Health Information Management Concepts, Principles, and Practice, 6e Pamela Oachs, Amy Watters
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Get Complete eBook Download by Email at discountsmtb@hotmail.com Health Information Management Concepts, Principles, and Practice Sixth Edition i AB103318_FM.indd 1 1/3/2020 3:08:11 PM Get Complete eBook Download link Below for Instant Download: https://browsegrades.net/documents/286751/ebook-payment-link-forinstant-download-after-payment Get Complete eBook Download by Email at discountsmtb@hotmail.com Health Information Management Concepts, Principles, and Practice Sixth Edition Pamela K. Oachs, MA, RHIA, CHDA, FAHIMA Amy L. Watters, EdD, RHIA, FAHIMA AB103318_FM.indd 3 1/3/2020 3:08:14 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Contents About the Volume Editors xxv About the Authors xxvi Acknowledgments xxxiv Forewordxxxvi Online Resources xxxvii Introduction xxxviii Part I Part II Part III Data Content, Standards, and Governance Chapter 1 The US Healthcare Delivery System Sandra R. Fuller, MA, RHIA, FAHIMA Chapter 2 Legal Issues in Health Information Management Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA 41 Chapter 3 Governing Data and Information Assets Merida Johns, PhD, RHIA 73 Chapter 4 Health Record Content and Documentation Rebecca B. Reynolds, EdD, RHIA, FAHIMA and Angela Morey, PhD, RHIA, CPHIMS 99 Chapter 5 Clinical Classifications, Vocabularies, Terminologies, and Standards Brooke Palkie, EdD, RHIA 143 Chapter 6 Data Management Marcia Y. Sharp, EdD, RHIA, and Charisse Madlock-Brown, PhD 175 Revenue Management and Compliance 3 207 Chapter 7 Reimbursement Methodologies Anita C. Hazelwood, EdD, RHIA, FAHIMA 209 Chapter 8 Revenue Cycle Management Lauree Handlon, MHA, RHIA, CCS, CRCR, COC, FAHIMA, FHFMA 243 Chapter 9 Clinical Documentation Integrity and Coding Compliance T. J. Hunt, PhD, RHIA, FAHIMA and Kathleen Kirk, PhD, RHIA 273 Chapter 10 Organizational Compliance and Risk Brooke Palkie, EdD, RHIA 301 Chapter 11 Data Privacy, Confidentiality, and Security Danika Brinda, PhD, RHIA, CHPS, HCISPP, and Amy Watters, EdD, RHIA, FAHIMA 315 Healthcare Informatics Chapter 12 AB103318_FM.indd 5 1 Health Information Technologies Scott B. Lee-Eichenwald, MSDD 353 355 v 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com vi Contents Part IV Part V Part VI Chapter 13 Health Information Systems Strategic Planning Margret K. Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS 405 Chapter 14 Consumer Health Informatics Ryan H. Sandefer, PhD 445 Analytics and Data Use Chapter 15 Healthcare Statistics Cindy Edgerton, MEd, MHA, RHIA 473 Chapter 16 Healthcare Data Analytics Susan White, PhD, RHIA, CHDA 499 Chapter 17 Data Visualization David Marc, PhD, CHDA 527 Chapter 18 Research Methods Shannon H. Houser, PhD, MPH, RHIA, FAHIMA 549 Chapter 19 Biomedical and Research Support Ryan H. Sandefer, PhD 585 Chapter 20 Quality Management Rosann M. O’Dell, DHSc, MS, RHIA, CDIP 609 Management Tools and Strategies AB103318_FM.indd 6 643 Chapter 21 Managing and Leading during Organization Change David X. Swenson, PhD, LP 645 Chapter 22 Human Resources Management Madonna M. LeBlanc, MA, RHIA, FAHIMA 691 Chapter 23 Employee Training and Development Karen R. Patena, MBA, RHIA, FAHIMA 719 Chapter 24 Work Design and Process Improvement Pamela K. Oachs, MA, RHIA, CHDA, FAHIMA 759 Chapter 25 Financial Management Rick Revoir, EdD, MBA, CPA 801 Leadership 843 Chapter 26 Project Management Brandon D. Olson, PhD, PMP 845 Chapter 27 Ethical Issues in Health Information Management Eric S. Swirsky, JD, MA 883 Chapter 28 Strategic Thinking and Management Susan E. McClernon, PhD, FACHE 915 Appendix A Check Your Understanding Odd-Numbered Answer Key Glossary Index 471 945 1011 1061 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents About the Volume Editors xxv About the Authors xxvi Acknowledgments xxxiv Forewordxxxvi Online Resources xxxvii Introduction xxxviii Part I Data Content, Standards, and Governance 1 Chapter 1 The US Healthcare Delivery System 3 History of Western Medicine Standardization of Medical Practice Standardization of Hospital Care Growth of the Allied Health Professions 4 5 6 7 Check Your Understanding 1.1 7 Modern Healthcare Delivery in the US Effects of the Great Depression Postwar Efforts Toward Improving Healthcare Access Influence of Federal Legislation Biomedical and Technological Advances in Medicine 8 8 8 9 11 Check Your Understanding 1.2 12 Healthcare Providers and Settings Organization and Operation of Modern Hospitals Types of Hospitals Organization of Hospital Services 12 13 14 15 Check Your Understanding 1.3 19 Organization of Ambulatory Care Private Medical Practice Hospital-Based Ambulatory Care Services Ambulatory Care Services Public Health Services Home Care Services Voluntary Agencies 20 21 21 21 22 22 23 Check Your Understanding 1.4 23 Long-Term Care Post-Acute Care Long-Term Care and the Continuum of Care Delivery of Long-Term Care Services Behavioral Health Services Integrated Delivery Systems 23 24 24 24 25 26 Check Your Understanding 1.5 27 Forces Affecting Healthcare Organizations Development of Peer Review and Quality Improvement Programs Malpractice 27 27 28 vii AB103318_FM.indd 7 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com viii Detailed Table of Contents Efforts at Healthcare Reengineering Value-Based Care Licensure and Certification of Healthcare Facilities Voluntary Accreditation Chapter 2 Chapter 3 AB103318_FM.indd 8 28 28 29 30 Check Your Understanding 1.6 31 Reimbursement of Healthcare Expenditures Evolution of Third-Party Reimbursement Government-Sponsored Reimbursement Systems Insurance Managed Care Continued Rise in Healthcare Costs Future of American Healthcare 31 31 31 33 33 35 37 Check Your Understanding 1.7 38 References 38 Legal Issues in Health Information Management 41 Organization of Government Sources of Law The Court System The Legal Process Public Law versus Private Law Civil Law versus Criminal Law 42 43 45 45 46 46 Check Your Understanding 2.1 48 Healthcare Causes of Action Torts Contract 48 48 54 Check Your Understanding 2.2 55 Legal Aspects of Health Information Management Form and Content of the Health Record The Legal Health Record The Electronic Health Record Retention of the Health Record Ownership of and Access to the Health Record 55 55 57 59 60 60 Check Your Understanding 2.3 61 The Health Record as Evidence Admissibility of the Health Record Consent and Advance Directives E-Discovery Privileges Government’s Right of Access to Health Records 61 61 62 63 65 65 Check Your Understanding 2.4 65 Release of Information Handling Highly Sensitive Information Wrongful Disclosure Medical Identity Theft Confidentiality of Quality Improvement Activities Incident Reports 66 66 67 67 68 68 Check Your Understanding 2.5 69 References 69 Governing Data and Information Assets 73 Governance Data Governance and Information Governance Data Governance Background 74 75 77 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents ix Chapter 4 Chapter 5 Information Governance Background Data Management Domains Data Life Cycle Management Data Architecture Management Metadata Management Master Data Management Content Management Data Security Management Information Intelligence and Big Data Data Quality Management Terminology and Classification Management 78 81 82 82 83 83 83 84 84 85 85 Check Your Understanding 3.1 85 Governance Program Planning Data and Information Governance Implementation and Stewardship Data Governance Frameworks Information Governance Frameworks 86 88 88 94 Check Your Understanding 3.2 96 References 97 Health Record Content and Documentation 99 Evolution of the Health Record Historical Overview Factors Influencing the Content of the Health Record Documentation and Maintenance Standards for the Health Record Content and Purpose of Today’s Health Record Responsibility for Quality Documentation 100 100 101 101 103 105 Check Your Understanding 4.1 106 Content and Format of the Health Record Administrative Information Clinical Data Conclusions at Termination of Care External Records Filed with the Health Record Specialized Health Record Content Format of the Health Record 107 107 108 116 117 118 121 Check Your Understanding 4.2 122 Management of Health Record Content Transcription Abstracting Incomplete Record Control Template (Forms) Design and Management 122 122 124 125 128 Check Your Understanding 4.3 129 Health Record Life Cycle Health Record Creation and Identification Health Record Storage and Retrieval Health Record Retention and Disposition 130 130 133 135 Check Your Understanding 4.4 140 References 141 Clinical Classifications, Vocabularies, Terminologies, and Standards Development of Classification Systems, Vocabularies, and Terminologies for Healthcare Data AB103318_FM.indd 9 143 145 Check Your Understanding 5.1 146 Common Healthcare Classifications and Code Sets International Classification of Diseases 147 147 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com x Detailed Table of Contents Healthcare Common Procedure Coding System Current Procedural Terminology Diagnostic and Statistical Manual of Mental Disorders International Classification of Primary Care Current Dental Terminology National Drug Codes Check Your Understanding 5.2 150 152 153 154 154 154 156 Other Healthcare Terminologies, Vocabularies, and Classification Systems 156 Systematized Nomenclature of Medicine—Clinical Terms 157 Logical Observation Identifiers Names and Codes 159 Clinical Care Classification 160 RxNorm161 MEDCIN 161 Emerging Healthcare Terminologies, Vocabularies, and Classifications 162 Chapter 6 AB103318_FM.indd 10 Check Your Understanding 5.3 165 Data Standardization National Library of Medicine’s Role in Healthcare Terminologies Mapping Initiatives 165 169 169 Check Your Understanding 5.4 170 References 170 Data Management 175 Data and Data Sources 176 Check Your Understanding 6.1 177 Facility-Specific Indices Master Patient Index Disease and Operation Indices Physician Index 177 177 178 178 Check Your Understanding 6.2 178 Registries Cancer Registries Trauma Registries Birth Defects Registries Diabetes Registries Implant Registries Transplant Registries Immunization Registries Other Registries 178 179 181 183 183 184 185 185 187 Check Your Understanding 6.3 187 Database Management and Design Relational Databases Entity Relationship Modeling Database Implementation Structured Query Language NoSQL Data Model and Use 188 188 188 189 190 190 Check Your Understanding 6.4 190 Healthcare Databases National and State Administrative Databases National, State, and County Public Health Databases Vital Statistics Clinical Trials Databases Health Services Research Databases National Library of Medicine 191 191 192 194 194 195 196 Check Your Understanding 6.5 196 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents xi Processing and Maintenance of Secondary Databases Manual versus Automated Methods of Data Collection Vendor Systems versus Facility-Specific Systems Data Security and Confidentiality Issues Trends in the Collection of Secondary Data 197 197 197 197 198 Check Your Understanding 6.6 199 Data Quality Data Quality Standards Data Quality Requirements for Information Systems Types of Data Dictionaries Development of Data Dictionaries 199 199 203 203 204 Check Your Understanding 6.7 204 References 205 Part II Revenue Management and Compliance 207 Chapter 7 Reimbursement Methodologies 209 Healthcare Reimbursement Systems Commercial Insurance Not-for-Profit Insurance Companies Types of Healthcare Savings Accounts Government-Sponsored Healthcare Programs Managed Care Chapter 8 AB103318_FM.indd 11 210 211 212 212 212 220 Check Your Understanding 7.1 224 Healthcare Reimbursement Methodologies Fee-for-Service Reimbursement Methodologies Case Rate or Episode-of-Care Reimbursement Methodologies 224 225 226 Check Your Understanding 7.2 227 Medicare’s Prospective Payment Systems Medicare’s Acute-Care Prospective Payment System Hospital-Acquired Conditions and Present on Admission Indicator Reporting Inpatient Psychiatric Facilities Prospective Payment System Resource-Based Relative Value Scale System Medicare and Medicaid Outpatient Prospective Payment System Ambulatory Surgery Centers Ambulance Fee Schedule Medicare Skilled Nursing Facility Prospective Payment System Home Health Prospective Payment System Inpatient Rehabilitation Facility Prospective Payment System Long-Term Care Hospital Prospective Payment System 228 228 230 231 232 233 234 235 235 237 238 239 Check Your Understanding 7.3 240 References 240 Revenue Cycle Management 243 Revenue Cycle Front-End Process Patient Access Components Pre-encounter Services 246 246 250 Check Your Understanding 8.1 250 Revenue Cycle Middle Process Clinical Services Clinical Documentation Case Management and Utilization Management 251 251 251 251 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xii Detailed Table of Contents Health Information Management and Clinical Coding Charge Capture Charge Description Master Chapter 9 Chapter 10 Check Your Understanding 8.2 260 Revenue Cycle Back-End Process Billing System Claims Preparation Claims Editing Claims Submission Payment Posting Collections and Account Follow-Up Denial Management Remittance Management 260 261 261 262 262 263 263 264 265 Check Your Understanding 8.3 266 Revenue Cycle Support Services Payer Relations and Health Plan Contracts Patient Relations and Customer Service Performance Measures for Improvement 266 266 267 268 Check Your Understanding 8.4 270 References 270 Clinical Documentation Integrity and Coding Compliance 273 Clinical Documentation Integrity Documentation for Coded Data Clinical Documentation Integrity Goals Operational Considerations Query Process Technology Considerations Supporting the CDI Process 274 275 275 276 285 290 291 Check Your Understanding 9.1 291 Coding Compliance Regulation Governmental Programs Exclusion from Federal Programs Auditing OIG Compliance Guidance Developing a Coding Compliance Plan Key Clinical Documents Coding Compliance Education 292 292 293 293 294 295 296 297 298 Check Your Understanding 9.2 298 References 299 Organizational Compliance and Risk Corporate Compliance Fraud Abuse Waste AB103318_FM.indd 12 253 254 256 301 302 302 305 306 Check Your Understanding 10.1 306 Fraud Surveillance External Drivers Internal Drivers 307 307 308 Check Your Understanding 10.2 308 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents xiii Chapter 11 Risk Management Incident Reporting Business Continuity and Contingency Planning Implications for Health Informatics and Information Management 308 309 310 312 Check Your Understanding 10.3 312 References 313 Data Privacy, Confidentiality, and Security 315 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 The Privacy Rule The Security Rule The HITECH-HIPAA Omnibus Privacy Act 316 317 319 319 Check Your Understanding 11.1 322 Privacy and Security Requirements for Disclosure Management Use and Disclosure of Patient Information with Patient Authorization Use and Disclosure of Patient Information without Patient Authorization Use and Disclosure Requiring an Opportunity to Object Patient Identity Management for Use and Disclosure of PHI Confidentiality of Alcohol and Drug Abuse Patient Records State Privacy and Security Laws 322 323 325 327 327 328 330 Check Your Understanding 11.2 331 Managing an Effective Security Program Risk Analysis and Risk Management Audit Logs and Monitoring Contingency Planning Data Security Methods 331 332 334 335 338 Check Your Understanding 11.3 343 Management of Privacy and Security in Health Information Exchange Mobile Health Technology and HIPAA 343 346 Check Your Understanding 11.4 346 Workforce Training HIPAA Training Components HIPAA Training Principles and Strategies 347 348 348 Check Your Understanding 11.5 349 References 350 Part III Healthcare Informatics 353 Chapter 12 Health Information Technologies 355 The Field of Informatics AB103318_FM.indd 13 356 Check Your Understanding 12.1 357 Current and Emerging Information Technologies in Healthcare Technologies Supporting the Capture of Different Types of Data and Formats Speech Recognition Technology Natural Language Processing Technology Electronic Document and Content Management Systems 358 358 358 359 360 Check Your Understanding 12.2 362 Technologies Supporting Efficient Access to and Flow of Data and Information Automatic Recognition Technologies Enterprise Master Patient Indices and Identity Management Cloud-Based Technologies and Applications 362 362 364 365 Check Your Understanding 12.3 367 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xiv Detailed Table of Contents Technologies Supporting the Diagnosis, Treatment, and Care of Patients Physiological Signal Processing Systems Point-of-Care Information Systems Mobile and Wireless Technology and Devices Automated Clinical Care Plans, Practice Guidelines, Pathways, and Protocols Telemedicine and Telehealth Systems Electronic Health Record Systems Chapter 13 Check Your Understanding 12.4 373 EHR Functionality and Technology Source Systems Core Clinical EHR Applications 373 373 376 Check Your Understanding 12.5 384 Health Information Exchange Interoperability and Its Challenges 385 386 Check Your Understanding 12.6 387 Models for HIE The Centralized Health Information Exchange Architecture The Decentralized HIE Architecture The Hybrid HIE Architecture The Health Record Banking HIE Architecture Legal Issues in the Exchange of Electronic Protected Health Information Exchange Methodologies DIRECT Exchange Query-Based Exchange Consumer-Mediated Exchange HIE Initiatives 387 387 388 389 390 391 392 393 393 394 394 Check Your Understanding 12.7 395 HIE Implementation Considerations Identification of a Trust Community Development of Governance Committees Identification of the Technology Platform Contracts and Participant Agreements Operational Policies Development of Vendor and Participant Project Teams Data Governance The Creation of the Sandbox for System Testing Stages of HIE Implementation Stage 1 of Implementation Stage 2 of Implementation Stage 3 of Implementation 395 395 396 396 396 396 396 397 397 397 397 398 398 Check Your Understanding 12.8 399 The Nationwide Interoperability Roadmap The Nationwide Privacy and Security Framework Health Information Management in HIE 399 401 401 Check Your Understanding 12.9 402 References 402 Health Information Systems Strategic Planning A Systems View System Development Life Cycle Strategic Planning for Health Information Systems AB103318_FM.indd 14 368 368 368 369 370 370 371 405 406 409 410 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents xv Strategic Planning Purpose Preparing for Strategic Planning for Health Information Systems Chapter 14 AB103318_FM.indd 15 410 412 Check Your Understanding 13.1 419 Carrying Out the Strategic Plan Project Management Requirements Analysis Acquisition Implementation Continued System Review and Support 420 420 422 423 427 429 Check Your Understanding 13.2 433 Strategic Planning for Health Information System Optimization EHR System Implementation Level of Maturity EHR System Adoption Level of Maturity EHR System Optimization Level of Maturity Strategic Planning for Ongoing Management of Health Information Health Data and Information Governance Plan Types of Health Data and Information Metadata Data Quality Management 433 433 433 434 434 435 435 436 438 Check Your Understanding 13.3 441 References 442 Consumer Health Informatics 445 Consumer Health Informatics and Consumer Engagement The Evolution of Consumer Engagement in Healthcare Consumer Assessment of Healthcare Providers and Systems Patient-Centered Medical Home Promoting Interoperability Programs Hospital Value-Based Purchasing Program 447 448 449 449 449 451 Check Your Understanding 14.1 451 Social Determinants of Health and Health Literacy HealthyPeople 2020 Health Literacy 451 452 452 Check Your Understanding 14.2 454 Health Information Online Resources Healthcare-Focused Websites Internet Forums Patient Activation Measure 454 454 454 455 Check Your Understanding 14.3 456 Patient Portals, Personal Health Records, and Telehealth Patient Portals Personal Health Records Telehealth Data Display 456 457 459 461 461 Check Your Understanding 14.4 462 Patient-Generated Health Data Personalized Medicine Consumer Informatics and Next Steps 462 464 464 Check Your Understanding 14.5 465 References 466 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xvi Detailed Table of Contents Part IV Analytics and Data Use 471 Chapter 15 Healthcare Statistics 473 Introduction to Healthcare Statistics Use of Statistics Sources of Data Descriptive versus Inferential Statistics Basic Calculations and Descriptive Statistics Ratio Rate Average Chapter 16 Check Your Understanding 15.1 478 Terminology Related to Healthcare Statistics Statistics Related to Volume of Service and Utilization Inpatient Census Occupancy Data Hospital Bed Turnover Length of Stay 478 479 479 483 484 484 Check Your Understanding 15.2 486 Statistics Related to Clinical Services and Patient Care Death Rates Autopsy Rates Hospital Infection Rates 487 487 489 490 Check Your Understanding 15.3 491 Ambulatory Care Statistics Statistics in Revenue Cycle Management Case-Mix Analysis Example One of Case-Mix Analysis Example Two of Case-Mix Analysis Public Health and Epidemiology Data Epidemiology Statistics Community-Based Disease Tracking Finding and Using Healthcare Statistics 491 492 492 492 493 493 494 494 495 Check Your Understanding 15.4 496 References 497 Healthcare Data Analytics Healthcare Initiatives and the Impact on Data Analytics Types of Data Descriptive versus Inferential Statistics Impact of Sampling Tools for Sampling and Design AB103318_FM.indd 16 474 474 475 476 476 476 476 477 499 500 501 502 504 506 Check Your Understanding 16.1 508 Analyzing Continuous Data Measures of Central Tendency Measures of Spread Inferential Statistics for Continuous Data Normal Distribution 509 509 510 510 512 Check Your Understanding 16.2 513 Analyzing Rates and Proportions Descriptive Statistics for Rates and Proportions Inferential Statistics for Rates and Proportions 514 514 514 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents xvii Chapter 17 Check Your Understanding 16.3 515 Analyzing Relationships between Two Variables Correlation Simple Linear Regression 516 516 517 Check Your Understanding 16.4 519 Analytics in Practice Data Mining Predictive Modeling Risk-Adjusted Quality Indicators Real-Time Analytics Opportunities for Health Information Management Professionals in Healthcare Data Analytics 520 520 520 521 523 Check Your Understanding 16.5 525 References 526 Data Visualization Data Visualization Related to Perception and Decision-Making Chapter 18 528 529 Charts versus Tables 529 Check Your Understanding 17.2 531 Considerations for Adopting Visualization Techniques Context of the Situation Experience of the User Presentation Method Complexity of the Data Using Data Visualization to Guide Decisions under the Value-Based Purchasing Program 531 531 532 533 538 541 Check Your Understanding 17.3 547 References 548 Research Methods 549 Research Methodology 550 Check Your Understanding 18.1 552 Research Process Defining Research Problem and Research Question 552 552 Performing a Literature Review Check Your Understanding 18.3 Selecting the Research Design Check Your Understanding 18.4 Collecting Data Check Your Understanding 18.5 Analyzing the Data Check Your Understanding 18.6 Disseminating Results 554 554 558 558 565 565 575 575 577 578 Check Your Understanding 18.7 581 References 581 Biomedical and Research Support Clinical and Biomedical Research Ethical Treatment of Human Subjects The Nuremberg Code and the Declaration of Helsinki The US Public Health Services Syphilis Study AB103318_FM.indd 17 527 Check Your Understanding 17.1 Check Your Understanding 18.2 Chapter 19 523 585 586 586 587 587 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xviii Detailed Table of Contents Chapter 20 Check Your Understanding 19.1 589 Protection of Human Subjects Institutional Assurances of Compliance Institutional Review Board Informed Consent Vulnerable Subjects 589 589 590 594 596 Check Your Understanding 19.2 596 Role of HIM Professionals in Research Privacy Considerations in Clinical and Biomedical Research Oversight of Biomedical Research Types of Biomedical Research Designs Risk Assessment 597 597 598 599 603 Check Your Understanding 19.3 605 Use of Comparative Data in Outcomes Research 605 Check Your Understanding 19.4 607 References 607 Quality Management Historical Perspectives in Healthcare Quality Patient Safety Concerns Emerge Legal Implications Related to Quality of Care Toward Systematic Quality and Performance Initiatives Today’s Drivers of Healthcare Quality Accreditation Standards Regulatory Requirements Quality Indicator Reporting and Transparency Value-Based Care Reforms The Patient as a Consumer AB103318_FM.indd 18 609 610 610 611 611 614 614 614 616 617 617 Check Your Understanding 20.1 617 Organizational Influence on Healthcare Quality Organizational Mission and Vision Influence of Leadership Organizational Culture Interprofessional Education and Practice Change Management Quality Management Tools and Processes Ongoing Quality Measure Reviews Quality Measure Review Findings Plan-Do-Check-Act Cycle Peer Review Tracer Methodology 618 618 619 619 619 620 621 621 622 622 624 626 Check Your Understanding 20.2 626 Assessing Outcomes and Effectiveness of Healthcare Comparative Effectiveness Research Measurement Approaches to Assessing Healthcare The Role of the Agency for Healthcare Research and Quality 627 627 628 628 Check Your Understanding 20.3 630 Systematic and Process-Driven Focus to Improve Performance Evidence-Based Care and Treatment Clinical Pathways Case Management Care Coordination Effective Deployment and Use of Information Technology 631 631 631 632 632 633 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents xix Professional Designations and Roles in Healthcare Quality Certifications Related to Quality Management The Health Information Manager Role in Healthcare Quality Data Stewardship and Information Governance Data Analytics Regulatory Compliance Emerging Trends Impacting Industry Conversations about Healthcare Quality Reputation, Brand Image, and Social Media Increased Utilization of Telehealth Services The Learning Health System 633 633 634 635 635 635 636 636 636 637 Check Your Understanding 20.4 637 References 638 Part V Management Tools and Strategies 643 Chapter 21 Managing and Leading during Organization Change 645 Landmarks in Management as a Discipline Scientific Management Administrative Management Humanistic Management and the Human Relations Movement Operations Management Contemporary Management AB103318_FM.indd 19 646 646 648 649 650 650 Check Your Understanding 21.1 653 Functions and Principles of Management Managerial Functions Levels of Management Managerial Skills Managerial Activities Trends in Management Theory 654 654 657 658 660 661 Check Your Understanding 21.2 662 Trends in Leadership Theory Classical Approaches to Leadership Theory Behavioral or Task-Relationship Theories of Leadership Contingency and Situational Theories of Leadership Values-Based Leadership Complexity Leadership and Systems Thinking 662 663 664 665 668 670 Check Your Understanding 21.3 672 Diffusion of Innovations Categories of Adopter Groups Diffusion Curve Dynamics Affecting Innovation Diffusion Innovator Roles 672 673 674 674 675 Check Your Understanding 21.4 675 Change Management Differences between Leaders and Managers Organization Development Change Agent Functions Internal and External Change Agents Stages of Change Leading through Cultural Change Response to Change 676 676 676 677 678 681 682 Check Your Understanding 21.5 683 References 683 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xx Detailed Table of Contents Chapter 22 Chapter 23 AB103318_FM.indd 20 Human Resources Management 691 Role of the Human Resources Department Human Resources Planning and Analysis Equal Employment Opportunity Practices Rights of Employees and Employers Staffing Compensation and Benefits Program Health and Safety Program Labor Relations 692 693 694 695 695 695 696 696 Check Your Understanding 22.1 698 Role of the HIM Manager in Human Resources Tools for Human Resources Planning Tools for Effective Communication Tools for Employee Empowerment 698 698 706 706 Check Your Understanding 22.2 708 Compensation Systems Compensation Surveys Job Evaluations Performance Management Performance Counseling and Disciplinary Action Termination and Layoff Conflict Management Grievance Management Maintenance of Employee Records Current Human Resources Trends and Practices 708 709 709 710 710 712 713 714 714 715 Check Your Understanding 22.3 716 References 716 Employee Training and Development 719 Training Program Development Departmental Employee Training and Development Plan Training and Development Model 720 722 722 Check Your Understanding 23.1 725 Elements of Workforce Training New Employee Orientation and Training On-the-Job Training Staff Development through In-Service Education Special Issues for Staff Development 725 725 730 733 736 Check Your Understanding 23.2 738 Adult Learning Strategies Characteristics of Adult Learners Education of Adult Learners Learning Styles Training Learners with Special Needs 738 738 739 740 741 Check Your Understanding 23.3 742 Delivery Methods Programmed Learning Classroom Learning Seminars and Workshops Simulations E-learning Intensive Study Courses 743 743 744 745 745 746 749 Check Your Understanding 23.4 749 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents xxi Chapter 24 Positioning Employees for Career Development Empowerment Delegation Coaching and Mentoring Promotion and Succession Planning Continuing Education Developing a Personal Career Plan Employment Laws and Regulations Impacting Training 750 750 751 752 753 754 754 755 Check Your Understanding 23.5 756 References 757 Work Design and Process Improvement Functional Work Environment Departmental Workflow Space and Equipment Aesthetics Ergonomics Chapter 25 760 760 760 762 763 Check Your Understanding 24.1 763 Methods of Organizing Work Work Division Patterns Work Distribution Analysis Work Scheduling Work Procedures 764 764 765 766 769 Check Your Understanding 24.2 771 Performance and Work Measurement Standards Criteria for Setting Effective Standards Types of Standards Methods of Communicating Standards Methods of Developing Standards 771 772 772 774 774 Check Your Understanding 24.3 776 Performance Measurement Performance Controls Variance Analysis Assessment of Departmental Performance 776 776 777 777 Check Your Understanding 24.4 780 Performance Improvement The Role of Customer Service Identification of Performance Improvement Opportunities Principles of Performance Improvement 780 780 781 782 Check Your Understanding 24.5 783 Process Improvement Methodologies Continuous Quality Improvement Business Process Redesign Workflow Analysis and Process Redesign 783 783 791 795 Check Your Understanding 24.6 799 References 799 Financial Management Healthcare Financial Management Accounting Accounting Concepts and Principles Authorities Financial Organization AB103318_FM.indd 21 759 801 802 804 804 806 807 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xxii Detailed Table of Contents Sources of Financial Data Uses of Financial Data 809 810 Check Your Understanding 25.1 811 Basic Financial Accounting Assets Liabilities Equity or Net Assets Revenue Expenses Recording Transactions Financial Statements Ratio Analysis 811 812 813 814 815 815 817 820 821 Check Your Understanding 25.2 825 Basic Management Accounting Describing Costs Cost Reports Internal Controls Preventive Detective Corrective 826 826 827 829 829 829 830 Check Your Understanding 25.3 830 Budgets Types of Budgets Operational Budgets Management of the Operating Budget Capital Budget Capital Projects 830 831 832 833 836 837 Check Your Understanding 25.4 841 References 841 Part VI Leadership 843 Chapter 26 Project Management 845 The Project Definition of a Project Determining a Project’s Purpose 846 846 847 Check Your Understanding 26.1 848 Project Management Project Management Process Alternative Project Methodologies Project Management Constraints Project Members Organizational Structures 848 849 850 852 853 854 Check Your Understanding 26.2 Team Structures AB103318_FM.indd 22 855 859 Check Your Understanding 26.3 861 The Project Manager Roles of a Project Manager Project Management Competencies 862 863 865 Check Your Understanding 26.4 867 The Project Management Process Initiating Planning 868 868 870 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Detailed Table of Contents xxiii Executing Monitoring and Controlling Closing Chapter 27 Check Your Understanding 26.5 875 Managing Project Change Types of Change Benefits of Change Negotiating Change and Managing Expectations Change Management Process 875 876 876 877 877 Check Your Understanding 26.6 878 Beyond Project Management Project Selection Program Management Project Portfolio Management 878 879 879 879 Check Your Understanding 26.7 880 References 880 Ethical Issues in Health Information Management Morality and Ethics in Health Information Management Morality Ethical Theories, Principles, and Concepts Chapter 28 883 885 885 887 Check Your Understanding 27.1 892 Ethical Foundations of Health Information Management Protection of Privacy, Maintenance of Confidentiality, and Assurance of Data Security Professional Code of Ethics Professional Values and Obligations Ethical Decision-Making Breach of Healthcare Ethics 892 893 893 896 896 900 Check Your Understanding 27.2 902 Important Health Information Ethical Problems Ethical Issues Related to Documentation and Privacy Ethical Issues Related to the Release of Information Ethical Issues Related to Coding Ethical Issues Related to Public Health and Sensitive Health Information Ethical Issues Related to Research Ethical Issues Related to Cultural Competence Ethical Issues Related to Electronic Health Record Systems Ethical Issues Related to End-of-Life Care Ethical Issues Related to Disparities and Literacy Ethical Issues Related to Social Media Use 902 902 902 903 904 904 905 906 908 909 910 Check Your Understanding 27.3 911 References 912 Strategic Thinking and Management From Strategic Planning to Strategic Management and Thinking Skills of Strategic Managers and Strategic Thinkers Elements of Strategic Thinking and Strategic Management AB103318_FM.indd 23 874 874 875 915 917 918 919 Check Your Understanding 28.1 920 Phase I: Environmental Assessment: Internal and External Understand Environmental Assessment Trends Assess and Manage Risk and Uncertainty 921 921 924 Check Your Understanding 28.2 925 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xxiv Detailed Table of Contents Phase II: Identifying Organizational Direction from Vision to Strategy Create a Commitment to Change with the Vision Understand the Driving Force Define Areas of Excellence Formulate Key Strategies 925 925 927 928 928 Check Your Understanding 28.3 929 Phase III: Strategy Formulation Tools for Strategic Thinking Determine Impact of Competition Identify a Future Strategic Profile Create a Platform for Strategic Innovation Develop Final Strategic Findings and Conclusions 929 929 931 931 931 932 Check Your Understanding 28.4 933 Phase IV: Implementation Roles of Strategic Goals and Strategic Objectives Importance of Implementation Plans 933 933 934 Check Your Understanding 28.5 935 Support for the Change Program Take a Systems Approach Create the Structure for Change Manage the Politics of Change Create a Sense of Urgency Engage with Communication Implementing Strategic Change Create and Communicate Short-Term Wins Pace and Refine Change Plans Maintain Momentum and Stay the Course Measure Your Results 936 936 937 937 938 938 939 939 940 940 941 Check Your Understanding 28.6 942 References 942 Appendix A Check Your Understanding Odd-Numbered Answer Key 945 Glossary1011 Index 1061 Online Appendices Appendix B Sample Documentation Forms Appendix C AHIMA Code of Ethics, Standards of Ethical Coding, and Ethical Standards for Clinical Documentation Improvement Professionals Appendix D Web Resources AB103318_FM.indd 24 1/3/2020 3:08:15 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com About the Volume Editors Pamela K. Oachs, MA, RHIA, CHDA, FAHIMA, is an assistant professor and director of the health information management undergraduate program in the College of St. Scholastica’s health informatics and information management department. She teaches courses related to health information technology, clinical quality management, healthcare management, and the US healthcare system. She has more than 20 years experience in healthcare and HIM education. Her career has included a variety of positions, both managerial and professional, in the ­areas of utilization management, quality improvement, medical staff credentialing, Joint Commission coordination, information technology, project management, and patient access. She has served on the region B and state board of directors of the Minnesota Health Information Management Association, has served as a commissioner on the Commission on Certification for Health Informatics and Information Management, is on the editorial review board of Perspectives in Health Information Management, and is a peer reviewer for the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM). Amy L. Watters, EdD, RHIA, FAHIMA, is an associate professor and director of the health information management graduate program at the College of St. Scholastica. Dr. Watters teaches courses related to health information technology, best practices in HIM, management and leadership, and applied research and writing. She has more than 20 years of HIM experience in a variety of areas, such as release of information, HIM and admitting management in acute-care settings, product management at a software and consulting firm, and HIPAA security at a multispecialty physician group. In addition to serving as coeditor of this textbook, Dr. Watters has coauthored chapters related to privacy and security in two textbooks, and published work in various peer reviewed publications. She has served on the board of directors of the Minnesota Health Information Management Association and the Minnesota Healthcare Information and Management Systems Society, has been President of the Northeastern Minnesota Health Information Management Association, and was appointed to the CAHIIM HIM Accreditation Council. She is also on the editorial review board for Perspectives in Health Information Management. In addition to both a bachelor’s and master’s degree in HIM, she has a doctoral degree in education, and focuses her research on community and its impact on online learning. xxv AB103318_FM.indd 25 1/3/2020 3:08:16 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com About the Authors Margret K. Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS, is president of Margret\A Consulting, LLC, in West Linn, OR, a consulting firm specializing in electronic health records and electronic health information. A leading authority on health IT strategies for over 40 years, she has extensive national and international experience in optimization and workflow redesign; HIPAA privacy, security, and transactions/code sets; and strategic planning for adoption of value-based care. She helped form and served as executive d ­ irector of the Computer-based Patient Record Institute, was associate executive director of AHIMA, associate professor at the University of Illinois at Chicago, and director of medical record services at the Illinois Eye and Ear Infirmary. She currently holds a clinical associate professorship at the University of Illinois at Chicago and serves as adjunct faculty at the College of St. Scholastica. She is a highly sought-after speaker, has published extensively, serves on several boards, and has earned numerous professional service awards. Danika E. Brinda, PhD, RHIA, CHPS, HCISPP, is an associate professor in the health information and informatics department at the College of St. Scholastica. She is also the owner of TriPoint Healthcare Solutions, which focuses on advising, educating, and operationalizing privacy and security requirements. Dr. Brinda has over 10 years of experience in healthcare privacy and security practices. She received her certified in healthcare privacy and security (CHPS) designation from the AHIMA and her healthcare information security and privacy practitioner (HCISPP) from (ISC)2. She also holds AHIMA’s registered health information administrator (RHIA) credential. Dr. Brinda is a local and national speaker regarding a wide variety of topics in healthcare privacy and security. Her expertise includes HIPAA risk assessment, HIPAA risk mitigation, privacy and security policy creation and management, privacy and security education, creation of privacy and security audits, Meaningful Use requirements, and evaluating best practices in privacy and security. Dr. Brinda has worked closely with both covered entities and business associates regarding HIPAA compliance. Dr. Brinda received her bachelor’s degree in health information management and computer science/ information systems from the College of St. Scholastica. She also received her master’s degree from the College of St. Scholastica in health informatics and information management. She completed her doctor of philosophy in information technology with a focus in information governance and security in 2015. Cindy Edgerton, MHA, MEd, RHIA, is the HIM program director at Charter Oak State College. Her professional background includes 20 years of experience as an educator and program director in HIM degree programs, including the development of one of the first online HIM associate degree programs. Currently, Cindy has created and designed curriculum for countless residential and online courses. This experience has been instrumental in many successful accreditations of HIM programs. She has been very involved in both AHIMA and her state-level association, Minnesota Health Information Management Association (MHIMA). She has been an elected board member for MHIMA and was an appointed member of the AHIMA Council for Excellence in Education. She has presented at the national AHIMA Assembly on Education conference for several years and was a presenter for the Train-the-Trainer Personal Health Record initiative. Cindy graduated with a bachelor’s degree in health information administration with a minor in management from the College of St. Scholastica. In 2007, she obtained her xxvi AB103318_FM.indd 26 1/3/2020 3:08:16 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com About the Authors xxvii master of education degree with a specialization in leadership in higher education from Capella University. She earned a second master’s degree, in healthcare administration, from Kaplan University in 2015. She has been a registered health information administrator since 1987. Scott B. Lee-Eichenwald, MSDD, has diverse professional experience in social sciences and medical technologies. In addition, he has been online teaching for more than 15 years. The bulk of his more than 20-year professional career has been spent working for medical devices companies. He has managed research and development projects and many large-scale technology implementation projects on a global scale. He received his Six Sigma Green Belt certification from the University of St. Thomas in 2012 and an information systems security certificate from Colorado Technical University in 2005. Scott earned a bachelor of arts degree in psychology from the College of St. Scholastica in 1992 and a masters of software design and development (MSDD) from the University of St. Thomas in 2001. Scott gained his professional experience working for Guidant, Boston Scientific, Medtronic, and Smiths Medical. In addition, he lived and worked for two years in Europe. In his spare time, he enjoys being outdoors hiking, biking, skiing, skating, and traveling with his wonderful wife and four children, ages 23, 21, 11, and 8. He is a huge Minnesota Wild fan, win or lose, and is an animal enthusiast with two blue Great Danes, three cats, and five rabbits. His family has hosted many foreign exchange students and they have traveled abroad in Ireland, England, France, Germany, Italy, Switzerland, Belgium, Iceland, and Norway. Sandra R. Fuller, MA, RHIA, FAHIMA, is chief operations officer at eCatalyst Healthcare Solu­ tions. Her work focuses on revenue cycle operations, coding, and health information management best practice. Prior to joining eCatalyst, she was the executive vice president and chief operating officer at AHIMA, where she led the professional and membership facing services of the association. Sandra was the director of patient data services at AB103318_FM.indd 27 the University of Washington Medical Center. Her volunteer activities included serving on the board of directors of AHIMA and acting as president of the Washington State Health Information Management Association. She was awarded the WSHIMA Professional Achievement Award in 1996. She ­authored the book Secure and Access Guidelines for Managing Patient Information, published in 1997 by AHIMA. Lauree Handlon, MHA, RHIA, CCS, COC, CRCR, FAHIMA, FHFMA, is the director of data quality and reimbursement at Cleverley + Associates, where she has worked since 2002. She primarily analyzes third party payer contractual arrangements for strategic pricing, payment assessments, and regional comparisons. Ms. Handlon also conducts frequent regulatory research, monitors data integrity by identifying anomalies in the Medicare public claims data and client submitted claims data, and provides Medicare prospective payment system and coding and billing education. Ms. Handlon received her master of health administration from the University of Cincinnati in 2017. She received a master’s degree in allied health management through the School of Health and Rehabilitation Sciences from the Ohio State University in 2008. She received her undergraduate degree in health information management and systems from the Ohio State University in 2000. Ms. Handlon also has been instructing part-time for the HIMS department in the School of Health and Rehabilitation Sciences at the Ohio State University since 2007 and has served as a clinical site preceptor since 2003. She has presented numerous educational sessions for HFMA, COPAM, Ohio Health Information Management Association (OHIMA), and other HIM-related professional organizations. She has written several articles regarding provider payment issues and revenue cycle topics. She has served as a review panel member for Perspectives in Health Information Management since 2012. She has pilot tested many of CMS’s Medicare Learning Network courses and has served as technical reviewer of various AHIMA textbooks. Ms. Handlon is a past-president and past two-term role as delegate for OHIMA. She is the current 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xxviii About the Authors Membership Chair for the Central Ohio chapter of HFMA. She is the current vice president of the University of Cincinnati MHA Alumni Council. She also past president of the Ohio State University School of Health and Rehabilitation Sciences Alumni Society, where she has served in various roles on the executive board since 2005. Systems for Monitoring HIV/AIDS Care and an advisor and consultant to the Global Health Projects monitoring and evaluation for Project HOPE. She is a well-published author and researcher and participates in research studies in health information and informatics, healthcare management, and public health. Anita C. Hazelwood, EdD, RHIA, FAHIMA, is a professor and allied health department head in the College of Nursing and Allied Health Professions at the University of Louisiana at Lafayette. Anita is the recipient of the Lafayette General Medical Center/BORSF Professorship in Health Sciences. ­ Anita is an AHIMA-approved ICD-10-CM/PCS trainer and has conducted numerous coding work­ shops throughout the state and nation. She has written numerous articles, coauthored many textbooks, and authored chapters in several HIM textbooks. Anita was the recipient of AHIMA’s Legacy Award in 2003. On a professional level, Anita is a member of AHIMA and has served on various committees and boards. Anita is currently serving as a member of CAHIIM’s Health Information Management Advisory Council. T. J. Hunt, PhD, RHIA, CHDA, FAHIMA, is an assistant professor in the Department of Health Informatics at Rutgers University. He previously served as associate dean and professor of health information management at Davenport University. Before transitioning to higher education, Dr. Hunt served in leadership roles with Sparrow Health System, ProMedica Health System, and Mercy Health Partners. He is a past-president of the Michigan Health Information Management Association (MHIMA) and the Lake Huron Health Information Management Association. He has presented at the International Federation of Health Information Management Associations (IFHIMA) Congress and General Assembly, AHIMA Convention and Exhibit, AHIMA Assembly on Education, and MHIMA State Conference. Dr. Hunt earned a doctor of philosophy degree in global leadership with a concentration in organizational management from Indiana Institute of Technology. He also has degrees in business administration, management information systems, and health information technology. T. J. is a registered health information administrator and certified health data analyst through AHIMA and has been recognized as a Fellow of AHIMA for service and contribution to the health information management profession. Shannon H. Houser, PhD, MPH, RHIA, FAHIMA, is a professor in the health services administration department and graduate program in health informatics at the University of Alabama at Birmingham (UAB), where she is also an associate scientist in the Center for AIDS Research. She is a visiting professor at Tsinghua University in China and participated in designing the curriculum and teaching courses in its master’s degree in hospital management. She serves in leadership roles in health information and informatics professions at both national and international levels. She is the chair for the AHIMA Foundation of Research Network (AFRN) and received AHIMA’s Triumph Award for research in 2007. She received her doctoral and master’s degrees in health behavior and epidemiology, respectively, from the UAB School of Public Health, and a bachelor of science degree in health information management from UAB. She served as a committee member of the National Academy of Medicine Committee to Review Data AB103318_FM.indd 28 Merida Johns, PhD, RHIA, has more than 40 years health information management experience on national and international levels and is a noted author and presenter in the field. She has over 50 published articles and has authored several books and chapters in health information management and healthcare informatics. Dr. Johns holds bachelor of arts and bachelor of science degrees from Seattle University; a master’s degree in community services administration from Alfred University, New York; and doctor of philosophy from the 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com About the Authors xxix Ohio State University. She began her c­ areer in 1973 and has held positions of director of quality assurance, assistant and director of medical record departments. Dr. Johns held tenured positions at the Ohio State University and the University of Alabama at Birmingham where in 1991 she was the founding director of the nation’s first master’s program in health informatics for the training of healthcare CIOs. Dr. Johns has held numerous elected and appointed professional positions with AHIMA, AMIA, CAHIIM, HIMSS, and professional state associations and nonprofit community groups. She served as AHIMA’s president in 1997 and has received three AHIMA national honors including Professional Achievement, Champion, and Distinguished Member awards. Most recently in 2013 she received the Illinois Health Information Management Association’s Professional Achievement Award. Currently Dr. Johns heads the Monarch Center for Women’s Leadership Development, a company she founded that provides leadership coaching and workshops to help women help themselves fulfill their leadership and economic potential and break the glass ceiling. Kathleen M. Kirk, PhD, RHIA, is a clinical professor in the department of health information management and health service administration at the City University of New York (CUNY) School of Professional Studies. She was previously an assistant professor at Rutgers University in the School of Health Professions. She earned her bachelor of science in health information management at Kean University, her master of science in healthcare administration at College of St. Elizabeth, and a doctor of philosophy in biomedical informatics at Rutgers University. Kathleen’s professional background includes 25 years of experience in health information management. She has held positions as an educator, HIM director, privacy officer, director of corporate compliance, and acting senior vice president of compliance operations. Madonna M. LeBlanc, MA, RHIA, FAHIMA, is an assistant professor in the health informatics and information management program in the School of Health Science (SHS) at the College of St. Scholastica (CSS) in Duluth, MN, and a graduate AB103318_FM.indd 29 of the CSS’s initial MA in HIM program. Prior to her teaching role, she managed HI services at St. Mary’s/Duluth Clinic Health System in Superior, WI. Her responsibilities included a broad spectrum of acute care HIM functions, from physician education to Joint Commission survey coordination. LeBlanc’s field experience also includes cancer registry and physician peer administration. She was co-faculty for six years in the SHS Interdisciplinary Health Science Leadership course at CSS designed to provide transdisciplinary collaboration and problem solving in the healthcare setting. LeBlanc served for six years on Minnesota Health Information Management Association’s (MHIMA) BOD as director delegate and president, was CSA community education coordinator for the AHIMA myPHR campaign, and volunteered on the AHIMA Council for Excellence in Education (CEE) Community workgroup and the AHIMA Scholarship Committee. Charisse Madlock-Brown, PhD, MLS, is a faculty member in health informatics and information management at the University of Tennessee Health Science Center. She received her master of library science and doctor of philosophy in health informatics from the University of Iowa. She has expertise in data management, data mining, and visualization. She has a broad background in health informatics with a current focus on obesity trends and multimorbidity. Her other areas of interest are network analysis and emerging topic detection in biomedicine. She has authored several book chapters and journal articles and continues to keep up to date on data integration, data architecture, database management, and analytic methods. She runs the UTHSC Research Pipelines labs, which provide online interfaces for distributed computing and storage systems. Her lab can manage projects from data extraction and transformation to modeling and visualization for small-scale and big data projects. David Marc, PhD, CHDA, is an associate professor, the health informatics and information management department chair, and the health informatics graduate program director at the College 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xxx About the Authors of St. Scholastica in Duluth, MN. Dr. Marc has a master’s degree in biological sciences and a doctor of philosophy in health informatics from the University of Minnesota and is a certified health data analyst. He previously served as the chair of the AHIMA Foundation Research Network and as a member of the AHIMA Council for Excellence in Education, where he co-chaired the Educational Programming Workgroup. Dr. Marc also served on the HIMSS Scholars Workgroup and the HIMSS Student and Early Careerists Committee. Dr. Marc frequently speaks at state and national meetings and workshops on topics related to healthcare data analytics. He is an accomplished researcher and author on topics related to health informatics and information management workforce trends. Susan E. McClernon, PhD, FACHE, is the CEO and president of Innovative Healthcare Leadership, LLC, a healthcare consulting firm that has been serving healthcare organizations since 2007. Sue has served in hospital administration for over 30 years, most recently as the chief operating officer of St. Mary’s Medical Center, a 350-bed tertiary care regional hospital in Duluth, MN, from 2004 to 2007. She served as COO of Brackenridge Hospital in Austin, TX, which was named as a top-100 hospital during her tenure between 1998 and 2004. Previously, she worked at Bayfront Medical Center in Florida, Ramsey Clinics in St. Paul, MN, and Allina Health in Minneapolis, MN. Sue completed her PhD at the University of Minnesota School of Public Health, Division of Health Policy and Management. She holds a master’s degree in healthcare management from the University of Minnesota and an undergraduate degree in healthcare management from the College of St. Scholastica. She completed her internship in quality at the AHA and her fellowship at Abbott Northwestern Medical Center in Minneapolis, MN. She is a fellow in the American College of Healthcare Executives. Sue also currently serves as the faculty director for the health services management program at the University of Minnesota–Twin Cities, which has almost 250 students. She led the development of the bachelor of applied science in health services management in 2014 when approved by the UMN AB103318_FM.indd 30 Board of Regents. She has also served as adjunct faculty at UMD and the health information management program at the College of St. Scholastica. Angela Morey PhD, RHIA, CPHIMS, is an associate professor of health informatics and information management (HIIM) and the bachelor of science HIIM program director at the University of Mississippi Medical Center. Before moving to Mississippi, she served as a physician liaison for a regional physician/hospital organization and as a director of HIM for a for-profit healthcare system. She has 22 years of experience in the HIM field, including 15 years in education. She holds a bachelor of science degree in HIM as well as a master of science degree in organizational management and a doctor of philosophy in clinical health science with a focus in health systems management. In addition, Dr. Morey is a past president of the Mississippi Health Information Management Association and a past president of the Mississippi chapter of the Healthcare Information and Management Systems Society. Rosann M. O’Dell, DHSc, RHIA, CDIP, is chair of the Department of Health Information Management at the University of Kansas School of Health Professions. In addition to her role in administration, she serves as a clinical assistant professor, teaching healthcare management and information governance courses. She is active in campus leadership, including service to committees such as faculty steering and faculty practice. Her scholarly activities include various roles providing expert reviews of scholarly articles and a textbook on the topic of electronic health records. She was also the lead author of a textbook on the topic of ICD-10-CM and ICD-10-PCS and authored a chapter in the fifth edition of this textbook. In her service to the profession of health information management, she was elected as a commissioner of CCHIIM, served on the AHIMA Consumer Engagement and Clinical Terminology and Classification Practice Councils, and served on the AHIMA Foundation Research and Periodicals Workgroup. Prior to her academic career, she primarily worked in acute care hospitals managing HIM operations 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com About the Authors xxxi and serving on institutional committees such as HIPAA privacy, HIPAA security, oncology services, and clinical ethics. Brandon D. Olson, PhD, PMP, is an associate professor and director of the master of science in applied data analytics at the College of St. Scholastica. Dr. Olson holds a doctor of philosophy in information technology with a specialization in project management and a master’s degree in computer information resource management. His research interests include project management, data analytics, knowledge management, and IT strategy. Prior to entering academia, Dr. Olson worked as a project manager in the pharmaceutical, healthcare, and business services industries. Dr. Olson also directs outreach programs for the Minnesota chapter of the Project Management Institute. Brooke Palkie, EdD, RHIA, is a graduate program director for health care administration and health informatics at Charter Oak State College with a teaching focus on classifications, vocabularies, and clinical data standards, as well as assessing healthcare quality and corporate compliance. Dr. Palkie is an AHIMA-approved ICD-10-CM/PCS trainer. Karen R. Patena, MBA, RHIA, FAHIMA, is a clinical associate professor and director of HIM programs, Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, at the University of Illinois at Chicago (UIC). She earned an master of business administration from DePaul University and is an alumnus of the University of Illinois health information management program. Previously, Karen was director of the independent study division of AHIMA and a faculty member at Indiana University and Prairie State College. She also has extensive experience in hospital medical record department management, including computer systems planning and implementation. Her areas of expertise include management, quality improvement and TQM, the use of computers in healthcare and systems analysis, and online curriculum development; and has presented tutorials at local, state, and national l­evels. She has served in numerous volunteer roles at AB103318_FM.indd 31 AHIMA, and currently is a member of the panel of accreditation surveyors for the Commission on Accreditation for Health Informatics and Information Management Education. Rick Revoir, EdD, MBA, CPA, is dean of the School of Business and Technology at the College of St. Scholastica. He holds a doctor of education degree from the University of Minnesota–Duluth and a master's of business administration from ­Arizona State University. He currently serves as president of the Duluth Seaway Port Authority Board of Commissioners. Prior to joining higher education, he worked for 11 years in a variety of healthcare finance positions. Rebecca B. Reynolds, EdD, RHIA, CHPS, FAHIMA, is a professor and chair of health informatics and information management at the University of Tennessee Health Science Center (UTHSC). Reynolds has taught healthcare policy, health information technology and systems, and legal issues while providing HIPAA training and interprofessional seminars for the medical, pharmacy, nursing, and health professions students on the UTHSC campuses. She has taught HIPAA seminars throughout Tennessee and has spoken at the Tennessee Bar Association’s Health Law Forum, the Tennessee Chapter of the American College of Surgeons, and the National Conference for Nurse Practitioners. She is co-editor and chapter author of the AHIMA publication Fundamentals of Law for Health Informatics and Information Management. Reynolds is active in AHIMA, serving as an elected member of the Commission on Certification of Health Informatics and Information Management (CCHIIM). She is a former Tennessee delegate to the AHIMA House of Delegates, as a member of the AHIMA Nominating Committee and on the AHIMA Foundation Committee on Excellence in Education Committee. She is also past president of the Tennessee Health Information Management Association (THIMA). Reynolds received the Outstanding New Professional Award from THIMA in 1995 and in 2004 received the THIMA Distinguished Member Award. In 2010 she was a co-recipient of the AHIMA Triumph Legacy Award. 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xxxii About the Authors Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA is professor and director of the health information management and systems program at the Ohio State University in Columbus, OH. She earned both her bachelor of science in medical record administration and her juris doctor ­degree from the Ohio State University. In addition to education, her professional experiences include work in behavioral health, home health, and acute care. She has served as an expert witness in civil litigation regarding the privacy and confidentiality of health information/HIPAA compliance. She has served on numerous AHIMA committees and is a member of AHIMA’s Council for Excellence in Education. She is a member of the board of directors of the Ohio Health Information Management Association (OHIMA). She is a recipient of the AHIMA Triumph Award and the OHIMA Distinguished Member Award. She is a speaker on the HIPAA Privacy Rule and a coeditor and coauthor of Fundamentals of Law for Health Informatics and Information Management, the author of Introduction to Health Information Privacy and Security, and a contributing author in Health Information Technology: An Applied Approach, Documentation for Health Records, Documentation for Medical Practices (all AHIMA-published titles) and Ethical Health Informatics: Challenges and Opportunities (published by Jones & Bartlett). She has been published in the Journal of AHIMA and in AHIMA’s Perspectives in Health Information Management. Ryan H. Sandefer, PhD, is the assistant vice president for academic affairs at the College of St. Scholastica. He is also an associate professor in the ­Department of Health Informatics and ­Information Management, where he teaches research methods and data analytics. He is responsible for coordinating and integrating planning efforts around new and expanding nontraditional programs. Through the use of data analytics and metrics, Dr. Sandefer deepens the college’s culture of evidence and the use of data for strategic ­decision-making. He ensures the alignment of initiatives with the college’s mission and values, especially the challenge of creating community among online and extended site learners. AB103318_FM.indd 32 Dr. Sandefer has a master’s degree in political science from the University of Wyoming and completed his doctor of philosophy in health informatics from the University of Minnesota. Dr. Sandefer served as the chair of the AHIMA Council for Excellence in Education, a presenter for AHIMA’s data analytics workshops, and an instructor for the certified health data analytics (CHDA) exam prep workshops. Dr. Sandefer has extensive experience working with large healthcare datasets and analytic procedures. Dr. Sandefer co-edited the AHIMA Press textbook Data Analytics in Healthcare Research: Tools and Strategies, which offers a unique opportunity to experience big data from a hands-on perspective using open source tools and data. Marcia Y. Sharp, EdD, MBA, RHIA, is an associate professor and program director at the University of Tennessee Health Science Center in the department of health informatics and information management. She teaches leadership, information technology, and healthcare information systems. Prior to teaching, Dr. Sharp served in leadership roles in health information management for over 15 years. She also has human resources (HR) experience as an HR director, and has retired from the US Navy Reserve. Previously, Dr. Sharp served as member of AHIMA’s Council for Excellence in Education (CEE). Additionally, she served on the CEE’s faculty development workgroup and as a delegate for the Tennessee Health Information Management Association. Currently, Dr. Sharp is a reviewer for AHIMA’s Perspectives in Health Information Management. She holds a doctoral degree in higher and adult education from the University of Memphis, a master of business administration from Webster University, and a bachelor of science in health information management from the ­University of Tennessee. David X. Swenson, PhD, LP, is a professor of management in the School of Business and Technology at the College of St. Scholastica, where he teaches strategic management, organization development, leadership, marketing, and thesis research. He is also the program director of a new online MBA program for rural health professionals. He has 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com About the Authors xxxiii a part-time consulting practice in organization development and forensic psychology, also holding a post-doctoral diplomate in the latter field. David has worked in the field of psychology for more than 40 years and has served as director of student development at the College of St. Scholastica and director of clinical services at the Human Resource Center of Douglas County, WI. He has authored more than 100 publications, including Stress Management for Law Enforcement. A doctoral graduate of the University of Missouri at Columbia in counseling and personnel services, David also has master’s degrees in management, school counseling, educational media and technology, and information technology leadership. technologies in healthcare. In particular, he is interested in impacts upon clinical relationships, the delivery of health services, economics, and end of life decision-making. His areas of expertise reside in topics related to ethical use of data, medical technologies, clinical interventions, and the sociotechnical milieu in which they converge. Eric received a bachelor of arts in religious studies from Ithaca College, a master of arts in South Asian Studies from the University of Wisconsin– Madison, a juris doctor from American University, and completed a fellowship in clinical medical ethics at the University of Chicago. Eric is currently completing a masters in health professions education at UIC. Eric S. Swirsky, JD, MA, is a clinical associate professor and the director of graduate studies in the Department of Biomedical and Health Information Sciences at the University of Illinois at ­Chicago (UIC). Eric has created applied ethics and professionalism curricula for both online and face-to-face environments and teaches classes on the ethical use of technology across disciplines from the undergraduate through the post-doctoral levels. He has received numerous awards and distinctions related to teaching excellence and is the chair of UIC’s Teaching Recognition Program. Eric serves on the board of directors of the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM), where he is board secretary and chair of the Bylaws Committee. Eric is also on the editorial board of the American Journal of Bioethics. His scholarly interests have focused upon ethical conundrums attendant to the use of digital and information Susan E. White, PhD, RHIA, CHDA, is the administrator of analytics at the James Cancer ­ Hospital at the Ohio State University Wexner Medical Center, where she leads a team of analytics specialists focused on measuring the performance of the cancer hospital’s operations. White is also an associate professor in the health information management and systems division at the Ohio State University, where she teaches data analytics, healthcare finance, and database courses. White served on AHIMA’s Board of Directors from 2015 to 2018. White is the author of AHIMA’s A Practical Approach to Analyzing Healthcare Data, Second Edition; Principles of Finance for Health Information and Informatics Professionals, Second Edition; and Certified Health Data Analytics (CHDA) Exam Preparation, Second Edition; as well as numerous peer- and editor-reviewed articles. White is a regular presenter at the state and national level on healthcare data analytics and big data. AB103318_FM.indd 33 1/3/2020 3:08:17 PM Get Complete eBook Download link Below for Instant Download: https://browsegrades.net/documents/286751/ebook-payment-link-forinstant-download-after-payment Get Complete eBook Download by Email at discountsmtb@hotmail.com Acknowledgments The volume editors and AHIMA Press staff would like to acknowledge Kathleen LaTour, MA, RHIA, FAHIMA, and Shirley Eichenwald-Maki, MBA, RHIA, FAHIMA, as the founding editors of this textbook. Their vision led to the creation of a practical, comprehensive resource written by industry experts for the education of future leaders in healthcare. We would like to express appreciation to the many authors who contributed chapters to this textbook. They willingly shared their expertise, met tight deadlines, accepted feedback, and contributed to building the body of knowledge related to health information management. Writing a chapter is a time-consuming and demanding task, and we are grateful for the authors’ contributions. We would also like to thank authors who contributed to previous editions of this textbook: •• Rita K. Bowen, MA, RHIA, CHPS, SSGB •• Elizabeth D. Bowman, RHIA, FAHIMA •• Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS •• Nadinia Davis, MBA, RHIA, CCS, CHDA, FAHIMA •• Chris R. Elliott, MS, RHIA •• Mehnaz Farishta, MS •• Susan H. Fenton, PhD, MBA, RHIA, FAHIMA •• Margaret M. (Maggie) Foley, PhD, RHIA, CCS •• Elizabeth Forrestal, PhD, RHIA, CCS, FAHIMA •• Kathy Giannangelo, RHIA, CCS, CPHIMS, FAHIMA •• Leslie L. Gordon, MS, RHIA, FAHIMA •• Morley L. Gordon, RHIT •• Michelle A. Green, MPS, RHIA, CPC, FAHIMA •• Matthew J. Greene, RHIA, CSS •• J. Michael Hardin, PhD •• Laurinda B. Harman, PhD, RHIA, FAHIMA •• Loretta A. Horton, MEd, RHIA, FAHIMA •• Diana Lynn Johnson, PhD •• Linda L. Kloss, MA, RHIA, FAHIMA •• Deborah Kohn, MPH, RHIA, CPHIMS, FACHE, FHIMSS •• Mary Cole McCain, MPA, RHIA •• Phillip McCann, MSC, MS, RHIA, CISSP •• Carol E. Osborn, PhD, RHIA •• Susan L. Parker, MEd, RHIA, FAHIMA •• Carol Ann Quinsey, MS, RHIA, CHPS •• Uzma Raja, PhD •• Lynda A. Russell, EdD, JD, RHIA, CHP •• Rita Scichilone, MHSA, RHIA, CCS, CCS-P, CHC-F •• Patricia B. Seidl, RHIA •• Kam Shams, MA •• C. Jeanne Solberg, MA, RHIA, FAHIMA •• Carol Marie Spielman, MA, RHIA •• Cheryl Stephens, MBA, PhD •• Carol Venable, MPH, RHIA, FAHIMA •• Karen Wager, DBA •• Valerie J. M. Watzlaf, PhD, RHIA, FAHIMA •• Janelle A. Wapola, MA, RHIA •• Andrea Weatherby White, PhD, RHIA •• Frances Wickham Lee, DBA, RHIA •• Vicki Zeman, MA, RHIA We also would like to thank the following reviewers who lent a critical eye to this endeavor. Current edition reviewers: •• Karen Bakuzonis, PhD, MS, RHIA •• Matthew Caines, DHEd, MSIT, MPH, RHIA, MCHES •• Dilhari R. DeAlmeida, PhD, RHIA •• Deborah S. Gilbert, MBA, RHIA •• Lois M. Hitchcock, MHA, RHIA, CPHQ •• Deborah Honstad, EdD, RHIA •• Dorinda M. Sattler, MJ, RHIA, CHPS, CPHRM Previous edition reviewers include: •• Janie L. Batres, MS, RHIA, CCS, CDIP •• Hertencia V. Bowe, EdD, MHSA, RHIA, FAHIMA •• Donna Bowers, JD, RHIA, CHP xxxiv AB103318_FM.indd 34 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Acknowledgments xxxv •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• AB103318_FM.indd 35 June E. Bronnert, RHIA, CCS, CCS-P Jill Burrington-Brown, MS, RHIA, FAHIMA Christopher G. Chute, MD, DrPH Karen Clancy, PhD, MBA Jill S. Clark, MBA, RHIA, CHDA, FAHIMA Kathryn DeVault, MSL, RHIA, CCS, CCS-P, PCS, FAHIMA Julie A. Dooling, MSHI, RHIA, CHDA, FAHIMA Claire Dixon-Lee, PhD, RHIA, CPH, FAHIMA Michelle L. Dougherty, MA, RHIA, CHP Melanie A. Endicott, MBA/HCM, RHIA, CCS, CCS-P, CDIP, CHDA, FAHIMA Susan H. Fenton, PhD, MBA, RHIA, FAHIMA Leslie A. Fox, MA, RHIA, FAHIMA Jennifer Garvin, PhD, MBA, RHIA, CCS, CPHQ, CTR, FAHIMA Kathy Giannangelo, RHIA, CCS, CPHIMS, FAHIMA Barry S. Herrin, JD, CHPS, FACHE, FAHIMA Beth Hjort, RHIA, CHPS Susan Hull, MPH, RHIA, CCS, CCS-P •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• Lolita M. Jones, MSHS, RHIA, CCS Karen Kostick, RHIT, CCS, CCS-P Donald T. Mon, PhD, FHIMSS Carol Ann Quinsey, MS, RHIA, CHPS Harry Rhodes, PhD, MBA, RHIA, CDIP, CHPS, CPHIMS, FAHIMA Theresa Rihanek, MHA, RHIA, CCS Dan Rode, MBA, CHPS, FAHIMA, FHFMA Angela Dinh Rose, MHA, RHIA, CHPS, FAHIMA Rita A. Scichilone, MHSA, RHIA, CCS, CCS-P, CHC Stephen A. Sivo, PhD Mary H. Stanfill, RHIA, CCS, CCS-P Diana M. Warner, MS, RHIA, CHPS, CPHI, FAHIMA Valerie J.M. Watzlaf, PhD, RHIA, FAHIMA Lou Ann Wiedemann, MS, RHIA, CDIP, CHDA, CPEHR, FAHIMA Maggie Williams, MA Ann Zeisset, RHIT, CCS, CCS-P 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Foreword As information becomes more central to the process of delivering healthcare, health information management professionals are finding themselves at the center of everything. From hospitals to physicians’ offices to telemedicine, it is clear that health information is the currency that circulates throughout the care system. Today as never before, getting the right information to the right people at the right time is paramount. At the same time, evolving technologies, payment strategies, and approaches to care suggest that in the future, information will be used in ways we can’t yet imagine. For example, patientlevel electronic health record data is being used by population health management experts in combination with public health data and screening and prevention data to identify social conditions that will impact peoples’ health. And the advancement of personalized medicine that could track genetic, molecular, and health data on a daily basis may mean that one day, doctors will be able to predict the onset of disease and identify the most personalized treatments. The centrality of health information and the new ways in which it is being used—and will be used in the future—means that AHIMA’s mission of empowering people to impact health and its vision of a world where trusted information is transforming health and healthcare by connecting people, systems, and ideas will be reality before long. The readers of Health Information Management: Concepts, Principles, and Practice will be the professionals making it happen. The sixth edition of this book has been updated to reflect the 2018 AHIMA health information management curricula competencies. Its editors, Pamela K. Oachs, MA, RHIA, CHDA, FAHIMA, and Amy L. Watters, EdD, RHIA, FAHIMA, have compiled a comprehensive overview of areas such as data content, standards, and governance, revenue management and compliance, informatics, analytics and data use, management tools and strategies, and leadership. With chapters written by individuals who are experts in their fields, this edition is a knowledgeable and informative reference and guide to this rich field of study. I’m pleased to welcome you into the HIM community and I look forward to seeing how, with your support, the health information management profession evolves to empower people to impact health. Wylecia Wiggs Harris, PhD, CAE AHIMA Chief Executive Officer xxxvi AB103318_FM.indd 36 1/3/2020 3:08:17 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Online Resources For Students For Instructors This book provides access to online learning tools and supplements to aid in mastering the subjects presented in each chapter. On the companion website you will find an online student workbook with assignments, activities, and a review quiz for each chapter, as well as the online appendices listed in the table of contents. To access the student resources, please follow the instructions on the inside front cover of this book. Instructor materials for this book are provided only to approved educators. Materials include an instructor manual with a variety of activities and assignments, a test bank with answer key, full answer key for the Check Your Understanding questions, and PowerPoint slides. Please visit http://www. ahima.org/publications/educators.aspx for further instruction on accessing instructor materials. If you have any questions regarding the instructor materials, please contact AHIMA Customer Relations at (800) 335-5535 or submit a customer support request at https://my.ahima.org/messages. xxxvii AB103318_FM.indd 37 1/3/2020 3:08:18 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Introduction Pamela K. Oachs, MA, RHIA, CHDA, FAHIMA and Amy L. Watters, EdD, RHIA, FAHIMA As the healthcare industry recognized the importance of clinical recordkeeping and its impact on patient care and delivery, the health information management (HIM) profession emerged. Originally referred to as medical record science, the field of HIM has been a recognized profession for over 90 years. Today, HIM is described as the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care (AHIMA 2019a). Once known as medical record librarians, the role of the HIM professional has changed significantly over time. Changes in healthcare reimbursement systems, new healthcare delivery models, and advancements in medicine and technology have all contributed to the array of skills that HIM professionals possess and the diversity of jobs and settings in which they work. These professionals affect the quality of patient information and patient care at every point in the healthcare delivery cycle and serve as a bridge to connect the clinical, operational, and administrative functions (AHIMA 2019a). Although the core of the HIM profession has always been to collect and maintain high-quality health data, the methods to do so have changed as healthcare has become more technology driven. The HIM professional’s knowledge and skills have transitioned from paper-based records and manual systems, to a focus on managing electronic content. This transition has created an information-rich environment requiring a unique mix of clinical, management, and information technology competencies. Subsequently, HIM roles have grown to include data reporting and analysis, requiring clinical documentation improvement (CDI) efforts. CDI drives positive decisions, quality care, and appropriate reimbursement, allowing for valuable assessment of quality measures and value-based care metrics. The critical role that CDI plays in the success of healthcare facilities prompted AHIMA, upon recommendation of industry experts, to update the meaning of CDI from clinical documentation improvement to clinical documentation integrity in 2020 to more fully describe what CDI professionals do and their value to the organization. The roles in which HIM professionals participate and their impact across the healthcare industry are vast. HIM professionals’ varied interactions with health information are at the heart of health information governance and stewardship. Through these activities HIM professionals impact policy, standards, education, and research (AHIMA 2011), all of which are critical to meeting the Triple Aim of healthcare. The Triple Aim, a framework established by the Institute for Healthcare Improvement (IHI), refers to the simultaneous pursuit of three dimensions of healthcare: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare (IHI n.d.). See figure I.1. Many healthcare organizations, policymakers, and federal agencies use the Triple Aim as a framework to achieve their Figure I.1. Triple Aim Population Health Experience of Care Per Capita Cost Source: IHI n.d. Reprinted with permission. The IHI Triple Aim framework was developed by the Institute for Healthcare Improvement in Boston, Massachusetts (www.ihi.org). xxxviii AB103318_FM.indd 38 1/3/2020 3:08:18 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Introduction xxxix goals and improve healthcare. The Triple Aim is intended to be transformational, serving as the foundation for organizations and communities to navigate a shift of focus in healthcare to optimizing health for individuals and populations (IHI n.d.). Although there are currently many healthcare-related government and industry initiatives with varying goals, each initiative relates to the Triple Aim in some way; and with their clinical, technical, and management expertise, HIM professionals are poised to lead the way. Proper management of health information is critical for the success of these challenging initiatives, requiring HIM professionals to continue to develop, utilize, and market their skills. AHIMA’s Council for Excellence in Education (CEE) is the leading force in education strategy for the HIM profession, guiding the academic community and workforce through improvements to education, coursework, and curricula (AHIMA 2019b). In response to the AHIMA’s HIM Reimagined (HIMR) initiative, which is focused on positioning HIM professionals for the future, AHIMA and the CEE developed the 2018 AHIMA health information management curricula competencies and revised the required Bloom’s Taxonomy levels. The competencies align HIM education with the skills and knowledge required to meet long-term HIM workforce needs. The curriculum, designed to prepare the HIM student, includes the following domains for all levels of HIM education: • Domain I: Data content, structure, and information governance • Domain II: Information protection: access, use, disclosure, privacy, and security provides HIM professionals with a combination of skills and competencies that differentiate them from other healthcare professionals (AHIMA 2019c). Content expertise is undeniably critical to success as an HIM professional; however, the academic community and healthcare industry also recognize the importance of interpersonal skills when developing a leader in the field. AHIMA’s 2014 workforce study found an increased need for interpersonal skills in the future of the HIM profession. Interpersonal skills such as negotiation and change management were noted as important as well as problem solving and critical thinking skills. Leadership, communication, and customer engagement and service were prominent in the top ten skills identified as most needed for the future of healthcare professionals (Caviart Group 2015). All of these skills are embedded in the HIM discipline and make up the core components of HIM leadership—communication skills, professionalism, and the concept of understanding organizational culture—all of which are critical for new and current HIM professionals alike (see figure I.2). Communication skills include not only being able to write and speak clearly, but also to listen carefully. At its most basic level, communication is the exchange of information, which is central to HIM; effective communication is the foundation for quality care, efficient processes, strong relationships, collaboration, and a positive work environment. Communication skills are a key component of professional behavior as well as an organizational culture based on respect. Figure I.2. Components of HIM leadership • Domain III: Informatics, analytics, and data use • Domain IV: Revenue cycle management • Domain V: Health law and compliance • Domain VI: Organizational management and leadership (AHIMA 2019c) In addition, supporting foundational knowledge in the areas of pathophysiology, pharmacology, anatomy and physiology, medical terminology, computer concepts and applications, and statistics AB103318_FM.indd 39 Communication Professionalism HIM Leadership Culture 1/3/2020 3:08:19 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com xl Introduction Professionalism is as integral to gaining respect in a chosen field as technical or content expertise. The ability to respectfully achieve results, meet goals, build relationships and network with others, adapt to change, accept new ideas, and offer creative solutions are all characteristics of a strong leader. One can be a leader in their role or area of expertise by having confidence in their knowledge and being honest, thoughtful, dependable, and collaborative. Behaving professionally in all situations instills confidence and trust from others, which is essential for HIM professionals who serve as a bridge among people, systems, and concepts. Understanding the workplace culture and what impacts it is another critical proficiency for the HIM leader. Thoughtful and effective communication skills along with consistent professional behavior create a culture of creativity, respect, and openness in the workplace. An environment where individuals are encouraged to share ideas, gain new skills, experience opportunities outside of their usual routine, and feel comfortable stating their opinions supports the development of strong leaders in HIM who can effect change (Mancilla et al. 2015). It is the efforts of these leaders who will impact the success of the Triple Aim and make lasting contributions to the transformation of the healthcare industry. References American Health Information Management Association. (2019a). Health Information 101: What is Health Information? https://www.ahima.org/ careers/healthinfo. American Health Information Management Association (2019b). Council for Excellence in Education. https://www.ahima.org/education/ academic-affairs/council-for-excellence. American Health Information Management Association. (2019c). Curricula Competencies. https:// www.ahima.org/education/academic-affairs/ academic-curricula. AB103318_FM.indd 40 Caviart Group. 2015. Results of the AHIMA 2014 Workforce Study. http://library.ahima.org/ PdfView?oid=300801. Institute for Healthcare Improvement. n.d. The IHI triple aim. Accessed June 25, 2019. http://www.ihi.org/ Engage/Initiatives/TripleAim/Pages/default.aspx. Institute for Healthcare Improvement. n.d. Triple Aim for Populations. Accessed June 25, 2019. http://www. ihi.org/Topics/TripleAim/Pages/default.aspx. Mancilla, D., C. Guyton-Ringbloom, and M. Dougherty. 2015 (June). Ten skills that make a great leader. Journal of AHIMA 86(6):38–41. 1/3/2020 3:08:19 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com PART I Data Content, Standards, and Governance 1 AB103318_Ch01.indd 1 1/2/2020 6:44:40 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com AB103318_Ch01.indd 2 1/2/2020 6:44:40 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com chapter 1 The US Healthcare Delivery System Sandra R. Fuller, MA, RHIA, FAHIMA Learning Objectives • Construct a timeline of the history of the healthcare delivery system from ancient times to the present • Compare the basic organization of the various types of hospitals and healthcare organizations • Evaluate the impact of external forces on the healthcare industry • Differentiate a hospital-based healthcare organization from an integrated delivery system • Compare the systems used for reimbursement of healthcare services • Assess the role of government in healthcare services • Evaluate the impact of regulatory change on the healthcare delivery system Key Terms Accountable care organization (ACO) Accreditation Acute care Allied health professional Ambulatory care Biotechnology Centers for Medicare and Medicaid Services (CMS) Certification Chief executive officer (CEO) Clinical privileges Continuum of care Deemed status For-profit healthcare organizations Health maintenance organization (HMO) Health reimbursement account (HRA) Health savings account (HSA) Home healthcare Hospice Hospital Hospital outpatient Inpatient Integrated delivery system (IDS) Investor-owned hospital chain Licensure Long-term care Managed care Managed care organization (MCO) Medicaid Medical device Medical staff Medical staff bylaws Medical staff classification Medicare Mission Multihospital system Network Not-for-profit healthcare organizations Organized healthcare delivery Peer review Point of service (POS) plan Post-acute care Preferred provider organization (PPO) Retail clinics Skilled nursing facility (SNF) Surgeon general Value-based purchasing Values Vision Workers’ compensation 3 AB103318_Ch01.indd 3 1/2/2020 6:44:42 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 4 Chapter 1 The US Healthcare Delivery System A broad array of healthcare services are available in the US today, ranging from simple preventive measures, such as vaccinations, to complex lifesaving procedures, such as heart transplants. An individual’s contact with the healthcare delivery system may begin with family planning and prenatal care before he or she is born and often continues through end-of-life planning and, potentially, hospice care. Healthcare services are provided by physicians, nurses, and other clinical providers who work in ambulatory care, acute care, rehabilitative and psychiatric care, and long-term care facilities. Healthcare services also are provided in the homes of hospice and home care patients. Assisted living centers, occupational health clinics, and public health department clinics also provide services to many Americans. While most healthcare is experienced locally and individually, healthcare is the single largest part of the US economy, consuming 17.9 percent of the gross domestic product (GDP) in 2017 (CMS 2019a). It is delivered by an ever-expanding variety of providers from large multi-institutional integrated delivery networks (IDNs) to nurse practitioners within the neighborhood drug store. Healthcare spending in the US grew to $3.5 trillion in 2017 and is expected to grow 0.8 percentage points faster than the GDP over the next ten years (CMS 2019a). In 2019, there were 6,210 registered hospitals in the US (AHA 2019). Over 5,200 of those were community hospitals, which include nonfederal, short-term general hospitals and other specialty hospitals. They also include academic medical centers and teaching hospitals not owned by the federal government. About 25 percent of the community hospitals were for-profit and investorowned, and over 3,000 were part of a system (AHA 2019). Multihospital systems include two or more hospitals owned, leased, sponsored, or contract managed by a central organization. Hospitals can also be part of a network, which comprises hospitals, physicians, and other providers and payers that collaborate to coordinate and deliver services to their community (AHA 2019). In addition to hospital systems and networks, there are other forms of organized healthcare delivery. Organized healthcare delivery can be defined as “that care providers have established relationships and mechanisms for communicating and working to coordinate patient care across health conditions, services, and care settings over time” (Kovner et al. 2011, 206). A multispecialty physician group practice that includes a health insurer is another example of organized care. Recent healthcare reform legislation, economic pressure, and the opportunity to provide better care through coordination and improved access to information continue to move healthcare away from the traditional freestanding solo practice of the past. This chapter discusses the origin and history of the healthcare industry in the US. Included in this history is the impact of external forces that have shaped the healthcare system of today. History of Western Medicine Modern Western medicine can be traced to the ancient Greeks who developed surgical procedures, documented clinical cases, and created medical books. Before modern times, European, African, and Native American cultures all had traditions of folk medicine based on spiritual healing and herbal cures. The first hospitals were created by religious orders in medieval Europe to provide care and respite to religious pilgrims traveling back and forth from the Holy Land. However, it AB103318_Ch01.indd 4 was not until the late 1800s that medicine became a scientific discipline. More progress and change occurred during the 20th century than over the preceding 2,000 years. The past few decades have seen dramatic developments in the way diseases are diagnosed and treated as well as the way healthcare is delivered. The medical knowledge that had been gained by ancient Greek scholars such as Hippocrates was lost during the Middle Ages. The European 1/2/2020 6:44:45 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com History of Western Medicine 5 Renaissance, a historical period beginning in the 14th century, revived interest in the classical arts, literature, and philosophy as well as in the scientific study of nature. This period also was characterized by economic growth and concern for the welfare of workers at all levels of society. With this concept came a growing awareness that a healthy population promoted economic growth. Prior to the 1700s, North America was made up of largely rural communities, and people were born, received treatment for illness, and died at home. As the population of cities grew in the US, as in other parts of the world, almshouses were created to house the sick and the poor. The first hospital in the British colonies of North America was established nearly 150 years after the first colony was established. In Philadelphia, civic leaders recognized the growing population brought with it increased illnesses among the poor and mental illness across all classes. Benjamin Franklin and other colonists persuaded the legislature to develop a hospital for the community “to care for the sick-poor and insane who were wandering the streets of Philadelphia” (Penn Medicine n.d.). The Pennsylvania Hospital was established in Philadelphia in 1752 and served as a model for the organization of hospitals in other communities. The New York Hospital opened in 1771 and started its first register of patients in 1791. Boston’s Massachusetts General Hospital opened in 1821. The proliferation of hospitals was an important part of the growth of Western medicine, as it created a locus for the standardization of medical practice and hospital care as well as the development of allied health professions. Standardization of Medical Practice Medical practice began evolving in ancient civilizations even before the ancient Greeks invented the construct of a medical diagnosis and prognosis and introduced ethics into medicine. In the 12th century, universities in Italy began training doctors. The discovery of germ theory in the 19th century eventually led to more effective treatments for many diseases. However, there was very little standardization in the training or practice of medicine. AB103318_Ch01.indd 5 An individual’s early medical education consisted of serving as an apprentice to an established practitioner. In the late 1700s, educational leaders recognized that medical results varied between practitioners and that increased educational requirements, research, and standardization or regulation could improve overall results (HHS 1976). The first attempts at regulation took the form of licensure. The first licenses to practice medicine were issued in New York in 1760. As the population of the US grew and settlers moved westward, the demand for medical practitioners far exceeded the supply. To staff new hospitals and serve a growing population, many private medical schools appeared almost overnight. However, these schools did not follow an established course of study, and some required that students train for only six months before graduating. The result was an oversupply of poorly trained physicians. The American Medical Association (AMA) was established in 1847 to represent the interests of physicians across the US (AMA n.d.). In 1876, the Association of American Medical Colleges (AAMC) was established (AAMC n.d.). AAMC’s mission was to standardize the curriculum for medical schools in the US and to increase the public’s awareness of the need to license physicians. Early in the 20th century, the need for curriculum reform in medical schools and licensure of physicians was recognized. In 1906, Abraham Flexner initiated a four-year study of medical colleges, visiting every medical college and carefully documenting his observations (Flexner 1910). In 1910, he presented his findings of the poor quality of medical training to the Carnegie Foundation, the AMA, and the AAMC. Based on his report and recommendations by the AMA’s Committee on Medical Education, several reforms were adopted. These reforms included that medical school applicants hold a college degree, that medical training be founded on science, and that medical students receive practical hospital-based training. These ­reforms had two consequences across the following decade; about half of the medical schools closed while the others adopted the change so that by 1920, most of the medical colleges in the US met the standards of the AAMC (Cooke et al. 2006). 1/2/2020 6:44:45 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 6 Chapter 1 The US Healthcare Delivery System Today, medical school graduates must pass a test administered by state medical boards before they can obtain a license to practice medicine. Many states now use a standardized licensure test developed in 1968 by the Federation of State Medical Boards of the United States. However, passing scores for the test vary by state. Most physicians also complete several years of residency training in addition to medical school. Specialty physicians also complete extensive postgraduate medical education. Board certification for the various specialties requires the completion of postgraduate training as well as a passing score on a standardized examination. Common medical specialties include the following: • Internal medicine • Pediatrics • Family practice • Cardiology • Psychiatry • Neurology • Oncology • Radiology Common surgical specialties include the following: • Anesthesiology • Cardiovascular surgery • Obstetrics and gynecology • Orthopedics • Urology • Ophthalmology • Otorhinolaryngology • Plastic and reconstructive surgery • Neurosurgery Some medical and surgical specialists undergo further graduate training to qualify to practice subspecialties. For example, the subspecialties of i­nternal medicine include endocrinology, pulmonary medicine, rheumatology, geriatrics, and hematology. Physicians also may limit their practices to the treatment of specific illnesses, such as an endocrinologist limiting his or her practice to the treatment of diabetes. Surgeons can work as general surgeons AB103318_Ch01.indd 6 or as specialists or subspecialists. For example, an ­orthopedic surgeon may limit his practice to surgery of the hand, knee, ankle, or spine. Some physicians and healthcare organizations employ physician assistants (PAs) and surgeon assistants (SAs) to help them carry out their clinical responsibilities. Such assistants may perform routine clinical assessments, provide patient education and counseling, and perform simple therapeutic procedures. Most PAs work in primary care settings, and most SAs work in hospitals and ambulatory surgery clinics. PAs and SAs always work under the supervision of licensed physicians and surgeons. Standardization of Hospital Care In 1910, Dr. Franklin H. Martin, who became the first editor of the Journal of the American College of Surgeons, suggested surgical care needed to pay better attention to patient outcomes (ACS n.d.). Martin learned these concepts from Dr. Ernest Codman, a British physician who thought that patient outcomes should be tracked over time to determine what treatment delivered the best results (Hazelwood et al. 2005). At that time, Martin and other American physicians were concerned about the conditions in US hospitals. It was thought that the lack of an organized medical staff and lax professional standards contributed to the problems. In the early 20th century, hospitals were used mainly for performing surgery. Most nonsurgical medical care was still provided in the home. It was natural, then, for the force behind improved hospital care to come from surgeons. The push for hospital reforms eventually led to the formation of the American College of Surgeons in 1913. In 1917, the leaders of the college asked the Carnegie Foundation for funding to plan and develop a hospital standardization program. The college then formed a committee to develop a set of minimum standards for hospital care and published the formal standards under the title of the Minimum Standards. Adoption of the Minimum Standards was the basis of the Hospital Standardization Program and marked the beginning of the modern accreditation 1/2/2020 6:44:45 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com History of Western Medicine 7 process for healthcare organizations. To this day, accreditation standards are developed to reflect reasonable quality standards, and the performance of each participating organization is evaluated annually against the standards. The accreditation process is voluntary. Healthcare organizations choose to participate in order to improve the care they provide to their patients. The American College of Surgeons continued to sponsor the hospital accreditation program until the early 1950s. In 1952 a new organization called the Joint Commission on Accreditation of Hospitals was formed by the American College of Physicians, the AMA, the American Hospital Association (AHA), and the Canadian Medical Association. The Joint Commission began performing accreditation surveys in 1953 (Joint Commission 2018a). The Joint Commission continues to survey several types of healthcare organizations today, including the following: • Acute-care hospitals • Long-term care facilities • Ambulatory care facilities • Psychiatric facilities • Home health agencies Several other organizations also perform accreditation of healthcare organizations. These include the American Osteopathic Association (AOA), the Commission on Accreditation of Rehabilitation Facilities (CARF), and the Accreditation Association for Ambulatory Health Care (AAAHC). Growth of the Allied Health Professions After World War I, many of the roles previously played by nurses and nonclinical personnel began to change. With the advent of modern diagnostic and therapeutic technology in the middle of the 20th century, the complex skills needed by ancillary medical personnel fostered the growth of specialized training programs and professional accreditation and licensure. Allied health professionals work with physicians, nurses, and pharmacists to make the healthcare system function. “Allied health professionals are involved with the delivery of health or related services pertaining to the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; rehabilitation and health systems management, among others” (ASAHP 2019). Allied health professionals comprise nearly 60 percent of the healthcare workforce and include careers such as dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, radiographers, and speech language therapists (ASAHP 2019). All 50 states require licensure for some allied health professions (physical therapy, for example). Practitioners in other allied health professions (occupational therapy, for example) may be licensed in some states, but not in others. Check Your Understanding 1.1 Instructions: Answer the following questions in a separate document. 1. Construct the timeline from the development of the first hospital in the late 1700s to initial hospital reform efforts in 1910 to accreditation of healthcare organizations as it exists today by noting key milestones. Evaluate how these milestones have impacted current Western medicine. 2. Review the findings and recommendations of the Flexner Report. What issues in the early practice of medicine did this report address and what actions resulted from it? 3. If you want to be a pediatrician, what educational path and examinations would be required? 4. Determine one reason why someone may choose a career in one of the allied health professions rather than a career as a physician. 5. Determine why the push for hospital reform came from surgeons. AB103318_Ch01.indd 7 1/2/2020 6:44:45 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 8 Chapter 1 The US Healthcare Delivery System Modern Healthcare Delivery in the US The 20th century was a period of tremendous change in American society. Advances in medical science promised better outcomes and increased the demand for healthcare services. But medical care has never been free. Even in the best economic times, many Americans have been unable to take full advantage of what medicine has to offer because they cannot afford it. Concern over access to healthcare was especially evident during the Great Depression of the 1930s. During the Depression, the US’s leaders were forced to consider how the poor and disadvantaged could receive the care they needed. Before the Depression, medical care for the poor and elderly had been handled as a function of social welfare agencies. During the 1930s, however, few people were able to pay for medical care. The problem of how to pay for the healthcare needs of millions of Americans became a public and governmental concern. Working Americans turned to prepaid health plans to help them pay for healthcare, but the unemployed and the unemployable needed help from a different source. Effects of the Great Depression The concept of prepaid healthcare, or health ­insurance, began with the financial problems of one hospital—Baylor University Hospital in Dallas, Texas (Thomasson 2003). In 1929, the ­administrator of the hospital arranged to provide 21 days of hospital services to Dallas’s schoolteachers for a fixed six-dollar payment. Before that time, a few large employers had set up company clinics and hired company physicians to care for their workers, but the idea of a prepaid health plan that could be purchased by individuals had never been tried before. The idea of public funding for healthcare services also dates back to the Great Depression. The decline in family income during the 1930s curtailed the use of medical services by the poor. In 10 working-class communities studied between 1929 and 1933, the proportion of families with incomes under $150 per capita had increased from 10 to 43 AB103318_Ch01.indd 8 percent. A 1938 Gallup poll asked people whether they had put off seeing a physician because of the cost, and the results showed that 68 percent of lower-income respondents had put off medical care, compared with 24 percent of respondents in upper-income brackets (Starr 1982, 271). The decreased use of medical services and the inability of many patients to pay meant lower ­incomes for physicians. Hospitals were in similar trouble. Beds were empty, bills went unpaid, and contributions to hospital fundraising efforts tumbled. As a result, private physicians and charities could no longer meet the demand for free services. For the first time, physicians and hospitals asked state welfare departments to pay for the treatment of people on relief. The push for government-sponsored health insurance continued in the late 1930s during the administration of President Franklin D. Roosevelt. However, compulsory health insurance (required by law) stood on the margins of national politics. It was not made part of the new Social Security program, and it was never fully supported by President Roosevelt. Postwar Efforts Toward Improving Healthcare Access After World War II, the issue of healthcare access finally moved to the center of national politics. In the late 1940s, President Harry Truman expressed unreserved support for a national health insurance program. However, the issue of compulsory health insurance became entangled with America’s fear of communism. Opponents of Truman’s healthcare program labeled it “socialized medicine,” and the program failed to win legislative support. The idea of national health insurance did not resurface until the administration of Lyndon Johnson and the Great Society legislation of the 1960s. The Medicare and Medicaid programs were legislated in 1965. Medicare is a federally funded program that helps pay the cost of providing healthcare services to those 65 years of age and older as well as eligible individuals with disabilities. Medicaid is 1/2/2020 6:44:47 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Modern Healthcare Delivery in the US 9 a joint federal and state program that assists with medical costs for those with low income. The issues of healthcare reform and national health insurance were again given priority during the first four years of President Bill Clinton’s administration in the 1990s. However, the complexity of American healthcare issues at the end of the 20th century doomed reform efforts. Significant healthcare reform legislation was proposed by President Barack Obama and passed in 2010. The Patient Protection and Affordable Care Act (ACA) addresses healthcare costs, coverage, and quality. Effective in 2019, Congress repealed the ACA provision ­requiring Americans to have healthcare coverage by passing the Tax Cuts and Jobs Act in 2017. Influence of Federal Legislation During the 20th century, Congress passed many pieces of legislation that had a significant impact on the delivery of healthcare services in the US. Many of these legislative efforts are described in table 1.1. Table 1.1. Federal healthcare legislation T Title Date of enactment Biologics Control Act Key provisions Impact 1902 Regulated the vaccines and serums sold via interstate commerce Launched the research laboratories that later became the National Institutes of Health (NIH) Social Security Act 1935 Provided states matching funds for maternal and infant care, rehabilitation of crippled children, general public health work, and aid for dependent children Extended the federal government’s role in public health. Hospital Survey and Construction Act (also known as the Hill-Burton Act) 1946 Authorized grants for states to construct new hospitals Created a boom in hospital construction; hospitals grew from 6,000 in 1946 to a high of 7,200 Public Law 89-97 1965 Amendments to Social Security that created Medicare and Medicaid Medicare provides healthcare benefits to citizens over the age of 65 Medicaid supports medical and hospital care for the medically indigent Public Law 92-603 1972 Expanded initial Medicare and Medicaid requirements for utilization review to include concurrent review; established the professional standards review organization (PSRO) program Efforts to curtail the rising costs of the Medicare and Medicaid programs by evaluating patient care services for necessity, quality, and cost-effectiveness Health Planning and Resources Development Act 1974 Created a system of local organizations called health systems agencies to make service and technology decisions Along with other legislation of this type, it was unsuccessful in slowing cost increases and was repealed in 1986 Utilization Review Act 1977 Required hospitals to conduct continued stay reviews to determine medical necessity of hospitalization for Medicare and Medicaid cases, also included fraud and abuse regulations An additional effort to control growing healthcare costs Peer Review Improvement Act 1982 Redesigned the PSRO program Hospitals began to review medical necessity and appropriateness of hospitalizations prior to admission; in 2002, they were given a new name of Quality Improvement Organizations (QIOs) Tax Equity and Fiscal Responsibility Act (TEFRA) 1982 Introduced the prospective payment system for Medicare reimbursement to control the rising cost of providing healthcare services to Medicare beneficiaries Changed Medicare reimbursement from a fee-for-service model to a predetermined level of reimbursement Continued AB103318_Ch01.indd 9 1/2/2020 6:44:47 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 10 Chapter 1 The US Healthcare Delivery System Table 1.1. Federal healthcare legislation (continued) Title Date of enactment Key provisions Impact Prospective Payment Act/Public Law 98-21 1982/1983 Defined the prospective payment system and Prospective payment was successful at slowing the rate of growth of healthcare the use of diagnosis-related groups (DRGs) spending so it was expanded to other as the methodology for inpatient care service modalities like outpatient services in 2000 Consolidated Omnibus Budget Reconciliation Act (COBRA) 1985 Allowed the federal government to deny reimbursement for substandard services provided to Medicare and Medicaid beneficiaries Began establishing a link between quality and reimbursement for services in the Medicare and Medicaid programs Healthcare Quality Improvement Act 1986 Established the National Practitioner Data Bank (NPDB) Provides a clearinghouse for medical practitioners who have a history of malpractice suits and other quality problems Omnibus Budget Reconciliation Act 1989 Instituted the Agency for Health Care Policy and Research now known as the Agency for Healthcare Research and Quality (AHRQ) The mission of AHRQ is to develop outcome measures to evaluate the quality of healthcare services Health Insurance Portability and Accountability Act (HIPAA) 1996 Addressed issues related to the portability of health insurance after leaving employment and administrative simplification of healthcare Reduced the barriers to changing employers due to existing health conditions and created a federal floor for healthcare privacy Mental Health Parity Act 1996 If mental health benefits are provided by an employer, it sets the annual and lifetime benefits equal to those for medical and surgical benefits provided Began the discussion of equating mental health benefits with other health benefits; provided increased coverage for those with severe, disabling brain disorders American Recovery and Reinvestment Act and the Health Information Technology for Economic and Clinical Health (HITECH) 2009 Accelerated the adoption of and use of information technology in healthcare through economic incentives and planned future financial penalties Expanded HIPAA privacy protections and established regional extension centers In 2009, 12% of hospitals and 22% of physicians had electronic health record systems (EHRs). By 2017, that number had grown to 96% and 82% respectively (ONC 2019). Patient Protection and Affordable Care Act (ACA) 2010 Enacted to provide insurance coverage to more Americans by helping small businesses afford insurance for their employees and extending the age limit for children to be covered by their parents’ insurance. It also extended coverage for pre-existing conditions. Mandatory coverage was repealed by the Tax Cuts and Jobs Act of 2018 (Galan 2018). In 2019, 8.4 million people were signed up for the Federal Health Insurance Exchange for Affordable Care Act coverage despite a change in the regulation no longer mandating individual coverage and a strong economy (Morse 2019). As the largest payer of healthcare services, the US government has a dual role of protecting the health of the population and ensuring that federal money is well spent. Beyond the legislative activities outlined previously, the Department of Health and Human Services (HHS) is responsible for just over one-quarter of all federal spending, and its mission is to “enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, AB103318_Ch01.indd 10 public health, and social services” (HHS 2018). Updated every four years, HHS’s strategic plan for the years from 2018 to 2022 contains five strategic goals: • Reform, strengthen, and modernize the Nation’s healthcare system. • Protect the health of Americans where they live, learn, work, and play. • Strengthen the economic and social wellbeing of Americans across the lifespan. 1/2/2020 6:44:47 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Modern Healthcare Delivery in the US 11 • Foster sound, sustained advances in the sciences. • Promote effective and efficient management and stewardship. (HHS 2019a) In setting these goals, HHS advances their mission and establishes strategic direction for programs over the time period. These priorities are demonstrated in research and policy initiatives. Biomedical and Technological Advances in Medicine Rapid progress in medical science and technology during the late 19th and 20th centuries revolutionized the way healthcare was provided. One of the most important scientific advancements was the discovery of bacteria as the cause of infectious disease. An important technological development was the use of anesthesia for surgical procedures. These 19th-century advances formed the basis for the development of antibiotics and other pharmaceuticals and the application of sophisticated surgical procedures in the 20th century. Table 1.2 offers a timeline of key biological and technological advances at a glance. These scientific advances continue today through research and development in the diverse discipline of biotechnology. Biotechnology is “the manipulation (as through genetic engineering) of living organisms or their components to produce useful usually commercial products (such as pest resistant crops, new bacterial strains, or novel pharmaceuticals)” (Merriam-Webster n.d.). Two examples of the types of companies in the field of biotechnology are pharma (a pharmaceutical or drug company) and medical device companies. These companies conduct research on, develop, market, and distribute drugs for the healthcare industry. A medical device is an instrument, a machine, or an implement or apparatus intended for use in the diagnosis of disease or for monitoring or treatment of a condition. A medical device is used by a physician for a patient who has a condition whereby a body part does not achieve any of its primary intended purposes, such as a heart valve. Medical devices can be used for life support, such as anesthesia ventilators; as well as for monitoring of patients, such as fetal monitors; and other uses, such as incubators (WHO n.d.). Table 1.2. Key biological and technological advances in medicine Time Event 1842 First recorded use of ether as an anesthetic 1860s Louis Pasteur laid the foundation for modern bacteriology 1865 Joseph Lister was the first to apply Pasteur’s research to the treatment of infected wounds 1880s–1890s Steam first used in physical sterilization 1895 Wilhelm Roentgen made observations that led to the development of x-ray technology 1898 Introduction of rubber surgical gloves, sterilization, and antisepsis 1940 Studies of prothrombin time first made available 1941–1946 Studies of electrolytes; development of major pharmaceuticals 1957 Studies of blood gas 1961 Studies of creatine phosphokinase 1970s Surgical advances in cardiac bypass surgery, surgery for joint replacements, and organ transplantation 1971 Computed tomography first used in England 1974 Introduction of whole-body scanners 1980s Introduction of magnetic resonance imaging 1990s Further technological advances in pharmaceuticals and genetics; Human Genome Project 2000s NIH creates roadmap to accelerate biomedical advances, creates effective prevention strategies and new treatments, and bridges knowledge gaps in the 21st century AB103318_Ch01.indd 11 1/2/2020 6:44:47 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 12 Chapter 1 The US Healthcare Delivery System Check Your Understanding 1.2 Instructions: In a separate document, match the descriptions with the appropriate legislation and respond to the listed questions. 1. _____ Hospital Survey and Construction (Hill-Burton) Act 2. _____ Tax Equity and Fiscal Responsibility Act 3. _____ Public Law 89-97 of 1965 4. _____ Utilization Review Act 5. _____ Omnibus Budget Reconciliation Act of 1989 6. _____ Public Law 92-603 of 1972 7. _____ Healthcare Quality Improvement Act of 1986 8. _____ Biologics Control Act 9. _____ Patient Protection and Affordable Care Act of 2010 a. b. c. d. e. f. g. Created the Medicare and Medicaid programs to pay the cost of healthcare for the elderly and the poor Authorized grants for states to construct new hospitals Required concurrent review for Medicare and Medicaid patients Launched laboratories that became the NIH Required hospitals to conduct continued-stay reviews for Medicare and Medicaid patients Established the National Practitioner Data Bank Expanded Medicaid to all non-Medicare eligible people under age 65 with incomes up to 133 percent of the federal poverty level h. Changed Medicare reimbursement from a fee-for-service basis to a predetermined level of reimbursement to ­control the rising cost of providing healthcare services to Medicare beneficiaries i. Instituted the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) to develop patient outcome measures. 10. Analyze the impact of federal legislation on healthcare over time. Determine at least one trend and discuss whether it is positive or negative. 11. Assess the role that legislation and federal policy have in US healthcare. Do you agree that this role is appropriate for the well-being of US citizens? Why or why not? Healthcare Providers and Settings According to the US Department of Labor, a healthcare provider or health professional is an organization or a person who delivers proper healthcare in a systematic way professionally to any individual in need of healthcare services (29 CFR 825.118). Healthcare delivery AB103318_Ch01.indd 12 can be viewed as a continuum of services that cuts across services delivered in ambulatory, acute, sub-acute, long-term, residential, and other care environments. There are several alternatives for healthcare delivery along this continuum. 1/2/2020 6:44:48 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Organization and Operation of Modern Hospitals 13 Organization and Operation of Modern Hospitals The term hospital can be applied to any healthcare facility that has the following four characteristics: • An organized medical staff • Permanent inpatient beds • Around-the-clock nursing services • Diagnostic and therapeutic services Most hospitals provide acute-care services to inpatients. Acute care is the short-term care provided to diagnose and treat an illness or injury. The ­individuals who receive acute-care services in hospitals are considered inpatients. An inpatient is a person who is provided with room, board, and continuous general nursing services in an area of an acute-care facility where patients generally stay at least overnight (AHIMA 2014). The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. The decision to admit a patient is a complex medical judgment that can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s bylaws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to be considered when making the decision to admit include such things as: • The severity of the signs and symptoms exhibited by the patient; • The medical predictability of something adverse happening to the patient; • The need for diagnostic studies that appropriately are outpatient services (that is, their performance does not ordinarily AB103318_Ch01.indd 13 require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and • The availability of diagnostic procedures at the time when and at the location where the patient presents. (CMS 2017a) The average length of stay (ALOS) in an acutecare hospital is 30 days or less. Hospitals that have ALOSs longer than 30 days are considered longterm care facilities. (Long-term care is discussed in detail later in this chapter.) With ongoing advances in surgical technology, anesthesia, and pharmacology, the ALOS in an acute-care hospital was 4.6 days in 2016 (Freeman et al. 2018). In addition, many diagnostic and therapeutic procedures that once required inpatient care can now be performed on an outpatient basis. For example, before the development of laparoscopic surgical techniques, a patient might be hospitalized for 10 days after a routine appendectomy (surgical removal of the appendix). Today, a patient undergoing a laparoscopic appendectomy might spend only a few hours in the hospital’s outpatient surgery department and go home the same day. The influence of managed care and the emphasis on cost control in the Medicare and Medicaid programs also have resulted in shorter hospital stays. In large acute-care hospitals, hundreds of clinicians, administrators, managers, and support staff must work closely together to provide effective and efficient diagnostic and therapeutic services. Most hospitals provide services to both inpatients and outpatients. A hospital outpatient is a patient who receives hospital services without being admitted for inpatient (overnight) clinical care. Outpatient care is considered a kind of ambulatory care. (Ambulatory care is discussed later in this chapter.) 1/2/2020 6:44:50 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 14 Chapter 1 The US Healthcare Delivery System Types of Hospitals Modern hospitals are complex organizations. Much of the clinical training for physicians, nurses, and allied health professionals is conducted in hospitals. Medical research is another activity carried out in hospitals. Hospitals can be classified in many different ways according to the following items: • Number of beds • Type of services provided • Type of patients served • For-profit or not-for-profit status • Type of ownership The following sections describe each of these criteria in detail. Number of Beds A hospital’s number of beds is based on the number of beds that it has equipped and staffed for patient care. The term bed capacity is sometimes used to reflect the maximum number of inpatients the hospital can treat. Hospitals with fewer than 100 beds are usually considered small. Most of the hospitals in the US fall into this category, but some large, urban hospitals have more than 500 beds. The number of beds is usually broken down by adult beds and pediatric beds; the number of maternity beds and other special categories may be listed separately. Hospitals also can be categorized on the basis of the number of outpatient visits per year. The number of hospital beds declined dramatically in the late 1900s with shorter lengths of stay and more procedures being done on an outpatient basis. Type of Services Provided Some hospitals specialize in certain types of services and treat specific illnesses: • Rehabilitation hospitals provide long-term care services to patients recuperating from debilitating or chronic illnesses and injuries such as strokes, head and spine injuries, and gunshot wounds. Patients often stay in rehabilitation hospitals for several months. AB103318_Ch01.indd 14 • Psychiatric hospitals provide inpatient care for patients with mental and developmental ­disorders. In the past, the ALOS for psychiatric inpatients was longer than it is today. Rather than months or years, most patients now spend only a few days or weeks per stay. However, many patients require repeated hospitalization for chronic psychiatric illnesses. (Behavioral healthcare is discussed in detail later in this chapter.) • General acute-care hospitals provide a wide range of medical and surgical services to diagnose and treat most illnesses and injuries. • Specialty hospitals provide diagnostic and therapeutic services for a limited range of conditions (for example, burns, cancer, tuberculosis, and obstetrics and gynecology). Type of Patients Served Some hospitals specialize in serving specific types of patients. For example, children’s hospitals provide specialized pediatric services in a number of medical specialties. Cancer centers offer integrated treatment regimens for cancer diagnosis and therapies. There are also hospitals that specialize in surgical cases and even further specialization for cardiac or orthopedic surgeries. For-Profit or Not-for-Profit Status Hospitals also can be classified on the basis of their ownership and profitability status. Notfor-profit healthcare organizations use excess funds to improve their services and to finance educational programs and community services. For-profit healthcare organizations are privately owned. Excess funds are paid back to the managers, owners, and investors in the form of bonuses and dividends. Type of Ownership The most common ownership types for hospitals and other kinds of healthcare organizations in the US include the following: • Government-owned hospitals are operated by a specific branch of federal, state, or local 1/2/2020 6:44:50 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Organization and Operation of Modern Hospitals 15 government as not-for-profit organizations. Government-owned hospitals are sometimes called public hospitals. They are supported, at least in part, by tax dollars. Examples of federally owned and operated hospitals include those operated by the Department of Veterans Affairs to serve retired military personnel. The Department of Defense operates facilities for active military personnel and their dependents. Many states own and operate psychiatric hospitals. County and city governments often operate public hospitals to serve the healthcare needs of their communities, especially those residents who are unable to pay for their care. • Proprietary hospitals may be owned by private foundations, partnerships, or investorowned corporations. Large corporations may own a number of for-profit hospitals, and the stock of several large US hospital chains is publicly traded. • Voluntary hospitals are not-for-profit hospitals owned by universities, churches, charities, religious orders, unions, and other not-forprofit entities. They often provide free care to patients who otherwise would not have access to healthcare services. Organization of Hospital Services The organizational structure of every hospital is designed to meet its specific needs. For example, most acute-care hospitals are made up of a board of directors, a professional medical staff, an ­executive administrative staff, medical and surgical services, patient care (nursing) services, diagnostic and laboratory services, and support services (for example, nutritional services, environmental safety, and health information management [HIM] services). Board of Directors The board of directors has primary responsibility for setting the overall direction of the hospital. In some hospitals, the board of directors is called the governing board or board of trustees. The board works with the chief executive officer (CEO) and AB103318_Ch01.indd 15 the leaders of the organization’s medical staff to develop the hospital’s strategic direction as well as its mission, vision, and values: • Mission: A statement of the organization’s core purpose and philosophies • Vision: A description of the organization’s desired future that sets direction and rationale for change • Values: A descriptive list of the organization’s fundamental principles or beliefs Other specific responsibilities of the board of directors include the following: • Establishing bylaws in accordance with the organization’s legal and licensing requirements • Selecting qualified administrators • Approving the organization and makeup of the clinical staff • Monitoring the quality of care The board’s members are elected for specific terms of service (for example, five years). Most boards also elect officers, commonly a chair, vice chair, president, secretary, and treasurer. The size of governing boards varies considerably. Individual board members are called directors, board members, or trustees. Individuals serve on one or more standing committees such as the executive committee, joint conference committee, finance committee, strategic planning committee, and building committee. The makeup of the board depends on the type of hospital and the form of ownership. For example, the board of a community hospital is likely to include local business leaders, representatives of community organizations, and other people interested in the welfare of the community. The board of a teaching hospital, on the other hand, is likely to include medical school alumni and university administrators, among others. Boards of directors face strict accountability in terms of cost containment, performance management, and integration of services to maintain fiscal stability and to ensure the delivery of high-quality patient care. 1/2/2020 6:44:50 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 16 Chapter 1 The US Healthcare Delivery System Medical Staff The medical staff consists of physicians who have received extensive training in various medical disciplines (for example, internal medicine, pediatrics, cardiology, obstetrics and gynecology, orthopedics, and surgery). The medical staff’s primary objective is to provide high-quality care to the patients who come to the hospital. The physicians on the hospital’s medical staff diagnose illnesses and develop patient-centered treatment regimens. Moreover, physicians on the medical staff may serve on the hospital’s governing board, where they provide critical insight relevant to strategic and operational planning and policy making. The medical staff is the aggregate of physicians and other approved practitioners who have been granted permission to provide clinical services in the hospital. This permission is called clinical privileges. An individual physician’s privileges are limited to a specific scope of practice. For ­example, an internal medicine physician would be permitted to diagnose and treat a patient with pneumonia but not to perform a surgical procedure. Most members of the medical staff are not employees of the hospital. However, there are exceptions as many hospitals employ radiologists, anesthesiologists, and hospitalists. Additionally, hospitals may contract with companies that provide physicians for specific services like emergency department physicians or radiologists. Medical staff classification refers to the organization of physicians according to clinical assignment. Typical medical staff classifications include active, provisional, honorary, consulting, courtesy, and medical resident assignments. Depending on the size of the hospital and on the credentials and clinical privileges of its physicians, the medical staff may be separated into departments such as medicine, surgery, obstetrics, pediatrics, and other specialty services. Officers of the medical staff usually include a president or chief of staff, a vice president or chief of staff elect, and a secretary. These offices are authorized by a vote of the entire active medical staff. The president presides at all regular meetings of the medical staff and is an ex officio member of all medical staff committees. The secretary ensures AB103318_Ch01.indd 16 that accurate and complete minutes of medical staff meetings are maintained and that correspondence is handled appropriately. The medical staff operates according to a predetermined set of policies. These policies are called the medical staff bylaws. The bylaws spell out the specific qualifications that physicians must demonstrate before they can practice medicine in the hospital. The bylaws are considered legally binding. Any changes to the bylaws must be approved by a vote of the medical staff and the hospital’s governing body. Administrative Staff The leader of the administrative staff is the CEO. The CEO is responsible for implementing the policies and strategic direction set by the hospital’s board of directors. He or she also is responsible for building an effective executive management team and coordinating the hospital’s services. Today’s healthcare organizations commonly designate a chief financial officer (CFO), a chief operating officer (COO), and a chief information officer (CIO) as members of the executive management team. The executive management team is responsible for managing the hospital’s finances and ensuring that the hospital complies with the federal, state, and local regulations, standards, and laws that govern the delivery of healthcare services. Depending on the size of the hospital, the CEO’s staff may include healthcare administrators with job titles such as vice president, associate administrator, department director or manager, or administrative assistant. Department-level administrators manage and coordinate the activities of the highly specialized and multidisciplinary units that perform clinical, administrative, and support services in the hospital. Healthcare administrators may hold advanced degrees in healthcare administration, nursing, public health, or business management. A growing number of hospitals are hiring physician executives to lead their executive management teams. Many healthcare administrators are ­fellows of the American College of Healthcare Executives. 1/2/2020 6:44:50 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Organization and Operation of Modern Hospitals 17 Patient Care Services Most of the direct patient care delivered in hospitals is provided by professional nurses. Modern nursing requires a diverse skill set, advanced clinical competencies, and postgraduate education. In almost every hospital, patient care services constitute the largest clinical department in terms of staffing, budget, specialized services offered, and clinical expertise required. Nurses are responsible for providing continuous, around-the-clock treatment and support for hospital inpatients. The quantity and quality of nursing care available to patients are influenced by a number of factors, including the nursing staff’s educational preparation and specialization, experience, and skill level. The level of patient care staffing is also a critical component of quality. Traditionally, physicians alone determined the type of treatment each patient received. However, today’s nurses are playing a wider role in treatment planning and case management. They identify timely and effective interventions in response to a wide range of problems related to the patients’ treatment, comfort, and safety. Their responsibilities include performing patient assessments, creating care plans, evaluating the appropriateness of treatment, and evaluating the effectiveness of care. At the same time that they provide technical care, effective nursing professionals also offer personal caring that recognizes the patients’ concerns and the emotional needs of patients and their families. Diagnostic and Therapeutic Services The services provided to patients in hospitals go beyond the clinical services provided directly by the medical and nursing staff. Many diagnostic and therapeutic services involve the work of allied health professionals. Allied health professionals receive specialized education and training, and their qualifications are registered or certified by a number of specialty organizations. Diagnostic and therapeutic services are critical to the success of every patient care delivery system. Diagnostic services include clinical laboratory, radiology, and nuclear medicine. Therapeutic services include radiation therapy, occupational therapy, and physical therapy. AB103318_Ch01.indd 17 Clinical Laboratory Services The clinical laboratory is divided into two sections: anatomic pathology and clinical pathology. Anatomic pathology deals with human tissues and provides surgical pathology, autopsy, and cytology services. Clinical pathology deals mainly with the analysis of body fluids, principally blood, but also urine, gastric contents, and cerebrospinal fluid. Physicians who specialize in performing and interpreting the results of pathology tests are called pathologists. Laboratory technicians are allied health professionals trained to operate laboratory equipment and perform laboratory tests under the supervision of a pathologist. Radiology Radiology involves the use of radioactive isotopes, fluoroscopic and radiographic equipment, and CT and MRI equipment to diagnose disease. Physicians who specialize in radiology are called radiologists. They are experts in the medical use of radiant energy, radioactive isotopes, radium, cesium, and cobalt as well as x-rays and radioactive materials. They also are experts in interpreting x-ray, MRI, and CT diagnostic images. Radiology technicians are allied health professionals trained to operate radiological equipment and perform radiological tests under the supervision of a radiologist. Nuclear Medicine and Radiation Therapy Radiologists also may specialize in nuclear medicine and radiation therapy. Nuclear medicine involves the use of ionizing radiation and small amounts of short-lived radioactive tracers to treat disease, specifically neoplastic disease (that is, nonmalignant tumors and malignant cancers). Because of the mathematics and physics of tracer methodology, nuclear medicine is widely applied in clinical medicine. However, most authorities agree that medical science has only scratched the surface in terms of nuclear medicine’s potential capabilities. Radiation therapy uses high-energy x-rays, ­cobalt, electrons, and other sources of radiation to treat human disease. In current practice, radiation therapy is used alone or in combination with surgery or chemotherapy (drugs) to treat many types of cancer. In addition to external beam therapy, 1/2/2020 6:44:50 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 18 Chapter 1 The US Healthcare Delivery System radioactive implants and therapy performed with heat (hyperthermia) are available. Occupational Therapy Occupational therapy is the medically directed use of work and play activities to improve patients’ independent functioning, enhance their development, and prevent or decrease their level of disability. The individuals who perform occupational therapy are credentialed allied health professionals called occupational therapists. They work under the direction of physicians. Occupational therapy is made available in acute-care hospitals, clinics, and rehabilitation centers. Providing occupational therapy services begins with an evaluation of the patient and the selection of therapeutic goals. Occupational therapy activities may involve the adaptation of tasks or the environment to achieve maximum independence and to enhance the patient’s quality of life. An occupational therapist may treat decreased functionality related to developmental deficits, birth defects, learning disabilities, traumatic injuries, burns, neurological conditions, orthopedic conditions, mental deficiencies, and psychiatric disorders. Within the healthcare system, occupational therapy plays various roles. These roles include promoting health, preventing disability, developing or restoring functional capacity, guiding adaptation within physical and mental param­ eters, and teaching creative problem solving to ­increase independent function. Physical Therapy and Rehabilitation Physical therapy and rehabilitation services have expanded into many medical specialties—especially in neurology, neurosurgery, orthopedics, geriatrics, rheumatology, internal medicine, cardiovascular medicine, cardiopulmonary medicine, psychiatry, sports medicine, burn and wound care, and chronic pain management. It also plays a role in community health education. Credentialed allied health professionals administer physical therapy under the direction of physicians. Medical rehabilitation services involve the entire healthcare team: physicians, nurses, social workers, occupational therapists, physical therapists, AB103318_Ch01.indd 18 and other healthcare personnel. The objective is to either eliminate the patients’ disability or alleviate it as fully as possible. Physical therapy can be used to improve the cognitive, social, and physical abilities of patients impaired by chronic disease or injury. The primary purpose of physical therapy in rehabilitation is to promote optimal health and function by applying scientific principles. Treatment modalities include therapeutic exercise, therapeutic massage, biofeedback, and applications of heat, low-energy lasers, cold, water, electricity, and ultrasound. Respiratory Therapy Respiratory therapy involves the treatment of patients who have acute or chronic lung disorders. Respiratory therapists work under the direction of qualified physicians and surgeons. The therapists provide such services as emergency care for stroke, heart failure, and shock patients. They also treat patients with chronic respiratory diseases such as emphysema and asthma. Respiratory treatments include the administration of oxygen and inhalants such as bronchodilators. Respiratory therapists set up and monitor ventilator equipment and provide physiotherapy to improve breathing. Ancillary Support Services The ancillary units of the hospital provide vital clinical and administrative support services to patients, medical staff, visitors, and employees. Clinical Support Services The clinical support units provide the following services: • Pharmaceutical services • Food and nutrition services • HIM (health record) services • Social work and social services • Patient advocacy services • Environmental (housekeeping) services • Purchasing, central supply, and materials management services • Engineering and plant operations 1/2/2020 6:44:50 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Organization and Operation of Modern Hospitals 19 HIM services are managed by credentialed HIM professionals—RHIAs and RHITs. The pharmacy is staffed by registered pharmacists and pharmacy technologists. Food and nutrition services are managed by registered dietitians (RDs), who develop general menus, special-diet menus, and nutritional plans for individual patients. Social work services are provided by licensed social workers and licensed clinical social workers. Patient advocacy services may be provided by several types of healthcare professionals; most commonly, registered nurses and licensed social workers. istrative support services to operate effectively. Administrative support services provide business management and clerical services in several key areas, including the following: • Admissions and central registration • Claims and billing (business office) • Accounting • Information services • Human resources • Public relations • Fund development • Marketing Administrative Support Services In addition to clinical support services, hospitals need admin- Check Your Understanding 1.3 Instructions: In a separate document, write the best terms or phrases to complete the following sentences. 1. A 35-year-old patient was diagnosed with meningitis and received antibiotics each day during her three days in the hospital. This type of short-term care is considered _____. a. Outpatient care b. Ambulatory care c. Acute care d. Long-term care 2. The hospital provided shareholders with dividends from the profits of the previous fiscal year. This hospital is _____. a. b. c. d. For-profit Not-for-profit Privately owned Research-based 3. The Veterans Affairs hospital is considered a _____ hospital. a. b. c. d. Government-owned Voluntary State-owned Proprietary 4. The hospital’s CEO is retiring at the end of the year. Selecting a new qualified CEO is the responsibility of _____. a. b. c. d. The board of directors Hospital administration The medical staff The nursing staff 5. A patient suffered the loss of her index finger due to frostbite. As part of her course of treatment, the patient receives _____, where she practices tying her shoes and writing with a pencil. a. Physical therapy b. Occupational therapy c. Social services d. Nursing AB103318_Ch01.indd 19 1/2/2020 6:44:50 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 6. A stroke patient must regain strength and coordination in the affected side in order to walk again. They are seen by a _____. a. Nurse b. Health information manager c. Physician d. Physical therapist 7. The hospital was recently cited during a Joint Commission survey for not having a comprehensive strategic plan. The _____ is responsible for taking action to resolve this issue. a. Chief financial officer b. Chief executive officer c. Chief nursing officer d. Chief information officer 8. An autopsy has been requested by the district attorney’s office. The department to contact in the hospital is _____. a. b. c. d. Radiology Nursing Health information Clinical laboratory services Organization of Ambulatory Care Ambulatory care is the provision of preventative or corrective healthcare services on a nonresident basis in a provider’s office, clinic setting, or hospital outpatient setting. Ambulatory care encompasses all the health services provided to individual patients who are not residents in a healthcare facility. Such services include the educational services provided by community health clinics and public health departments. Primary care, emergency care, and ambulatory specialty care (including ambulatory surgery) can all be considered ambulatory care. Ambulatory specialists include gastroenterologists, neurologists, and cardiologists and others who perform a variety of diagnostic tests and therapies in the ambulatory setting. Ambulatory care services are provided in a variety of settings including urgent care centers, school-based clinics, public health clinics, and neighborhood and community health centers. Current medical practice emphasizes performing healthcare services in the least costly setting possible. This change in thinking has led to decreased utilization of emergency services, increased utilization of nonemergency ambulatory facilities, decreased hospital admissions, and shorter hospital stays. The AB103318_Ch01.indd 20 need to reduce the cost of healthcare also has led primary care physicians (PCPs) to treat conditions they once would have referred to specialists. The need to reduce cost and to provide access led facilities to increase the use of PAs and nurse practitioners. These physician extenders provide both primary care to patients and specialized technical assistance to physicians. Nurse practitioners may practice independently in many states, while PAs practice under the supervision of a physician or hospital. State licensing regulations govern their scope of practice. Physicians who provide ambulatory care services fall into two major categories: physicians working in private practice and physicians working for ambulatory care organizations. Physicians in private practice are self-employed. They work in solo, partnership, and group practices set up as for-profit organizations. Alternatively, physicians who work for ambulatory care organizations are employees of those organizations. Ambulatory care organizations include the following: • Health maintenance organizations • Hospital-based ambulatory clinics 1/2/2020 6:44:52 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Organization of Ambulatory Care 21 • Walk-in and emergency clinics • Hospital-owned group practices and health promotion centers • Freestanding surgery centers • Freestanding urgent care centers • Freestanding emergency care centers • Health department clinics • Neighborhood clinics • Home care agencies • Community mental health centers • School and workplace health service agencies • Prison health services agencies Ambulatory care organizations also employ other healthcare providers including nurses, laboratory technicians, podiatrists, chiropractors, physical therapists, radiology technicians, psychologists, and social workers. Private Medical Practice Private medical practices are physician-owned entities that provide primary care or medical and surgical specialty care services in a freestanding office setting. The physicians may have medical privileges at local hospitals and surgical centers but are not employees of those healthcare entities. Hospital-Based Ambulatory Care Services In addition to providing inpatient services, many acute-care hospitals provide various ambulatory care services. These services include emergency services; trauma care; and outpatient surgical, diagnostic, and therapeutic services. Emergency Services and Trauma Care Hospital-based emergency departments provide specialized care for victims of traumatic accidents and life-threatening illnesses. In urban areas, many also provide walk-in services for patients with minor illnesses and injuries who do not have access to regular PCPs. Many physicians on the hospital staff also use the emergency care department as a setting to AB103318_Ch01.indd 21 a­ ssess patients with problems that may either lead to an inpatient admission or require equipment or diagnostic imaging facilities not available in a private office or nursing home. Emergency services function as a major source of unscheduled admissions to the hospital. Outpatient Surgical Services Ambulatory surgery refers to any surgical procedure that does not require an overnight stay in a hospital. It can be performed in the outpatient surgery department of a hospital or in a freestanding ambulatory surgery center. Hospitals report that a growing number of all surgeries are performed in the ambulatory surgery setting (Steiner et al. 2017). The increased number of procedures performed in an ambulatory setting can be attributed to improvements in surgical technology and anesthesia and the utilization management demands of third-party payers. Outpatient Diagnostic and Therapeutic Services Outpatient diagnostic and therapeutic services are provided in a hospital or one of its satellite facilities. Diagnostic services are those services performed by a physician to identify the disease or condition from which the patient is suffering. Therapeutic services are those services performed by a physician to treat the disease or condition that has been identified. Hospital outpatients fall into different classifications according to the type of service they receive and the location of the service. For example, emergency outpatients are treated in the hospital’s emergency or trauma care department for conditions that require immediate care. Clinic outpatients are treated in one of the hospital’s clinical departments on an ambulatory basis. And referral outpatients receive special diagnostic or therapeutic services in the hospital on an ambulatory basis, but responsibility for their care remains with the referring physician. Ambulatory Care Services Community-based ambulatory care services refer to those services provided in freestanding facilities that are not owned by or affiliated with a hospital. Such facilities can range in size from a small medical practice with a single physician to a large clinic 1/2/2020 6:44:52 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 22 Chapter 1 The US Healthcare Delivery System with an organized medical staff (Masters and Nester 2001, 9–13). Among the organizations that provide ambulatory care services are specialized treatment facilities. Examples of these facilities include birthing centers, cancer treatment centers, renal dialysis centers, and rehabilitation centers. Freestanding Ambulatory Care Centers Freestanding ambulatory care centers (ACCs) provide emergency services and urgent care for walkin patients. Urgent care centers (sometimes called emergicenters or immediate care centers) provide diagnostic and therapeutic care for patients with minor illnesses and injuries. They do not serve ­seriously ill patients, and most do not accept ­ambulance cases. Two groups of patients find these centers attractive. The first group consists of patients seeking the convenience and access of emergency services without the delays and other forms of negative feedback associated with using hospital services for non-lifethreatening problems. The second group consists of patients whose insurance treats urgent care centers preferentially compared with physicians’ offices. As they have increased in number and become familiar to more patients, many of these centers now offer a combination of walk-in and appointment services. In 2000, the first retail clinics opened, and their number increased rapidly. From 2006 to 2014, retail clinics grew from 200 to 1,800 and the number of visits grew from 1.5 million to 10.5 million in 2012 (Rand Corporation n.d.). It was projected that the number of retail clinics would grow to 2,800 in 2018 (Rand Corporation 2016). However, the growth has been concentrated in the midwestern and southern states and in urban areas. These retail clinics treat non-life-threatening acute illnesses and offer routine wellness services such as flu shots, sports physicals, and prescription refills. These visits are covered by most insurers, including Medicare. Freestanding Ambulatory Surgery Centers Generally, freestanding ambulatory surgery centers provide surgical procedures that take anywhere from 5 to 90 minutes to perform and that require less than a four-hour recovery period. Patients must schedule their surgeries in advance and be prepared to return home on the same day. Patients AB103318_Ch01.indd 22 who experience surgical complications are sent to an inpatient facility for care. Most ambulatory surgery centers are for-profit entities. They may be owned by individual physicians, managed care organizations (MCOs), or entrepreneurs. Generally, ACCs can provide surgical services at lower cost than hospitals can because their overhead expenses are lower. Public Health Services Although states have constitutional authority to implement public health programs, a wide variety of federal programs and laws assist them. HHS is the principal federal agency for ensuring health and providing essential human services. All of its agencies have some responsibility for prevention. Through its 10 regional offices, HHS coordinates closely with state and local government agencies, and many HHS-funded services are provided by these agencies as well as by private-sector and nonprofit organizations. The Office of the Secretary of HHS has two units important to public health: the Office of the Surgeon General of the United States and the Office of Disease Prevention and Health Promotion (ODPHP). ODPHP has an analysis and leadership role for health promotion and disease prevention. The surgeon general is appointed by the president of the US and provides leadership and authoritative, science-based recommendations about the public’s health. The surgeon general has ­responsibility for the public health service (PHS) workforce (HHS 2019b). Home Care Services Home healthcare is a wide range of healthcare services that can be delivered in the home. These services include nursing services such as catheter insertion, wound care, and well-being checks. The home care market was a $100 billion industry in 2016 and was projected to grow to $225 billion in 2024 (Wood 2017). The two main reasons for this explosive growth are the increased number of seniors as the large number of babies born after World War II reach 65, and the lower cost of home healthcare when compared to other post-acute services. Moreover, patients generally prefer to be 1/2/2020 6:44:52 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Long-Term Care 23 cared for in their own homes, no matter how complex their medical problems. In 1989, Medicare rules for home care services were clarified to make it easier for Medicare beneficiaries to receive such services. Patients are eligible to receive home health services from a qualified Medicare provider when they are homebound; when they are under the care of a specified physician who will establish a home health plan; and when they need physical or occupational therapy, speech therapy, or intermittent skilled nursing care. Many hospitals have formed their own home healthcare agencies to increase revenues and at the same time allow them to discharge patients from the hospital earlier. Voluntary Agencies Voluntary agencies provide healthcare and healthcare planning services, usually at the local level and to low-income patients. Their services range from giving free immunizations to offering family planning counseling. Funds to operate such agencies come from a variety of sources, including local or state health departments, private grants, and different federal bureaus. One common example of a voluntary agency is the community health center. Sometimes called neighborhood health centers, community health centers offer comprehensive, primary healthcare services to patients who otherwise would not have access to them. Often patients pay for these services on a sliding scale based on income or according to a flat rate, discounted fee schedule supplemented by public funding. Some voluntary agencies offer specialized services such as counseling for battered and abused women. Typically, these are set up within local communities. An example of a voluntary agency that offers services on a much larger scale is the Red Cross. Check Your Understanding 1.4 Instructions: Answer the following questions in a separate document. 1. You wake up on Saturday morning with a very sore throat and a low-grade fever. What is the most appropriate setting to seek healthcare services? Explain why. 2. You wake up on Saturday morning with severe chest pain, dizziness, and nausea. What is the most appropriate setting to seek healthcare services? Explain why. 3. You are scheduled for a colonoscopy, a procedure that requires general anesthesia but takes less than two hours to complete. Where would you expect to be seen? Explain why. 4. You have a family including three active teenagers, each involved in a winter sport. Which of the various healthcare settings is(are) appropriate for completing their sports physicals and why? 5. Your grandmother just had her hip replaced and will be recuperating at your house. She will be alone during the day because everyone in the household is at work. What options do you have for her rehabilitation? 6. Your neighbor was laid off from his job a month ago and lost his health insurance. He has a history of high blood pressure and is not feeling well. What options does he have for getting evaluated by medical personnel? Long-Term Care Long-term care is the healthcare rendered in a non-acute-care facility to patients who require inpatient nursing and related services for more than 30 consecutive days. Skilled nursing AB103318_Ch01.indd 23 facilities (SNFs), nursing homes, long-term care facilities, and rehabilitation hospitals are the principal facilities that provide long-term care. Rehabilitation hospitals provide recuperative services for 1/2/2020 6:44:53 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 24 Chapter 1 The US Healthcare Delivery System patients who have suffered strokes and traumatic injuries as well as other serious illnesses. Specialized long-term care facilities serve patients with chronic respiratory disease, permanent cognitive impairment, and other incapacitating conditions. Long-term care encompasses a range of health, personal care, social, and housing services provided to people of all ages with health conditions that limit their ability to carry out normal daily activities without assistance. People who need ­ long-term care often have multiple physical and mental disabilities. Moreover, their need for the mix and intensity of long-term care services can change over time. Long-term care is mainly rehabilitative and supportive rather than curative. Moreover, healthcare workers other than physicians can provide longterm care in the home or in residential or institutional settings. For the most part, long-term care requires little or no clinical technology; however, there is growing adoption of electronic health records in long-term care facilities (AHIMA 2014). Post-Acute Care Post-acute care supports patients who require ongoing medical management or therapeutic, ­rehabilitative, or skilled nursing care (AHA 2010). Patients require frequent physician oversight and advanced nursing care but no longer require the acute interventions and diagnostic services of acute-care settings. It is delivered in a variety of environments, including long-term acute-care hospitals (LTACHs), SNFs, rehabilitation centers, and at home-by-home health services (AHA 2010). In 2015, there were 428 LTACHs in the US. Covered by Medicare, LTACHs provide intensive long-term services for patients with complex medical problems (AHA n.d.). Medicare requires an LTACH to meet the same conditions of participation as an acute-care hospital; however, the ALOS must be greater than 25 days. Long-Term Care and the Continuum of Care The availability and cost of long-term care is one of the most important health issues facing the US AB103318_Ch01.indd 24 and the world today. In the US, by 2060, people over the age of 65 will double from 50 to 100 million (Haseltine 2018). As discussed earlier, healthcare is now viewed as a continuum of care. That is, patients are provided care by different caregivers at several different levels of the healthcare system. In the case of long-term care, the patient’s continuum of care may have begun with a primary provider in a hospital and then continued with home care and eventually care in an SNF. That patient’s care is coordinated from one care setting to the next. Moreover, the roles of the different care providers along the patient’s continuum of care are continuing to evolve. Health information managers play a key part in providing consultation services to long-term care facilities with regard to developing systems to manage information from a diverse number of healthcare providers. Delivery of Long-Term Care Services Long-term care services are delivered in a variety of settings. Among these settings are SNFs or nursing homes, residential care facilities, hospice programs, and adult day care programs. Skilled Nursing Facilities or Nursing Homes The most important providers of formal, longterm care services are nursing homes. SNFs, or nursing homes, provide medical, nursing, and, in some cases, rehabilitative care around the clock. The majority of SNF residents are over age 65 and quite often are classified as the frail elderly. Many nursing homes are owned by for-profit organizations. However, SNFs also may be owned by not-for-profit groups as well as local, state, and federal governments. Nursing homes are no longer the only option for patients needing long-term care. Various factors play a role in determining which type of long-term care facility is best for a particular patient, including cost, access to services, and individual needs. Residential Care Facilities New living environments that are more homelike and less institutional are the focus of much attention 1/2/2020 6:44:53 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com Long-Term Care 25 in the current long-term care market (assisted living and memory care centers, for example). Residential care facilities now play a growing role in the continuum of long-term care services. Having affordable and appropriate housing available for elderly and disabled people can reduce the level of need for institutional long-term care services in the community. Institutionalization can be postponed or prevented when the elderly and disabled live in safe and accessible settings where assistance with daily activities is available. Hospice Programs Hospice is an interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, social, and economic needs of the terminally ill and their families provided mainly in the home. Hospice is based on a philosophy of care imported from England and Canada that holds that during the course of terminal illness, the patient should be able to live life as fully and as comfortably as possible but without artificial or mechanical efforts to prolong life. In the hospice approach, the family is the unit of treatment. An interdisciplinary team provides medical, nursing, psychological, therapeutic, pharmacological, and spiritual support during the final stages of illness, at the time of death, and during bereavement. The main goals are to control pain, maintain independence, and minimize the stress and trauma of death. Hospice services have gained acceptance as an alternative to hospital care for the terminally ill. The number of hospices is likely to continue to grow because this philosophy of care for people at the end of life has become a model for the nation. Adult Day Care Programs Adult day care programs offer a wide range of health and social services to elderly persons during the daytime hours. Adult day care services are usually targeted to elderly members of families in which the regular caregivers work during the day. Many elderly people who live alone also benefit from leaving their homes every day to participate in programs designed to keep them active. The goals of adult day care programs are to delay AB103318_Ch01.indd 25 the need for institutionalization and to provide respite for the caregivers. They are also known as day health centers. Behavioral Health Services From the mid-19th century to the mid-20th century, psychiatric services in the US were based primarily in long-stay institutions supported by state governments and patterns of practice were relatively stable. Over the past 50 years, however, remarkable changes have occurred. These changes include a reversal of the balance between institutional and community care, inpatient and outpatient services, and individual and group practice. The shift to community-based settings began in the public sector, and community settings r­ emain dominant. The private sector’s bed capacity increased in the 1970s and 1980s, including psychiatric units in nonfederal general hospitals, private psychiatric hospitals, and residential treatment centers for adults and children. Substance abuse centers and child and adolescent inpatient psychiatric units grew particularly quickly in the 1980s, as investors recognized their profitability. In the 1990s, the growth of inpatient private mental health facilities leveled off and the number of outpatient and partial treatment settings increased sharply. The number of mental health organizations providing 24-hour services (hospital inpatient and residential treatment) increased significantly over the 32-year period from 1970 to 2002 (Foley et al. 2004). Community hospitals are the primary source of inpatient psychiatric care delivered in ­either designated psychiatric units or in scatter beds throughout the medical units due to the closure of public psychiatric hospitals (Mark et al. 2010). However, in the last decade the number of nonfederal psychiatric hospitals has grown by 35 percent, to 620 (AHA 2019). Residential treatment centers for emotionally or behaviorally disturbed children provide inpatient services to children under 18 years of age. The programs and physical facilities of residential treatment centers are designed to meet patients’ daily living, schooling, recreational, socialization, and routine medical care needs. 1/2/2020 6:44:53 PM Get Complete eBook Download by Email at discountsmtb@hotmail.com 26 Chapter 1 The US Healthcare Delivery System Day hospital or day treatment programs occupy one niche in the spectrum of behavioral healthcare settings. Although some provide services seven days a week, many programs provide services only during business hours. Day treatment patients spend most of the day at the treatment facility in a program of structured therapeutic activities and then return to their homes until the next day. Day treatment services include psychotherapy, pharmacology, occupational therapy, and other types of rehabilitation services. These programs provide alternatives to inpatient care or serve as transitions from inpatient to outpatient care or discharge. They also may provide respite for family caregivers and a place for rehabilitating or maintaining chronically ill patients. The number of day treatment programs has increased in response to pressures to decrease the length of hospital stays. Insurance coverage for behavioral healthcare continues to lag behind coverage for other medical care. Although treatments and treatment settings have changed, rising healthcare costs and insurers’ continuing fear of the potential cost of this coverage have maintained the differences ­between medical and behavioral healthcare benefits. Although the majority of individuals who are covered by health insurance have some outpatient psychiatric coverage, the coverage is often quite restricted. Typical restrictions include limits on the number of outpatient visits, higher copayment charges, and higher deductibles. Behavioral healthcare has changed significantly over the past 40 years, as psychopharmacologic treatment has made possible the shift away from long-term custodial treatment. Psychosocial treatments continue the process of care and rehabilitation in community settings. There are fewer large state hospitals; they have been replaced by psychiatric units in general hospitals, new outpatient clinics, community mental health centers, day treatment centers, and halfway houses. Treatment has become more effective and specific, based on our growing understanding of the brain and behavior (Kovner et al. 2011). Integrated Delivery Systems Many hospitals have responded to financial pressures by rapidly merging, acquiring, and entering into affiliations and various risk-sharing reimbursement agreements with other acute and nonacute providers, hospital-based healthcare systems, physicians and physician group practices, and MCOs. Transactions have included mergers of nonprofit organizations into either investor-owned or other nonprofit entities. An integrated delivery system (IDS) combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care. An IDS may also be called integrated health system, IDN, integrated care system (network), organized delivery system, community care network, integrated healthcare organization, integrated service network, or population-based IDS. These are all referring to the same thing. The goal of an IDS is to organize the entire continuum of care, from health promotion and disease AB103318_Ch01.indd 26 prevention to primary and secondary acute care, tertiary care, long-term care, and hospice care, to maximize its effectiveness across episodes of illness and pathways of wellness. The ACA created a new model of IDS called the accountable care organization (ACO). An ACO is a group of service providers that work together to manage and coordinate care of Medicare fee-for-­ service beneficiaries. The ACO receives incentive payments for delivering and coordinating care efficiently and effectively while focusing on preventative care and education. Guidelines for the establishment of an ACO are under the purview of the secretary of HHS, but they may include quality reporting, ­e-prescribing, and the use of electronic health records. At the end of the first quarter of 2017, there were 923 ACOs in the US covering 32 million individuals (CHCS 2017). This is an increase of 2.2 million covered lives in one year. However, as the ACO model matures, there is turnover in ACOs as some discontinue their Medicare contracts. Further discussion of ACOs can be found in chapters 13 and 16. 1/2/2020 6:44:55 PM Get Complete eBook Download link Below for Instant Download: https://browsegrades.net/documents/286751/ebook-payment-link-forinstant-download-after-payment
