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SESSION 1 : HEALTH INFORMATION
HTTP: / /THECOLBERTREPORT.CC.COM/VIDEOS/UDR4LU/ERIC-TOPOL
HCAD 5387Information Systems for
Health Care Administration
Introduction
One of the most common themes in just about every current or recent past plan to reform healthcare has been the reliance on IT to deliver Lower Costs Fewer errors Better outcomes Increased overall system efficiencies
Creative Destruction of Medicine
Super Convergence
Old Medicine
New Medicine
Wireless Censors
Genomics
Imaging
Information Systems
Mobile Connectivity + Bandwidth
Internet
Social Networking
Computing Power + Data Universe
Cre
ati
ve
Dest
ruct
ion
Introduction
One of the main expected drivers is electronic medical records
But that is not the only area Improved information on diagnosis Coordination Delivery
From Population to Individual Medicine
American College of Physicians and AmericanEHR Partners:“Challenges with Meaningful Use: EHR Satisfaction & Usability
Diminishing”
Satisfaction and usability ratings for certified electronic health records have decreased since 2010.
Overall, user satisfaction fell 12 percent from 2010 to 2013.
The percentage of clinicians who would not recommend their EHR to a colleague increased from 24 percent in 2010 to 39 percent in 2013.
Clinicians who were "very satisfied" with the ability for their EHR to improve care dropped by 6 percent compared to 2010, while those who were "very dissatisfied" increased by 10 percent.
Thirty-four percent of users were "very dissatisfied" with the ability of their EHR to decrease workload — an increase from 19 percent in 2010.
In 2013, 32 percent of the responders had not returned to normal productivity compared to 20 percent in 2010.
Dissatisfaction with ease-of-use increased from 23 percent in 2010 to 37 percent in 2013, while satisfaction with ease-of-use dropped from 61 to 48 percent
National Bureau of Economic ResearchHospital-Level IT adoption
“Health IT and Patient Outcomes” (health economists at Minnesota/PENN)
Health IT adoption reduces mortality for the most complex patients but does not affect outcomes for the median patient.
Benefits from IT adoption are skewed to large institutions with a severe case mix
Benefits are primarily experienced by patients whose diagnoses require cross-specialty care coordination
Introduction
We have a long way to go About 40% of physicians and 27% of hospitals are
using basic electronic health records But we’ve made progress – just 4 years ago these
percentages were 20% and 10%, respectively However, relatively few are meaningfully applying
health IT to advance care coordination, aide clinical decision making, or report health outcomes.
So there is potential but no guarantees
Introduction
Ask Heath care executives if they feel good about the quality, accessibility, and timeliness of clinical and business data at their organization and the answer is generally – NO
Why? Or why is healthcare so far behind?
Why does Healthcare Lag in IT?
1. Large number of small organizations2. Incentives are misaligned
Better management of chronically ill may actually cost providers money.
Goals of physicians may be different from goals of hospital Higher quality/more efficient care may not result in
increased “customers”
3. Fragmented system4. Network externality5. Complexity of care
Health care vs. Banking What is happening to try to resolve this?
HITECH
Health Information Technology for Economic and Clinical Health – HITECH Part of the 2009 American Recovery and Reinvestment
Act In February 2010 $750 million in grants and contracts
went to agencies in 40 states and to 30 nonprofit organizations to “facilitate the exchange of health information.”
Also $225 million to 55 training programs to help train people for jobs in the health care and Health IT sectors.
HITECH
Carrots and Sticks The carrots:
$14-27 billion will go to physicians, hospitals and other providers in the form of bonuses on their Medicare and Medicaid payments. Fiscal year 2011 (October 2010) to hospitals January 2011 physicians (up to $18,000) If they can demonstrate that they are making
“meaningful use” of health IT in addition to merely purchasing it and installing it.
Then comes the stick In 2015(6?) payments will be replaced by penalties for
those not showing meaningful use.
HITECH
Responsibility for implementing provisions held by HHS Office of the National Coordinator for Health IT Dr. Karen B. DeSalvo, MD, MPH, MSc Formerly Farzad Mostashari, David Blumenthal August 2010 plan for certifying electronic health
record systems was released. Functional Interoperable Secure
Defining Meaningful Use
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html
First Payment Year
2011 2012 2013 2014 2015 2016
2011 Stage1*
Stage1
Stage1
Stage2*
Stage2
Stage 3
2012 Stage1*
Stage 1
Stage2*
Stage2
Stage 3
2013 Stage1*
Stage1
Stage2
Stage2
2014 Stage1*
Stage1
Stage2
2015 Stage2* Indicates 3 months
What is MU?
To receive an EHR incentive payment, providers have to show that they are “meaningfully using” their EHRs. Stage 1
13 (hospitals) or 14 (professionals) core objectives that must be met
5 objectives from a menu of 10 Focus is on having technology in place and collecting data
Stage 2 – 2014 for those who started in 2011 Similar criteria must be met But focus is on using the data
Stage 3 Focus on achieving improvements in quality, safety, and
efficiency
1. Introduction
But what exactly is “IT”?The book breaks the subject into 4 basic
areas1. Healthcare information
a) Define health informationb) Data qualityc) Regulations, Laws, and Standards of Health
Information
2. Healthcare Information Systemsa) Evolution of Health Systems – past and futureb) Selection and Implementation
1. Introduction
3. Information Technology The core technology behind the systems – how they
work Architectures Databases, networks, standards, and security
The idea is not to make you great programmers, but to be able “speak the language” a little better
4. Top Level View of IT How IT departments are organized IT’s role in strategy Budgeting and governance Managing Change
Chapter 1: Health Care Information
What is Healthcare Information? HIPAA, Protected Health Information (PHI): Any
information, whether oral or recorded in any form or medium that
a) Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse, and
b) Relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health to an individual
Information
National Alliance for Health Information Technology Definitions Electronic Medical Record: An electronic record of
health related information on an individual that can be created, gathered, managed, and consulted within one organization
Electronic Health Record: conforms to nationally recognized interoperability standards, across more than one organization
Personal Health Record: conforms to nationally recognized interoperability standards, drawn from multiple sources, managed shared, and controlled by the individual.
Joint Commission and Information
Patient-Specific data and information (LOS)
Aggregate data and information (ALOS)
Comparative data and information Combining internal and external data to aid organizations in
evaluating their performance
Knowledge-based information a collection of stored facts, models and information that can be
used for designing and redesigning processes and for problem solving. It is found in the clinical, scientific and management literature
Types of Healthcare DataPrimary PurposeType
Clinical Administrative
Patient-Specific
Those items generally included as a part of the patient medical record are in italics
Identification SheetProblem ListMedication RecordHistoryPhysicalProgress NotesConsultationsPhysicians’ OrdersImaging and X-ray resultsLab resultsImmunization RecordOperative ReportPathology ReportDischarge SummaryDiagnoses CodesProcedure Codes
Identification SheetConsentsAuthorizationsPre-authorization SchedulingAdmission/RegistrationInsurance EligibilityBillingDiagnoses CodesProcedure Codes
Aggregate Disease IndexesSpecialized RegistersOutcomes DataStatistical ReportsTrend AnalysisAd hoc Reports
Cost ReportsClaims Denial AnalysisStaffing AnalysisReferral AnalysisStatistical ReportsTrend AnalysisAd hoc Reports
Purpose of Patient Records
Patient CareCommunicationLegal DocumentationBilling and ReimbursementResearch and Quality Management
Content of Patient Records
Identification Problem list Medication record (MAR) History and physical Progress notes Consultation Physician’s orders Imaging and x-ray reports Laboratory reports Consent and authorization forms Operative report Pathology report Discharge summary
Administrative Data
One of the primary purposes on the administrative data side is billing.
A big part of all this deals with diagnosis and procedure codes. CPT-4 Current Procedural Terminology -- the
standard for physician’s office, outpatient, and ambulatory care coding for reimbursement purposes.
ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification Hospitals use this to determine which DRG the patient
falls in
Move to ICD-10
Starting on October 1 2013 2014 2015 ICD-10 will replace ICD-9
Originally planned to adopt earlier, but significant push back by providers
Belief is that ICD-9 is outdated and new codes will provide more specificity and better data for public health surveillance and research initiatives.
This will be a huge deal in terms of impact and cost. Lots of practice management and other electronic systems
cannot accommodate the ICD-10 codes and need to be replaced
Move to ICD-10
ICD-10-CM codes used in documenting diagnoses (cm=clinical modification) 3-7 characters in length and total 68,000 ICD-9-CM are 3-5 digits and number over 14,000
ICD-10-PCS are the procedure codes and are alphanumeric 7 characters in length and total about 87,000
procedures ICD-9-PCS procedure codes are only 3-4 numbers in
length and total about 4,000 codes
Specificity looks like this…
ICD-10-CM
Many possible codes
S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture
S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture
S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture
S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture
S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture
S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture
S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
ICD-9-CM
821.01 Fracture of femur, shaft,
closed
Benefits
Codes in ICD-10 are more specific, which means…
Improved care management of beneficiaries Clinical data with greater specificity Reliable and robust clinical data that can be used to
make intelligent, data driven decisions More accurate payments Reduced number of miscoded, rejected and improper
reimbursement claims Better data for fraud and abuse monitoring
Benefits Cont’d
Better understanding of the value of new medical procedures
Improved disease managementBetter understanding of healthcare
outcomesMore ICD codes to address global disease
emergencies
Challenges of Implementation
TrainingConverting Systems & InterfacesEnsuring readiness across vendors and
payersPayer contracts Potential slow-down in dropping claimsDocumentation ImprovementRewriting reports & queriesBudget
Financial Impact
$30 Billion – U.S. a 10-physician practice $285,000 (MGMA)Smaller practices is about $83,000 (MGMA)$2-3 Million – for a typical large hospital
system Testing Training Productivity Losses Revenue Losses Reimbursement System Changes
AMA and ICD 9 10 11?
The AMA policy has been “vigorously working to stop the implementation of the ICD-10” For over a decade they have persuaded CMS to hold off
under the argument that it is too burdensome on physicians Currently we are set to adopt ICD-10 October 15. The World Health Organization is set to consider ICD-11 in
May of 2015 There was some push to skip straight from ICD-9 to ICD-11 But the AMA just issued a report arguing against going to 11 Basically ICD-9 is outdated and it limits the ability to
correctly code It will be hard enough to get to ICD-10, ICD-11 will be a
disaster
Chapter 2: Health Care Quality Data
This chapter stresses the importance of quality when it comes to data
Data vs. Information Information is processed data Data are raw facts, not very useful for decision
making. One of the keys to turning data to information is
having quality data
Problems of Poor Quality Data
Diminished quality of Patient care data can lead to problems with Patient care Communication among providers & patients
Documentation Reimbursement Outcomes assessment Research
American Health Information Management Association
(AHIMA) Data Quality Model
AccuracyAccessibility
needs to be available to the appropriate decision makerComprehensivenessConsistency
e.g., abbreviationsCurrency
diagnosis on discharge can be different than on admission. if you want a report on the diagnoses treated during a particular
time frame, which of these two diagnoses should be included?Definition
easy to understand definitions, data dictionaries how many people are in this class?
American Health Information Management Association
(AHIMA) Data Quality Model
Granularity – or atomicity. Data elements are “atomic” in the sense that they cannot be
further subdivided. Eg, a patient’s name is stored as three elements: last, first,
middle. Not as one element. Census – daily for staffing, monthly for long range planning.
Precision – how close to actual size, weight, or other standard does the data need to be? Drug dose, LOS The necessary precision in recording outdoor temp is different
from recording patient temp (100 vs. 99.6o)Relevancy – the question or aim of the data must be
clarified to ensure relevant dataTimeliness – HCAHP Scores
Types and Causes of errors
Systematic vs. random errors Systematic errors are those that can be attributed to
standard procedures (the procedure is broken) Random errors are not attributed to a flaw in the
system IT can help with many of these errors
Systematic vs. Random ErrorsSystematic Random
Unclear data definitionsUnclear data collection guidelinesPoor interface designProgramming errorsIncomplete data sourceUnsuitable data format in the
sourceData dictionary is lacking or not
availableData dictionary is not adhered toGuidelines or protocols are not
adhered toLack of insufficient data checksNo system for correcting detected
data errorsNo control over adherence to
guidelines and data definitions
Illegible handwriting in data sourceTyping errorsLack of motivationFrequent personnel turnoverCalculation errors (not built into
the system)
Using IT to Improve Data Quality
Data Error Prevention Compose a minimum set of necessary data items Define data and data characteristics in a data
dictionary Develop a data collection protocol Create user friendly data entry forms or interface Compose data checks Create a quality assurance plan Train and motivate users
Using IT to Improve Data Quality
Data Error Detection Perform automatic data checks Perform data quality audits Review data collection protocols and procedures Check inter- and intraobserver variability Visually inspect completed forms Routinely check completeness of data entry
Using IT to Improve Data Quality
Actions for Data Quality Improvement Provide data quality reports to users Correct inaccurate data and fill in incomplete data
detected Control user correction of data errors Give feedback of data quality results and
recommendations Resolve identified causes of data errors Implement identified system changes Communicate with users