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