BUSI 505-DO3
The U.S. Healthcare System and Health Informatics
Dr. Johnson
4/28/21
Joshua-Paul Johnian Sr.
Governance and Organizational Structures in Informatics
In our previous discussion post we reviewed privacy, security and quality standards in
informatics and how patients, providers and larger networks of healthcare technology are
managing the ongoing challenges that come with an increasingly integrated healthcare system.
With the recent healthcare reforms from the mid-2000’s to the ACA the U.S. healthcare system
has entered into uncharted relationships of governance, compliance and quality standards. In this
discussion I will explore some of the new governance structures, why they are essential to health
informatics and the relationship between health IT and the present needs of the U.S. healthcare
system.
In Health Information Management and Technology Shanholtzer and Ozanich write,
“Government regulations are mandatory minimum requirements. Policies set by third-party
payers may exceed government regulations and are mandatory in order to participate in the
plan.” [CITATION Bet162 \l 1033 ] While the process of accreditation and additional federal
and or state standards may vary health information technology both effects and is affected by the
world of governance and the structures established to maintain the process of healthcare
compliance. Prior to the significant healthcare reforms of the 1960’s the process of healthcare
reimbursement, provided care and even comprehensive health insurance was limited in scope
and services provided. In a direct parallel, to the pre-reform U.S. healthcare system, the
relationship between patient, practitioner and reimbursement was not as complicated or diverse
and therefore compliance was not streamlined or comprehensive. However, with the overhaul
U.S. healthcare, through Medicare and Medicaid, the U.S. government became an invested
partner within healthcare which meant patients were given an added layer of confidence, in their
practitioners, that came through refined processes of accreditation. Furthermore, as medical
professionals provided services the means by which they were able to paid, for services, were re-
adjusted to federal standards which necessitated new guidelines for compliance and governance.
As the U.S. healthcare system grew, over sixty years, regulatory agencies, accrediting bodies and
third-party payers were introduced as compliance agencies to address the multiple layers of
healthcare services resulting in what was once simplified and limited healthcare system to
become a more diverse and complex structure of reporting and accountability.
While different agencies, bodies and payers provide necessary requirements and regulations, for
the integrity of the healthcare system, the advancement of HITECH and Meaningful Use
technologies have added another layer of compliance to assist in monitoring. Today, within the
word of health informatics and compliance HIM professionals are essential employees that,
“need to know which regulations apply to documentation as a whole, but he or she also needs to
know which regulations apply only to certain areas.” [ CITATION Bet162 \l 1033 ] In March
2010 the passage of the ACA marked a significant shift in the overall healthcare direction of the
United States, both in policy and practice, resulting in new pathways of addressing health
reform, management of costs and renewed focus on quality patient outcomes. Morgan and
Campbell write, “The ACA is hence the latest example of delegated governance — a pervasive
and long-standing feature of the American welfare state in which responsibilities for
administering and delivering social programs are shifted away from the federal government to
private agents or lower levels of government.” [ CITATION Mor11 \l 1033 ] While the ACA did
engage the federal government in a new level of healthcare partnership this relationship was not
a top-down approach; rather the ACA required partnership with state legislatures and multiple
establish oversight bodies to encourage the success of health reforms which also resulted in an
entire a renewed focus of Health IT professionals.
From conditions of participation to HIPPA, the HITECH Act and various rules and regulations
financial incentives were designed, as part of the framework, to both incentivize or exercise
punitive penalties for compliance and or non-compliance. Furthermore, as large portions of the
U.S. healthcare system are administered by CMS government standards and benchmarks have
become essential measurements to gauge the success or areas of needed improvements. Another
example how IT governance has been affected and improved through the ACA is evidenced in
the complex hospital system. According to Belmont et., al they write, “Hospital boards are
accountable for the quality of care at their institutions, under federal reimbursement regulations
and accreditation standards.” [ CITATION Bel11 \l 1033 ] Therefore, as the ACA and health IT
governances require multiple levels of oversight, and checks and balances, hospital board
members should take an increasingly active role in quality oversight, and hiring of IT
professionals, to ensure that the Affordable Care Act's new mandates are met. “Given the act's
emphasis on clinically integrated, systems-based care, hospital boards and their medical staffs
need to reevaluate the design and effectiveness of their quality oversight processes, including
those specifically related to the credentialing and peer review of physicians and other licensed
independent practitioners on staff.” [ CITATION Bel11 \l 1033 ]
Due to these changes the process of credentialing requires higher levels of verification that
physicians and other practitioners have the necessary education, training, and experience to
practice Belmont continues, “A systems-based approach to quality oversight requires proactive
board leadership. Recent studies demonstrate that effective implementation of a comprehensive
approach to quality from the top down can greatly improve a hospital's quality record. A
successful quality oversight program therefore should be board driven.” [ CITATION Bel11 \l
1033 ] Finally, Belmont concludes, “In addition, the board should carefully consider what
benchmarks and standards are used in the information it receives. In addition to the hospital's
own quality goals, an ever-increasing number of external standards must be met to satisfy
regulatory, accreditation, and insurance requirements. Examples include the Joint Commission's
National Patient Safety Goals, the National Quality Forum's quality benchmarks, the CMS policy
on hospital-acquired conditions, and the benchmarks employed for value-based purchasing
incentives in the Affordable Care Act.” [ CITATION Bel11 \l 1033 ]
In 2013 a study that sampled the combination of health IT professionals sitting on the governing
board of health care organizations in New York City discovered, “As the USA focuses on
reforming its health care system to improve the quality, safety and cost of care, the governance of
HCOs must be critically examined including more health professionals on HCO boards may
provide significant gains for the organizations the people they serve.” [ CITATION Mas13 \l
1033 ] In conclusion, in 1 Peter 5:2 we read a New Testament example of a shepherd’s
responsibility for the oversight of his flock, not under compulsion, but voluntary not for
dishonest gain but willingly. Likewise, in Genesis 43:12 we read the principle for returning an
item of value due to an oversight. While both instances provide dated examples mostly
unfamiliar to a modern age; wealth and resources, from any period of time, requires oversight,
regulation and a system of fairness to monitor what is right or fair. Today, many IT governance
bodies may appear to be cumbersome layers of accountability however, their purpose and role is
to ensure the healthcare system reflects the needs and changes of patient care as well as what the
healthcare system is able to tolerate. Whether the ACA or newer reforms continue health IT, and
oversight, are the only guidelines to ensure the overall quality of the system’s success or if
additional reforms and oversight are needed to maintain a system that reflect both market and
social justice outcomes.
Bibliography
Belmont, E., Haltom, C. C., Hastings, D. A., Homchick, R. G., Morris, L., & al., e. (2011). A
new quality compass: hospital boards' increased role under the affordable care act. Health
Affairs, 1282-1289.
Mason, D. J., Keepnews, D., Holmberg, J., & Murray, E. (2013). The representation of health
professionals on governing boards of health care organizations in new york city. Journal
of Urban Health, 888-901.
Morgan, K. C. (2011). Delegated governance in the affordable care act. Journal of Health
Politics, Policy and Law , 387-391.
Shanholtzer, B. &. (2016). Health Information Management and Technology. New York City:
McGraw Hill Education.
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