Lecture 14
Policy, Legal, and Regulatory
Issues in HIS
(Chapters 18,19,20)
http://www.csun.edu/~dn58412/IS531/IS531_SP15.html
Learning Outcomes
1. Status of current healthcare delivery
system and related policies in US
2. Legal issues and their implementation
3. Regulatory issues and agencies
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Status of U.S. Healthcare
Delivery System
Higher expenditure
Standardization
Fragmented care
Unequal access to care
Less-than-optimal safety
Poor evaluation by patients
Payment for service rather than
maintaining wellness
• Lack of rewards for primary care
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Healthcare Reform
• Health IT was seen as a tool to aid the
reform process with HER, PHR, HIE
• President Bush’s executive orders in 2004,
2006 to create National Health
Information Technology Coordinator
• President Obama’s ARRA 2009 supports
2014 goal for the EHRs
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National Health Information
Technology Policy
• Even with the creation many committees,
taskforces, workgroups the United States
has been very slow to follow.
• The American Recovery and Reinvestment
Act (ARRA) of 2009 supported adoption of
a nationwide health information
infrastructure.
• Education of professionals and general
public is needed.
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Our Roles
• Public
– Need greater awareness on benefits and
risks
• Nurses
– Professional responsibility
– Professional duty
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Issues
• Lack of motivation to share information
across institutions
• Established constituencies are resistant to
change
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Legislation
• Electronic Signatures in Global and National
Commerce Act (ESIGN) in 2000: legal
status for electronic signature
• Medicare Improvements for Patients and
Providers Act (MIPPA) in 2008: financial
incentive fro e-prescribing
• Health Insurance Portability and
Accountability Act (HIPAA) in 1996: legal
protection for personal health information
• American Recovery and Reinvestment Act
(ARRA) in 2009: provision for IT in HIS
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HIPAA
• The Health Insurance Portability and
Accountability Act (1996) called for the
establishment of an electronic patient
records system and privacy rules.
• It also affects all aspects of health
information management, including
privacy and security of patient records,
coding, and reimbursement.
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ARRA
• The American Recovery and Reinvestment
Act (2009) included provision for
information technology in general and
health information technology.
• HITECH Act makes changes to HIPAA and
provides more funding for EHRs.
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EHR Incentives
• In 2011, Medicare and Medicaid will
provide financial incentives to physicians
and hospitals for meaningful use of health
information technology.
• Negative incentives will begin in 2015.
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Privacy and Security Provisions
• Breaches in privacy and security are
reportable to DHHS.
• Patients can restrict some disclosure of
personal health information.
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Patient Protection and
Affordable Care Act (2010)
• Guarantees access to healthcare for all
Americans
• Creates new incentives to change clinical
practice and improve quality of care
• Gives practitioners more information to
improve practice
• Give patients more information to make
conscious decisions
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Regulatory Agencies
• Regulatory agencies are public
authorities or government agencies
responsible for exercising authority over
some area in a regulatory or supervisory
capacity.
• Health insurance regulation is visible at
every government level.
• Each state determines how it will fill this
regulatory role mandated at the federal
level.
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Regulatory Issues
• The ability to access sensitive health
information in electronic patient records
by many different sources generates
growing concerns over privacy and
confidentiality.
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Medicare
• Medicare:
– Part A: facility-related expenses (no
premium, annual deductible)
– Part B: medically necessary physician
and outpatient expenses (80% with
annual deductible)
– Part C: Advantage Plan with some
additional benefits (monthly premium)
– Part D: certain prescription drugs and
medical supplies
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Medicaid
• Medicaid eligibility is determined by
income and regulated by state
• Medicaid covers approved expenses but
not paid by Medicare
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State Health Departments
• Public health conditions in marketplaces
and workforces
• Schools, mental health facilities,
rehabilitation hospitals
• Diseases , contamination
• Regulated by federal, state, county
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Reimbursement Issues
• Medicare, Medicaid, and other third-party
payers dictate reimbursement criteria.
• Documentation is key to documenting the
need for service and reimbursement.
• Automated systems enhance the quality of
documentation, which can improve
reimbursement, track claims status, report
denials, and shorten the revenue cycle.
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Electronic Data Interchange in
Reimbursement
• Adhere to a uniform format
• Common terms:
– Common procedural Terminology
– Healthcare Common Procedure Coding
System
• National provider Identifier
• Unique Physician Identification Number
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Pay for Performance
• Control for quality of healthcare services
provided to patients by professional and
facilities
• Hospital-based
• Physician-based
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ICD-10-CM codes
• ICD-10-CM codes (WHO’s International
Classification of Diseases)
• System of codes for diagnoses and
procedures
• Provide reimbursement for services
delivered in outpatient areas
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Healthcare Common Procedure
Coding System (HCPCS)
• Level I (Current Procedural Terminology
[CPT])—numeric system used for services
and procedures furnished by physicians
and other providers, maintained by the
AMA
• Level II—products, supplies, durable
medical equipment, prosthetics, and
orthotics
• Medicare and Medicaid services maintain
and distribute HCPCS Level II codes
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Issues
• Expansion of the “Do Not Pay” List for
preventable complication
• Financial incentives for implementing
technology
– Adoption for certified HER Systems and
Medicare reimbursement
– Meaningful use of EHR
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References
• Health IT Legislation and Regulations
http://www.healthit.gov/policy-researchersimplementers/health-it-legislation
• Health Information Privacy (HIPAA, PSQIA)
http://www.hhs.gov/ocr/privacy/
• Medicare
https://www.medicare.gov/
• Medicaid
http://medicaid.gov/
• Medi-Cal (LA County)
http://dhs.lacounty.gov/wps/portal/dhs/coverageopti
ons/medical/
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