• Home

Health Information System

CHAPTER

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

McGraw-Hill

1

A Total Patient Encounter

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Learning Outcomes

When you finish this chapter, you will be able to:

1.1 Compare practice management (PM) programs and electronic health records (EHRs).

1.2 Discuss the government health information technology (HIT) initiatives that have led to integrated PM/EHR programs.

1.3 List the eight facts that are documented in the medical record for an ambulatory patient encounter.

1.4 Identify the additional uses of clinical information gathered in patient encounters.

1.5 Compare electronic medical records, electronic health records, and personal health records.

1-2

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Learning Outcomes (Continued)

When you finish this chapter, you will be able to:

1.6 Describe the four functions of a practice management program that relate to managing claims.

1.7 List the steps in the medical documentation and billing cycle.

1.8 Compare the roles and responsibilities of clinical and administrative personnel on the physician practice health care team.

1.9 Explain how professional certification and lifelong learning contribute to career advancement in medical administration.

1-3

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Key Terms

  • accounts receivable (A/R)
  • American Recovery and Reinvestment Act of 2009 (ARRA)
  • cash flow
  • certification
  • continuity of care
  • data mining
  • data warehouse
  • diagnosis code

1-4

  • documentation
  • electronic health record (EHR)
  • electronic medical record (EMR)
  • electronic prescribing
  • encounter
  • health informatics
  • health information exchange (HIE)

Teaching Notes:

There are a lot of key terms. Following are some activities to help present them.

  • Put students into small groups and assign each group a set of terms to define and learn. Follow up by having each group teach their set of terms to the rest of the class.
  • Assign each student a set number of terms to define as a homework assignment. Follow up by discussing all of the terms as a group activity during class.
  • Ask students whether any of the key terms are familiar to them already; use their responses to launch a discussion about the rest of the terms.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Key Terms (Continued)

  • Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  • health information technology (HIT)
  • integrated PM/EHR program
  • meaningful use
  • medical assistant (MA)
  • medical biller
  • medical coder

1-5

medical documentation and billing cycle

medical malpractice

medical necessity

medical record

National Health Information Network (NHIN)

patient examination

pay for performance (P4P)

Teaching Notes: See notes on Slide 4.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Key Terms (Continued)

  • personal health record (PHR)
  • Physician Quality Reporting Initiative (PQRI)
  • practice management (PM) program
  • procedure code
  • records retention schedule
  • regional extension centers (RECs)

1-6

  • revenue cycle management (RCM)
  • standards

Teaching Notes: See notes on Slide 4.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.1 Health Information Technology:
Tools for a Total Patient Encounter

1-7

  • Health information technology (HIT)—use of computers and electronic communications to manage medical information and its secure exchange
  • Practice management (PM) programs—used to perform administrative and financial functions in a medical office
  • Electronic health record (EHR)—computerized lifelong health care record for an individual that incorporates data from all sources that provide treatment for the individual

Learning Outcome: 1.1 Compare practice management (PM) programs and electronic health records (EHRs).

Teaching Notes: Ask students how familiar they are with computers and technology; use their responses to discuss why technology is key to PM programs and EHRs. Be sure to stress how federal laws are influencing the increasing use of technology in the health care field.

KEY: Ensure that students understand that a PM program, as its name implies, helps MANAGE an office by keeping files, appointments, and other office functions together, while an EHR serves to replace the common stacks of patient files and charts. EHRs are individualized for each patient and allow any doctor who sees an individual (primary care physician, specialist, hospital physician, etc.) to have immediate access to a patient’s entire health care record.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.1 Health Information Technology:
Tools for a Total Patient Encounter (Cont.)

1-8

  • Health informatics—knowledge required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine

Learning Outcome: 1.1 Compare practice management (PM) programs and electronic health records (EHRs).

Teaching Notes: Direct students to Figure 1.3 in the textbook (the health informatics Venn diagram) and ask them to discuss how the three skillset bubbles are related. What skills do students feel are the most important to master? Ask them to justify their responses.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.2 Major Government HIT Initiatives

1-9

  • Health Insurance Portability and Accountability Act of 1996 (HIPAA)—legislation that protects patients’ private health information, ensures health care coverage when workers change or lose jobs, and uncovers fraud and abuse in the health care system
  • Standards—technical specifications for the electronic exchange of information
  • Electronic prescribing (e-prescribing)—technology that enables a physician to transmit a prescription electronically to a patient’s pharmacy

Learning Outcome: 1.2 Discuss the government health information technology (HIT) initiatives that have led to integrated PM/EHR programs.

Teaching Notes: When talking about HIPAA, ask students if they have ever needed to sign a HIPAA form when going to a doctor’s appointment. Discuss the purpose of the form – disclosure of health information, privacy protection, patient rights.

Ask students to give some benefits and drawbacks for using e-prescribing. BENEFITS might include that this cuts down on errors, that messy handwriting is not an issue, and that quicker service is possible. DRAWBACKS might include that one must pay attention when entering information electronically and that reliance on technology can cause a healthcare worker to become “sloppy.”

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.2 Major Government HIT Initiatives (Continued)

1-10

  • Physician Quality Reporting Initiative (PQRI)—Medicare program that gives bonuses to physicians when they use treatment plans and clinical guidelines that are based on scientific evidence
  • American Recovery and Reinvestment Act of 2009 (ARRA)—$787 billion economic stimulus bill passed in 2009 that allocates $19.2 billion to promote the use of HIT

Learning Outcome: 1.2 Discuss the government health information technology (HIT) initiatives that have led to integrated PM/EHR programs.

Teaching Notes: Students should understand that PQRI allows physicians to prescribe alternative treatment plans and medicines as long as they are acceptable.

ARRA requires the government to develop standards for the electronic exchange of health information, strengthens federal privacy laws for personal health information, and produces a substantial savings for both the government and the health care field due to decreased errors and improvements in quality of care.

Because of the ARRA allocation of funds ($20 billion) to promote EHRs, it is estimated that 90% of doctors and 70% of hospitals will be using EHRs within ten years.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.2 Major Government HIT Initiatives (Continued)

1-12

  • Health information exchange (HIE)—network that enables the sharing of health-related information among provider organizations according to nationally recognized standards
  • National Health Information Network (NHIN)—common platform for health information exchange across the country
  • Integrated PM/EHR programs—programs that share and exchange demographic information, appointment schedules, and clinical data

Learning Outcome: 1.2 Discuss the government health information technology (HIT) initiatives that have led to integrated PM/EHR programs.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.2 Major Government HIT Initiatives (Continued)

1-11

  • Meaningful use—utilization of certified EHR technology to improve quality, efficiency, and patient safety in the health care system
  • Regional extension centers (RECs)—centers that offer information, guidance, training, and support services to primary care providers who are in the process of making the transition to an EHR system

Learning Outcome: 1.2 Discuss the government health information technology (HIT) initiatives that have led to integrated PM/EHR programs.

Teaching Notes: Direct students’ attention to Table 1-2 in the text and ask them to skim the meaningful use guidelines for 2010-2011.

Meaningful use is part of the HITECH Act; it provides financial incentives to practices that adopt and use EHRs. Ask students their thoughts on the meaningful use guidelines – should the government have to pay a practice to promote patient safety and quality care?

RECs are another part of the HITECH Act; they exist mainly to assist small practices with the transition to EHRs.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.3 Documenting the Patient Encounter

1-13

  • Encounter (or visit)—meeting of a patient with a physician or other medical professional for the purpose of providing health care
  • Patient examination—examination of a person’s body in order to determine his or her state of health

Learning Outcome: 1.3 List the eight facts that are documented in the medical record for an ambulatory patient encounter.

Teaching Notes: For slides 13-14, list the five bold terms (encounter, patient exam, documentation, medical record, continuity of care) on the board and read the definitions out loud. Ask students to match each definition to its proper term on the board.

Provide examples to solidify each term as needed.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.3 Documenting the Patient Encounter (Continued)

1-14

  • Documentation—record created when a physician provides treatment to a patient
  • Medical record—chronological health care record that includes information that the patient provides, such as medical history and the physician’s assessment, diagnosis, and treatment plan
  • Continuity of care—coordination of care received by a patient over time and across multiple health care providers

Learning Outcome: 1.3 List the eight facts that are documented in the medical record for an ambulatory patient encounter.

Teaching Notes: See notes on slide 13.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.3 Documenting the Patient Encounter (Continued)

1-15

Eight data points included in an ambulatory care medical record:

Patient’s name

Encounter date and reason

Appropriate history and physical examination

Review of all tests that were ordered

Diagnosis

Plan of care, or notes on procedures or treatments that were given

Instructions or recommendations that were given to the patient

Signature of the provider who saw the patient

Learning Outcome: 1.3 List the eight facts that are documented in the medical record for an ambulatory patient encounter.

Teaching Notes: Put students into pairs or small groups. Assign each group one of the eight data points and ask them to come up with a bulleted list of reasons why that particular data point is a necessary element of a patient’s medical record. Have groups share responses and discuss.

At the end of the activity, ask the class what might happen if one or more of the points were missing. Answers could include such things as a lawsuit, improper care, and the absence of a long-term record.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.4 Other Uses of Clinical Information

1-16

Clinical information has several important secondary uses that involve:

  • Legal issues
  • Quality review
  • Research
  • Education
  • Public health and homeland security
  • Billing and reimbursement

Learning Outcome: 1.4 Identify the additional uses of clinical information gathered in patient encounters.

Teaching Notes: For a homework (or in-class) assignment, create strips of paper and list one of the secondary uses of clinical information on each strip. Have each student pull a strip out of a hat (box, cup, etc.) and write a short paragraph on how clinical information would be used in that particular situation. Students should cite at least one specific example.


For example, if a student pulled out “research,” she could write about using the information to begin a clinical trial for an experimental treatment option and could cite a recent clinical trial that resulted in improved treatment and care.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.4 Other Uses of Clinical Information (Continued)

1-17

  • Medical malpractice—provision of medical services at a less-than-acceptable level of professional skill that results in injury or harm to a patient
  • Pay for performance (P4P)—provision of financial incentives to physicians who provide evidence-based treatments to their patients

Learning Outcome: 1.4 Identify the additional uses of clinical information gathered in patient encounters.

Teaching Notes: Proper documentation during patient encounters can protect a physician or practice in the event of a malpractice lawsuit. It can also prove that physicians are providing proper treatment in order to receive P4P funds.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.5 Functions of an Electronic Health Record Program

1-18

  • Electronic medical record (EMR)—computerized record of one physician’s encounters with a patient over time
  • EHRs, on the other hand, can include information from the EMRs of a number of different sources.
  • Personal health records (PHRs)—private, secure electronic health care files that are created, maintained, and owned by the patient

Learning Outcome: 1.5 Compare electronic medical records, electronic health records, and personal health records.

Teaching Notes: It is CRITICAL that students know the difference between an EMR and an EHR. Stress the differences, and give examples.

After discussing the differences, you might want to call out examples and have students decide if each example references an EHR, a PHR, or an EMR. For example, say:

“This record can be downloaded to a Flash drive for portability.” (PHR), or “This record is accessible by any physician who has contact with a patient.” (EHR)

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.5 Functions of an Electronic Health Record Program (Continued)

1-19

EHRs have eight core functions:

Health information and data element maintenance

Results management

Order management

Decision support

Electronic communication and connectivity

Patient support

Administrative support

Reporting and population management

Advantages of EHRs include safety, quality, and efficiency.

Learning Outcome: 1.5 Compare electronic medical records, electronic health records, and personal health records.

Pages:

Teaching Notes: Have students reference Table 1.3 in their textbook; use that as a bridge to discussing the 8 pieces of information that need to be included.

Ask students how EHRs help with safety, quality, and efficiency. Possible answers include that they allow for the immediate retrieval of information and the elimination of handwriting errors.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.6 Functions of a Practice Management Program

1-20

Practice management (PM) programs have functions related to managing claims, including:

  • Creating electronic claims
  • Electronically monitoring claim status
  • Receiving electronic payment notification
  • Handling electronic payments

Learning Outcome: 1.6 Describe the four functions of a practice management program that relate to managing claims.

Teaching Notes: When using a PM program, the entire process flow of claim management is automated, which results in quicker and more efficient service. The PM program even allows for automatic payments to be sent right to a bank, through an electronic fund transfer (EFT).

One worry among health care practitioners is whether switching to electronic services such as PM programs will eliminate their jobs. Ask students to discuss this possibility.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.7 The Medical Documentation and
Billing Cycle

1-21

  • Cash flow—movement of monies into and out of a business
  • Medical documentation and billing cycle—ten-step process that results in timely payment for medical services

Learning Outcome: 1.7 List the steps in the medical documentation and billing cycle.

Teaching Notes: Define each term and illustrate why the term is important for students. Cash flow can make or break a business, and the documentation and billing cycle needs to be followed exactly to ensure proper and timely payment.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.7 The Medical Documentation and
Billing Cycle (Continued)

1-22

The Medical Documentation and Billing Cycle:

  • Step 1: Preregister patients
  • Step 2: Establish financial responsibility for visit
  • Step 3: Check in patients
  • Step 4: Review coding compliance
  • Step 5: Review billing compliance
  • Step 6: Check out patients
  • Step 7: Prepare and transmit claims
  • Step 8: Monitor payer adjudication
  • Step 9: Generate patient statements
  • Step 10: Follow up patient payments and collections

Learning Outcome: 1.7 List the steps in the medical documentation and billing cycle.

Teaching Notes: Put the 10 steps on the board in no particular order. Instruct students not to refer their textbooks, and see if they can put the steps into their correct order. Students should be able to explain why they ordered the steps the way they did.

This could be done as a whole-class activity, a group assignment, or an individual assignment.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.7 The Medical Documentation and
Billing Cycle (Continued)

1-23

  • Diagnosis code—code that represents the physician’s determination of a patient’s primary illness
  • Procedure code—code that represents the particular service, treatment, or test provided by a physician
  • Medical necessity—treatment that is in accordance with generally accepted medical practice

Learning Outcome: 1.7 List the steps in the medical documentation and billing cycle.

Teaching Notes: When compliance officers review submitted codes to determine medical necessity, they will look at:

  • whether the service or diagnosis is in line with generally accepted medical practices,
  • whether the service is clinically appropriate in terms of frequency, duration, etc., and
  • whether the service was just for the “convenience” of the medical or healthcare staff.

Ask students what they think will happen if a diagnosis or treatment is deemed “medically unnecessary.” (The practice will not be reimbursed.) Discuss why this protocol helps patients. (It protects them from costly and unnecessary treatments and procedures.)

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.7 The Medical Documentation and
Billing Cycle (Continued)

1-24

  • Accounts receivable (A/R)—monies that are coming into a practice
  • Revenue cycle management (RCM)—management of the activities associated with a patient encounter to ensure that the provider receives full payment for services

Learning Outcome: 1.7 List the steps in the medical documentation and billing cycle.

Teaching Notes: Ask students to brainstorm various RCM activities that might help increase payments. Write all of the responses on the board; then compare the students’ list to the bulleted list on page 32 of the textbook.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.7 The Medical Documentation and
Billing Cycle (Continued)

1-25

  • Data warehouse—collection of data that includes all areas of an organization’s operations
  • Data mining—process of analyzing large amounts of data to discover patterns or knowledge
  • Record retention schedule—plan for the management of records that lists types of records and indicates how long they should be kept

Learning Outcome: 1.7 List the steps in the medical documentation and billing cycle.

Teaching Notes: When talking about data warehousing and mining, discuss the special HIT training a student would need to complete these tasks. Stress that some health care workers need to learn new skills, such as creating databases and working with statistics and spreadsheets, because these skills were not necessary for a medical office worker in the pre-electronic era.

Ask students why there needs to be a schedule for keeping records. (There needs to be a history and evidence of past encounters, but keeping everything forever would be prohibitive in terms of space.)

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.8 The Physician Practice Health Care Team: Roles and Responsibilities

1-26

  • Physicians—primary clinicians in the practice
  • Physicians’ assistants (PAs)—health care professionals who treat minor injuries and assist with many aspects of an encounter
  • Nurses—health care professionals who perform a wide range of clinical and nonclinical duties
  • Medical assistants (MAs)—health care professionals who perform both administrative and certain clinical tasks in physician offices

Learning Outcome: 1.8 Compare the roles and responsibilities of clinical and administrative personnel on the physician practice health care team.

Teaching Notes: After discussing the roles of the various clinical and administrative personnel, identify specific tasks (taking vital signs, filing out records, handling reimbursement, etc.) and see if students can correctly identify the person responsible for each task.

Optional assignment: Have students choose one role to research in more depth, and have them write a one-page summary of that role.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.8 The Physician Practice Health Care Team: Roles and Responsibilities (Cont.)

1-27

  • Medical billers—health care professionals who perform administrative tasks throughout the medical billing cycle
  • Medical coders—medical office staff members with specialized training who handle the diagnostic and procedural coding of medical records
  • Practice or office managers—individuals who direct the business operations of physician practices
  • Compliance officers—individuals who investigate and resolve all compliance issues relating to coding, billing, documentation, and reimbursement

Learning Outcome: 1.8 Compare the roles and responsibilities of clinical and administrative personnel on the physician practice health care team.

Teaching Notes: See notes on slide 26.

*

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

1.9 Administrative Careers Working with Integrated PM/EHR Programs

1-28

  • Certification—nationally recognized designation that acknowledges that an individual has mastered a standard body of knowledge and meets certain competencies
  • Education in the health care field is a lifelong commitment.

Learning Outcome: 1.9 Explain how professional certification and lifelong learning contribute to career advancement in medical administration.

Teaching Notes: For a homework or in-class assignment, ask students to research the types of certification available to them in the healthcare field they are considering.

Discuss the benefits of obtaining and maintaining certifications.

Optional: Encourage students to apply for student membership in a professional society or organization.

*