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Introduction to Health Care Information Chapter 1 Outline Types of Health Care Information Patient Encounter Data Patient Specific Information Clinical Administrative Combined Aggregate Information Clinical Administrative Combined Comparative Information

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introduction to health care information

Introduction to Health Care Information

Chapter 1

Managing Health Care Information Systems

outline
Outline

Types of Health Care Information

  • Patient Encounter Data
  • Patient Specific Information
    • Clinical
    • Administrative
    • Combined
  • Aggregate Information
    • Clinical
    • Administrative
    • Combined
  • Comparative Information
  • Expert Knowledge based Information
types of health care information
Types of Health Care Information
  • Definitions vary
    • HIPAA

defines health information as verbal or written information created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse that relates to the physical or mental health of an individual, or payment for provision of health care. HIPAA specifically refers to this type of information as protected health information, or PHI.

    • JCAHO

urges health care leaders to take “responsibility for managing information, just as they do for ... human, material, and financial resources.”

types of health care information4
Types of Health Care Information
  • Framework
    • Internal Data/Information
      • Patient Encounter
        • Patient specific
        • Aggregate
        • Comparative
      • General Operations
    • External Data/Information
      • Comparative
      • Expert/Knowledge-based
patient specific clinical
Patient Specific—Clinical
  • Purpose of Patient Records
    • Patient care
    • Communication
    • Legal documentation
    • Billing and Reimbursement
    • Research and Quality Management
patient specific clinical7
Patient Specific—Clinical
  • Content of Patient Records
    • Identification Sheet
    • Problem List
    • Medication Record
    • History and Physical
    • Progress Notes
    • Consultation
patient specific clinical8
Patient Specific--Clinical
  • Content of Patient Records
    • Imaging and X-ray reports
    • Laboratory reports
    • Consent and authorization forms
    • Operative Reports
    • Pathology Reports
    • Discharge Summary
    • Other
patient specific clinical9
Patient Specific—Clinical
  • Overview of Inpatient Encounter
    • Scheduling
    • Preadmission
    • Admission/Registration
    • Treatment
      • Medical
      • Nursing
      • Ancillary
    • Discharge
patient specific clinical11
Patient Specific—Clinical
  • Physician’s Office Patient Flow
    • Check In
    • Move to Exam Room
    • Examination
    • Check Out
    • Later activities
patient specific administrative
Patient Specific—Administrative
  • Data Needed for Reimbursement
    • UB 92
    • CMS 1500
  • Other Uniform Data Sets
    • ACDS
    • UHDDS
uniform hospital discharge data set elements journal of ahima 72 no 10 2001
Uniform Hospital Discharge Data Set Elements Journal of AHIMA 72, no.10 (2001).
  • UHDDS elements as adopted in 1986 are:

1.    Personal identification

2.    Sex

3.    Race

4.    Ethnicity

5.    Residence

6.    Hospital identification

7-8.  Admission and discharge dates

9-10.  Attending physician and operating physician

11.    Diagnoses: Principal diagnosis & Other diagnoses

12.    Procedure and date

13.    Disposition of patient

14.   Expected payer

patient specific combined
Patient Specific—Combined
  • Coding Systems
    • ICD-9-CM
      • National Center for Health Statistics
      • Inpatient and Outpatient Diagnoses
      • Inpatient Procedures
    • CPT
      • American Medical Association
      • Outpatient Procedures
patient specific combined16
Patient Specific—Combined
  • Coding Standards
    • Compliance Issues
    • Fraud & Abuse Issues
aggregate clinical
Aggregate—Clinical
  • Disease and Procedure Indexes
  • Specialized Registers
    • Emergency Room
    • Operating Room
    • Trauma
    • Tumor
    • Other
  • Ad hoc Reports
aggregate administrative
Aggregate—Administrative
  • Limitless Ad hoc Reports
  • Specific Examples
    • Medicare Cost Reports
    • Health Care Statistics
      • Census
      • Discharge
aggregate combined
Aggregate—Combined
  • Ad hoc Reports
    • Trend analysis
    • Statistical reports
    • Quality improvement
comparative
Comparative
  • Outcome Measures
    • Benchmarking
    • Balanced Scorecards
    • Clinical Value Compass
comparative22
Comparative
  • Health Care Data Sets
    • HEDIS
      • NCQA
    • ORYNX
      • JCAHO
    • CMS
    • Leapfrog Group
expert of knowledge based
Expert of Knowledge-based
  • Clinical, scientific and management print literature
  • On-line resources
summary
Summary
  • Types of Health Care Information
  • Internal
    • Patient Specific Information
      • Clinical
      • Administrative
      • Combined
    • Aggregate Information
      • Clinical
      • Administrative
      • Combined
summary cont
Summary (cont.)
  • External
    • Comparative Information
    • Expert of Knowledge-based Information