Health Informatics Week 1

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CHAPTER

1 A Total Patient

Encounter

Learning Outcomes

When you finish this chapter, you will be able to:

1.1 Compare practice management (PM) programs and

electronic health records (EHRs).

1.2 Discuss the government health information

technology (HIT) initiatives that have led to

integrated PM/EHR programs.

1.3 List the eight facts that are documented in the

medical record for an ambulatory patient encounter.

1.4 Identify the additional uses of clinical information

gathered in patient encounters.

1.5 Compare electronic medical records, electronic

health records, and personal health records.

1-2

Learning Outcomes (Continued)

When you finish this chapter, you will be able to:

1.6 Describe the four functions of a practice

management program that relate to managing

claims.

1.7 List the steps in the medical documentation and

billing cycle.

1.8 Compare the roles and responsibilities of clinical and

administrative personnel on the physician practice

health care team.

1.9 Explain how professional certification and lifelong

learning contribute to career advancement in

medical administration.

1-3

Key Terms

• accounts receivable

(A/R)

• American Recovery and

Reinvestment Act of

2009 (ARRA)

• cash flow

• certification

• continuity of care

• data mining

• data warehouse

• diagnosis code

1-4

• documentation

• electronic health record

(EHR)

• electronic medical record

(EMR)

• electronic prescribing

• encounter

• health informatics

• health information

exchange (HIE)

Key Terms (Continued)

• Health Insurance

Portability and

Accountability Act of

1996 (HIPAA)

• health information

technology (HIT)

• integrated PM/EHR

program

• meaningful use

• medical assistant (MA)

• medical biller

• medical coder

1-5

• medical documentation

and billing cycle

• medical malpractice

• medical necessity

• medical record

• National Health

Information Network

(NHIN)

• patient examination

• pay for performance

(P4P)

Key Terms (Continued)

• personal health record

(PHR)

• Physician Quality

Reporting Initiative

(PQRI)

• practice management

(PM) program

• procedure code

• records retention

schedule

• regional extension

centers (RECs)

1-6

• revenue cycle

management (RCM)

• standards

1.1 Health Information Technology:

Tools for a Total Patient Encounter 1-7

• Health information technology (HIT)—use of

computers and electronic communications to

manage medical information and its secure

exchange

• Practice management (PM) programs—used

to perform administrative and financial functions

in a medical office

• Electronic health record (EHR)—computerized

lifelong health care record for an individual that

incorporates data from all sources that provide

treatment for the individual

1.1 Health Information Technology:

Tools for a Total Patient Encounter (Cont.) 1-8

• Health informatics—knowledge required to

optimize the acquisition, storage, retrieval, and

use of information in health and biomedicine

1.2 Major Government HIT Initiatives 1-9

• Health Insurance Portability and

Accountability Act of 1996 (HIPAA)—

legislation that protects patients’ private health

information, ensures health care coverage when

workers change or lose jobs, and uncovers fraud

and abuse in the health care system

– Standards—technical specifications for the electronic

exchange of information

• Electronic prescribing (e-prescribing)—

technology that enables a physician to transmit a

prescription electronically to a patient’s

pharmacy

1.2 Major Government HIT Initiatives

(Continued) 1-10

• Physician Quality Reporting Initiative

(PQRI)—Medicare program that gives bonuses

to physicians when they use treatment plans and

clinical guidelines that are based on scientific

evidence

• American Recovery and Reinvestment Act of

2009 (ARRA)—$787 billion economic stimulus

bill passed in 2009 that allocates $19.2 billion to

promote the use of HIT

1.2 Major Government HIT Initiatives

(Continued) 1-12

• Health information exchange (HIE)—network

that enables the sharing of health-related

information among provider organizations

according to nationally recognized standards

• National Health Information Network

(NHIN)—common platform for health information

exchange across the country

• Integrated PM/EHR programs—programs that

share and exchange demographic information,

appointment schedules, and clinical data

1.2 Major Government HIT Initiatives

(Continued) 1-11

• Meaningful use—utilization of certified EHR

technology to improve quality, efficiency, and

patient safety in the health care system

• Regional extension centers (RECs)—centers

that offer information, guidance, training, and

support services to primary care providers who

are in the process of making the transition to an

EHR system

1.3 Documenting the Patient Encounter 1-13

• Encounter (or visit)—meeting of a patient with a

physician or other medical professional for the

purpose of providing health care

• Patient examination—examination of a

person’s body in order to determine his or her

state of health

1.3 Documenting the Patient Encounter

(Continued) 1-14

• Documentation—record created when a

physician provides treatment to a patient

• Medical record—chronological health care

record that includes information that the patient

provides, such as medical history and the

physician’s assessment, diagnosis, and

treatment plan

• Continuity of care—coordination of care

received by a patient over time and across

multiple health care providers

1.3 Documenting the Patient Encounter

(Continued) 1-15

Eight data points included in an ambulatory care

medical record:

1. Patient’s name

2. Encounter date and reason

3. Appropriate history and physical examination

4. Review of all tests that were ordered

5. Diagnosis

6. Plan of care, or notes on procedures or treatments

that were given

7. Instructions or recommendations that were given to

the patient

8. Signature of the provider who saw the patient

1.4 Other Uses of Clinical Information 1-16

Clinical information has several important

secondary uses that involve:

– Legal issues

– Quality review

– Research

– Education

– Public health and homeland security

– Billing and reimbursement

1.4 Other Uses of Clinical Information

(Continued) 1-17

• Medical malpractice—provision of medical

services at a less-than-acceptable level of

professional skill that results in injury or harm to

a patient

• Pay for performance (P4P)—provision of

financial incentives to physicians who provide

evidence-based treatments to their patients

1.5 Functions of an Electronic Health

Record Program 1-18

• Electronic medical record (EMR)—

computerized record of one physician’s

encounters with a patient over time

– EHRs, on the other hand, can include information

from the EMRs of a number of different sources.

• Personal health records (PHRs)—private,

secure electronic health care files that are

created, maintained, and owned by the patient

1.5 Functions of an Electronic Health

Record Program (Continued) 1-19

EHRs have eight core functions:

1. Health information and data element maintenance

2. Results management

3. Order management

4. Decision support

5. Electronic communication and connectivity

6. Patient support

7. Administrative support

8. Reporting and population management

Advantages of EHRs include safety, quality, and

efficiency.

1.6 Functions of a Practice Management

Program 1-20

Practice management (PM) programs have

functions related to managing claims, including:

– Creating electronic claims

– Electronically monitoring claim status

– Receiving electronic payment notification

– Handling electronic payments

1.7 The Medical Documentation and

Billing Cycle 1-21

• Cash flow—movement of monies into and out of

a business

• Medical documentation and billing cycle—

ten-step process that results in timely payment

for medical services

1.7 The Medical Documentation and

Billing Cycle (Continued) 1-22

The Medical Documentation and Billing Cycle:

– Step 1: Preregister patients

– Step 2: Establish financial responsibility for visit

– Step 3: Check in patients

– Step 4: Review coding compliance

– Step 5: Review billing compliance

– Step 6: Check out patients

– Step 7: Prepare and transmit claims

– Step 8: Monitor payer adjudication

– Step 9: Generate patient statements

– Step 10: Follow up patient payments and collections

1.7 The Medical Documentation and

Billing Cycle (Continued) 1-23

• Diagnosis code—code that represents the

physician’s determination of a patient’s primary

illness

• Procedure code—code that represents the

particular service, treatment, or test provided by

a physician

• Medical necessity—treatment that is in

accordance with generally accepted medical

practice

1.7 The Medical Documentation and

Billing Cycle (Continued) 1-24

• Accounts receivable (A/R)—monies that are

coming into a practice

• Revenue cycle management (RCM)—

management of the activities associated with a

patient encounter to ensure that the provider

receives full payment for services

1.7 The Medical Documentation and

Billing Cycle (Continued) 1-25

• Data warehouse—collection of data that

includes all areas of an organization’s

operations

• Data mining—process of analyzing large

amounts of data to discover patterns or

knowledge

• Record retention schedule—plan for the

management of records that lists types of

records and indicates how long they should be

kept

1.8 The Physician Practice Health Care

Team: Roles and Responsibilities 1-26

• Physicians—primary clinicians in the practice

• Physicians’ assistants (PAs)—health care

professionals who treat minor injuries and assist

with many aspects of an encounter

• Nurses—health care professionals who perform

a wide range of clinical and nonclinical duties

• Medical assistants (MAs)—health care

professionals who perform both administrative

and certain clinical tasks in physician offices

1.8 The Physician Practice Health Care

Team: Roles and Responsibilities (Cont.) 1-27

• Medical billers—health care professionals who

perform administrative tasks throughout the medical

billing cycle

• Medical coders—medical office staff members with

specialized training who handle the diagnostic and

procedural coding of medical records

• Practice or office managers—individuals who

direct the business operations of physician practices

• Compliance officers—individuals who investigate

and resolve all compliance issues relating to coding,

billing, documentation, and reimbursement

1.9 Administrative Careers Working with

Integrated PM/EHR Programs 1-28

• Certification—nationally recognized

designation that acknowledges that an individual

has mastered a standard body of knowledge

and meets certain competencies

• Education in the health care field is a lifelong

commitment.