Introduction to Health Care Information

1. Managing�Health Care Information Systems Introduction to Health Care Information Chapter 1

2. Managing�Health Care Information Systems Outline Types of Health Care Information Patient Encounter Data Patient Specific Information Clinical Administrative Combined Aggregate Information Clinical Administrative Combined

3. Managing�Health Care Information Systems Outline (cont.) Comparative Information Expert of Knowledge-based Information

4. Managing�Health Care Information Systems Types of Health Care Information Definitions vary HIPAA JCAHO others

5. Managing�Health Care Information Systems Types of Health Care Information Framework Internal Data/Information Patient Encounter Patient specific Aggregate Comparative General Operations

6. Managing�Health Care Information Systems Types of Health Care Information Framework External Data/Information Comparative Expert/Knowledge-based

7. Managing�Health Care Information Systems Patient Encounter Data

8. Managing�Health Care Information Systems Patient Specific�Clinical Purpose of Patient Records Patient care Communication Legal documentation Billing and Reimbursement Research and Quality Management

9. Managing�Health Care Information Systems Patient Specific�Clinical Content of Patient Records (myPHR, 2004) Identification Sheet Problem List Medication Record History and Physical Progress Notes Consultation

10. Managing�Health Care Information Systems Patient Specific--Clinical Content of Patient Records (myPHR, 2004) Imaging and X-ray reports Laboratory reports Consent and authorization forms Operative Reports Pathology Reports Discharge Summary Other

11. Managing�Health Care Information Systems Patient Specific�Clinical Overview of Inpatient Encounter Scheduling Preadmission Admission/Registration Treatment Medical Nursing Ancillary Discharge

12. Managing�Health Care Information Systems

13. Managing�Health Care Information Systems Patient Specific�Clinical Physician�s Office Patient Flow Check In Move to Exam Room Examination Check Out Later activities

14. Managing�Health Care Information Systems

15. Managing�Health Care Information Systems Patient Specific�Administrative Data Needed for Reimbursement UB 92 CMS 1500 Other Uniform Data Sets ACDS UHDDS

16. Managing�Health Care Information Systems 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

17. Managing�Health Care Information Systems 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

18. Managing�Health Care Information Systems Patient Specific�Combined Coding Standards Compliance Issues Fraud & Abuse Issues

19. Managing�Health Care Information Systems Aggregate�Clinical Disease and Procedure Indexes Specialized Registers Emergency Room Operating Room Trauma Tumor Other Ad hoc Reports

20. Managing�Health Care Information Systems Aggregate�Administrative Limitless Ad hoc Reports Specific Examples Medicare Cost Reports Health Care Statistics Census Discharge

21. Managing�Health Care Information Systems Aggregate�Combined Ad hoc Reports Trend analysis Statistical reports Quality improvement

22. Managing�Health Care Information Systems Comparative Outcome Measures Benchmarking Balanced Scorecards Clinical Value Compass

23. Managing�Health Care Information Systems Sources for Comparative DataKelly, 2003

24. Managing�Health Care Information Systems Comparative Health Care Data Sets HEDIS NCQA ORYNX JCAHO CMS Leapfrog Group

25. Managing�Health Care Information Systems Expert of Knowledge-based Clinical, scientific and management print literature On-line resources

26. Managing�Health Care Information Systems Summary Types of Health Care Information Internal Patient Specific Information Clinical Administrative Combined Aggregate Information Clinical Administrative Combined

27. Managing�Health Care Information Systems Summary (cont.) External Comparative Information Expert of Knowledge-based Information