Health Care Information Regulations, Laws, and Standards
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Transcript Health Care Information Regulations, Laws, and Standards
Chapter 3
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Discuss how accreditation, facility licensure, and
certification influence the information needs of
health care facilities.
Identify and differentiate among major health care
accrediting bodies.
Understand and manage the impact of the health
record as a legal document.
Discuss the HIPAA privacy regulations and their
relevance to health care organizations and
consumers.
Describe the laws, regulations, and standards that
govern patient confidentiality.
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Licensure, Certification &
Accreditation
Facility Licensure
Certification
Joint Commission Accreditation
Other Accrediting Organizations
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Legal Aspects of Health Care
Information
Health Record as a Legal Document
Definition
Retention of Health Records
Authentication
Privacy and Confidentiality
Pre-HIPAA
HIPAA
Release of Information
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
States oversee facility licensure
Facilities must have a license to
operate
Emphasis is on standards for
physical plant, safety, etc.
Minimum standards for patient
records
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Gives authority to participate in
Medicare and Medicaid
Standards were established in 1970’s
Hospitals with Joint Commission
Accreditation have “deemed” status
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Voluntary external review
Well known agencies
Joint Commission—hosptials and other
health care facilities
NCQA—managed care plans
CARF—Rehabilitation facilities
AAAHC—Ambulatory care facilities
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Possible Benefits
Deemed status for CMS programs and some
state licensure
Required for reimbursement from some
payers
Validates quality of care
May influence liability insurance
May enhance managed care contracts
Gives competitive edge over non-accredited
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Founded as non-profit in 1951
85% of all general hospitals; 95% of
those over 200 beds
Now includes other types of
healthcare organizations
Survey every three years to compare
practice to standards
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Accreditation decisions
Accreditation
Provisional accreditation
Conditional accreditation
Preliminary denial of accreditation
Denial of accreditation
Preliminary accreditation
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Emphasis on health care information
and documentation of care
~150 JCAHO hospital standards are scored on
patient medical record alone
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Goal:
“ to support decision making to improve
patient outcomes, improve health care
documentation, assure patient safety, and
improve performance in patient care,
treatment, and services, governance,
management, and support processes”
(JCAHO, 2004)
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
There is a large section of the IM
standards devoted to content and
maintenance of patient records
Other IM standards relate to
IM planning
Confidentiality and security
IM processes
Information-based decision making
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
National Committee for Quality
Assurance
Accreditation of health plans and
managed care organizations
(MCOs)
HEDIS and measuring quality
(chapter 1)
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Began accrediting MCOs in 1991
~3/4 of all enrollees in an HMO are in
one accredited by NCQA
NCQA surveys organizations
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Published standards grouped into
five categories
Access & service
Qualified providers
Staying healthy
Getting better
Living with illness
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Assigns one of five accreditation levels
Excellent
Commendable
Accredited
Provisional
Denied
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Commission of Accreditation of
Rehabilitation Facilities (CARF)
www.carf.org
Accreditation Association for
Ambulatory Health Care (AAAHC)
www.aaahc.org
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
What is the legal Health Record?
No simple answer in the electronic
environment
State and Federal laws are being
modified
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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AHIMA define Legal Health Record (LHR)
“the documentation of the healthcare
services provided to an individual in any
aspect of healthcare delivery by a
healthcare provider organization.”
(Amatayakul, 2001)
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
AHIMA defines four categories of
patient data
Legal Health Record
Patient-Identifiable Source Data
Administrative Data
Derived Data
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Most states have retention
requirements
When no state requirements retain
records
At least as long as the statute of limitations
For minors, until the age of majority (defined by
the state)
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Joint Commission defines authentication as
(JCAHO, 2008)
“the validation of correctness for both the
information itself and for the person who
is the author or the user of the
information”
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Forms of Authentication
Handwritten signature
Electronic signature
Most states allow or are silent on electronic
signatures
CMS and Joint Commission recognize
electronic signatures
Policies and procedures are needed to
insure that electronic signature codes, etc
are not shared
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Privacy—individual's right to be left
alone
In health care—the right to limit access to health
care information
Confidentiality—the expectation that
information will only be used for its
intended purpose
Confidentiality relies on trust
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Pre-HIPAA
A few federal and state laws, but no
comprehensive federal regulation to protect
private health information
HIPAA
Multiple Sections, including
Privacy Rule
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
Key definitions
Covered Entities
Health plans
Health care clearinghouses
Health care providers
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Key definitions
Protected Health Information (PHI)
Relates to physical or mental health,
provision of or payment for health care
Identifies the person
Created or received by a covered entity
Transmitted or maintained in any form
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Five major components
Boundaries
Security
Consumer control
Accountability
Public Responsibility
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
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Health care organizations need
comprehensive policies and
procedures for releasing patient
information
Routine Use –requires consent
Non-routine Use—requires
authorization
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Patient Name
Patient Date or Birth
Name of entity to whom
the information is being
released
Description of the health
information being
disclosed
Statement of the reason
or purpose for the
disclosure
Date, event or condition
on which the
authorization will expire
Statement that the
authorization may be
revoked by the patient (or
legal representative)
Patient (or legal
representative) signature
Date of signature—must
be after the encounter
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
Facility Licensure
Certification
Accreditation Standards and Processes
Joint Commission (www.jcaho.org)
NCQA (www.ncqa.org)
Other Accrediting Bodies
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
Health Record as a Legal Document
Retention of Health Records
Authentication of Health Information
Privacy and Confidentiality
HIPAA Privacy Rule
Release of Information
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser