Health information system electronic health record week 1

Chapter 2: Regulatory Environment

Most Regulated Industry

• Health Care is one of the most regulated

industries in the US.

• It is vital to be aware of and understand

what regulations may affect the facility.

Standards

Statements concerning proper procedures taken in a given situation:

• Explicit or implicit

• National or local

• Validated or Consensual

• Used or ignored

• Periodically updated or static

Legal Standards

• Judicial system (court decisions) provides

initiative for implementing standards public health rules

– Disease reporting requirements

– Immunizations

– Worker’s comp

– Licensing of professionals

Federal Mandatory Regulations

• CMS

• OSHA

• HIPAA

• EMTALA

• Mammography Quality Standards Act

• Safe Medical Devices Act

• MedWatch

• MWTA

• EPA

State Mandatory Regulations

• Professional Licensure of Providers

• Smoke-free Workplaces

• Smoke-free Environment

• Violence Prevention

State Mandated Risk Management Legislation

• Risk Management Responsibility

• Governing Body Involvement

• Risk Identification

• Risk Analysis

• Risk Management Education

State Mandated Risk Management Legislation

• Sharing Information

• Patient Grievance Procedures

• Immunity and Confidentiality for Providers

• Risk Management Follow-up Procedures

Reimbursement Standards

Payers set their own standards for

reimbursement

• Fee for service

• Negotiated fees

• Capitation

• Prospective payment

• RBRVS

Medicare Incentives to Improve Quality

• Evidence based medicine in now generally accepted as essential to effective and safe medical practice.

• This link was presented in 2 seminal works from IOM:

– Crossing the Quality Chasm

– To Err Is Human

Deficit Reduction Act 2003 and Beyond

• Pay for Posting

• Pay for Performance

• Value Based Purchasing

• Scores and Withhold Determination

False Claims Act

• Anti-fraud activities

• Lawsuits

• Revocation of Medicare participation

Practice Guidelines

• Accreditation Programs develop standards

and facilities can voluntarily apply for review

– Joint Commission on the Accreditation of

Healthcare Organizations (Joint Commission)

– National Committee for Quality Assurance

(NCQA)

• Many equate facility accreditation with quality

– Medicare accepts a JCAHO accreditation as

evidence that a hospital meets Medicare

conditions of participation

Summary

• IGNORANCE of the Law is no excuse

• Know the regulations

– Identify which ones are pertinent to the facility

– Ensure that appropriate policies are in place

– Document compliance