Introduction to Health Care Usa 1228800612153371 9

7/31/2019 Introduction to Health Care Usa 1228800612153371 9

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Nainil Chheda (http://www.nainil.com/research) 1

(USA)

The Not So ShortIntroduction to Health Care

By Nainil ChhedaHealth Care Strategist

Website: http://www.nainil.comEmail: [email protected]


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Table of ContentHealth Care Statistics

Basic Outline of Patient FlowElectronic Medical RecordsPersonal Health Records

NHIN / RHIOHIPAAStandards & InteroperabilityCertificationDiscussion Topics (Consumer Empowerment &Population Health)


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President: George W. BushIn 2004, US President

George W. Bushlaunched an initiativeto make electronicmedical recordsavailable to mostAmericans within thenext 10 years (by

2014).

By computerizinghealth records, wecan avoiddangerous medicalmistakes, reducecosts, and improvecare.

President George W.Bush, State of theUnion Address,January 20, 2004


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GDP & Health Care SpendingHealth spending in

2006 is projected at$2.1 trillion, whichaccounts for 16percent of the grossdomestic product.

Cited From:John A. Poisal, Christopher Truffer, Sheila Smith,

Andrea Sisko, Cathy Cowan, Sean Keehan, BridgetDickensheets, and National Health ExpendituresTeamHealth Spending Projections Through 2016: ModestChanges Obscure Part D's ImpactHealth Affairs Web Exclusive, February 21, 2007

The health shareof gross domesticproduct (GDP) isexpected to holdsteady in 2006before resuming itshistorical upward

trend, reaching19.6 percent ofGDP by 2016.


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Define Health CareHealth care includes, but is not limited topreventive, diagnostic, therapeutic,rehabilitative, maintenance, mental healthor palliative care and sale or dispensing ofa drug, device, equipment or other item inaccordance with a prescription.

Retrieved from: www.dpw.state.pa.us/General/HIPPAPrivacy/003670787.htm on February 24, 2007using Google Definition.


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Definitions in Care - 1Care Giver: Healthcare professional;family member or friend who attends to theneeds of a patient; who helps in identifyingor preventing or treating illness or

disability. (Provider of Care)

Care Taker: Patient; a person whorequires medical assistance. (If covered byan insurance policy: Insured)


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Definitions in Care - 2Health Insurance: A contractual relationship

whereby an insurance company (the insurer)agrees to reimburse the insured for health carecosts in exchange for a premium. The contract(policy) generally stipulates the type of health

care benefits covered as well as costs to bereimbursed.Retrieved from www.valleyhealth.biz/glossary.html on February 24, 2007 using Google Dictionary.

Co-pay: An arrangement where the insuredpays a specified amount for various services andthe health carrier (insurance company) pays theremaining charges.

Retrieved from www.kellerlowry.com/glossary/glossary_c.htm on February 24, 2007 using GoogleDictionary.


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Definitions in Care - 3Prescription: Written instructions (usuallysent via Fax / Electronically) from aphysician to a pharmacy / druggistconcerning the form and dosage of a drug

to be issued to a given patient.Retrieved from http://wordnet.princeton.edu/perl/webwn on February 24, 2007 using GoogleDictionary.

Claim: The formal request by a

policyholder or claimant for payment ofloss under an insurance policy.Retrieved from www.apmc.us/IndustryGlossary on February 24, 2007 using Google Dictionary.


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Definitions in Care - 3Clearing House: A public or private entitythat processes or facilitates the processingof nonstandard data elements of healthinformation into standard data elements.(HIPAA, Subtitle F, Section 262(a) Section1171(2))

Retrieved from www.hipaabasics.com/glossary.htm on February 24, 2007 using Google Dictionary.


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Start of TransactionThis slide has been intentionally left blankby the author.


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Patient Flow* Schedule an Appointment

* Front Office (CollectsPersonal & Insurance

Details. Co-pay may beCollected Upfront.)

*In Exam Room: MedicalAssistant collects Vitals,

Allergy info., CurrentMedications.

*Doctor Examines thePatient, Orders Labs, X-

Rays, PrescribesMedication

* Relevant Patient Datais Recorded in the

Patients Chart.* Patient Schedules a

Follow-up Appointment.

* Co-pay may be Paidbefore Leaving.

* Billing Staff Creates aClaim and Sends it toInsurance Company.

* The Doctor Receivesthe Payment from the

Insurance Company

Patient Flow

1

2

3

4

5

6


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Schedule an AppointmentPatient Calls the practice to schedule anappointment.


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DoctorDoctor examines the patients previousrecords (if any)Doctor examines the patient

Doctor (may) order lab work / diagnostictests (X-Rays, etc) to be performed on thepatient

Doctor orders a medication for the patientand submits it (electronically or by fax)


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Lab or Diagnostic TestLab (e.g. HgA1c).Diagnostic Test (e.g. X-Ray)Patient often has to go to another facility to

have the test performedTest orders are submitted to and receivedby the lab companyElectronic communication between thedoctors office and the lab is possible


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ChartDoctor / Staff: Relevant Patient Data is Recorded in thePatients Chart.Chart may contain the following but is not limited to:

Chief ComplaintHistory of Present illness (HPI)

Current MedicationPast Medical HistorySurgical HistoryAllergiesHospitalizationReview of Systems (ROS)Vital SignsExamination


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Follow Up AppointmentFront Office Staff schedules a Follow UpAppointment (if needed)A patient may or may not have insurance.

Patient has insurance: Co-payment may be Paidbefore Leaving.Patient does not have insurance: Patient usuallypays the charges before leaving or the billing person

mails them a statement.Patient Leaves the Doctors Office.


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Billing (If Patient has Insurance)Billing Staff Creates a ClaimBilling Staff reviews the Claim data beforesending it to the Insurance Company.

Billing Staff sends the claim (usuallyelectronically) to the Insurance Company.


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InsuranceOften, insurance companies only cover a

portion of the services provided by thedoctor to the patient.The Insurance company processes theclaims and renders the necessary ClaimAmount to the doctor.Doctors Billing Staff posts the paymentreceived to the system to show theamount collected.


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Miscellaneous TransactionsDuring this whole process there may be

multiple instances where in:the patient calls the doctor;doctor receives faxes from pharmacy / patient;

lab / diagnostic results are received by thedoctor;messages are exchanged by the doctor and the

patientAll the (above) transactions are recordedand are attached to the patients chart.


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End of TransactionThis slide has been intentionally left blankby the author.


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Electronic Health RecordsAn Electronic Health Record (EHR) is a

medical record or any other informationrelating to the past, present or futurephysical and mental health, or condition of

a patient which resides in computerswhich capture, transmit, receive, store,retrieve, link, and manipulate multimedia

data for the primary purpose of providinghealth care and health-related services.Retrieved from: http://en.wikipedia.org/wiki/EHR on February 24, 2007 using Google Definition.


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What is the need for EHR?"Every year 98,000patients die due topreventable medicalerrors in the businessprocess of care.

Thats equivalent to a 747crashing every day, killingall aboard. If hospitalswere airlines, would youfly?

John D. Halamka, MD, CIO, HarvardMedical School

Medical errors may result in:A patient inadvertently given the

wrong medicine.A clinician misreading the resultsof a test.An elderly woman with ambiguoussymptoms (shortness of breath,abdominal pain, and dizziness)

whose heart attack is notdiagnosed by emergency roomstaff.

Retrieved from:http://www.ahrq.gov/research/errors.htm EHR onFebruary 24, 2007.


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How do errors occur?Errors can occur at any point in the health care delivery system:

Medication Errors

These are preventable mistakes in prescribing and delivering medication topatients, such as prescribing two or more drugs whose interaction is knownto produce side effects or prescribing a drug to which the patient is known tobe allergic.

Surgical ErrorsDiagnostic Inaccuracies

Incorrect diagnoses may lead to incorrect and ineffective treatment orunnecessary testing, which is costly and sometimes invasive. Also,inexperience with a technically difficult diagnostic procedure can affect theaccuracy of the results.

System FailuresAlthough errors in medication, surgery, and diagnosis are the easiest to

detect, medical errors may result more frequently from the organization ofhealth care delivery and the way that resources are provided to the deliverysystem.

Retrieved from: http://www.ahrq.gov/research/errors.htm EHR on February 24, 2007.


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Key Attributes of an EHRWorkflow automation

Rapid and organizedaccess to clinical dataMulti-user concurrentaccessFlexibility in dataentryDecision supportcapability

Error prevention

Reporting capabilityCompliance withregulations and lawsRobust architectureTechnically soundplatform


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Perceived Benefits Of Electronic HealthRecords (EHRs) To The Practice, 2005

Cited From: Gans D, Kralewski J, Hammons T and Dowd B.Medical Groups Adoption Of Electronic Health Records And Information SystemsHealth Affairs, Vol 24, Issue 5, 1323-1333


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Percentage Of Office-Based PhysiciansUsing EHR, By Specialty

Cited From: Catharine W. Burt and Jane E. Sisk,Which Physicians And Practices Are Using Electronic Medical Records?,

Health Affairs, Vol 24, Issue 5, 1334-1343


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Barriers To Implementing ElectronicHealth Records (EHRs), 2005

Cited From: Gans D, Kralewski J, Hammons T and Dowd B.Medical Groups Adoption Of Electronic Health Records And Information SystemsHealth Affairs, Vol 24, Issue 5, 1323-1333


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Personal Health RecordPersonal health records are electronicsummaries of a patient's medical recordthat are often portable and easilyaccessed by the patient.

Retrieved from http://www.aafp.org/fpm/20060500/57anin.html on February 24, 2007.


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Various Models of PHROne version of personal health records is a

provider-owned digital summary that patientscan access but cannot change.A second model is a patient-owned programpatients can use to enter and organize theirhealth information.The third model is a portable digital file that canbe transferred between computers and thatcorresponds closely to the Continuity of CareRecord standard.



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PHR UsesPersonal health

records empowerpatients by allowingthem to monitor their

health data.

Personal health

records have thepotential to improvepatient-provider

relationships, patientsafety and quality ofcare.



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NHINNationwide Health Information Network (NHIN)

National Health Information Network describesthe technologies, standards, laws, policies,programs and practices that enable healthinformation to be shared among health decision

makers, including consumers and patients, topromote improvements in health andhealthcare.

The path to a national network of healthcare informationis through the successful establishment of RegionalHealth Information Organizations (RHIO).

Retrieved from http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=143 onFebruary 24, 2007.


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RHIO Regional Health InformationOrganization

Regional HealthInformation Organization(RHIO) is a multi-stakeholder organizationthat enables the

exchange and use ofhealth information, in asecure manner, for thepurpose of promoting the

improvement of healthquality, safety andefficiency.

U.S. Department ofHealth see RHIOs as thebuilding blocks for thenational healthinformation network

(NHIN). When completethe NHIN will provideuniversal access toelectronic health records.

Retrieved from http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=143 on February 24, 2007.


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Goal of NHIN and RHIOsInterconnect clinicians so that they can

exchange health information using advancedand secure electronic communication.Personalize care with consumer-based healthrecords and better information for consumers.Improve population health through advancedbio-surveillance methods and streamlinedcollection of data for quality measurement and

research.Retrieved from http://www.hhs.gov/asl/testify/t060622a.html on February 24, 2007.


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NHIN Sustainability FactorA true market can't be made from the top-

down approach.

Widespread electronic medical recordsuse "is really fundamental to making thisthing (NHIN) work," said Micky Tripathi,

president and CEO of the Massachusetts eHealth Collaborative.


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What are the HIPAA AdministrativeSimplification Provisions?

National standards for electronic data

transmissionUnique health identifiers for providers,employers, plans, and individualsSecurity standards to protect electronicallymaintained health information

Privacy and confidentiality provisions forindividually identifiable health care data


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HIPAA ComplianceSoftware and

hardware, in and ofthemselves, cannotbe HIPAA compliant.

They can only aid anorganization becomeHIPAA compliant.

HIPAA compliance

is an organizationalobligation, not atechnical

specification.

Cited From:

http://www.hipaadvisory.com/action/Compliance/compliant.htmContracting for "HIPAA Compliant" Software and Devicesby John R. Christiansen - Stoel Rives LLP


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Who must comply with HIPAA?Health care providers or any other person

or organization that furnishes, bills, or ispaid for health care in its normal course ofbusiness

Health plans that provide or pay the costof medical care, including Medicare andMedicaid

Health care clearinghouses that processdata elements or transactions


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Standardization & InteroperabilityStandardization

The process ofestablishing standardsthat are documentedagreements containing

technical specificationsor other precise criteriato be used consistentlyas rules, guidelines, or

definitions ofcharacteristics.

Interoperability

The ability of two ormore systems, orcomponents toexchange information,

and to use theinformation that hasbeen exchanged.

Retrieved from www.globalvoice.com/index.aspon February 24, 2007.


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Need for StandardizationTo create trust and confidence in the

health care servicesIncrease market relevance

To facilitate exchange of informationHelp prevent duplication of effort andensure interoperability between the

various technical solutions in health care


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Need for InteroperabilityThere is a need for transportability that willenable the next provider easy access to thelatest patient records.There is a need for personal health record(PHR) which contains the patient-entered

information.There is a need for containment of cost bydeveloping a more systematic approach tohealthcare information transportability whereby

all disciplines work together towards adocumented, integral approach to the individualpatient.


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Example of Health Care Standardsfacilitating Interoperability

CCR Continuity of Care Recordshttp://www.centerforhit.org/x201.xml

CDA Clinical Document Architecturehttp://www.hl7.org/Library/standards_non1.htm

CCD Continuity of Care Documenthttp://en.wikipedia.org/wiki/Continuity_of_Care_Record

PDF/H Portable Document Format -Healthcare

http://www.aiim.org/article-pr.asp?ID=32097


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CCR (Standard)The CCR may be used as a vehicle to

exchange clinical information amongproviders, institutions, or other entities.It may also be used by the patient as abrief summary of recent care.


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CCR BenefitsThe next healthcare provider will not have to search for or guess about apatient's allergies, medications, or current and recent past diagnoses andother pertinent information.The next healthcare provider will be informed about the patient's mostrecent healthcare assessment and services.The next healthcare provider will be informed about recommendations ofthe caregiver who last treated the patient.As patient demographics will be provided, time and effort will be saved bynot having to repeatedly ask a patient for demographic information in detail.Rather, this information can be more quickly and easily verified.A patient's insurance status will be more easily established. Over time, thiscan be expanded within the system.Costs associated with the patient's care will be reduced, for examplethrough avoiding repetitive tests and basic information gathering.

The effort required to update the patient's most essential and relevantinformation will be minimized

Retrieved from http://www.medrecinst.com/press/news/info.asp?id=217 on February 24, 2007.


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CertificationCertification - A certificate is an official

document affirming some fact. Certificationis the process of obtaining a certificatethrough a certifying authority.


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CCHITCCHIT Certificate Commission for

Health Information Technology

CCHITs mission:To accelerate the adoption of healthinformation technology by creating an

efficient, credible and sustainable productcertification program


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CCHITs GoalReduce the risk of HIT investment by physicians

and other providersEnsure interoperability (compatibility) of HITproducts

Assure the participants that the ROI will beimproved qualityProtect the privacy of patients' personal health

informationRetrieved from http://www.cchit.org


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Who would benefit from CCHITPhysicians & Hospitals

Health SystemsVendors

Healthcare consumers (accurate & securerecord of health)Standards development expertsQuality Improvement Organizations


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Consumer EmpowermentConsumer Empowerment: The biggest question

of the health care industry currently is "Whoowns the Patients Data?" The answer to it is notquite simple. Realistically the patient should bethe owner of his/her data. How would thecurrent/future health care applications supportthe question of "Ownership of data?" Will thepatient be able to control who is allowed to seehis/her medical record?


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Population HealthBiosurveillance (Population Health): Currently there is noreal time surveillance for any diseases. HenceBiosurveillance is required. For example: If there is aninfluenza attack on a particular state/region, the healthcare communities can submit (real-time) patient data tothe state health registry and the state health department

would run various algorithms to trigger "Alerts" to thehealth care officials declaring a state/region wide"Influenza Alert". This will help in early detection of adeadly disease wide spread in a Geographic area. Also,

bio-terrorism can be detected in its early stages with thehelp of Biosurveillance.


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Nainil Chheda (About)Nainil Chheda, ( http://www.nainil.com ) MS (MIS) is a Knowledge Research Specialist ateClinicalWorks LLC MA (USA), providing technical coordination services in a web applicationdevelopment environment. In addition, he is responsible for ensuring the overall development ofthe product in compliance with the various healthcare standards (CCR, CDA) and certifications

(CCHIT).

He specializes in Section 508 Compliance for website usability and design. In addition hespecializes in change management, task co-ordination, process improvement and identifying andaddressing organizational concerns. He also consults to firms in the healthcare industry, as wellas the web hosting industry.

He is a frequent attendant at the nationwide healthcare conferences and various standards andinteroperability committee meetings. His most recent research concentrates on the aspects of thegame theory in application towards finding equilibrium in the healthcare industry. His researchconcerns reaction from electronic health record (EHR) vendors, healthcare providers, end-userissues in medical informatics.

Nainil has written a variety of healthcare and information system research papers andpresentations.

He holds a Masters (in MIS) from the Temple University (PA, USA) and a B.Com from MumbaiUniversity (Maharashtra, INDIA). He has research interest in the Game Theory and the GoverningDynamics of the Internet.


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Nainil Chheda (Professional Affiliation)Member of AMIA (American Medical Informatics Association) - (2007 to present)

Member of AIIM (Association for Information and Image Management) - (2007 to present)

Member of Technical Work Group (Marketing) for PDF-H (Portable Document Format - Healthcare) - (2006 to present)Member of PHR SIG (Patient Health Record Special Interest Group) - (2006 to present)

Member of CEND (Consumer Empowerment National Demonstration) - (2006 to present)

Member of Technical Work Group for ASTM (American Society for Testing and Materials) - Subcommittee E31 - CCR(Continuity of Care Records) - (2005 to present)

Member of EHRVA (Electronic Health Records Vendor Association) - (2005 to present)

Member of ANSI (American National Standards Institute) HITSP (Health Information Technology Standards Panel) - (2005 topresent)

Member of AIS (Association for Information Systems) - (2004 to present)

Member of ACM (Association of Computer Machinery) - (2004,2006 - present)

Member of Kshana (Social Organization) - (2002 to present)

Former member of InterGov (Internet Government)


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Nainil Chheda (Contact)Email: [email protected]

Direct Line: +1 (267) 241 3796Website: http://www.nainil.com


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Copyright InformationNo part of this publication may be reproduced or transmitted in anyform or for any purpose without the express permission of NainilChheda ( [email protected] ). The information contained herein maybe changed without prior notice.

Data contained in this document serves informational purposes only.

The information in this document is proprietary to Nainil Chheda.This document is a preliminary version and not subject to otheragreement with Nainil Chheda. Nainil assumes no responsibility forerrors or omissions in this document. Nainil does not warrant theaccuracy or completeness of the information, text, graphics, links, orother items contained within this material. Nainil shall have noliability for damages of any kind including without limitation direct,special, indirect, or consequential damages that may result from theuse of these materials.

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