Chapter 1

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 To be able to compare and contrast the various

definitions of health care information.
 To be able to describe the major types of health care
information (internal and external) that are captured or
used, or both, in health care organizations.
 To be able to cite specific examples of the major types
of health care information.
 To be able to understand the content and uses of
patient records.
 To be able to follow a patient’s or client’s health
information throughout a typical encounter or process.

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Types of Health Care Information
 Patient Encounter Data
 Patient Specific Information
 Clinical
 Administrative
 Combined
 Aggregate Information
 Clinical
 Administrative
 Combined
 Comparative Information
 Expert of Knowledge-based Information

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 Definitions vary
 The Health Insurance Portability and
Accountability Act (HIPAA) was established
1996
 the federal legislation that includes provisions
to protect patients’ health information from
unauthorized disclosure
 National Alliance for Health Information
Technology
 Joint Commission

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 any information, whether oral or recorded in
any form or medium, that—
 (A) is created or received by a health care
provider, health plan, public health authority,
employer, life insurer, school or university, or
health care clearinghouse; and
 (B) relates to the past, present, or future
physical or mental health or condition of an
individual, the provision of health care to an
individual, or the past, present, or future
payment for the provision of health care to an
individual .(HIPAA)

 Electronic medical record: An electronic record of

health-related information on an individual that can
be created, gathered, managed, and consulted by
authorized clinicians and staff within one healthcare
organization.
 Electronic health record: An electronic record of
health-related information on an individual that
conforms to nationally recognized interoperability
standards and that can be created, managed, and
consulted by authorized clinicians and staff across
more than one healthcare organization.
 Personal health record: An electronic record of
health-related information on an individual that
conforms to nationally recognized interoperability
standards and that can be drawn from multiple
sources while being managed, shared, and
controlled by the individual [Alliance, 2008].
  A health information system (HIS) refers to a
system designed to manage healthcare data.
This includes systems that collect, store,
manage and transmit a patient’s electronic
medical record (EMR), a hospital’s operational
management or a system supporting
healthcare policy decisions

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Patient encounter is defined

as an interaction between a
patient and one or more
healthcare participants for the
purpose of providing patient
services or assessing the
health status of a patient.

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 Primary Purpose
Type Clinical Administrative

Patient-Specific • Identification Sheet • Identification Sheet

• Problem List • Consents
• Medication Record
Those items generally included as a
• History • Authorizations
part of the patient medical record
are in italics • Physical • Pre-authorization
• Progress Notes • Scheduling
•
•
Consultations
Physicians’ Orders
• Admission/Registration
• Imaging and X-ray results • Insurance Eligibility
• Lab results • Billing
• Immunization Record • Diagnoses Codes
• Operative Report
• Pathology Report • Procedure Codes
• Discharge Summary
• Diagnoses Codes
• Procedure Codes
Aggregate • Disease Indexes • Cost Reports
• Specialized Registers • Claims Denial Analysis
• Outcomes Data • Staffing Analysis
• Statistical Reports • Referral Analysis
• Trend Analysis • Statistical Reports
• Ad hoc Reports • Trend Analysis
• Ad hoc Reports

 Purpose of Patient Records

1. Patient care
2. Communication
3. Legal documentation
4. Billing and Reimbursement
5. Research and Quality Management

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
The American Health Information Management Association
(AHIMA) maintains the Web site www.myPHR.com . which lists
the following components as being common to most patient
records

 Content of Patient Records (myPHR, 2008)

 Identification Sheet
 Problem List
 Medication Record
 History and Physical
 Progress Notes
 Consultation

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 Content of Patient Records (myPHR, 2008)

 Imaging and X-ray reports
 Laboratory reports
 Consent and authorization forms
 Operative Reports
 Pathology Reports
 Discharge Summary
 Other

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
  Figure 1.2 displays a screen from an
electronic medical record. A patient record
may contain some or all of the documentation
just listed.
 Depending on the patient’s illness
or injury and the type of treatment facility, he
or she may need specialized health care
services.

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Measurements of a patient's temperature,

respiratory rate, pulse and blood pressure.

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 Tutorial 1
Find out patient Richard Stein’s date of birth.

http://highered.mheducation.com/olcweb/cgi/plugi
npop.cgi?it=swf::1014::753::/sites/dl/free/007340197
8/585865/Tutorial_01.swf::Tutorial%201

Activity 1
Find out patient Joe L. Brown’s date of birth.

http://highered.mheducation.com/olcweb/cgi/plugi
npop.cgi?it=swf::1014::753::/sites/dl/free/007340197
8/585865/Activity_01.swf::Activity%201

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 https://www.solismed.com/demo.html
 https://www.open-emr.org/demo/

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 Overview of Inpatient Encounter
Figure 1.3 diagrams shows some of the core
activities and processes the patient
will undergo during a hospital stay .
 The middle column represents the basic
patient flow in an inpatient episode of care.
 Patient flow : The progression of patients
from when they enter the practice's system
by scheduling an appointment until they exit
the system by leaving the office after a
physician visit
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 Overview of Inpatient Encounter
 Scheduling
 Preadmission
 Admission/Registration
 Treatment
 Medical
 Nursing
 Ancillary
 Discharge

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 Physician’s Office Patient Flow

 Check In
 Move to Exam Room
 Examination
 Check Out
 Later activities

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 Data Needed for Reimbursement

 Uniform bill
 UB 04 or CMS-1450
 CMS 1500
 Other Uniform Data Sets Three examples are
 Uniform Hospital Discharge Data Set (UHDDS)
 Uniform Ambulatory Care Data Set (ACDS)
 Minimum Data Set (MDS)

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
  Three examples of Uniform Data Sets are UHDDS,
ACDS &MDS
 These data sets share two purposes:
1. To identify the data elements that should be
collected for each patient, and
2. To provide uniform definitions for common terms
and data elements
 The UHDDS is the oldest uniform data set used in
the United States. The earliest version was
developed in 1969 by the National Center for Health
Statistics.
 In 1974, the federal government adopted the
UHDDS definitions as the standard for the Medicare
and Medicaid programs

 UHDDS elements as adopted in 1986 are:

1. Personal identification
2. Sex
3. Race
4. Ethnicity
5. Residence
6. Hospital identification
7-8. Admission and discharge dates
9-10. Attending physician and operating physician
11. Diagnoses: Principal diagnosis & Other
diagnoses
12. Procedure and date
13. Disposition of patient
14. Expected payer

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 Coding Systems
Two major coding systems are employed by
health care providers today:
 ICD-9-CM (International Classification of
Diseases, Ninth Revision, Clinical
Modification—modified for use in the United
States), published by the National
Center for Health Statistics
 CPT (Current Procedural Terminology),
published by the American Medical
Association
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 Coding Standards
 As coding has become intimately linked to
reimbursement, directly determining the
amount of money a health care organization
can receive for a claim from insurers, the
government has increased its scrutiny of
coding practices.
 There are official guidelines for accurate
coding, and health care facilities that do not
adhere to these guidelines are liable to
charges of fraudulent coding practices
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 Patient records, uniform billing information,

and discharge data sets are the main sources of
the data that go into the literally hundreds of
aggregate reports or queries that are developed
and used by providers and executives in health
care organizations
 Disease and Procedure Indexes
 Specialized Registers
 Emergency department or operating room
 Trauma and tumor registries
 Other
 Ad hoc Reports
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 Limitless Ad hoc Reports
 Specific Examples
 Medicare Cost Reports
 Health Care Statistics
 Census statistics
 Discharge statistics

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 Health care executives are often

interested in aggregate reports that
combine clinical and administrative data.
 Ad hoc statistical reports and trend
analyses may draw from both clinical and
administrative data sources, for example.
 These reports may be used for the
purpose of improving customer service,
quality of patient care, or overall
operational efficiency.
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
  Comparative data and information,
gathered internally and externally, are
used for both clinical and
administrative purposes by health care
organizations.
 Outcome Measures
 Benchmarking
 Balanced Scorecards
 Clinical Value Compass
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser
 Clinical, scientific and management print
literature
 On-line resources

Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition Wager ~ Lee ~ Glaser

 KAREN A. WAGER ,FRANCES WICKHAM LEE,

JOHN P. GLASER. Health Care Information
Systems: A Practical Approach for Health Care
Management. Chapter 1. 2nd Edition. Jossey-
Bass.2009 .