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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Health Care Information
Regulations, Laws, and Standards
Chapter 3
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Learning ObjectivesDiscuss 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.
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
OutlineLicensure, Certification & Accreditation Facility Licensure Certification Joint Commission Accreditation Other Accrediting Organizations
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
OutlineLegal 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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Facility LicensureStates oversee facility licensure
Facilities must have a license to operate
Emphasis is on standards for physical plant, safety, etc.
Minimum standards for patient records
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
CertificationGives authority to participate in Medicare and Medicaid
Standards were established in 1970’s
Hospitals with Joint Commission Accreditation have “deemed” status
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
AccreditationVoluntary external reviewWell known agencies
Joint Commission—hosptials and other health care facilities
NCQA—managed care plans CARF—Rehabilitation facilities AAAHC—Ambulatory care facilities
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
AccreditationPossible 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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Joint Commission (www.jointcommission.org)
Founded as non-profit in 195185% 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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Joint Jommission(www.jointcommission.org)
Accreditation decisions Accreditation Provisional accreditation Conditional accreditation Preliminary denial of accreditation Denial of accreditation Preliminary accreditation
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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)
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Joint Commission Information 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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Joint Commission IM Standards
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
NCQA (www.ncqa.org)National Committee for Quality AssuranceAccreditation of health plans and managed care organizations (MCOs)
HEDIS and measuring quality (chapter 1)
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
NCQA (www.ncqa.org)Published standards grouped into five categoriesAccess & serviceQualified providersStaying healthyGetting betterLiving with illness
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
NCQA (www.ncqa.org)Assigns one of five accreditation levelsExcellentCommendableAccreditedProvisionalDenied
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Other Accrediting Bodies
Commission of Accreditation of Rehabilitation Facilities (CARF) www.carf.org
Accreditation Association for Ambulatory Health Care (AAAHC) www.aaahc.org
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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)
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Health Record as a Legal Document
AHIMA defines four categories of patient data Legal Health Record Patient-Identifiable Source Data Administrative Data Derived Data
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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)
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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”
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Privacy and Confidentiality
Privacy—individual's right to be left alone In health care—the right to limit access to
health care informationConfidentiality—the expectation
that information will only be used for its intended purpose Confidentiality relies on trust
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Privacy Violations
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
HIPAA Privacy RuleKey definitions
Covered Entities Health plans Health care clearinghouses Health care providers
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
HIPAA Privacy RuleKey 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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
HIPAA Privacy RuleFive major components
BoundariesSecurityConsumer controlAccountabilityPublic Responsibility
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Release of InformationHealth care organizations need comprehensive policies and procedures for releasing patient information Routine Use –requires consentNon-routine Use—requires authorization
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Release of Information Authorization Elements
Patient NamePatient Date or BirthName 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
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Authorization for Release of Information
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
SummaryFacility LicensureCertificationAccreditation Standards and Processes
Joint Commission (www.jcaho.org) NCQA (www.ncqa.org) Other Accrediting Bodies
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Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Summary (cont.)Health Record as a Legal DocumentRetention of Health RecordsAuthentication of Health InformationPrivacy and ConfidentialityHIPAA Privacy RuleRelease of Information