Managing Health Care Information Systems: A Practical Approach for Health Care Executives / Edition 1 available in Hardcover
Managing Health Care Information Systems: A Practical Approach for Health Care Executives / Edition 1
- ISBN-10:
- 0787974684
- ISBN-13:
- 9780787974688
- Pub. Date:
- 05/13/2005
- Publisher:
- Wiley
Managing Health Care Information Systems: A Practical Approach for Health Care Executives / Edition 1
Buy New
$80.00Buy Used
$55.10-
PICK UP IN STORE
Your local store may have stock of this item.
Available within 2 business hours
-
SHIP THIS ITEM
Temporarily Out of Stock Online
Please check back later for updated availability.
Overview
Managing Health Care Information Systems teaches key principles, methods, and applications necessary to provide access to timely, complete, accurate, legible, and relevant health care information. Written by experts for students and professionals, this well-timed book provides detailed information on the foundations of health care information management; the history, legacy, and future of health care information systems; the architecture and technologies that support health care information systems; and the challenges for senior management in information technology, such as organization, alignment with strategic planning, governance, planning initiatives, and assessing and achieving value. Comprehensive in scope, Managing Health Care Information Systems includes substantial discussion of data quality, regulation, laws, and standards; strategies for system acquisition, use, and support; and standards and security. Each chapter includes an overview and summary of the material, as well as learning activities. The activities provide students with the opportunity to explore more fully the concepts presented.
Product Details
| ISBN-13: | 9780787974688 |
|---|---|
| Publisher: | Wiley |
| Publication date: | 05/13/2005 |
| Edition description: | REV |
| Pages: | 528 |
| Product dimensions: | 7.28(w) x 9.43(h) x 1.55(d) |
About the Author
Karen A. Wager, D.B.A., is associate professor in the Department of Health Administration and Policy at the Medical University of South Carolina.
Frances Wickham Lee, D.B.A., is associate professor in the Department of Health Administration and Policy at the Medical University of South Carolina.
John P. Glaser, Ph.D., is vice president and chief information officer of Partners HealthCare System, Inc., Boston, Massachusetts.
Read an Excerpt
Managing Health Care Information Systems
By Karen A. Wager
John Wiley & Sons
ISBN: 0-7879-7468-4Chapter One
INTRODUCTION TO HEALTH CARE INFORMATION
Although it may seem self-evident, it is worth stating: health care information is the reason we need health care information systems. No study of information systems in health care would be complete without an examination of the data and information they are designed to support. The focus of this chapter will be on the data and information that are unique to health care, such as the clinical information created during patients' health care encounters, the administrative information related to those encounters, and the external information used to improve the clinical care and administrative functions associated with those encounters.
We begin the chapter with a brief discussion of some common definitions of health care information. Then we introduce the framework that will be used for exploring various types of health care information. The first section of the chapter looks at data and information created internally by health care organizations, discussing this information at both the individual level and the aggregate level. This chapter also examines some core processes involved in an inpatient and an ambulatory care clinical encounter to further explain how and when internal health care data and information originates and how it is used. The final section of this chapter examines health care data and information created, at least in part, externally to the health care organization, and addresses both comparative and knowledge-based data and information.
Types of Health Care Information
Different texts and articles define health care information or health information differently. Often it is the use or setting of the health information that drives the definition. For example, the government or an insurance company may have certain definitions of health care information and the hospital, nursing home, or physicians' offices others. In this book we are primarily interested in the information generated or used by health care organizations, such as hospitals, nursing homes, physicians' offices, and other ambulatory care settings. Of course this same information may be used by governmental agencies or insurance companies as well.
HIPAA and JCAHO Definitions
The Health Insurance Portability and Accountability Act (HIPAA), the recent, sweeping federal legislation that includes provisions to protect patients' health information from unauthorized disclosure, defines health information as "verbal or written information created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse that relates to the physical or mental health of an individual, or payment for provision of healthcare." HIPAA specifically refers to this type of information as "protected health information," or PHI. To meet the definition of PHI, information must first of all be "identifiable," that is, the information has an individual patient perspective and the patient's identity is known. HIPAA-defined PHI may exist outside a traditional health care institution and is therefore not an appropriate definition for an organizational view of information such as ours. HIPAA is certainly an important piece of legislation, and it has a direct impact on how health care organizations create and maintain health information (HIPAA is discussed further in Chapter Three). However, not all the information that must be managed in a health care organization is protected health information. Much of the information used by health care providers and executives is neither patient specific nor identifiable.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the major accrediting agency for health care organizations in the United States, offers a framework for examining health care information within health care organizations. JCAHO accreditation standards have been developed over the years to, among other things, measure the quality of the different types of health care information that are found in and used with health care organizations. JCAHO (2004a)urges health care leaders to take "responsibility for managing information, just as they do for ... human, material, and financial resources." JCAHO clearly acknowledges the vital role that information plays in ensuring the provision of quality health care.
JCAHO (2004a) divides health care information into four categories:
Patient-specific data and information
Aggregate data and information
Knowledge-based information
Comparative data and information
Although the JCAHO framework is for information at the organizational level, it is a little too general for our purposes. Therefore we have outlined a framework for this book that expands on JCAHO's basic division of health care information.
Framework for Discussing Types of Health Care Data
Our framework for looking at data and information created, maintained, manipulated, stored, and used within health care organizations is shown in Figure 1.1. The first level of categorization in our framework is internal versus external.
Within the broad category of data and information created internally by the health care organization, we will focus on clinical and administrative information directly related to the activities surrounding the patient encounter, both individual encounters and collective encounters. We break information related to the patient encounter into the subcategories of patient specific, aggregate, and comparative. Our focus is on the clinical and administrative individual and aggregate health care information that is associated with a patient encounter. Table 1.1 lists the various types of data and information that fall into the patient encounter subcategories of patient-specific and aggregate. Information typically found in a patient medical record is shown in italics. Although the comparative data and information subcategory is shown as part of both the internal and external categories, it will be discussed as part of the external data and information.
The second major component of internal health care information in our framework is general operations. Data and information needed for the health care organization's general operations are not a focus of this text. Health care executives do, however, need to be concerned not only with the information directly related to the patient encounter but also with information about the organization's general operations. Health care organizations are, after all, businesses that must have revenues exceeding costs to remain viable. The standard administrative activities of any viable organization also take place in health care settings. Health care executives interact with information and information systems in such areas as general accounting, financial planning, personnel administration, and facility planning on a regular if not daily basis. Our decision to focus on the information that is unique to health care and not a part of general business operations is not intended to diminish the importance of general operations but rather is an acknowledgment that a wealth of resources for general business information and information systems already exists.
In addition to using internally generated patient encounter and general operations data and information, health care organizations use information generated externally (Figure 1.1). Comparative data, as we will explain, combine internal and external data to aid organizations in evaluating their performance. The other major category of external information used in health care organizations is expert or knowledge-based information, which is generally collected or created by experts who are not part of the organization. Health care providers and executives use this type of information in decision making, both clinical and administrative. A classic example of knowledge-based clinical information is the information contained in a professional health care journal. Other examples are regional or national databases or informational Web sites related to health or management issues.
Internal Data and Information: Patient Specific-Clinical
The majority of clinical, patient-specific information created and used in health care organizations can be found in or has as its original source patients' medical records. This section will introduce some basic components of a patient medical record. It will also examine an inpatient and an ambulatory care patient encounter to show how the patient medical record is typically created. All types of health care organizations-inpatient, outpatient, long-term care, and so forth-have patient medical records. These records may be in electronic or paper format, but the purpose and basic content are similar regardless of type of record or type of organization.
Purpose of Patient Records
There are several key purposes for maintaining medical records. As we move into the discussion of clinical information systems in subsequent chapters, it will be important to remember the reasons health care organizations keep medical records. These reasons remain constant whether the record is part of a state-of-the-art electronic system or part of a basic, paper-based manual system.
1. Patient care. Patient records provide the documented basis for planning patient care and treatment. This purpose is considered the number one reason for maintaining patient records. Health care executives need to keep this primary purpose in mind when examining health care information systems. Too often other purposes, particularly billing and reimbursement, may seem to take precedence over patient care.
2. Communication. Patient records are an important means by which physicians, nurses, and others can communicate with one another about patient needs. The members of the health care team generally interact with patients at different times during the day, week, or even month. The patient record may be the only means of communication between various providers.
3. Legal documentation. Patient records, because they describe and document care and treatment, can also become legal records. In the event of a lawsuit or other legal action involving patient care, the record becomes the primary evidence for what actually took place during the episode of care. An old but absolutely true adage about the legal importance of patient records says, "If it was not documented, it was not done."
4. Billing and reimbursement. Patient records provide the documentation patients and payers use to verify billed services. Insurance companies and other third-party payers insist on clear documentation to support any claims submitted. The federal programs Medicare and Medicaid have oversight and review processes in place that use patient records to confirm the accuracy of claims filed. Filing a claim for a service that is not clearly documented in the patient record could be construed as fraud.
5. Research and quality management. Patient records are used in many facilities for research purposes and for monitoring the quality of care provided. Patient records can serve as source documents from which information about certain diseases or procedures can be taken, for example. Although research is most prevalent in large academic medical centers, studies are conducted in other types of health care organizations as well.
The importance of maintaining complete and accurate patient records cannot be underestimated. Not only do they serve as a basis for planning patient care, they also serve as the legal record documenting the care that was provided to patients by the organization. Patient medical records provide much of the source data for health care information that is generated within and across health care organizations. The data captured as a part of the patient medical record become a permanent record of that patient's diagnoses, treatment, and response to treatment.
Content of Patient Records
The American Health Information Management Association sponsors the Web site myPHR.com, which lists the following components as being common to most patient records, regardless of the type of facility or whether the medical record system is electronic or paper based (myPHR, 2004). The specific content of medical records is determined to a large extent by external requirements, standards, and regulations (discussed in Chapter Three). This is not an exhaustive list, but it provides a general overview of content and of the person or persons responsible for the content. It reveals that the patient record is a repository for varied clinical data and information that is produced by many different individuals involved in the care of the patient.
Identification sheet. Information found on the identification sheet (sometimes called a face sheet or admission/discharge record) originates at the time of registration or admission. The identification sheet is generally the first report or screen a user will encounter when accessing a patient record. It lists at least the patient name, address, telephone number, insurance, and policy number, as well as the patient's diagnoses and disposition at discharge. These diagnoses are recorded by the physicians and coded by administrative personnel. (Diagnosis coding is discussed later in this chapter.) The identification sheet is used as both a clinical and an administrative document. It provides a quick view of the diagnoses that required care during the encounter. The codes and other demographic information are used for reimbursement and planning purposes.
Problem list. Patient records frequently contain a comprehensive problem list, which lists significant illnesses and operations the patient has experienced. This list is generally maintained over time. It is not specific to a single episode of care and can be maintained by the attending or primary care physician or collectively by all the health care providers involved in the patient's care. Medication record. Sometimes called a medication administration record (MAR), this record lists medicines prescribed for and subsequently administered to the patient. This record often also lists any medication allergies the patient may have. Nursing personnel are generally responsible for documenting and maintaining medication information. In an inpatient setting, nurses are responsible for administering medications according to physicians' written or verbal orders.
History and physical. The history describes any major illnesses and surgeries the patient has had, any significant family history of disease, patient health habits, and current medications. The information for the history is provided by the patient (or someone acting on his or her behalf) and is documented by the attending physician at the beginning of or immediately prior to an encounter or treatment episode. The physical component of the record states what the physician found when he or she performed a hands-on examination of the patient. The history and physical together document the initial assessment of the patient and provide the basis for diagnosis and subsequent treatment of the patient. They also provide a framework within which physicians and other care providers can document significant findings. Although obtaining the initial history and physical is a one-time activity during an episode of care, continued reassessment and documentation of that reassessment during the patient's course of treatment is critical. Results of reassessments are generally recorded in progress notes.
Progress notes. Progress notes are made by the physicians, nurses, therapists, social workers, and other clinical staff caring for the patient. Each provider is responsible for the content of his or her notes. Progress notes should reflect the patient's response to treatment along with the provider's observations and plans for continued treatment. There are many forms of progress notes. In some organizations all care providers use the same note format, in others each provider type uses a specialized format.
Consultation. A consultation note or report records opinions about the patient's condition made by physicians or other health care providers other than the attending physician or primary care provider. Consultation reports may come from people inside or outside a particular health care organization, but copies are maintained as part of the patient record.
(Continues...)
Excerpted from Managing Health Care Information Systems by Karen A. Wager Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Tables, Figures, and Exhibits.
Foreword.
Acknowledgments.
About the Authors.
Introduction.
PART ONE: HEALTH CARE INFORMATION.
1. Introduction to Health Care Information.
2. Health Care Data Quality.
3. Health Care Information Regulations, Laws, and Standards.
PART TWO: HEALTH CARE INFORMATION SYSTEMS.
4. History and Evolution of Health Care Information Systems.
5. Current and Emerging Use of Clinical Information Systems.
6. System Acquisition.
7. System Implementation and Support.
PART THREE: INFORMATION TECHNOLOGY.
8. Information Architecture and Technologies That Support Health Care Information Systems.
9. Health Care Information System Standards.
10. Security of Health Care Information Systems.
PART FOUR: SENIOR MANAGEMENT IT CHALLENGES.
11. Organizing Information Technology Services.
12. IT Alignment and Strategic Planning.
13. IT Governance and Management.
14. Management’s Role in Major IT Initiatives.
15. Assessing and Achieving Value in Health Care Information Systems.
Appendixes.
A. Overview of the Health Care IT Industry.
B. Sample Project Charter.
References.
Index.
What People are Saying About This
"This is the first book that comprehensively describes both opportunities and issues in the effective management of information technology in health care."
—James. I. Cash, Ph.D., retired James E. Robinson Professor, Harvard Business School, and chairman of IT Committee, Partners Healthcare Board of Trustees
"The challenges of managing information systems and technology in an electronic health care environment are many. But finally here is a book that succinctly takes the reader from the basics to the boardroom in meeting such challenges. This book is a great resource."
—Melanie S. Brodnik, Ph.D., director, Health Informatics and Information Management, The Ohio State University
"As IT breaks out of the business office and permeates the clinical world, every health care executive will need first-hand, in-depth knowledge of the topic. This book is just what that the doctor ordered."
—Mark Leavitt, M.D., Ph.D., medical director and director of ambulatory care, Healthcare Information and Management Systems Society
"Managing Healthcare Information Systems transcends the complexity of health care and presents in one place, a clear, concise view of health care computing. The detail and clarity of the book speak to the author’s in-depth knowledge of health care computing and their ability to make it understandable for all in the field. This book must be the foundation for all students embarking on careers in health care and is an outstanding refresher for those of us already in the field."
—Bert Reese, vice president and chief information officer, Sentara Healthcare