Introduction to health care information
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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

Chapter 1

Managing Health Care Information Systems


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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


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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.”


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Types of Health Care Information

  • Framework

    • Internal Data/Information

      • Patient Encounter

        • Patient specific

        • Aggregate

        • Comparative

      • General Operations

    • External Data/Information

      • Comparative

      • Expert/Knowledge-based



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Patient Specific—Clinical

  • Purpose of Patient Records

    • Patient care

    • Communication

    • Legal documentation

    • Billing and Reimbursement

    • Research and Quality Management


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Patient Specific—Clinical

  • Content of Patient Records

    • Identification Sheet

    • Problem List

    • Medication Record

    • History and Physical

    • Progress Notes

    • Consultation


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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


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Patient Specific—Clinical

  • Overview of Inpatient Encounter

    • Scheduling

    • Preadmission

    • Admission/Registration

    • Treatment

      • Medical

      • Nursing

      • Ancillary

    • Discharge


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Patient Specific—Clinical

  • Physician’s Office Patient Flow

    • Check In

    • Move to Exam Room

    • Examination

    • Check Out

    • Later activities


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Patient Specific—Administrative

  • Data Needed for Reimbursement

    • UB 92

    • CMS 1500

  • Other Uniform Data Sets

    • ACDS

    • UHDDS


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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


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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


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Patient Specific—Combined

  • Coding Standards

    • Compliance Issues

    • Fraud & Abuse Issues


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Aggregate—Clinical

  • Disease and Procedure Indexes

  • Specialized Registers

    • Emergency Room

    • Operating Room

    • Trauma

    • Tumor

    • Other

  • Ad hoc Reports


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Aggregate—Administrative

  • Limitless Ad hoc Reports

  • Specific Examples

    • Medicare Cost Reports

    • Health Care Statistics

      • Census

      • Discharge


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Aggregate—Combined

  • Ad hoc Reports

    • Trend analysis

    • Statistical reports

    • Quality improvement


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Comparative

  • Outcome Measures

    • Benchmarking

    • Balanced Scorecards

    • Clinical Value Compass



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Comparative

  • Health Care Data Sets

    • HEDIS

      • NCQA

    • ORYNX

      • JCAHO

    • CMS

    • Leapfrog Group


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Expert of Knowledge-based

  • Clinical, scientific and management print literature

  • On-line resources


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Summary

  • Types of Health Care Information

  • Internal

    • Patient Specific Information

      • Clinical

      • Administrative

      • Combined

    • Aggregate Information

      • Clinical

      • Administrative

      • Combined


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Summary (cont.)

  • External

    • Comparative Information

    • Expert of Knowledge-based Information


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