Part I Flashcards
Introduction
What is the definition of biomedical informatics?
The interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for sci. inquiry, problem solving, decision making, motivated by efforts to improve human health
Describe the spectrum of informatics?
BMI - biomedical informatics Bioinformatics Translational informatics - TBI, clinical research informatics (CRI) Health informatics
What is Hersh’s definition of BMI?
- Biomedical and health informatics (BMHI) is the field concerned with the optimal use of information, often aided by technology, to improve individual health, healthcare, public health, and biomedical research
- Informatics applied in a more focused domain is {X} informatics, e.g., nursing, dental, pathology, primary care, etc.
- Can be classified by “level” of domain but also has some overarching areas, e.g., imaging and research
What is the “fundamental theorem?”
a human brain + computer > human brain
What informatics is / isn’t?
- Is: cross-training where basic informational science meets biomed. application domain; tower of achevement: model formulate, system dev, system implement, study of effects
- Isn’t: tinkering with computers, work with large datasets, circumscribed roles, profession of health info manage, anything with a computer
History of informatics
- Informatics - Dreyfus 1962
- “Medical informatics” - 1974 (Collen)
- France - informatique > Russia > rest of europe
What are early EHRs?
- COSTAR,
- HELP,
- TMR,
- Regenstrief,
- El Camino,
- VistA,
- MYCIN,
- Internist-1,
- ELHILL,
- Problem-knowledge coupler
Who are the administrative leaders and exec positions in IT and informatics?
- CIO - chief info officer
- CCIO - chief clin. informatics officer
- CMIO - chief med. info officer
- CHIO - chief health info officer
- CXO - other
- HIM - health information officer
What is the Chief Medical Informatics Officer?
Serves as
- (1) liaison between clinicians and IT
- (2) executive informatician
- (3) director of clinical IT systems;
- leadership, communication, concensus building most important
What did the AMDIS CMIO Survey find?
95 respondents - priorities are:
- EHR optimization,
- data analytics,
- population health
- Challenges -
- competing priorities,
- org. culture,
- clinician disconnect,
- shortage of resources and talent;
- 68% still practice,
report to CMO, CIO, CEO, COO
Describe informatics organizations
HIMSS - Healthcare information and Management Systems Society
AMDIS - Assn Med. Directors of Information Systems
AHIMA - American Health Information Management Association
ANI - Alliance for Nursing Informatics
PHII - Public Health Informatics Institute
Society for Imaging Informatics in Medicine - SIIM
ISCD - Int. society for comp bio.
What is Homer Warner’s Summarization of informatics?
10% med
10% tech
80% sociology
What are some Informatics Challenges
Evidence-based informatics:
- Appropriate outcome measures may be indirect from system intervention
- Unit of analysis - beyond person, include clinic, hospital unit, etc.
List international ethical codes relevant to informatics
- Article 12 - Univ. Declaration Human Rights
- Hippocratic Oath
- European Convention on Human Rights
What are the US ethical codes?
- Code of Fair information practice
- Belmont report
- common rule
- AMIA Conflict of interest
What is the ethically relevant part of the Universal Declaration of Human Rights?
Article 12 - “No one shall be subjected to arbitrary interference with his privacy, family, home or correspondence, nor to attacks upon his honour and reputation. Everyone has the right to the protection of the law against such interference or attacks.” - mentions PRIVACY
How is the Hippocratic oath ethically relevant?
Privacy - “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”
What is the Code of Fair Information Practice?
- No personal data record-keeping system whose existence is secret
- Must be a way for person to find out what info about the person is in record and how it’s used
- Must be a way to prevent info about person from being used without consent
- Must be a way to amend or correct a record
- Organization - must assure reliability of data for intended use and take precautions to prevent misuse
Describe the Belmont Report
Belmont Report on ethical principles and guidelines for protection of Human Subjects of Research
- Respect for persons
- Beneficence (1) no harm (2) max benefits, minimize harms
Common Rule
1991 - outlines basic provisions of
- IRBs
- informed consent
- assurances of compliance
Describe the AMIA Conflict of Interest Policy
- REAL or APPARENT divided loyalty
- There is no monetary threshold for a COI
What does the US Bill of Rights say about privacy?
Fourth amendment - protection from unreasonable search, seizure
Describe the American Recovery and Reinvestment Act
Title XIII - health information technology
Title IV - medicare and medicaid health information technology
What is the model and context for security?
- Threat assessment
- Asset list
- Policy
- Education
- Technical measures
What are privacy protections with EMRs?
Most US hospitals use policy and audits against access to records
How do computing systems ensure legal compliance?
- Authenticate / authorize
- Non-repudiation
- Billing based on codes, based on
- Med Record docs
- Audit trails,
- doc. version hx
- Compliance and general counsel
Considerations for macros / templates / cut and paste
Should avoid this, since you’re billing and guiding patient care, can cause errors
HIPAA Security Rule
Defines confidentiality, integrity and availability
The HIPAA Security Rule requires physicians to protect patients’ electronically stored, protected health information (known as “ePHI”) by using appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity and security of this information.
TJC JCAHO IM Standards
Patient-Specific information –
- 1 The hospital has a complete and accurate medical record for every individual assessed, cared for, treated or served. –
- 2 Records contain patient-specific information, as appropriate, to the care, treatment, and services provided. –
- 3 The medical record thoroughly documents operative or other high risk procedures and the use of moderate or deep sedation or anesthesia.
TJC IM Standards
Information Management Planning
1.1 The hospital plans and designs information management processes to meet internal and external information needs.
• Confidentiality and Security
- 1 Information privacy and confidentiality are maintained.
- 2 Information security, including data integrity, is maintained.
- 3 The hospital has a process for maintaining continuity of information.
What is the role of a Medical Records Committee?
Oversight to meet goals of info management
Oversight for implementation of regs
Oversight for meeting accreditation standards
Policy / Procedure review
Understanding of record and systems functionality and impact on flow
Advisory / direction in area of system fn / work flow, appropriate entries, chart completion, forms management, audits and quality
What is involved in HIM?
Hospital Bylaws, Rules and regulations
estab. Medical Records Committee, and professional staff record responsibilities
Hospital policy and procedures guide hospital operations
- regulatory bodies - state and federal (state: division of health) => state: division of health; federal: CMS, medicare, HIPAA; accreditation
- Joint Commission
Describe key coding standards
ICD-10, CPTL HIPAA standards
HIM Key Operators
Release of Information
Master Patient Index and Encounters HIM
Credentials and certifications
coding cert, privacy cert, health information credentials: RHIA, RHIT
What is a capital budget?
Planning process for expenditure of relatively large sums on long-term assets such as replacing worn out assets with new ones and developing new business opportunities.
What is an operating budget?
A detailed projection of all estimated income and expenses based on forecasted revenue during a given period (usually one year). a complete operating budget consists of not only a projected profit and loss statement but also a supporting cash flow statement, as well as a balance sheet.
What is depreciation?
To lower the price or estimated value of [Webster], particularly of a long-term asset that has diminishing value over time.
What is net present value?
The difference between the present value of all cash inflows and the present value of all cash outflows; used to determine whether or not a project is an acceptable investment. [Garrison, 1994].
What are the principles of managerial accounting?
Managerial accounting is concerned with providing information to managers, in contrast to financial accounting, which is concerned with providing information to stockholders and others outside an organization.
- Includes accounting information (budgets, performance reports for controlling), tools for organizing and directing and decision making.
- There are many differences between financial and managerial accounting.
Is managerial accounting different from financial accounting?
Yes:
more emphasis on data for managers,
more emphasis on the future,
emphasis on non-monetary data
emphasizes segments of organization;
NOT goverened by GAAP
What are the tools in managerial accounting?
Fixed and variable costs
Profit and loss statements
Operating leverage - Operating leverage is a cost-accounting formula that measures the degree to which a firm or project can increase operating income by increasing revenue. A business that generates sales with a high gross margin and low variable costs has high operating leverage.
Cost-volume-profit analysis
What are the different types of budgets?
Statistics - calculate budget needed for various what-if scenarios
Revenue - revenue receipts of gov and expenditure met from revenue
Cash - prediction of future cash receipts and expenditures for time period
Expense - include spending data items
Operating
Capital
What is time value analysis?
Involves taking future value of lump sum and present value of lump sum
Net present value: value of the sum of future cash flows presented in today’s dollars
Compounded and Discounted Amounts
The time value of money accounted for by concept of compounding interest; sum invested today will accrue interest in future - a fixed sum paid in future worth less than same amount today
EXAM What are the parts of a balance sheet?
Assets = Liabilities + Equity
assets = current + fixed
liabilities = current + long-term debt
What are the parts of an Income statement?
Operating earnings = gross profit - (operating expenses + depreciation)
What is Cash Flow?
Amount that changed hands during accounting period
What are the costs of HICT?
Implementation (support, training, admin, etc)
Maintenance (support, application support, user support, etc.)
RDTE (research, development, training, evaluation)
Main sources of hospital expenses
Salaries/wages/benefits = 50%
All supplies - 31% Depreciation and interest - 8%
Pharmaceuticals - 8%
Prov. uncollectible accts - 3%
Major ROI clinical systems?
Drug savings - 29%
ADE prevention - 15%
Dec. billing - 13%
Inc. billing capture - 14%
Radiology savings - 15%
What are the determinants of individual & population health?
Policy making - local, state, national
Social factors - economics, environment, education, etc.
Health services - health care, public health
Individual behaviour - diet, lifestyle, activity
Biology and genetics
Primary domains, org. structures, cultures, processes
Health care delivery Public health Clinical research Education of health professionals Personal health
EXAM What are the levels of care?
Primary - initial / ongoing in office/clinic
Secondary - specialty care provided in community
Tertiary care - high specialized care provided by referral in large academic med centre
Quaternary care - extension of tertiary, advanced levels of med
EXAM What are the five “p” stakeholders?
Patient
Provider - doctors, etc.
Purchaser - employer/gov
Payor - insurance company
Public Health
Major problems with US healthcare
Costs Health disadvantage - life expectancy, infant mort 20% waste in system - overtreatment, failure of care coord, failure of care delivery, admin complexity, pricing failure, fraud/abuse
What is Public Health?
the science of protecting and improving the health of communities through education, promotion, and research for disease / injury prevention
Core public health activities?
assessment, policy development, assurance
What are some public health activities?
Prevent epidemics, protect env. hazards, prevent injuries, promote healthy behaviours, respond to disasters, assure quality and accessibility
What are the categories of clinical research (according to NIH)?
Patient-oriented research
Epidemiologic and behavioral studies
Outcomes research and health service research
What is translational research?
Accelerate resarch results from lab to clin. environment along T1/T2/T3 axis: T0 - basic animal res. T1 - translate to humans T2 - translate to patients T3 - translate to practice T4 - translate to communities
Describe personal health
Decision-making related - half of adults make healthcare decisions for others in their family 3/4 are interested in information to help inform decisions
Describe the flow of medical knowledge
Payer, hospital, labs, Rx, ambulatory, person, public health
EXAM: Describe Mulrow’s theory of knowledge
Evidence + patient/clin pref + constraints => clinical decision / knowledge
What are some policy and regulatory frameworks?
Dept Health Human Services Centers for Medicare and Medicaid Services Centers for Disease Control Prevention Food and Drug Administration National Institutes of Health
How is US healthcare financed?
total spending > 17% per person spending doubled from 1996 to 2015 ($9990) half the spending growth due to medical price inflation - rising cost of services to patients
EXAM Who are the major healthcare payors in the US?
Private health insurance - for most employed citizens and dependents
Medicare - government insurance for elderly & disabled
Medicaid - gov. insurance for indigent
SCHIP - gov. insurance for uninsured low-income children
Other
How is the money spent and paid?
Payer: private health insurance, medicare, medicaid, out-of-pocket
Contributor: fed. gov, household, private business…
Category: hospital care, physician & clin services…
What are the 3 goals of obamacare?
- Regulation of coverage
- Major expansion of coverage
- Bending the cost curve
What is EMTALA?
Emergency Medical Treatment and Labor Act (EMTALA) - passed in 1986 - requires emergency dept to evaluate patients and treat emergent conditions
EXAM What are 10 Obamacare objectives?
- small biz tax credit
- close medicare donut hole
- require larger (>50) employers to offer health insurance coverage
- expand medicaid for low-income Americans <133%
- Create health insurance exchanges with subsidies for 400% poverty level
- Community rating for insurance policies - no denial of insurance for pre-existing illness
- Require coverage of essential health cond’t
- Increase payroll tax of upper-income Americans & some taxes
- Individual mandate for health insurance
Has Obamacare been successful?
Yes - uninsured > 20% reduced to 11.5 - 13.1%
What cost measures did the ACA implement?
Bundled payments and accountable care: pt. centered medical homes, accountable care organizations Focus on care that works - IPAB - independent payment advisory board PCORI - patient-centered outcomes research institute
EXAM Health care quality and the IOM reports
Triple aim: better health, better healthcare, lower cost
Quality measured in 3 categories:
(1) structural (factors that make it easier or harder to deliver high qual care),
(2) process - factors describing healthcare content and activities
(3) outcomes - changes attributable to care
QUALITY AIMS FOR 21st CENTURY HEALTHCARE
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
What is the HITECH act?
Health Information Technology for Economic and Clinical Health (HITECH) act of the ARRA (American Recovery and Reinvestment Act)
What is the centerpiece of the HITECH act?
Meaningful use - must use certified EHR connected for health information exchange, submit data on clinical qual measures
EXAM For MU, what are the five goals of the healthcare system?
- Improve qual/safety/eff
- Engage pts in their care
- Inc. coord of care
- Improve health status of pop.
- Ensure privacy and security ex.
- Implement drug-drug int. check ==> improve qual, safety, efficiency provide summary => involve in care
How is HITECH implemented?
Increased medicare/medicaid reimbursements to:
EPs (eligible professionals, MD, DO, DDS, etc) and
Eligible hospitals (EHs)
EXAM What are the stages of HITECH?
2009 - HITECH policies 2011 -
Stage 1 MU (capture /share data) 2014 -
Stage 2 MU (advanced care processes w. decision support) 2017 -
Stage 3 MU (improved outcomes)
What are the HITECH reimbursement amounts
EPs: $44-63k
EHs: $2-9M -vary by medicare vs. medicaid qual -amount of medicare / medicaid pts seen -d/c per yr
How was MU operationalized?
Stage 1 - obj. announced in 2010; payments started 2011 (EPs) and 2010 (EHs) Stage 2 - objectives announced in 2012; start pushed back one year 2014 EH: mod stage2/3 EP: Advanced care info
Criteria for Stage 1-2 MU?
Core obj - all met Menu obj - selected from set Stage 1 - EP meet 15 core, 5/10 menu EH - 14 core, 5/10 menu One menu - public health obj. Stage 2 - EP 17 core, 3/6 menu EH - 16 core, 3/6 menu
EXAM What are the specific stage 1 MU?
Pt demo, vital signs, up-to-date prob. list, active med list, active allergy list, smoking, clinical summaries, pts with electronic copy, transmit prescriptions electronically, CPOE, drug-drug/ drug-allergy checks, electronically exchange key clincal info among providers, one clin. decision support rule & ability track compliance, implement privacy/safety systems, report measure to CMS
What are Stage 1 MU options?
Drug formularty checks, labs, list of patients by specific cond’t, identify pt. specific education resources, med reconciliation between care settings, transmit immunization data, submit syndromic data to public health, advanced directives for 65 or older, electronic data on reportable lab to pub. health, send reminders to pts, provide pts with timely electronic access to health info
What are the Stage 2 EP core obj?
CPOE E-Rx Demographics Vital Signs Smoking Status Interventions Labs Pt List Preventive Reminders Pt access Visit summaries Education resources Secure messages Rx. Reconciliation Summary of care Immunizations Security analysis
What are the stage 2 menu objectives?
- Imaging results - more than 10% of imaging results thru EHR tech. 2. Family history - record family health hx more than 20% 3. Syndromic surveillance - successful ongoing transmission syndromic 4. cancer - successful transmission 5. specialized registry - successful transmission 6. progress notes - enter note for more than 30% of pts
Stage 2 hospital core objectives?
CPOE, demographics, vitals, smoking, interventions, labs, patient lists, eMAR, patient access, education resources, Rx reconciliation, summary of care, immunizations, labs, syndromic surveillance, security analysis
Stage 2 hospital menu items?
Progress notes, E-Rx, imaging results, family hx, advanced directives, labs
What are Stage 3 criteria?
Protect electronic pt. records, electronic prescribing, CDS, CPOE, pt. access, pt enagement / coord, health info exchange, public health/clin data registry reporting
What are the CQMs?
Clin quality measures = CQM
- changed before 2014 to after for EPs, EHs, CAHs Core:
htn / BP measure,
preventive care (tobacco use/cessation),
adult weight,
alternatives - if denominator core measures = 0, wt. assessment and counseling, preventive care (influenza imm < 50yr, childhood imm status) Emerg admission decision time, median time depart Stroke - therapy, education, rehab…
EXAM What are the NQS domains?
- Patient and family engage
- Pt. safety
- Care coordination
- Population and pub health
- Efficient use of healthcare resources
- Clinical processes/effectiveness
How has EHR adoption changed from MU?
Office-based: 16.9 to 50.5 (2008-2014) Emerg: 16.5 to 53.6 (2007-2011) Outpt dept: 8.9 to 57.4 (2007-2011) Non-fed hospitals…
