CHAPTER 3 & 4 STUDY GUIDE Flashcards
Know the difference between fee for value and fee for service
Fee for Value- value-based reimbursement models compensate providers not for the quantity of procedures performed, but rather for the quality of the care they provide, measured by patient health outcomes.
Fee for Service- billing for healthcare services after the services have been provided (retrospectively) according to the facility’s or office’s actual fees for each service.
Be able to identify health informatic activities
Health Informatics- the practice of information and knowledge management across clinical healthcare and public health domains
Require technical expertise such as project management, systems management, programming, and database management. Other positions analyze and use the data created in an integrated computerized healthcare system. These include data analysts, reporting specialists, and biostatisticians.
Focuses on the processes of electronic exchange, digital storage, and the computerized manipulation of health data
Know how medical records are filed
On-site Client/ Server solutions
Cloud-based solutions
Know terminal digit filing
Terminal Digit filing- Breaking a medical record number into segments of single or multiple digits, with filing based on the last segment as the primary file placement, followed by the middle segment, and then first segment
Identify centralized and decentralized registration processes
Centralized registration Process- type of hospital registration in which all patients presenting for any type of care are registered through one central area, regardless of the type of care being sought
Decentralized registration process- type of hospital registration in which there are multiple points of patient access, depending on the type of care being sought-inpatient admission, emergency department, outpatient diagnostics, ambulatory surgery, and so on
Know the different methods of how medical record numbers are assigned
Medical Record Number- a unique numeric identifier for each patient seen in a health facility’ sometimes referred to as a health record number// is assigned medical record numbers are assigned sequentially by the computer system or manually during the registration process
Master Patient (Person) Index (MPI)- a permanent listing of all patients who have been admitted to or received care in a healthcare facility; it is the key to locating patient records in a facility and is maintained permanently
Back in the day the medical record numbers given to patients were their social security number
Know the role of the HIM manager
Health Information Management (HIM)- is the practice of acquiring, analyzing, and protecting medical information to provide quality patient care, and until recent years, in a hard copy format
Role of a HIM- Health information managers are responsible for information governance, or ensuring enterprise-wide health data integrity, privacy, and security. Some of their main responsibilities may include: Implement processes and systems to support accurate and complete medical record documentation.
Understand the patient perspective of how integrated delivery networks impact the patient
Integrated delivery network- a network of hospitals and physicians organized under a single parent company for the purpose of providing care across the full continuum of a patient population’s needs
Integrated delivery networks-
To capture efficiencies and saving from economies of scale by spreading costs over a larger base of operations To efficiently integrate HIT and health information exchange into facilities To better provide continuity of care to patients To be better positioned for future changes to healthcare reimbursement To better compete on quality and costs To provide better care to patients by providing a full range of services on a timely and convenient basis
Provide one stop shopping offering all services that patients need, including primary care, specialists, and acute and long-term care, along with all support services
Be able to put chart numbers in terminal number sequence (Page 107)
Terminal Digit filing- Breaking a medical record number into segments of single or multiple digits, with filing based on the last segment as the primary file placement, followed by the middle segment, and then first segment
Define concurrent documentation
Concurrent means “happening simultaneously.” The concurrent health record is the developing health record that is compiled while the patient is hospitalized or being seen in an ambulatory setting.
CAHIM health informatics- what is included
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)- an independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality Accreditation Standards for Health informatics and Health Information Management (HIM,2014) educational programs (CAHIIM,2014)
Endorsed a health informatics curriculum at the graduate level, consisting of three parts:
- Information systems
- Informatic principles
- Information technology
HIM is an underlying element that shapes all parts of health informatics allowing information to be used properly and effectively. Health informatics is built on top of this governed information and is focused on the resources, devices, and methods required for optimizing the-
acquisition
storage
retrieval
use of clinical and related patient data
Tools include not only computers but also-
clinical guidelines
formal medical terminologies
information & communication systems
EHR
- EHR captures more information than an EMR and its designed to be exchanged and used at any point of care, following the patient, EHRS need to meet Meaningful use standards
Portal
a secure website where a patient can access information from a provider’s EHR, such as diagnoses, lab results, discharge summaries, immunizations, and imaging study reports. a portal typically contains other information and functionality, such as the ability to schedule appointments, refill prescriptions, email clinicians, check insurance claims data, make payments and gain access to online forms
MPI-Master Patient (Person) Index
- a permanent listing of all patients who have been admitted to or received care in a healthcare facility; it is the key to locating patient records in a facility and is maintained permanently
HITECH
legislation resulting from the ARRA that provides incentives to providers and hospitals that adopt or upgrade existing electronic health record EHR systems and associated technologies and use them in specified ways.
- allocated $32 billion to revolutionize healthcare//consisting of $30 billion to Medicare and Medicaid incentive payments to physicians and hospitals to adopt and use health information technology (HIT) and EHRs in ways defined as “meaningful”
- anticipated the passage of the Affordable Care Act (ACA) as well as the acts specific goals of cost reduction through the introduction of new models of payment, improvement of care delivery and administrative processes, and improvement of quality through measurement and reporting.
Principle goals
- increase the use of EHRs - establishment of a nationwide healthcare information system, and data analysis as well as reporting among hospitals, physicians, labs, pharmacies, clinics, public health organizations, payers, and patients, - make the fundamental changes that are required by ACA possible
Meaningful use
The Section of HITECH meant to increase the effective use of electronic health records through monetary incentives to adopt and use certified technology.
Meaningful Use requirements ensure that EHRs are used to achieve benchmarks in improving patient care in a way that can support payment reform and reporting requirements in the future
IDN
Integrated delivery network- a network of hospitals and physicians organized under a single parent company for the purpose of providing care across the full continuum of a patient population’s needs
Administrative data
nonmedical data, such as a patient’s identifiers, insurance-related data, authorizations, and business correspondence
CDI (Page 112)- (Clinical Documentation Improvement)
the review of health records, usually concurrently, to ensure that the documentation in the health record is at the level of specificity that allows for code assignment that accurately depicts the patient’s diagnoses and procedures performed
mHealth (Page 83)
mobile-based or mobile-enhanced solutions that deliver healthcare
Legacy systems (Page 74)
prior computer or business systems used to accomplish the tasks now accomplished by a new system’ often, legacy systems continue to be partially used during system upgrade cycles
Change management (Page 71)
a structured approach for ensuring that changes in an organization are thoroughly and smoothly implemented and that the benefits of change are achieved
Workflow (Page 71)
a well-defined sequence of activities undertaken in order to achieve a work outcome
Personal health record (Page 82)
a paper record, a website, or software that contains information similar to that in an EHR such as diagnoses, medications, and medical history. the patients can also add information themselves, such as notes from other clinicians (ex-specialists) their personal notes and observations, and data from home monitoring devices or other sources. the patient or the patient’s caregiver determines who has access to a PHR
WORM technology (Page 110)
WORM is an acronym for “write once, read many” meaning that records may be read numerous times, but nothing on the disk can be altered in anyway
Scanned records added to the EHR from optical disks cannot be altered, added to, or deleted.
Jukebox (Page 114)
a means of storing multiple optical discs using a robotic arm that loads and unloads optical disks for delivery of requested health records
Enterprise - health system
a great number of hospitals are apart of a health system
-health information is shared by each facility in the enterprise. Thus, an accurate complete master patient index is crucial
Demographic data (Page 91)
administrative data that identify the patient- name, date of birth, address, and gender
Project Management (Page 72-73)
the application of knowledge, skills and techniques to execute projects efficiently and effectively
eSignature (Page 101)
a digitized signature placed on a chart entry through the use of a personal identification number (PIN)
hybrid record (Page 96)
health record maintained in paper, electronic format, and or in the form of recordings or tracing derived from diagnostic tests
record retention plan
a written policy that documents the length of time a health care facility retains its health records, the form (medium) in which the records will be kept, and the location(s) of the records
regional extension center (Page 69)
an organization funded by the HITECH act to assist providers by extending EHR adoption training and support services, offering guidance in EHR implementation, troubleshooting related technical issues, and meeting Meaningful use
Fax
Can easily fall into the wrong hands, which would be a violation of privacy
If you do fax patient information, make sure you are faxing it to a dedicated fax machine in a secure location and make certain Yes. The Privacy Rule allows covered health care providers to share protected health information for treatment purposes without patient authorization, as long as they use reasonable safeguards when doing so. These treatment communications may occur orally or in writing, by phone, fax, e-mail, or otherwise.
Be able to flow chart a patient from registration through the process of permanently filing the medical record (Page 98)
- patient is registered
- previous records are delivered to care unit if applicable
- documentation is written by physicians, nurses, therapists, and other healthcare professionals, and results of tests are filed in the record
- patient is discharged
- health record is assembled
- health record is analyzed for missing documentation
- physician(s) and other healthcare professionals complete missing documentation or signatures
- health record is reviewed again until it is complete
- record is permanently filed (until needed again)
Concurrent Analysis is the same as?
Quantative Analysis
On-site client/ Server solutions
A form of filing medical records
the use of computers in a network where functions are split between server talks and client tasks; the client computer makes requests of the more powerful server computer in order undertake local processes
the client computer runs the EHR software in a clinic, and the patient data and additional software supporting the EHR are stored on the server. In this case, Patient records are stored on a server in a secured area at the hospital or doctor’s office. Hospitals and most clinics use this model.
Cloud- Based Solutions
A form of filing medical records
service in which software and data are stored on remote computers and accessed by a local computer through the internet, typically using a browser
Most EHR Vendors offer a hosted version of their EHR. Under this model, the client software is more or less the same, but the health data and application software is “In the cloud” being hosted on remote servers by the vendor and accessed via a secured internet connection. The provider does not have to maintain, secure, and back up a local server but does have to pay monthly fees to the vendor.
The second type of cloud solution is an EHR that is available only over the Web. This is a “pure” cloud-based solution and is accessed through a browser. Very little customization can be done with this type of EHR, and it is simpler than the cloud solutions offered by traditional client/server vendors. This pure cloud EHR is a cost-effective solution for smaller practices that cannot afford the EHR, server maintenance and customization expenses of the other solutions.
