Clinical Informatics

Clinical Informatics Intersection of Clinical Care, IT, Health System

Informatics vs Information Technology Informatics is rooted in a domain. Informatics is more about information than technology.

Biomedical Informatics / Biomedical and Health Informatics BMI/BMHI concerned with the optimal use of information, often aided by the use of technology, to improve individual health, health care, public health, and biomedical research.
Translational bioinformatics TBI methods to optimize transformation of large data sets (eg genetic analyses) into knowledge
Imaging Informatics efficiency, accuracy, and reliability of radiologic services within the medical enterprise
Public Health Informatics promote and support areas of public health, often utilizing large datasets that come from disparate sources
Clinical research informatics CRI informatics applications in clinical research

Medical Record Committee or HIM; overseeing the goals of information mgmt; maintenance of TJC standards. Preparation for TJC review. Policy & Procedure approval; understand functionality of information systems, functionality, work flow, etc
Health Information Management HIM Hospital leaders have ultimate responsibility; bylaws of hospital, medical records committee, policies and procedures; CODING (ICD 9 & 10, CPT)
Registered Health Information Administrator RHIA
Registered Health Information Technician RHIT

American Medical Informatics Association AMIA non-profit organization dedicated to the development and application of biomedical and health informatics in the support of patient care, teaching, research, and health care administration
Healthcare Information and Management Systems Society HIMSS non-profit organization focused on operational use of health IT
American Health Information Management Association AHIMA HIM professionals (management of medical records - less education required)
Alliance for Nursing Informatics ANI
Association of Medical Directors of Information Systems AMDIS
Agency for Heatlhcare Research and Quality AHRQ 1 of 12 divisions of HHS; EPC and NGC programs. Defines QIs

Fundamental theorem of informatics (friedman 2009) Informatics is more about using technology to help people do cognitive tasks better than about building systems to mimic or replace human expertise.
Moore's Law The number of transistors in a dense integrated circuit doubles every two years.
Confidentiality A condition in which information is shared or released in a controlled manner. Per HIPPA, that e-PHI is not available/disclosed to unathorized persons.
Security A number of measures that organizations implement to protect information and systems - not only confidentiality but also availability and integrity. The information is there to be used as it is intended to be used.
Privacy An individual's desire to limit the disclosure of personal information.
Model for Security and Privacy Threat assessment, asset list, policy, education, technical measures; most US hospitals conduct random audits.
Technical Practices authenication, access controls, audit trails, physical security and database recovery, remote acccess points, external electronic communications, software discipline, system assessment
Organization Practices Security/confidentiality policies, committees, information security officers, education/training, sanctions, authorization forms, patient access to audit logs (required by LAW)
authentication Proving you are who you say you are
authorization what youre allowed to do once authenticated
nonrepudiation ability to ensure a party to a contract or communication cannot deny the authenticity of their signature; in e-commerce: protects a sender against the false assertion of the receiver that the messages has not been received, and a receiver against the false assertion of the sender that the message has been sent. ie if you sign it you wrote it.
audit trails who did what and when
Document Version History various versions of document in its lifecycle
CMS guidelines on use of macros A macro is a command in a computer or dictation application in an EMR that automatically generates predetermined text that is not edited by the user.
cloning cutting and pasting from medical record
Release of Information ROI not straightforward. Required by clinical care and other regulations / legal requests that covers information your organization maintains. Must meet all HIPAA, state, federal disclosure regulations. Must also maintain master patient Index and Encounters. Every patient has one MRN. Every patient visit has an encouter.
spoofing senders address appears to be who it says its from
phishing look legit; presenting a fake webpage that looks like its coming from legit source --> sends people to bad place
Denial of Service DOS denied legitimate use of router for other purposes
Electronic records and electronic signatures ERES

Autonomy Freedom from external control or influence, eg informed consent
Beneficence / nonmaleficence Action that is done for the beneift of others / an obligation not to inflict harm, eg Hippocratic Oath
Hippocratic Oath (privacy) Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.
Best Interest standard Determining the best interest of an individual who cannot make decisions for himself
Confidentiality Rules or promises that limit access to or place restrictions on information discerned or communicated during a patient consultation
Disclosure Information relevant to the patient's understanding of their condition, treatment options, and potential outcomes must be provided in order for the patient to make well-informed decisions
Fidelity Faithfulness to a person, cause, or belief, demonstrated by continuing loyalty and support
Informed Consent Medical intervention should not be done if the patient has not given implicit or explicit consent
Justice Just behavior and treatment to all people
Rights Entitlement or claim others are obliged to respect
Veracity Habitual truthfulness
Normative ethical theories investigate how one should morally act
Virtue ethics the study of character; being 'good' is shown through character rather than deeds or actions (Aristotle)
Deontology the study of the nature of duty and obligation; holds true to obligations to others and society when evaluating an ethical dilemma (Kant)
Consequentialism morality of an action depends on result: branches into Utilitarianism (theory that actions are right if they benefit the majority), Egoism (study of the self and its needs), Intellectualism (action that promotes the most knowledge is best), Care ethics (study of relationships, empathy, vulnerability), Pragmatic ethics (moral progress in society is similar to its progression in science - it evolves), Role ethics (morality based upon relationship with their community)
Meta-ethics seeks to understand ethical properties eg 'what is good'. Semantic theories seeks to answer "what is the meaning of moral terms?", Substantial theories seek to answer "what is the nature of moral judgements?", Justification theories seek to answer "why be moral?"
Descriptive ethics the study of people's attitudes and beliefs on morality
Applied ethics moral examination of private and public life issues that are matters of moral judgment
Universal Declaration of Human Rights (article 12) 30 basic human rights (UN). No one shall be subjected to arbitrary interference with his privacy, family, home, or correspondance, nor to attacks upon his honor and reputation. Everyone has the right to the protection of the law against such interference or attacks. Motherhood and childhood are entitled to special care and assistance.
European Convention on Human Rights (article 8) Everyone has the right to respect for his private and family life, his home and his correspondence. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.
Code of Fair Information Practice 1973: fairness in handling information. 1 No personal data record-keeping systems whose existence is secret. 2. Must be able to find out what info is in a record and how its being used. 3. must be a way to prevent information that was obtained for one purpose from being used for other purposes without the patient's consent. 4. Must be a way for a person to correct or amend a record of identifiable information. 5. Any organization must assure reliability of the data for their intended use and take precautions against misuse.
Belmont Report (1979) 1979: several principles : RESPECT for persons; BENEFICENCE: maximize possible benefits and minimize possible harms. JUSTICE ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly the fair distribution of costs and benefits to potential research participants and equally --> implemented in many regulatory agencies
The Common Rule (1991) Since many regulatory agencies subscribe to it and IRB. Code of Federal Regulations
Conflict of Interest COI apparent conflict of interest if a leader or someone has a suggestion of divided loyalty then there is possilbity of conflict between loyalties
US Law : Bill of Rights 4th ammendment : protection from unreasonable search and seizure.

Protected Health Information PHI Individually identifiable information about health status, provision of health care, payment for health care that is created or collected by a CE (or BA of CE) that can be linked to a specific individual
Health Information Exchange HIE the mobilization of health care information electronically across organizations within a region, community or hospital system; may also refer to the organization that facilitates the exchange.
Health Insurance Portability and Accountability Act (1996) HIPAA aka Kennedy-Kassenaum Act, protects health insurance coverage for personnel when lose/change jobs; governs electronic transactions in health care; standards a focus: standards for financial transaction and code sets; unique identifiers for patients (never came to be), healthcare providers, and employers; development of privacy and security standards for transmission of data. eg requires HCPCS for transactions involving health care information
Office of Civil Rights OCR Enforces HIPAA security and privacy rules
HIPAA Privacy rule How, when, and to whom PHI may be disclosed
HIPAA Security rule Secures PHI using administrative, technical, and physical safeguards
Covered Entity CE Health care providers, Health plans, Health care clearinghouses (nonstandard <-> standard format)
Business Associate BA separate person/organization a CE contracts with to help it with its health care activities
HIPAA Preemption Analysis determine the difference between HIPAA laws and the state's laws
American Recovery and Reinvestment Act (2009) ARRA 831B, aka stimulus or recovery act
Health Information Technology for Economic and Clinical Health Act (2009) HITECH Refers to Title XIII in part A and title IV in part B of ARRA; Established MU requirements for EHRs; Established the ONC for HIT; Established HIT policy and standards committee. Expands HIPAA.
HITECH changes to HIPAA Privacy and security rules apply to BAs; increased enforcement including civil and criminal penalties; limited data sets; security risk assessment; breach notification requirements; new rules for accounting and reporting disclosures of PHI, charitable fundraising and sales of PHI. BA agreements may need to be updated and demonstrate documented policies/procedures; BA must notify CE and HHS of breaches
Deidentified Data Not considered PHI (ie not covered by the privacy rule): health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information. Can be disclosed without restriction
Expert determination One method to deidentify data: a person with appropriate knowledge and experience with statistical principles and methods for rendering information not indiviudally identifiable determines that the risk is very small that the information could be used alone or with other information to identify an individual and documents the method and results of the analysis
Limited Data Set / Safe Harbor A form of PHI that a CE is permitted to disclose for research, public health, or health care operations without obtaining consent; data use agreement contract required for research. Must remove names, street addresses, email, SSN, phone numbers, MRN, health plan beneficiary numbers, account numbers, device and vehicle identifiers, photos. DOB (year only, if age < 89) is kosher.
Office of the National Coordinator for Healthcare IT ONC Established in 2004 by legislative order, mandated in HITECH; oversees national activities to promote HIT and HIE; established certification crtieria for EHR; established HIE standards
Standards, Implementation Specifications & Certification Criteria S&CC Specifies capabilities and functions that complete EHRs and EHR modules must perform in order to be certified under the ONC HIT certification program
Certified EHR Technology CEHRT Certified by ONC, provides users security that the systems have the basic features need to attest to MU.
Certified Health IT Product List CHPL Published by the ONC: authoritative comprehensive listing of CEHRT and EHR modules
Accredited Testing Laboratory ATL tests and certified EHR
Computerized Provider Order Entry CPOE process which allows the ordering practitoner to use a computer to directly enter medical orders; patient safety advantage (Bates, 1998, 55% reduction in nonintercepted serious medication errors)
View, download, transmit VDT
Meaningful Use MU EHR incentive program for EPs; must use CEHRT, e-prescribing, HIE, report CQMs; MU criteria map to one or more of five goals: improving quality safety efficiency, engaging patients, increasing coordination, improving health status of population, ensuring privacy and security
Eligible Professional EP Med/dental/pod/optom/chiro Doc + <90% hospital based (Medicare route). Med/dental/NP/CNM/PA, >30% medicaid vol or >20% pedi (Medicaid route)
Eligible Hospital EH Hospitals paid under IPPS, Medicare Advantage Hospitals through Medicare. Acute care hospitals and children's hospitals through Medicaid
Critical Access Hospital CAH a designation given to certain rural hospitals by CMS
MU stages 1 (2010): capturing/sharing data (implementing system). 2 (2014): advanced care processes with decision support. 3(2017?): improved clinical outcomes through quality, safety, and efficiency measures.
MU stage 1 Existence and basic use of an EHR; core and menu objectives; payments began 2010(EH), 2011(EPs)
MU stage 2 MU2 Objectives announced 2012; start delayed to 2014; raised bar with emphasis on patient engagement and HIE. 7 broad categories: CQMs, Clinical, Utilization, Public Health, Privacy & Security, Patient Engagement, Care Coordination
MU modified stage 2 2015-17; single set of objectives/measures. 10 for EPs (1 Public Health), EHR 2014-certified. Reporting period based on calendar year.
Modified Stage 2 MU Objectives (EP requirements) 1. Protect PHI (conduct security analysis) 2. CDS (x5, drug-drug, drug allergy) 3. CPOE (>60% med, >30% labs, >30% rads) 4. E-prescribing (>50%) 5. HIE (summary record (CCD), e-transmit >10%) 6. Patient Specific Education (provided to >10%) 7. Medication Reconciliation (>50% transitions) 8. VDT (>50% pts provided access to VDT (within 4d), at least 1 pt did. 9 Secure messaging to patients 10. Public Health Reporting (immunization or syndromic surveilance reporting, specialized registry
Modified Stage 2 MU Objectives (EH requirements) 9 Objectives. No secure message objective. E-prescribing for hospital >10 hospital dc rx, patient specific education >10%
MU Incentive 44-63k for EPs, 2-9M for EHs var by medicare vs medicaid, amount of medicare/aid pts seen, discharges per year
Patient Protection and Affordable Care Act (2010) PPACA small business tax credits; closing the donut hole; requirement for large employers (>50) to offer coverage; expanding medicaid (<133% of poverty level), health insurance exchanges, prohibiting denial for prexisting illness, tax increases, individual mandate, and much more.
Physician Payments Sunshine Act aka Open Payments program, enacted with ACA, requires manufactures of drugs/devices to report payments and gifts given to physicians and teaching hospitals.
Medicare Access and CHIP Reauthorization Act of 2015 MACRA Emphasis on high-quality high-value health care; development of new measures and quality reporting. Stabilizes fee updates: annual positive updates of 0.5%/yr to 2019. 2020-2025 freeze; 2026- MDs can receive a 0.75% increase if they participate in APMs (otherwise 0.25% increase); consolidates medicare quality programs (MIPS; subsets PQRS,VM,EHR penalties in 2018, new composite score); bonus pool for top performers (500M/yr); cost is 213B, offset by 70B in savings; access to data; quality metrics public; requires EHR interoperability by 2018
Merit-Based Incentive Program MIPS Reporting begins in 2017. Penalites start 2019. MIPS will be the only Medicare quality reporting program: separate MU, PQRS, VM will phase out. Will be administered at the NPI level. =MU+PQRS+VBM+Clinical Practice Improvement (6 categories - pending, participation in PCMH). Performance threshold
Alternative Payment Model APM Altenative to MIPS. Provides 5% bonus (2019-2024). Requires CEHR, quality masures, 'more than nominal financial risk'
Value-Based Modfiier VBM Created by ACA, mandates CMS apply a value modifier under MPFS; to evaluate cost and quality measures to calculate payment for Medicare services.
Physician Fee Schedule PFS
Performance management The process of collecting and tracking data to assess progress towards goals and determining if the wanted results are achieved: 1. Define performance standards that encompass organizational goals 2. Define measurements that can empirically assess these goals 3. Report the progress of measurements to assess performance and determine whether goals are met 4. Continuously improve programs or processes to better meet organizational goals
Utilization management evaluation of whether health care services, procedures, facilities are appropriate and medically needed
Medicare Sustainable Growth Rate SGR 1997-2015; ended with MACRA; a method to ensure the yearly increase in the expense per Medicare beneficiary did not exceed the growth in GDP.
Health Information Organization HIO oranization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.
HIPAA Privacy rule applied to HIOs Correction (can dispute record), Openness and transparancy (about how PHI is used), Individual choice (about how PHI is used), Collection use and disclosure limitation (only to the extent necessary), Safeguards (admin/technical/physical to ensure integrity), Accountability. HIO considered a BA.
Food and Drug Administration Safety and Innovation Act (2012) FDASIA gives FDA authority to collect user fees from industry, promote innovation through faster patient access to products, increase stakeholder involvement in FDA processes, enhance the safety of the drug supply chain
The Joint Commission TJC nonprofit accredits and certifies heathcare organizations based on quality and performance standards. Established NPSG.
National Patient Safety Goals NPSG established by TJC; eg reduction of MDRO, catheter-related blood stream infection, SSI
Sentinel Event (TJC) any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness
JCAHO standard 6.1 The hospital has a complete and accurate medical record for every individual assessed, cared for, treated or served.
JCAHO standard 6.2 Records contain patient-specific information, as appropriate, to the care, treatment, and services provided.
JCAHO standard 6.3 The medical record throughly documents operative or other high risk procedures and the use of moderate or deep sedation or anesthesia.
JCAHO standard 6.4 For patients receiving contuing ambulatory care services, the medical record contains a summary list of all significant diagnoses, procedures, drug allergies, and medications. (also in meaningful use)
JCAHO standard 6.5 Designated qualifed personnel accept and trasncribe verbal orders from authorized individuals.
JCAHO standard 6.6 The hospital can provide access to all relevant information from a patient's record when needed for use in patient care, treatment and services.
JCAHO Information Mgmt Standards IM planning, privacy, confidentiality, and security.
ORYX Performance measurements and improvement initiative managed by TJC
Leapfrog Voluntary program that described '4 leaps' that would improve safety and quality of US healthcare system. 1. CPOE 2. Evidenced-based hospital referral 3. ICU Physician Staffing 4. Safe Practice Score (a list of NQF-endorsed safe practices)
Sarbanes-Oxley Act of 2002 Audit functions for financial data
21 CFR Part 11 (FDA) Part of code of federal regulations that establishes the FDA regulations on electronic records and electronic signatures; defines criteria under which electronic records and signatures are considered trustworthy.
Family Educational Rights and Privacy Act FERPA protects privacy of student education records.
Payment Card Industry Data Security Standard PCIDSS
Digital Millenium Copyright Act (1998) DMCA
Patient-Centered Medical Home PCMH Primary care organizational method in which care coordinated by PCP. Should be physician led practice, whole-person orientation, integrated and coordinated care, focus on quality and safety, accessible, compassionate, culturally effective.
Accountable Care Organization ACO group of doctors, hospitals, other providers who come together voluntarily to give coordinated high quality care to their Medicare patients. Provider reimbursements tied to quality metrics and reduction in the cost of care. Coordinate to reduce medical errors, avoid duplication of services, increase patient involvement, contain costs, share savings (incentive).
Medicare Shared Savings Program basic program for medicare FFS providers
Advance Payment ACO Model supplementary to shared savings program, allows physician-based providers to receive upfront monthly payments to invest in care coordination
Pioneer ACO Model (no longer accepting applications); already provide coordinated care; move to a population based payment similar to Medicare shared savings program
Independent Payment Advisory Board IPAB changing medicare coverage and reimbursement when cost targets are not met
Patient-Centered Outcomes Research Institute PCORI Supports comparative effectiveness research

The Health System All the activities whose primary purpose is to promote, restore, or maintain health
Stakeholders Ps: patient, provider, purchaser (employers or govt), payor (insurance cos, govt), public health
US Health System Problems US pays more; leveling of costs over last 4 yrs, US has health disadvantage: life expectancy and infant mortality among the lowest; lots of waste : overtreatment, failures of coordination, failures of care delivery, administrative complexity, pricing failures, fraud and abuse

Determinants of individual/population health 1. Social and Economic Environment (income, social status, policymaking), 2. Physical Environment, 3. Individual Characteristics and Behaviors.

Primary domains, organizational structures, cultures, and processes Healthcare Delivery, Public Health, Research, Education of Health Professionals, Personal Health

1. Health care delivery 80% report some kind of symptoms...most takes place outside of hospitals
Levels of care Primary: initial and ongoing care, Secondary: specialty care provided in the community, Tertiary: highly specialized, provided by referral in large academic medical ct; Quarternary; extension of tertiary care in reference to advanced levels of highly specialized medicine

2. Public Health the science of protecting and improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention. Funded by taxpayers
Epidemiology study of disease in populations
Public health perspective population-based view focuses on preventing disease as well as societal impacts on health; usually a governmental activity
National Public Health Performance Standards Program NPHPSP outlines a fundamental framework of essential public health services: assessment, policy development, assurance
Occupational and Safety Health Administration OSHA administers occupational health (wellbeing of the workforce)

3. Clinical research studies/trials in human subjects that determine best approaches to mechanisms of disease, interventions, clinical trials, development of new technologies; epidemiologic and behavioral studies; outcomes research and health services research. NIH.
Clinical research phases Preclinical: efficacy/toxicity, nonhuman. Phase 0: pharmacodynamic/kinetic, subtherapeutic in humans. Phase 1: Dose-ranging subtherapeutic, Phase 2: Test for efficacy and safety, Phase 3: test for efficacy and safety, large group. Phase 4: Drug in use, survey long term effects.
Translational research translation of basic biologic finding into specific treatments; how to accelerate research results. T1/T2/T3 : T1- bench to bedside, clinical efficacy research; T2- academic setting to community (who benefits?) outcomes research, comparative effectiveness research, health services research; T3- optimizing delivery of healthcare (quality and cost, implementation, scaling).

Personal Health Record PHR maintained by the patient in an electronic format. Not subject to HIPAA privacy rule

Data flow Unidirectional (linearly without interruption; bidirectional (can move between two senders and receivers), multidirectional (moves between multiple senders/receivers)

Quality The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM)
Donabedian Quality Framework Structural: attribute of the setting (eg #specialists for a given patient population, #clinical guidelines implemented, often Yes/No), Process: how care is actually given and received (eg %diabetics who are screened for proteinuria, %children with OM who are treated apprpriately), Outcomes: intermediate (eg HbA1C, lipid profile) or end measures (quality of life, functional status, satisfaction)
National Quality Forum NQF nonprofit organization promotes patient safety using quality measures and reporting. Collects and standardizes quality measures in QPS. Each NQF-endorsed measure has an NQF number, defined steward, and update / revision cycle (like a clearinghouse for quality measures that orther organizations may adopt)
National Quality Strategy NQS 6 Domains: Safety, Clinical processes/effectiveness, Efficient use of healthcare resources, Patient/family engagement, Care coordination, Population/public health
Clinical Quality Measure CQM derived from NQF measures, CMS requirement (2% penalty), MU requirement: must report 9/64, at least 1 in at least three NQS domains; EHs/CAHs complete 16/29 at least three NQS domains. Each CQM has an eCQM that uses HQMF (XML-based) and NLM value set
Quality Positioning System QPS tool used by the NQF to standardize quality measures
Institute for Healthcare Improvement IHI Triple Aim: improve patient experience (quality/satisfaction), improve health of populations, reduce per capita cost
Ambulatory Care Quality Alliance AQA voluntary collaborative of helathcare providers, users, purchasers etc that focus on improving healthcare quality
National Commitee for Quality Assurance NCQA publish and matintain HEDIS; intent is to allow consumers to benchmark health plans; required process of physician and hospital accreditation
Health Effectiveness Data and Information Set HEDIS published by NCQA; a non-governmental quality monitoring program supported by America's heatlh plans.
Health Quality Measure Format HQMF HL7 standard for representing a health quality measure as an electronic document: "eMeasures"
Quality Indicator QI use hospital inpatient data; identified by AHRQ : Prevention QI, Patient Safety QI, Inpatient QI, Pediatric QI
Physican Consortium for Performance Improvement PCPI AMA organization whose goal is to enhance quality & safety by developing and implementing EBM
Physician Quality Reporting System PQRS for e-reporting CQMs. Eligible for an incentive of 0.5% estimated Medicare part B PFS; can report through qualified PQRS registry, directly with CEHRT, QCDR, Medicare B claims
Qualified Clinical Data Registry QCDR

Medicaid income restrictions, state elibigility e.g pregnancy, low-income children. Jointly state/federal funded managed by individual states and covers a wider range of services than Medicare
Children's Health Insurance Program CHIP provides health coverage to eligible children (8.1M) in families with income too high for Medicaid; through Medicaid and separate CHIP programs; administered by states, funded jointly by state and fed
Health economics and financing most financed on the notion of insurance; payment methods vary by country: fee-for-service (most prevalent in US), private managed care (roll insurance function into delivery function: HMO, PPO), government-financed (single payer, Canada, US), government-provided(UK)
Billing for services A bill is based on codes; codes based on medical record documentation.
How is healthcare financed total spending projected to reach 1/5 of GDP; per-person spending ($9,000 in 2012); half of spending growth due to medical price inflation, other half due to aging population. CMS expects private insurance premiums to grow at 5.4% per year
US Healthcare expenditures higest per capita expenditure (2.5x OECD avg)
Organisation for Economic Cooperation and Development OECD benchmarking organization for developed countries
Payors of healthcare private health insurance, medicare, medicaid, state childrens health insurance program (SCHIP), out-of-pocket expenses, expenses for public health; payer mix
Centers for Medicare and Medicaid CMS federal agency within HHS that admnisters Medicare and works with state govts to administer Medicaid, SCHIP, portability standards; administers HIPAA, overseeds lab quality under CLIA and maintains
Medicare Federal health insurance program for age >65 and some disabilities. PART A: for those >65, some disabilities, ALS, CRF, long-term govt employee or child/widow of; PART B: physician services, outpatient care, home health care, equipment, preventative services if meet qualifications for part A (extra premiums), PART D: similar to B but helps cover prescription drug costs
Medicare Advantage PART C, a hybrid approach in which a private insurer manages Medicare benefits while govt pays premiums. Better funded
Inpatient Prospectrive Payment System IPPS a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A; each case is categorized into a DRG; each DRG has a payment weight assigned to it based on the average resources used to treat Medicare patients in that DRG.
Diagnosis-Related Group DRG describes a bundle of services a hospital might provide; flat rate per case for inpatient hospital care to rewards hospitals for efficiency; original intent was to aggregate ICD-9 codes into groups for health services research; set of several hundred codes 'lump' hospital illnesses; adopted in 80s for prospective payment for hospitalization in Medicare
Donut Hole Part D has monthly out-of-pocket premiums; $310 deductible then you pay 25% of costs up to $2,970. Until costs reach $4,550 you are in donut hole and owe 100% of drug costs (then drops to 5%). ACA phases out donut hole in 2020
TRICARE public health program for the military
Private insurers Offer managed care services
Health Maintenance Organization HMO require PCP approval for additional services. Reimbursement through capitation
Capitation Payment arrangement that pays physician/group set amount for each enrolled person, per period of time, whether or not that person seeks care. Based on average expected health care utilization, greater payment for patients with significant PMH
Preferred Provider Organization PPO physicians, organizations, other providers contracted with the insurance company to provide services. Reimbursed using discounted fees or on contracted fee basis
Independent Practice Association IPA contracting organizations of independent physicians
Health Savings Account HAS set aside pretax dollars to pay for healthcare expenses
Exclusive Provider Organization EPO network but not required to have a PCP
Point of Service POS PCP is 'point of service' to obtain care inside or outside network
High Deductible Health Plan HDHP high deductible in exchange for lower premiums, even catastrophic only coverage
Discount medical cards purchase card in exchange for lower rates on health care
Leadership positions in finance CFO oversees finances; Treasurer assists CFO and is responsible for funding, planning, budgeting, reporting, banking, bookkeeping, and controlling assets; Controller is chief officer of accounting, responsible for financial statements, ledgers, accounts payble, payroll, tax compliance; Accountant manages financial records; Bookkeeper records entries into financial records
Financial accounting standardized process; income statement summarizes revenue and expenses during time period; Balance Sheet summarizes assets, liabilities, equity during time period; Cash flow statement summarizes cash inflow and outflow during time period - based on operating activities, investing activities, financing activities.

Forces shaping healthcare delivery PPACA; regulation and coverage (eliminating coverage restriction, high risk pools; expanding coverage: mandates, exchanges, employer penalties, medicaid expansion; bending the cost curve: incentives for higher quality lower cost care.

Institute of Medicine quality components Safety, Effectiveness, Efficiency, Patient-centeredness, Timeliness, Equity
Healthcare quality agenda IOM reports advocate informatics solutions; Computer-based patient record (1997); For the Record (1997, informed HIPAA legislation); Networking health (2000, role of internet); To Err is Human 1999, medical errors epidemic(eg 98000 deaths, 1M injuries annually, 29B cost, #6 cause of death), a systems problem), Crossing the quality chasm (2001; aims and rules)
IOM recent reports Knowing what works in health care (2008), digital infrastructure (2009), health IT and patient safety (2012), best care lower cost (2013)

Safety Avoiding harm to patients from the care that is intended to help them

Effectiveness Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively). Care is consistent and reliable regardless of where, when and from whom

Efficiency Avoiding waste, inlcuding waste of equipment, supplies, ideas, and energy; match access to demand

Patient-centeredness Providing care that is respectful of and responsive to patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

Timeliness Reducing waits and sometimes harmful delays for both those who receive and those who give care

Equity Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status