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
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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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 Assigns one of five accreditation levels
 Excellent
 Commendable
 Accredited
 Provisional
 Denied
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 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
Wager ~ Lee ~ Glaser
 Five major components
 Boundaries
 Security
 Consumer control
 Accountability
 Public Responsibility
Health Care Information Systems: A Practical Approach for Health Care Management 2nd Edition
Wager ~ Lee ~ Glaser
 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
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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
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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
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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
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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