Health Care Informatics

LESSON 6 Government vs. Private Sector Oversight LECTURE NOTES ______________________________________________________________________________________

The actions and behaviors of health care providers are ultimately controlled by governmental

laws, rules, and regulations. They are considered to be minimal standards that health care

providers need to comply with. Such minimum standards are designed to protect the health and

safety of the public. Typically, governmental rules are not frequently updated due to the

complexity of the process. Thus, they do not necessarily keep up with changes in conditions or

new trends in health care delivery.

Compliance with governmental regulations is enforced by agencies through both routine surveys

and complaints by patients. Sanctions may be imposed by governmental agencies for violations

of standards, but providers typically have a time period in which to correct violations, or they

have the ability appeal the action or sanction being imposed. This can prolong the compliance

process for extended periods of time.

Professional standards are created by groups and organizations that have information and/or

knowledge of current health care delivery systems, changes in technology or treatment options,

educational updates, the latest evidence-based practices, and other factors that might influence

better options for providing superior outcomes to a patient.

Accreditation is considered to be voluntary since the provider chooses to follow the standards

and guidelines directed by a professional group or association. In some instances, governmental

agencies accept accreditation in lieu of oversight, if the standards are equal to or exceed

governmental mandates and the accreditation has been approved. The terminology used is

referred to as “deemed status,” or the provider has been “deemed” to meet the mandated

governmental standards.

The accreditation process can be developed by using on-site surveys, completion of an

application, attendance at educational venues, or completion of an examination by the

accrediting organization. For example, The Joint Commission for the Accreditation of Hospitals (JCAHO) has adopted very specific requirements for how health records are maintained by health

care organizations. The American Family Practice Association creates standards for health records

for Family Practice Physicians. The American Health Information Association (AHIMA) has also

been instrumental in establishing standards for health records as well as establishing procedures to

meet those standards, and they have been adopted or replicated by other standard-setting

organizations. Other organizations provide accreditation to other professions and care settings such

as CARF, ACS, CAP, etc.

For electronics, a number of voluntary, quasi-governments and the federal government have

developed and/or proposed requirements for electronic health care information systems. This has

involved standards for electronic transmissions, protocols for record formatting, terminology,

interoperability of data, etc. All of this oversight and the requirements have created an alphabet of

credentials, acronyms, and buzzwords such as CCHIT, HL7, SNOWMED, ICD-9-CM, just to name a

few. These acronyms are readily available on the Internet for review and reference.