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Health Care Information Regulations, Laws, and Standards. Chapter 3. Learning Objectives. Discuss how accreditation, facility licensure, and certification influence the information needs of health care facilities. Identify and differentiate among major health care accrediting bodies.

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Health Care Information Regulations, Laws, and Standards


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health care information regulations laws and standards

Health Care Information Regulations, Laws, and Standards

Chapter 3

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

learning objectives
Learning Objectives

Discuss how accreditation, facility licensure, and certification influence the information needs of health care facilities.

Identify and differentiate among major health care accrediting bodies.

Understand and manage the impact of the health record as a legal document.

Discuss the HIPAA privacy regulations and their relevance to health care organizations and consumers.

Describe the laws, regulations, and standards that govern patient confidentiality.

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

outline
Outline
  • Licensure, Certification & Accreditation
    • Facility Licensure
    • Certification
    • Joint Commission Accreditation
    • Other Accrediting Organizations

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

outline4
Outline
  • Legal Aspects of Health Care Information
    • Health Record as a Legal Document
      • Definition
      • Retention of Health Records
      • Authentication
    • Privacy and Confidentiality
      • Pre-HIPAA
      • HIPAA
      • Release of Information

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

facility licensure
Facility Licensure

States oversee facility licensure

Facilities must have a license to operate

Emphasis is on standards for physical plant, safety, etc.

Minimum standards for patient records

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

certification
Certification

Gives authority to participate in Medicare and Medicaid

Standards were established in 1970’s

Hospitals with Joint Commission Accreditation have “deemed” status

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

accreditation
Accreditation
  • Voluntary external review
  • Well known agencies
    • Joint Commission—hosptialsand other health care facilities
    • NCQA—managed care plans
    • CARF—Rehabilitation facilities
    • AAAHC—Ambulatory care facilities

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

accreditation8
Accreditation
  • Possible Benefits
    • Deemed status for CMS programs and some state licensure
    • Required for reimbursement from some payers
    • Validates quality of care
    • May influence liability insurance
    • May enhance managed care contracts
    • Gives competitive edge over non-accredited

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

joint commission www jointcommission org
Joint Commission (www.jointcommission.org)

Founded as non-profit in 1951

85% of all general hospitals; 95% of those over 200 beds

Now includes other types of healthcare organizations

Survey every three years to compare practice to standards

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

joint jommission www jointcommission org
Joint Jommission(www.jointcommission.org)
  • Accreditation decisions
    • Accreditation
    • Provisional accreditation
    • Conditional accreditation
    • Preliminary denial of accreditation
    • Denial of accreditation
    • Preliminary accreditation

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

joint commission www jcaho org
Joint Commission (www.jcaho.org)
  • Emphasis on health care information and documentation of care
      • ~150 JCAHO hospital standards are scored on patient medical record alone

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

joint commission information management
Joint Commission Information Management

Goal:

“ to support decision making to improve patient outcomes, improve health care documentation, assure patient safety, and improve performance in patient care, treatment, and services, governance, management, and support processes” (JCAHO, 2004)

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

joint commission information management13
Joint CommissionInformation Management
  • There is a large section of the IM standards devoted to content and maintenance of patient records
  • Other IM standards relate to
      • IM planning
      • Confidentiality and security
      • IM processes
      • Information-based decision making

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

joint commission im standards
Joint Commission IM Standards

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

ncqa www ncqa org
NCQA (www.ncqa.org)
  • National Committee for Quality Assurance
      • Accreditation of health plans and managed care organizations (MCOs)
      • HEDIS and measuring quality (chapter 1)

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

ncqa www ncqa org16
NCQA (www.ncqa.org)

Began accrediting MCOs in 1991

~3/4 of all enrollees in an HMO are in one accredited by NCQA

NCQA surveys organizations

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

ncqa www ncqa org17
NCQA (www.ncqa.org)
  • Published standards grouped into five categories
      • Access & service
      • Qualified providers
      • Staying healthy
      • Getting better
      • Living with illness

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

ncqa www ncqa org18
NCQA (www.ncqa.org)
  • Assigns one of five accreditation levels
    • Excellent
    • Commendable
    • Accredited
    • Provisional
    • Denied

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

other accrediting bodies
Other Accrediting Bodies
  • Commission of Accreditation of Rehabilitation Facilities (CARF)
      • www.carf.org
  • Accreditation Association for Ambulatory Health Care (AAAHC)
      • www.aaahc.org

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

health record as a legal document
Health Record as a Legal Document
  • What is the legal Health Record?
    • No simple answer in the electronic environment
    • State and Federal laws are being modified

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

health record as a legal document21
Health Record as a Legal Document

AHIMA define Legal Health Record (LHR)

“the documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization.”

(Amatayakul, 2001)

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

health record as a legal document22
Health Record as a Legal Document
  • AHIMA defines four categories of patient data
    • Legal Health Record
    • Patient-Identifiable Source Data
    • Administrative Data
    • Derived Data

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

retention of health records
Retention of Health Records
  • Most states have retention requirements
  • When no state requirements retain records
      • At least as long as the statute of limitations
      • For minors, until the age of majority (defined by the state)

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

authentication of health information
Authentication of Health Information

Joint Commission defines authentication as (JCAHO, 2008)

“the validation of correctness for both the information itself and for the person who is the author or the user of the information”

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

authentication of health information25
Authentication of Health Information
  • Forms of Authentication
    • Handwritten signature
    • Electronic signature
      • Most states allow or are silent on electronic signatures
      • CMS and Joint Commission recognize electronic signatures
      • Policies and procedures are needed to insure that electronic signature codes, etc are not shared

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

privacy and confidentiality
Privacy and Confidentiality
  • Privacy—individual's right to be left alone
    • In health care—the right to limit access to health care information
  • Confidentiality—the expectation that information will only be used for its intended purpose
    • Confidentiality relies on trust

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

privacy and confidentiality27
Privacy and Confidentiality
  • Pre-HIPAA
    • A few federal and state laws, but no comprehensive federal regulation to protect private health information
  • HIPAA
    • Multiple Sections, including
    • Privacy Rule

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

privacy violations
Privacy Violations

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

hipaa privacy rule
HIPAA Privacy Rule
  • Key definitions
    • Covered Entities
      • Health plans
      • Health care clearinghouses
      • Health care providers

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

hipaa privacy rule30
HIPAA Privacy Rule
  • Key definitions
    • Protected Health Information (PHI)
      • Relates to physical or mental health, provision of or payment for health care
      • Identifies the person
      • Created or received by a covered entity
      • Transmitted or maintained in any form

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

hipaa privacy rule31
HIPAA Privacy Rule
  • Five major components
    • Boundaries
    • Security
    • Consumer control
    • Accountability
    • Public Responsibility

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

release of information
Release of Information
  • Health care organizations need comprehensive policies and procedures for releasing patient information
      • Routine Use –requires consent
      • Non-routine Use—requires authorization

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

release of information authorization elements
Release of Information Authorization Elements
  • Patient Name
  • Patient Date or Birth
  • Name of entity to whom the information is being released
  • Description of the health information being disclosed
  • Statement of the reason or purpose for the disclosure
  • Date, event or condition on which the authorization will expire
  • Statement that the authorization may be revoked by the patient (or legal representative)
  • Patient (or legal representative) signature
  • Date of signature—must be after the encounter

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

authorization for release of information
Authorization for Release of Information

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

summary
Summary
  • Facility Licensure
  • Certification
  • Accreditation Standards and Processes
    • Joint Commission (www.jcaho.org)
    • NCQA (www.ncqa.org)
    • Other Accrediting Bodies

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

summary cont
Summary (cont.)

Health Record as a Legal Document

Retention of Health Records

Authentication of Health Information

Privacy and Confidentiality

HIPAA Privacy Rule

Release of Information

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser