stable
•During the past 45 years, however, remarkable changes have occurred
•These changes include a reversal of the balance between institutional and community care, inpatient and outpatient services, and individual and group practice.
Behavioral Health Services: numbers of long-stay residents in state mental hospitals: where did he shift to community-based settings begin?
•Today, the number of long-stay residents in state mental hospitals is estimated to be well below 80,000
•In 1955, it was more than 500,000
•The shift to community-based settings began in the public sector and community settings remain dominant
•The private sector's bed capacity increased in the 1970s and 1980s, including psychiatric units in non-federal general hospitals, private psychiatric hospitals, and residential treatment centers for children.
Behavioral Health Services: Substance abuse and child adolescent inpatient psych:
•Substance abuse centers and child and adolescent inpatient psychiatric units grew particularly quickly in the 1980s, as investors recognized their profitability
•In the 1990s, the growth of inpatient private mental health facilities leveled off and the number of outpatient and partial treatment settings increased sharply
Behavioral Health Services: patients with sever mood disorders:
•Some patients with treatment-resistant schizophrenia, severe mood disorders, or chronic cognitive impairment may be dangerous to themselves or others
•State and county hospitals may be returning to their traditional role by providing asylum to disabled patients who are unable to function in their communities
Behavioral Health Services: Residential treatment centers for emotionally or behaviorally disturbed children:
•Residential treatment centers for emotionally or behaviorally disturbed children provide inpatient services to children under 18 years of age
•The programs and physical facilities of residential treatment centers are designed to meet patients' daily living, schooling, recreational, socialization, and routine medical care needs
Behavioral Health Services: Day-hospital or day-treatment programs: How do they work? What services do they provide?
•Day-hospital or day-treatment programs occupy one niche in the spectrum of behavioral healthcare settings
•Although some provide services seven days a week, many programs provide services only during business hours, Monday through Friday
•Day-treatment patients spend most of the day at the treatment facility in a program of structured therapeutic activities and then return to their homes until the next day •Day-treatment services include psychotherapy, pharmacology, occupational therapy, and other types of rehabilitation services
•These programs provide alternatives to inpatient care or serve as transitions from inpatient to outpatient care or discharge •They also may provide respite for family caregivers and a place for rehabilitating or maintaining chronically ill patients
•The number of day-treatment programs has increased in response to pressures to decrease the length of hospital stays
Insurance coverage for behavioral healthcare:
•Insurance coverage for behavioral healthcare has always lagged behind coverage for other medical care
•Although treatments and treatment settings have changed, rising healthcare costs, the absence of strong consumer demand for behavioral health coverage, and insurers' continuing fear of the potential cost of this coverage have maintained the differences between medical and behavioral healthcare benefits
•Although most individuals covered by health insurance have some outpatient psychiatric coverage, the coverage is often quite restricted
•Typical restrictions include limits on the number of outpatient visits, higher copayment charges, and higher deductibles
Behavioral Health Services: How has it grown? What has supplemented large state hospitals?
•Behavioral healthcare has grown and diversified, particularly during the past 40 years, as psychopharmacologic treatment has made possible the shift away from long-term custodial treatment
•Psychosocial treatments continue the process of care and rehabilitation in community settings
•Large state hospitals have been supplemented—and in many cases replaced—by psychiatric units in general hospitals, new outpatient clinics, community mental health centers, day-treatment centers, and halfway houses
Behavioral Health Services: How has treatment changed?
•Treatment has become more effective and specific, based on our growing understanding of the brain and behavior
•Recent advances in the biological and behavioral sciences continue to improve opportunities for diagnosing, treating, and preventing psychiatric disorders
Check your understanding 12.6:
1. I am a patient. I went to see the doctor who owns her own office practice. This type of care is called which of the following?
C. Private medical practice
Check your understanding 12.6:
2. My daughter fell and cut herself tonight. I believe that she needs stitches. It is not an emergency but I believe that she really needs to see someone tonight for treatment. What type of setting would I most likely access?
D. Freestanding ambulatory care center
Check your understanding 12.6:
3. I work for a healthcare provider that provides ambulatory care to low-income patients. We receive funding from many sources. What type of setting do I work for?
A. Voluntary agency
Check your understanding 12.6:
4. A physician needs to find a place to care for a terminally ill patient. What type of long term care setting is the most appropriate?
B. Hospice
Check your understanding 12.6:
5. Which of the following statements is true about behavioral health?
D. Insurance coverage generally places restrictions on the psychiatric care such as a limit on the number of outpatient visits
Check your understanding 12.6: Instructions: Match the descriptions provided with the terms to which they apply. 6-10.
6. Day-treatment program
c. Provides alternatives to inpatient care or serves as a transition from inpatient to outpatient care or discharge
7. Skilled nursing facility
e. Healthcare rendered in a nonacute care facility to patients who require inpatient nursing and related services for more than 30 consecutive days
8. Residential care facility
a. Are designed to meet patient's daily living, schooling, recreational, socialization, and routine medical care needs
9. Public health service
b. Has an analysis and leadership role for health promotion and disease prevention
10. Continuum of care
d. Care provided by different caregivers at several different levels of the healthcare system
Reimbursement of Healthcare Expenditures:
•Reimbursement of healthcare expenditures has a long history in the United States
•Traditionally healthcare services were paid for on a fee-for-service basis
•However the entrance of third-party payer systems over 60 years ago has dramatically changed how expenditures of healthcare are reimbursed
Evolution of Third-Party Reimbursement:
•The evolution of third-party reimbursement systems for healthcare services began more than 60 years ago
•It created a need for systematic and accurate communications between healthcare providers and third-party payers such as commercial health insurance companies (for example, Aetna) and medical plans similar to Blue Cross/Blue Shield (also called the Blues).
How are most commercial health insurance provided?
•Most commercial health insurance is provided in the form of group policies offered by employers as part of their fringe benefit packages for employees
•Unions also negotiate health insurance coverage during contract negotiations. In most cases, employees pay a share of the cost and employers pay a share
•Individual health insurance plans can be purchased but usually are expensive or have limited coverage and high deductibles
•Individuals with preexisting medical conditions often find it almost impossible to get individual coverage
Commercial insurers also sell major medical and cash payment policies:
•Major medical plans are directed primarily at catastrophic illness and cover all or part of treatment costs beyond those covered by basic plans
•Major medical plans are sold as both group and individual policies
•Cash payment plans provide monetary benefits and are not based on actual charges from healthcare providers
•For example, a cash payment plan might pay the beneficiary $150 for every day he or she is hospitalized or $500 for every ambulatory surgical procedure
•Cash payment plans are often offered as a benefit of membership in large associations such as the American Association of Retired Persons (AARP)
Like the Blues, commercial insurance companies are subject to supervision by state insurance commissioners:
•However, such supervision does not include rate regulation
•One general requirement is that commercial plans establish premium rates high enough to cover all potential claims made under the insurance they provide.
Government-sponsored Reimbursement Systems:
Until 1965, most of the poor and many of the elderly in the United States could not afford private healthcare services. As a result of public pressure calling for attention to this growing problem, Congress passed Public Law 89-97 as an Amendment to the Social Security Act. The amendments created Medicare (Title XVIII) and Medicaid (Title XIX)
•Federal health insurance for the aged, called Medicare, was first offered to retired Americans in July 1966
•Today, retired and disabled Americans who are eligible for Social Security benefits automatically qualify for Medicare coverage without regard to income
•Coverage is offered under two coordinated programs: hospital insurance (Medicare Part A) and medical insurance (Medicare Part B)
Medicare Part A:
•Financed through payroll taxes
•Initially, coverage applied only to hospitalization and home healthcare
•Subsequently, coverage for extended care in nursing homes was added
•Coverage for individuals eligible for Social Security disability payments for over two years and those who need kidney transplantation or dialysis for end-stage renal disease also were added
Medical insurance under Medicare Part B is optional:
•It is financed through monthly premiums paid by eligible beneficiaries to supplement federal funding
•Part B helps pay for physician's services, outpatient hospital care, medical services and supplies, and certain other medical costs not covered by Part A
•At the present time, Medicare Part B does not provide coverage of prescription drugs
What did the Balanced Budget Act of 1997 give medicare beneficiaries?
•The Balanced Budget Act of 1997 gave Medicare beneficiaries the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B) •These programs were known as Medicare+Choice or Part C plans
How did the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 make Medicare+Choice plans more appealing?
•The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 made Medicare+Choice plans more appealing to Medicare beneficiaries because prescription drug coverage was made available
•The prescription drug coverage was referred to as Medicare Advantage (MA) •Effective January 1, 2006, any Medicare Advantage Plan that also included Part D prescription drug benefits is known as a Medicare Advantage Prescription Drug plan or a MA-PD
•These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies.
Unlike Medicare Parts A and B, Part D is:
•Part D coverage is not standardized
•Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover them, and are free to choose not to cover some drugs at all
•Medicaid is a medical assistance program for low-income Americans
•The program is funded partially by the federal government and partially by state and local governments
•The federal government requires that certain services be provided and sets specific eligibility requirements
Medicaid covers the following benefits:
•Inpatient hospital care
•Outpatient hospital care
•Laboratory andx-ray services
•SNF and home health services for persons over 21 years old
•Physician services
•Family planning services
•Rural health clinic services
•Early and periodic screening, diagnosis, and treatment services
•Individual states sometimes cover services in addition to those required by the federal government.
Services Provided by Government Agencies: Federal health insurance programs
Covers health services for several additional specified populations
1. TRICARE, originally referred to as the Civilian Health and Medical Program for the Uniformed Services (CHAMPUS)
2. The Department of Veterans Affairs (VA)
Federal health insurance programs: TRICARE
•TRICARE, originally referred to as the Civilian Health and Medical Program for the Uniformed Services (CHAMPUS), pays for care delivered by civilian health providers to retired members of the military and the dependents of active and retired members of the seven uniformed services
•The Department of Defense administers the TRICARE program
•It also provides medical services to active members of the military
Federal health insurance programs: The Department of Veterans Affairs (VA):
•Provides healthcare services to eligible veterans of military service
•The VA hospital system was established in 1930 to provide hospital, nursing home, residential, and outpatient medical and dental care to veterans of the First World War
•Today, the VA operates more than 950 medical centers throughout the country
•The medical centers are currently being organized into 22 Veterans Integrated Service Networks (VISNs) to increase the efficiency of their services
Indian Health Service:
Through the Indian Health Service, HHS also finances the healthcare services provided to native Americans living on reservations in the United States
State governments and healthcare facilities:
•State governments often operate healthcare facilities to serve citizens with special needs, such as the developmentally disabled and mentally ill
•Some states also offer health insurance programs to those who cannot qualify for private healthcare insurance
•Many county and local governments also operate public hospitals to fulfill the medical needs of their communities
•Public hospitals provide services without regard to the patient's ability to pay
Workers' Compensation:
•An insurance system operated by the individual states
•Each state has its own law and program. In 1910, New York enacted the first workers' compensation law
•Workers' compensation programs cover healthcare costs and lost income associated with work-related injuries and illnesses •Federal government employees are covered by the Federal Employees' Compensation Act (FECA).
Who passes legislation that addresses workers' compensation?
•Individual states pass legislation that addresses workers' compensation coverage for nonfederal government employees
•Some states exclude certain workers (for example, business owners, independent contractors, farm workers, and so on)
•Texas employers are not required to provide workers' compensation coverage
Managed Care
•Managed care is a broad term used to describe several types of prepaid healthcare plans
•Common types of managed care plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans •MCOs work to control the cost of, and access to, healthcare services while striving to meet high-quality standards
•They manage healthcare costs by negotiating discounted providers' fees and controlling patients' access to expensive healthcare services
What was the development of managed care an indirect result of?
The development of managed care was an indirect result of the federal government's enactment of the Medicare and Medicaid laws in 1965.
Medicare and Medicaid legislation prompted the development of what?
•Investor-owned hospital chains and stimulated the growth of university medical centers
•Both furthered the corporate practice of medicine by increasing the number of management personnel and physicians employed by hospitals and medical schools
Reimbursement by MCOs:
•Reimbursement by MCOs varies depending on the type of organization and the contract negotiated
•For example, members of HMOs pay a set premium and are entitled to receive a specific range of healthcare services
•In most cases, employers and employees share the cost of the plan.
How do HMOs control costs?
•HMOs control costs by requiring members of the plan to seek services only from a preapproved list of providers, who are reimbursed at discounted rates
•The plans also control access to medical specialists, expensive diagnostic and treatment procedures, and high-cost pharmaceuticals
•They generally require preapproval for specialty consultations, inpatient care, and surgical procedures
Further federal support for the corporate practice of medicine resulted from:
•Further federal support for the corporate practice of medicine resulted from passage of the HMO Act of 1973
•Amendments to the act enabled managed care plans to increase in numbers and to expand enrollments through healthcare programs financed by grants, contracts, and loans
After years of unchecked healthcare inflation, what did the government authorize?
•After years of unchecked healthcare inflation, the government authorized corporate cost controls on hospitals, physicians, and patients for reimbursement of government-sponsored healthcare such as Medicare
•DRGs, PPSs, and the resource-based relative value scale (RBRVS) are examples of these controls.
What did the growth of managed care seem to reduce?
•The growth of managed care seemed to reduce inflation of healthcare costs during the early and mid-1990s
•However, healthcare costs are again rapidly rising
•Higher costs are making employers ask workers to pay a larger share for healthcare services
•MCOs face major challenges in remaining fiscally strong in the coming years
Consumer-driven Healthcare
•Consumer-driven healthcare is a new strategy in the private insurance market
•This method allows employees more choice in their healthcare decision making •Consumer-driven plans vary, but basically employers provide employees with a personal care account
•This account is a fixed amount and offered in the form of a voucher, refundable tax credit, higher wages, or some other transfer of funds
Health Savings Accounts (HSA):
•Health savings accounts, HSAs or (also called medical savings accounts or MSAs), offer their members the opportunity to control how their healthcare dollars are spent with a tax-advantaged savings account and comprehensive medical insurance coverage
•HSAs are much like IRAs in that they combine high-deductible health insurance with a tax-advantaged savings account
•The money that a member saves in his or her account assists in paying the deductible •Most accounts limit the member to contributing the amount of the deductible into the tax-deferred account
•This money is kept for medical expenses that qualify under the insurance plan
What is the benefit of an HSA?
•The benefit of an HSA is that the member pays for this deductible with pretax dollars •This means that the member saves the money that ordinarily would have gone to pay taxes, which, in effect, decreases the cost of the deductible
•When the member has paid off the deductible, the insurance provider begins to pay
•The money in the savings account earns interest and is owned by the member who holds the account
•HSAs allow members to save approximately 70 percent or more on the cost of their health insurance
Healthcare Reform Initiatives:
•The continuing high cost of healthcare has prompted calls for healthcare reform over the past several decades
•The costs of healthcare have several impacts
•Many families and individuals are unable to obtain healthcare insurance and forgo healthcare because of its high costs
•Since 2002 the uninsured rate has grown with 46.3 million uninsured reported in 2008 (U.S. Census Bureau 2009)
What has contributed to a large and increasing share of U.S. bankruptcies?
•Illness and medical bills contribute to a large and increasing share of U.S. bankruptcies with one study citing that 62.1 percent of all bankruptcies in 2007 were medically related
•In addition the United States spends over $2.2 trillion on healthcare each year
•That number represents approximately 16 percent of the total economy and is growing rapidly
The following are among the steps taken in 2009 by the federal government to reform healthcare with the goals of alleviating escalating costs, improving access, and increasing quality:
•Instituting provisions to provide individuals who have lost or recently lost their jobs with a tax credit to keep their health insurance through COBRA
•Increasing healthcare coverage for children through the reauthorization of the Children's Health Insurance Program (CHIP) that provides support, options, and incentives for states to provide coverage for an additional four million children in CHIP and Medicaid who are uninsured
•Computerizing America's health records in five years
•Developing and disseminating information on effective medical interventions
•Investing in prevention and wellness
Congress also began to debate various pieces of healthcare reform legislation in 2009.
•The goals of reform included reducing healthcare costs, protecting and increasing consumers' choices, and guaranteeing access to quality, affordable healthcare for all Americans
•President Barack Obama signed into law the Patient Protection and Affordable Care Act on March 23, 2010, and the Health Care and Education Reconciliation Act on March 30, 2010
•Together, these acts include a number of healthcare provisions that are to be implemented within four years
Check Your Understanding 12.7:
1. A disadvantage of individual health plans is:
D. They cost more than group policies
Check Your Understanding 12.7:
2. I am retired from the military. I am seeing a civilian healthcare provider for my care. What insurance do I most likely have?
Check Your Understanding 12.7:
3. An HMO is a model of a prepaid healthcare plan that falls under what type of reimbursement philosophy?
B. Managed care
Check Your Understanding 12.7:
4. Which of the following best describes workers' compensation insurance?
B. Insurance system covering healthcare costs associated with work-related injuries
Check Your Understanding 12.7:
5. Which of the following allows the patient to pay for deductible with pretax dollars?
D. Health savings accounts
12.7 Check your understanding: 6-10. Instructions: Match the descriptions with the appropriate legislation:
6. __F__ The development of managed care was a direct result of the federal government's enactment of the Medicare and Medicaid laws in 1965.
7. __T__ Medicare Part B is optional.
8. __T__ Workers' compensation plans are operated by the state governments.
9. __F__ One of the disadvantages of the health savings accounts is that the deductible is paid with pretax dollars.
10. __T__ Medicaid is co-funded by federal and state governments
Real-World Case:
This case study is extracted from a presentation at the 2004 IFHRO Congress and AHIMA Convention titled "e-HIM Framework and Case Study"
Evolution from e-Health Task Force to e-HIM Task Force. During the past decade, the Internet and its derived technologies have revolutionized the way business is conducted. In healthcare, the following examples illustrate this transformation:
•Increasing numbers of consumers access the Internet for information about healthcare providers, treatment options, and their own personal health information
•Health Web sites provide consumers with tools to develop and maintain their own online health records
•Consumers and health providers correspond via e-mail.
•Businesses and consumers purchase supplies and equipment over the Internet.
•Health information management (HIM) business processes, such as transcription and coding, use the Internet for off-site transaction processing
The Internet and its derived technologies create a plethora of opportunities for HIM professionals. What will HIM professionals understand about this technology?
•HIM professionals who understand and embrace this technology will harness and direct it to improve health information and the efficacy of healthcare for consumers, providers, vendors, payers, and all those in the healthcare supply chain
•Those who fail to understand and embrace this technology will be left behind, and their opportunities will be forfeited to faster-moving, better-focused professionals
The work of the AHIMA e-Health Task Force (2001) resulted in the following vision statement:
Vision for e-Health Information Management
•E-health presents a new frontier for managing health information
•HIM professionals will reinvent traditional HIM functions for a health record model in which the patient is part of the documentation team
•In this model, the health record will be designed and/or maintained by a trusted third-party organization or by the patient. •Individually identifiable data will be transmitted and accessed via the Internet
HIM professionals will clearly define the mission-critical role of a "cyber health record practitioner."
•They will develop standards of practice that support the implementation of AHIMA's tenets that its e-Health Task Force developed in 2000 and address the security, privacy, and quality standards for personal health information on the Internet.
In early 2003, AHIMA appointed a task force of experts to develop a vision of the e-HIM future.
The task force developed the following vision of the future of health information: "The future state of health information is electronic, patient-centered, comprehensive, longitudinal, accessible, and credible."
The task force's vision is not only theoretical, but it also offers practical guidance for anyone traveling the road toward e-HIM.
•Advancing the recommendations of the e-HIM Task Force, AHIMA created workgroups to develop practice standards that focus on areas that play an integral role in the transition from paper to electronic health records.
The following issues were selected for the initial standards development for the complete medical record in a hybrid electronic health record environment:
•Implementing electronic signatures
•E-mail as a provider-patient electronic communication medium and its impact on the electronic health record
•Electronic document management as a component of the electronic health record
•Core data sets for the physician-practice electronic health record
•Speech recognition in the electronic health record
From HIM to e-HIM; The knowledge and expertise for managing handwritten medical records containing source patient data have evolved through these steps:
•Independent management of paper medical records in settings across the continuum of care
•Scanning paper documents for multiple user access
•Entering data into automated systems that generate electronic patient data
•Integrated delivery systems that electronically manage the patient across the continuum of care
•Network integration and e-health information management
HIM professionals remain actively involved in developing effective processes to preserve patient privacy, confidentiality, and security. Why is this?
This is because the introduction of the Internet for accessing, transferring, and transmitting health information expanded the uses of source patient data (that is, the medical record as HIM professionals traditionally know it) as Internet-based business-to-business companies and business-to-consumer companies flourished
Career Opportunities for e-HIM professionals:
•The application of HIM skills, expertise, and experience described in the previous section meet the job requirements of several roles in e-health businesses
•This section discusses mission-critical functions and processes in e-health companies that HIM professionals can develop, manage, or perform
•Some skills transfer easily into the e-health environment while some require translation due to the differences in the work setting or to accommodate differences in the capabilities of advanced technologies.
Many of these e-HIM processes are interrelated or complementary.
•Processes and/or functions may be decentralized in some e-health organizations and centralized in others in much the same way that HIM processes have always composed an HIM department in traditional healthcare provider organizations
•In e-health companies as well as traditional settings, many HIM functions exist outside the HIM department
•With e-health companies and providers varying in purpose and scope (from traditional healthcare provider organizations delivering services electronically, to clinical systems vendors, to application service providers, to consumer healthcare Internet Web sites), the concept of a professionally led HIM function or department will vary depending on the organization's structure, resources, and needs
In the traditional and e-healthcare organizations, HIM professionals are responsible for managing two basic healthcare business objectives:
•Enabling the collection and storage of complete, accurate, and legal health information
•Facilitating the use of health information for patient care, quality evaluation, reimbursement, compliance, utilization management, education, research, funding, and in legal proceedings
How are the objectives accomplished?
•The first objective is accomplished in the traditional setting through functions generally consolidated and managed under the auspices of the HIM director. It includes such functions as record assembly, analysis, coding and abstracting, correspondence, special registries, and medical transcription.
•The second objective includes use of the information through functions such as creating and maintaining efficient filing and retrieval systems, master patient indices, chart and information retrieval and filing, release of information, and data retrieval for quality assurance, registries (for example, tumor, trauma), and other evaluative purposes
•These objectives are met within a highly regulated environment and managed with limited resources
•This necessitates professional guidance by those with health information management skills, which includes knowledge in the administration of highly regulated activities.
•Clearly, e-health companies having many of the same business objectives and challenges as traditional healthcare organizations need HIM knowledge and skills in developing processes that will meet their business objectives with a high level of quality and cost benefit
Roles, Resources, and Competencies in e-HIM:
"Revolution" is an overused word, but when applied to the effect of all that is digital, automated, or electronic in the healthcare industry, it is entirely accurate. Over the last decade, established relationships, value chains, and strategies have been radically altered or swept away.
As the revolution continues:
•The "front-line" challenge to HIM professionals is clear
•They can allow the technologies to roll uncontrolled through and around their organizations, in effect, handing over their rich knowledge base and expert skills to faster-moving, better-focused professionals in professions that don't even exist yet
•Or they can understand the potential of the Internet and control and direct its power to the benefit of their customers, health plan members, and patients.
Future of e-HIM and Where You Might Work: Domain manager:
Domain manager: Owns responsibility for a defined body of knowledge such as HIM, coding, laboratory, pharmacy, and so forth. Knowledge and authority may cross organizational lines as they maintain the integrity of the technical implementation of that body of knowledge. May work closely with product managers, operations staff, quality control, and so forth.
Future of e-HIM and Where You Might Work: Project manager:
Project manager: Manages the implementation of systems necessary to support personal health records, Web site content, and other projects
Future of e-HIM and Where You Might Work:
Medical language and classification expert: Employs skills in the design and use of medical vocabularies and classification; defines data and retrieves information from e-health systems
Future of e-HIM and Where You Might Work: Compliance officer
Compliance officer: Designs, implements, and maintains a compliance program that assures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services via the Internet
Future of e-HIM and Where You Might Work:
Information security expert: Designs, implements, or maintains an information security program that balances requirements of privacy, integrity, and availability of data. Understands the legal and social issues related to information security.
Future of e-HIM and Where You Might Work:
Patient information coordinator: Provides services to patients wanting to understand how to optimize their experience on the e-health Web site and create and maintain accuracy of their personal health records. Educates patients on protecting the privacy of their personal health information
Future of e-HIM and Where You Might Work: Reimbursement manager:
Reimbursement manager: Designs systems and procedures that assure generation of accurate clinical documentation needed to substantiate billing. Also involved in designing systems to efficiently classify information for billing. Develops and implements systems to assure the secure transfer of required data to billing centers, clearinghouses, or third-party payers.
Future of e-HIM and Where You Might Work: Data quality manager:
Data quality manager: Ensures the quality of health information by performing quality reliability and validity checks. Develops reports and advises clinicians on identifying critical indicators
Future of e-HIM and Where You Might Work: Privacy officer:
Privacy officer: Oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization's policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the healthcare organization's information privacy practices.
Future of e-HIM and Where You Might Work: Product manager:
Product manager: Responsible for overall implementation of a specific product or product line. This may include coordinating and managing the use, case design, development, quality control, version control, modifications and updates, and so forth.
The e-HIM Task Force (AHIMA) report outlines:
The e-HIM Task Force (AHIMA) report outlines new roles and competency areas to help you envision ways to expand your scope of knowledge.
New paths open to HIM professionals
•Business process engineer, information system designer, and consumer advocate are just a few new paths open to HIM professionals
•Decision support is another important area where HIM professionals will be building, querying, and analyzing databases to give clinicians the information they need to decide how to treat current patients or analyze patterns in past patient care.
Coders will have several migration paths once code assignment becomes automated.
Coders will play key roles as data quality and integrity monitors and data analysts
•Others will become clinical vocabulary managers, helping to make the national information infrastructure a reality by ensuring consistency and linkages between different codes
•Check out the AHIMA Web site to explore more information on these exciting emerging roles for HIM professionals