From Health Care Information Systems: A Practical Approach for Health Care Management (4th ed.):
- Chapter 10: Performance Standards and Measures.
These resources also align to the weekly content:
- CMS Information Security and Privacy Overview.
- Success Stories.
PROVIDER EVALUATION (QUALITY AND SAFETY)
Provider Evaluation (Quality and Safety)
Overview
In this age of acute competition and alignment of providers, systems are evolving to
improve contracting opportunities, including population health, Accountable Care
organizations, and models of health care delivery. They are targeting quality care at a
value price. This assignment explores a provider of your choice to determine their
desirability to be a member of a system and recommend improvements they may need
to make to become more competitive in their market.
Requirements
Write a 2–3 page proposal in which you evaluate and make recommendations for a
provider you have chosen in terms of safety, quality, and evidence-informed health care
by doing the following:
•
•
•
•
•
•
•
•
•
•
Choose a health care provider—nursing home, hospital, home care, etc.
Using the search function on Medicare.gov to review your provider’s measures on safety, quality, and evidenceinformed health care.
Pay attention to the publicly reported outcomes on mortality, rehospitalization, and infection rates, as well as patient
satisfaction and preventive care.
Note: If you have chosen a home health provider, use the Home Health Quality Measures website to review their
home health quality measures.
Identify other providers in the same geographic area, review their outcomes, and compare your provider (e.g., search
by Zip code).
Determine how these outcomes impact this provider as a potential member for a health system, Accountable Care
organization, or as a contender to obtain population health contracts.
Based on the reports, determine which quality initiative the providers should address through evidence-based
practices, such as safety, quality, rehospitalizations, mortality, etc.
Would your provider be the desired member of a system?
What is your recommendation for this provider to improve their outcomes in order to improve reimbursement and to
become a desirable member of a system of providers?
Use the Strayer Library to find at least two academic resources. Note: Wikipedia and similar websites are do not
qualify as academic resources.
This course requires the use of Strayer Writing Standards. For assistance and
information, please refer to the Strayer Writing Standards link in the left-hand menu of
your course. Check with your professor for any additional instructions.
The specific course learning outcome associated with this assignment is:
•
Evaluate healthcare data, outcomes, and potential improvements in relation to safety, quality, and evidence-informed
healthcare.
Health Care
Information Systems
Health Care
Information Systems
A Practical Approach for Health
Care Management
Fourth Edition
Karen A. Wager
Frances Wickham Lee
John P. Glaser
Cover design by Wiley
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Library of Congress Cataloging-in-Publication Data
Library of Congress Cataloging-in-Publication Data has been applied for and is on file with
the Library of Congress.
9781119337188 (paperback)
9781119337126 (ePDF)
9781119337089 (ePub)
Printed in the United States of America
FOURTH EDITION
PB Printing
10 9 8 7 6 5 4 3 2 1
Contents
Tables, Figures, and Exhibits …………………………………………………………………….. xi
Preface …………………………………………………………………………………………………. xv
Acknowledgments ………………………………………………………………………………..xxiii
The Authors ………………………………………………………………………………………… xxv
Part 1
Major Environmental Forces That
Shape the National Health Information
System Landscape ………………………………………………. 1
1
2
3
The National Health Information
Technology Landscape …………………………………………………………… 3
Learning Objectives
1990s: The Call for HIT
2000–2010: The Arrival of HIT
2010–Present: Health Care Reform and the Growth of HIT
Summary
Key Terms
Learning Activities
References
Health Care Data …………………………………………………………………. 21
Learning Objectives
Health Care Data and Information Defined
Health Care Data and Information Sources
Health Care Data Uses
Health Care Data Quality
Summary
Key Terms
Learning Activities
References
Health Care Information Systems …………………………………………. 65
Learning Objectives
Review of Key Terms
Major Health Care Information Systems
History and Evolution
Electronic Health Records
Personal Health Records
Key Issues and Challenges
v
vi · C O N T E N T S
Summary
Key Terms
Learning Activities
References
4 Information Systems to Support Population
Health Management ……………………………………………………………. 99
Learning Objectives
PHM: Key to Success
Accountable Care Core Processes
Data, Analytics, and Health IT Capabilities and Tools
Transitioning from the Record to the Plan
Summary
Key Terms
Learning Activities
References
Part 2 Selection, Implementation, Evaluation, and
Management of Health Care Information
Systems ………………………………………………………….. 139
5 System Acquisition …………………………………………………………….. 141
Learning Objectives
System Acquisition: A Definition
Systems Development Life Cycle
System Acquisition Process
Project Management Tools
Things That Can Go Wrong
Information Technology Architecture
Summary
Key Terms
Learning Activities
References
6 System Implementation and Support …………………………………. 179
Learning Objectives
System Implementation Process
Managing Change and the Organizational Aspects
System Support and Evaluation
Summary
Key Terms
Learning Activities
References
7 Assessing and Achieving Value in Health Care
Information Systems ………………………………………………………….. 215
Learning Objectives
Definition of IT-Enabled Value
C O N T E N T S · vii
8
The IT Project Proposal
Ensuring the Delivery of Value
Analyses of the IT Value Challenge
Summary
Key Terms
Learning Activities
References
Organizing Information Technology Services ………………………. 251
Learning Objectives
Information Technology Functions
Organizing IT Staff Members and Services
In-House versus Outsourced IT
Evaluating IT Effectiveness
Summary
Key Terms
Learning Activities
References
Part 3 Laws, Regulations, and Standards That
Affect Health Care Information Systems ………….. 285
9
Privacy and Security …………………………………………………………… 287
Learning Objectives
Privacy, Confidentiality, and Security Defined
Legal Protection of Health Information
Threats to Health Care Information
The Health Care Organization’s Security Program
Beyond HIPAA: Cybersecurity for Today’s Wired Environment
Summary
Key Terms
Learning Activities
References
10 Performance Standards and Measures ………………………………… 323
Learning Objectives
Licensure, Certification, and Accreditation
Measuring the Quality of Care
Federal Quality Improvement Initiatives
Summary
Key Terms
Learning Activities
References
11 Health Care Information System Standards ………………………… 357
Learning Objectives
HCIS Standards Overview
Standards Development Process
viii · C O N T E N T S
Federal Initiatives Affecting Health Care IT Standards
Other Organizations Influencing Health Care IT Standards
Health IT Standards
Vocabulary and Terminology Standards
Data Exchange and Messaging Standards
Health Record Content and Functional Standards
Summary
Key Terms
Learning Activities
References
Part 4
Senior-Level Management Issues Related
to Health Care Information Systems
Management ………………………………………………….. 393
12 IT Alignment and Strategic Planning ………………………………….. 395
Learning Objectives
IT Planning Objectives
Overview of Strategy
The IT Assest
A Normative Approach to Developing Alignment and IT Strategy
IT Strategy and Alignment Challenges
Summary
Key Terms
Learning Activities
References
13 IT Governance and Management ……………………………………….. 427
Learning Objectives
IT Governance
IT Budget
Management Role in Major IT Initiatives
IT Effectiveness
The Competitive Value of IT
Summary
Key Terms
Learning Activities
Notes
References
14 Health IT Leadership Case Studies………………………………………. 467
Case 1: Population Health Management in Action
Case 2: Registries and Disease Management in the PCMH
Case 3: Implementing a Capacity Management
Information System
Case 4: Implementing a Telemedicine Solution
Case 5: Selecting an EHR For Dermatology Practice
Case 6: Watson’s Ambulatory EHR Transition
C O N T E N T S · ix
Case 7: Concerns and Workarounds with a Clinical
Documentation System
Case 8: Conversion to an EHR Messaging System
Case 9: Strategies for Implementing CPOE
Case 10: Implementing a Syndromic Surveillance System
Case 11: Planning an EHR Implementation
Case 12: Replacing a Practice Management System
Case 13: Implementing Tele-psychiatry in a Community Hospital
Emergency Department
Case 14: Assessing the Value and Impact of CPOE
Case 15: Assessing the Value of Health IT Investment
Case 16: The Admitting System Crashes
Case 17: Breaching The Security of an Internet Patient Portal
Case 18: The Decision to Develop an IT Strategic Plan
Case 19: Selection of a Patient Safety Strategy
Case 20: Strategic IS Planning for the Hospital ED
Case 21: Board Support for a Capital Project
Supplemental Listing of Related Case Studies and Webinars
Appendixes
A.
B.
Overview of the Health Care IT Industry …………………………….. 525
The Health Care IT Industry
Sources of Industry Information
Health Care IT Associations
Summary
Learning Activities
References
Sample Project Charter, Sample Job Descriptions,
and Sample User Satisfaction Survey………………………………….. 539
Sample Project Charter
Sample Job Descriptions
Sample User Satisfaction Survey
Index ………………………………………………………………………………………………….. 559
Tables, Figures, and Exhibits
TABLES
1.1 Stages of Meaningful Use ……………………………………………………….. 9
1.2 Differences between Medicare and Medicaid EHR
incentive programs……………………………………………………………….. 11
1.3 MIPS performance categories…………………………………………………..13
2.1 Ten common hospital statistical measures ………………………………….47
2.2 Terms used in the literature to describe the five common
dimensions of data quality ……………………………………………………..52
2.3 Excerpt from data dictionary used by AHRQ surgical site infection
risk stratification/outcome detection …………………………………………56
3.1 Common types of administrative and clinical information systems….68
3.2 Functions defining the use of EHRs ………………………………………….76
3.3 Sociotechnical dimensions ………………………………………………………92
4.1 Key attributes and broad results of current ACO models …………….. 106
5.1 Sample criteria for evaluation of RFP responses ……………………….. 161
7.1 Financial analysis of a patient accounting document
imaging system …………………………………………………………………..227
7.2 Requests for new information system projects ………………………….. 230
9.1 HIPAA violation categories …………………………………………………… 302
9.2 Top ten largest fines levied for HIPAA violations as of
August 2016 ………………………………………………………………………. 303
9.3 Resources for conducting a comprehensive risk analysis…………….. 309
9.4 Common examples of vulnerabilities and mitigation strategies…….. 310
10.1 2015 approved CMS accrediting organizations …………………………..329
10.2 Major types of quality measures …………………………………………….336
10.3 Excerpt of CQMs for 2014 EHR Incentive Programs ……………………338
10.4 MIPS performance categories…………………………………………………349
11.1 Relationships among standards-setting organizations …………………. 361
11.2 Excerpt from CVX (clinical vaccines administered) …………………….374
11.3 Excerpt from NCPDP data dictionary ………………………………………380
11.4 X12 TG2 work groups …………………………………………………………. 381
11.5 Excerpt from the HL7 EHR-S Functional Model …………………………386
xi
xii · T A B L E S , F I G U R E S , A N D E X H I B I T S
12.1
12.2
12.3
12.4
13.1
14.1
A.1
A.2
A.3
IT initiatives linked to organizational goals ………………………………397
Summary of the scope of outpatient care problems …………………… 402
Assessment of telehealth strategic opportunities ……………………….. 413
Summary of IT strategic planning ………………………………………….. 414
Target increases in an IT operating budget ……………………………….442
List of cases and corresponding chapters …………………………………469
IT interests of different health care organizations ………………………526
Health care provider market: NAICS taxonomy …………………………527
Changes in application focus resulting from changes
in the health care business model ………………………………………….528
A.4 Major health care IT vendors, ranked by revenue ……………………… 530
B.1 Revision history …………………………………………………………………. 541
B.2 Issue management ………………………………………………………………549
FIGURES
1.1
2.1
2.2
2.3
2.4
2.5
2.6
3.1
3.2
3.3
3.4
3.5
3.6
4.1
5.1
5.2
5.3
5.4
Milestones for a supportive payment and regulatory environment ….15
Health care data to health care knowledge…………………………………23
Sample EHR information screen ………………………………………………33
Sample EHR problem list ……………………………………………………….34
Sample EHR progress notes …………………………………………………….34
Sample EHR lab report …………………………………………………………..35
Sample heart failure and hypertension query screen…………………….45
History and evolution of health care information systems
(1960s to today) …………………………………………………………………..70
Sample drug alert screen ………………………………………………………..73
Sample patient portal …………………………………………………………….74
Percent of non-federal acute care hospitals with adoption of at
least a basic EHR with notes system and position of a certified
EHR: 2008–2015 ……………………………………………………………………75
Office-based physician practice EHR adoption since 2004 ……………..77
The ONC’s roadmap to interoperability ……………………………………..84
Percent of nonfederal acute care hospitals that electronically
exchanged laboratory results, radiology reports, clinical care
summaries, or medication lists with ambulatory care providers
or hospitals outside their organization: 2008–2015 ……………………. 118
Systems development life cycle ………………………………………………144
System usability scale questionnaire ……………………………………….163
Cost-benefit analysis ……………………………………………………………164
Example of a simple Gantt chart ……………………………………………167
T A B L E S , F I G U R E S , A N D E X H I B I T S · xiii
6.1
7.1
7.2
7.3
8.1
10.1
10.2
12.1
12.2
12.3
12.4
13.1
13.2
13.3
Project timeline with project phases ……………………………………….189
IT investment portfolio…………………………………………………………237
Days in accounts receivable ………………………………………………….239
Digital intensity versus transformation intensity ………………………..246
IT organizational chart: Large health system …………………………….257
Screenshot from NQF ………………………………………………………….. 341
Projected timetable for implementation of MACRA ……………………. 350
Overview of IT strategy development ………………………………………400
IT initiative priorities ………………………………………………………….. 415
IT plan timetable and budget ……………………………………………….. 416
Hype cycle for emerging technologies, 2014 ……………………………..422
IT budget decision-making process …………………………………………443
Gross margin performance differences in high IT–use industries ….. 461
Singles and grand slams ……………………………………………………….463
EXHIBITS
2.1
2.2
2.3
5.1
9.1
9.2
10.1
10.2
11.1
11.2
12.1
12.2
12.3
Excerpt from ICD-10-CM 2016 ………………………………………………….38
Excerpt from ICD-10 PCS 2017 OCW …………………………………………40
Patient encounter form coding standards …………………………………..41
Overview of System Acquisition Process ………………………………….147
Sample release of information form ………………………………………..294
Cybersecurity framework core ………………………………………………. 318
Medical Record Content: Excerpt from South Carolina Standards
for Licensing Hospitals and Institutional General Infirmaries ……….326
Medical Record Content: Excerpt from the Conditions of
Participation for Hospitals …………………………………………………….328
Excerpt from ONC 2016 Interoperability Standards Advisory ………..366
X12 5010 professional claim standard………………………………………382
IT initiatives necessary to support a strategic goal for a provider …. 410
IT initiatives necessary to support a strategic goal for a
health plan ……………………………………………………………………….. 411
System support of nursing documentation ………………………………. 412
In memory of our colleague Andy Pasternack
Preface
Health care delivery is in the early stages of a profound shift in its core strat
egies, organization, financing, and operational and care processes.
Reactive sick care is being replaced by proactive efforts to keep people
well and out of the hospital. Fragmented care delivery capabilities are being
supplanted by initiatives to create and manage cross-continuum systems
of care. Providers that were rewarded for volume are increasingly being
rewarded for quality and efficiency.
New forms of reimbursement, such as bundles and various types of cap
itation, are causing this shift. To thrive in the new era of health care delivery,
providers are creating health systems, such as accountable care organizations,
that include venues along the care spectrum.
In addition providers are introducing new processes to support the
need to manage care between encounters, keep people healthy, and ensure
that utilization is appropriate. Moreover, as reimbursement shifts to incentimproved provider performance these organizations will have a common
need to optimize operational efficiency, improve financial management, and
effectively engage consumers in managing their health and care.
These changes in business models and processes follow on the heels of
the extraordinary increase in electronic health record adoption spurred by
the Meaningful Use program of the US federal government.
On top of a foundation of electronic health records, the industry will add
population health management applications, systems that support extensive
patient engagement, broader interoperability, and more significant use of
analytics. Providers involved in patient care will need immediate access to
electronic decision-support tools, the latest relevant research findings on a
given topic, and patient-specific reminders and alerts. Health care executives
will need to be able to devise strategic initiatives that take advantage of access
to real-time, relevant administrative and clinical information.
In parallel with the changes in health care, information technology (IT)
innovation continues at a remarkable pace. The Internet of Things is creating
a reality of intelligent homes, cars, and equipment, such as environmental
sensors and devices attached to patients. Social media use continues to grow
xv
xvi · P R E F A C E
and become more sophisticated and capable. Mobile personal devices have
become the device of choice for personal and professional activities. Big data
has exceptional potential to help identify new diagnostic and therapeutic
algorithms, conduct most market surveillance, and assess the comparative
effectiveness of treatments.
For providers to prosper in this new era they must be very effective in
developing IT strategies, implementing the technology, and leveraging the
technology to improve organizational performance. They must understand
the nature of health care data and the challenges of privacy and security.
Clinicians and managers must appreciate the breadth of health care IT and
emerging health care IT trends.
The transformation of the health care industry means that IT is no longer
a necessary back-office evil—it is an essential foundation if an organization is
to survive. That has not been true in the past; provider organizations could
do quite well in a fee-for-service world without computerized physician order
entry and other advanced IT applications.
Having ready access to timely, complete, accurate, legible, and rele
vant information is critical to health care organizations, providers, and
the patients they serve. Whether it is a nurse administering medication to
a comatose patient, a physician advising a patient on the latest research
findings for a specific cancer treatment, a billing clerk filing an electronic
claim, a chief executive officer justifying to the board the need for build
ing a new emergency department, or a health policy analyst reporting on
the cost-effectiveness of a new prevention program to the state’s Medicaid
program, each individual needs access to high-quality information with
which to effectively perform his or her job.
The need for quality information in health care, already strong, has
never been greater, particularly as this sector of our society strives to provide
quality care, contain costs, and ensure adequate access.
PURPOSE OF THIS BOOK
The purpose of this book is to prepare future health care executives with
the knowledge and skills they need to manage information and information
systems technology effectively in this new environment. We wrote this book
with the graduate student (or upper-level undergraduate student) enrolled in
a health care management program in mind.
Our definition of health care management is fairly broad and includes
a range of academic programs from health administration, health infor
mation management, and public health programs to master of business
P R E F A C E · xvii
administration (MBA) programs with an emphasis in health to nursing
administration and physician executive educational programs. This book
may also serve as an introductory text in health informatics programs.
The first (2005), second (2009), and third (2013) editions have been
widely used by a variety of health care management and health information
systems programs throughout the United States and abroad. Although we
have maintained the majority of the chapters from the third edition, this
edition has gone through significant changes in composition and structure
reflecting feedback from educators and students and the need to discuss
topics such as population health and recent changes in payment reform ini
tiatives. We have removed the section on the international perspective on
health care information technology and updated the case studies of organi
zations experiencing management-related information system challenges. We
also added a new chapter on the role of information systems in managing
population health.
ORGANIZATION OF THIS BOOK
The chapters in this book are organized into four major parts:
• Part One: “Major Environmental Forces That Shape the National
Health Information System Landscape” (Chapters One through Four)
• Part Two: “Selection, Implementation, Evaluation, and Management of
Health Care Information Systems” (Chapters Five through Eight)
• Part Three: “Laws, Regulations, and Standards That Affect Health
Care Information Systems” (Chapters Nine through Eleven)
• Part Four: “Senior-Level Management Issues Related to Health
Care Information Systems Management” (Chapters Twelve through
Fourteen)
In addition Appendix A provides an overview of the health care IT indus
try. Appendix B provides a compendium of a sample project charter, sample
job descriptions, and a sample user satisfaction survey.
The purpose of Part One (“Major Environmental Forces That Shape
the National Health Information System Landscape”) is to provide the
reader with the foundation needed for the rest of the book. This foun
dation includes an overview of the major environmental forces that are
shaping the national health IT landscape, such as Medicare’s alternative
payment programs. The reader will gain insight into the different types
of clinical, administrative, and external data used by health care provider
xviii · P R E F A C E
organizations. Additionally, the reader will gain an understanding of the
adoption, use, and functionality of health care information systems with
focus on electronic health records (EHRs), personal health records (PHRs),
and systems need to support population health management (e.g., data
analytics, telehealth).
Specifically Part One has four chapters:
• Chapter One: National Health Information Technology Landscape. This
chapter discusses the various forces and activities that are shaping
health information systems nationally. The chapter reviews the
HITECH Act, the Affordable Care Act, HIPAA, and national efforts to
advance interoperability.
• Chapter Two: Health Care Data. This chapter examines the range
of health care data and issues with data quality and capture. This
examination is conducted from a cross-continuum, health system
perspective.
• Chapter Three: Health Care Information Systems. This chapter provides
an overview of clinical and administrative information systems. The
chapter focuses on the electronic health record and personal health
record and describes in greater detail the major initiatives that have
led to current adoption and use of EHRs by hospitals and physician
practices (e.g., Meaningful Use and health information exchanges).
The chapter also includes discussion on the state of EHRs in settings
across the care continuum (e.g., behavioral health, community care,
long-term care). It concludes with a discussion on important health
care information system issues including interoperability, usability,
and health IT safety.
• Chapter Four: Information Systems to Support Population Health
Management. This is a new chapter. Its purpose is to focus on the key
data and information needs of health systems to effectively manage
population health. Key topics include population health, telehealth,
patient engagement (including social media), data analytics, and
health information exchange (HIE).
The purpose of Part Two (“Selection, Implementation, Evaluation, and
Management of Health Care Information Systems”) is to provide the reader
with an overview of what is needed to effectively select, implement, evaluate,
and manage health care information systems. This section discusses issues
mid- and senior-level managers are likely to encounter related to managing
P R E F A C E · xix
change and managing projects. The reader will also gain insight into the role
and functions of the IT organization or department.
Specifically Part Two has four chapters:
• Chapter Five: System Acquisition. This chapter discusses the processes
that organizations use to select information systems. We have
included a discussion on the importance of system architecture.
• Chapter Six: System Implementation and Support. This chapter reviews
the processes and activities need to implement and support health
care information systems. We have included an examination of change
management and project management.
• Chapter Seven: Assessing and Achieving Value in Health Care
Information Systems. This chapter discusses the nature of the value
that can be obtained from health care information systems and the
approaches to achieving that value.
• Chapter Eight: Organizing Information Technology Services. This
chapter reviews the structure and responsibilities of the IT
organization. This chapter discusses IT senior management roles such
as the chief information officer and the chief medical information
officer.
The purpose of Part Three (“Laws, Regulations, and Standards That
Affect Health Care Information Systems”) is to provide the reader with an
overview of the laws, regulations, and standards that affect health care infor
mation systems. Emphasis is given to system security.
Specifically Part Three has three chapters:
• Chapter Nine: Privacy and Security. This chapter examines privacy and
security regulations and practices.
• Chapter Ten: Performance Standards and Measures. This chapter
discusses the wide range of regulations that affect health care
information systems, with an emphasis on new regulations related to
the focus on the continuum of care.
• Chapter Eleven: Health Care Information Systems Standards. This
chapter reviews the new and emerging standards that govern health
care data, transactions, and quality measures.
The purpose of Part Four (“Senior-Level Management Issues Related to
Health Care Information Systems Management”) is to provide the reader with
xx · P R E F A C E
an understanding of senior-level management responsibilities and activities
related to IT management.
Specifically Part Four has three chapters:
• Chapter Twelve: IT Alignment and Strategic Planning. This chapter
discusses the processes used by organizations to develop an IT
strategic plan. The chapter reviews the challenges faced in developing
these plans.
• Chapter Thirteen: IT Governance and Management. This chapter
discusses several topics that must be addressed by senior leadership
if IT is to be leveraged effectively: establishing IT governance,
developing the IT budget, and ensuring that projects are successful.
• Chapter Fourteen: Health IT Leadership Case Studies. This chapter
comprises case studies that provide real-world situations that touch on
the content of this textbook.
Each chapter in the book (except Chapter Fourteen) begins with a set of
chapter learning objectives and an overview and concludes with a summary
of the material presented and a set of learning activities. These activities are
designed to give students an opportunity to explore more fully the concepts intro
duced in the chapter and to gain hands-on experience by visiting and talking
with IT and management professionals in a variety of health care settings.
Two appendixes offer supplemental information. Appendix A presents an
overview of the health care IT industry: the companies that provide IT hard
ware, software, and a wide range of services to health care organizations.
Appendix B contains a sample project charter, sample job descriptions, and a
sample user satisfaction survey: documents referenced throughout the book.
Depending on the nature and interests of the students, various chapters
are worth emphasizing. Students and courses that are targeted for current
or aspiring senior executive positions may want to emphasize Chapter One
(National Health Care IT Landscape), Chapter Four (Population Health),
Chapter Seven (IT Value), Chapter Twelve (IT Strategy), and Chapter Thirteen
(IT Governance and Management). For classes focused on mid-level man
agement, Chapter One (National Health Care IT Landscape), Chapter Five
(System Selection), Chapter Six (System Implementation), and Chapter Seven
(IT Value) will merit attention.
Regardless of role, Chapter Two (Health Care Data), Chapter Three
(Health Care Information Systems), Chapter Eight (IT Organization), and
Part Three (Laws, Regulations, and Standards) provide important founda
tional knowledge.
P R E F A C E · xxi
One final comment. Two terms, health information technology (HIT) and
health care information systems (HCIS), are frequently used throughout the
text. Although it may seem that these terms are interchangeable, they are, in
fact, related but different. As used in this text, HIT encompasses the technol
ogies (hardware, software, networks, etc.) used in the management of health
information. HCIS describes a broader concept that not only encompasses HIT
but also the processes and people that the HIT must support. HCIS delivers
value to individual health care organizations, patients, and providers, as well
as across the continuum of care and for entire communities of individuals.
HIT delivers little value on its own. Both HCIS and HIT must be managed,
but the management of HCIS is significantly more difficult and diverse.
Health care and health care information technology are in the early stages
of a profound transformation. We hope you find this textbook helpful as we
prepare our students for the challenges that lie ahead.
Acknowledgments
We wish to extend a special thanks to Juli Wilt for her dedication and assis
tance in preparing the final manuscript for this book. We also wish to thank
the following MUSC students in the doctoral program in health administra
tion, who contributed information systems management stories and expe
riences to us for use as case studies: Penney Burlingame, Barbara Chelton,
Stuart Fine, David Freed, David Gehant, Patricia Givens, Shirley Harkey,
Victoria Harkins, Randall Jones, Michael Moran, Catrin Jones-Nazar, Ronald
Kintz, Lauren Lent, George Mikatarian, Lorie Shoemaker, and Gary Wilde.
To all of our students whom we have learned from over the years, we
thank you.
Finally, we wish to extend a very special thanks to Molly Shane Grasso
for her many contributions to Chapter Four, “Information Systems to Support
Population Health Management.”
xxiii
The Authors
Karen A. Wager is professor and associate dean for student affairs in the
College of Health Professions at the Medical University of South Carolina
(MUSC), where she teaches management and health information systems
courses to graduate students. She has more than thirty years of professional
and academic experience in the health information management profession
and has published numerous articles, case studies, and book chapters. Recog
nized for her excellence in interprofessional education and in bringing prac
tical research to the classroom, Wager received the 2016 College Teacher of
the Year award and the 2008 MUSC outstanding teaching award in the educa
tor-lecturer category and the 2008 Governor’s Distinguished Professor Award.
She currently serves as the chair of the Accreditation Council for the Com
mission on Accreditation of Healthcare Management Education (CAHME), is
a member of the CAHME board of directors, and is a past fellow of CAHME.
Wager previously served as a member of the HIMSS-AUPHA-CAHME Task
Force responsible for the development of a model curriculum in health
information systems appropriate for educating graduate students in health
administration programs. She is past president of the South Carolina chapter
of the Healthcare Information and Management Systems Society (HIMSS)
and past president of the South Carolina Health Information Management
Association. Wager holds a doctor of business administration (DBA) degree
with an emphasis in information systems from the University of Sarasota.
Frances Wickham Lee is professor and director of instructional operations
for Healthcare Simulation South Carolina at the Medical University of South
Carolina (MUSC). She recently joined the faculty at Walden University to
teach in the Master of Healthcare Administration program. Lee has more
than thirty years of professional and academic experience in the health
information management, including publication of numerous articles and
book chapters related to the field. She is past president of the North Carolina
Health Information Management Association and South Carolina chapter of
the Healthcare Information and Management Systems Society (HIMSS). Since
2007, Lee has broadened her expertise as a health care educator through
her membership in a pioneering team charged with bringing health care
xxv
xxvi · T H E A U T H O R S
simulation to students and practicing professionals across the state of South
Carolina. She holds a DBA degree with an emphasis in information systems
from the University of Sarasota.
John P. Glaser currently serves as the senior vice president of population health
for Cerner. He joined Cerner in 2015 as part of the Siemens Health Services
acquisition, where he was CEO. Prior to Siemens, Glaser was vice president
and CIO at Partners HealthCare. He also previously served as vice president of
information systems at Brigham and Women’s Hospital.
Glaser was the founding chair of the College of Healthcare Informa
tion Management Executives (CHIME) and the past president of the Healthcare Information and Management Systems Society (HIMSS). He has served
on numerous boards including eHealth Initiative, the American Telemedi
cine Association (ATA), and the American Medical Informatics Association
(AMIA). He is a fellow of CHIME, HIMSS, and the American College of Health
Informatics. He is a former senior advisor to the Office of the National Coor
dinator for Health Information Technology (ONC).
Glaser has published more than two hundred articles, three books on the
strategic application of information technology in health care. Glaser holds
a PhD in health care information systems from the University of Minnesota.
Health Care
Information Systems
PART ONE
Major Environmental
Forces That Shape
the National Health
Information System
Landscape
1
CHAPTER 1
The National Health
Information Technology
Landscape
LEARNING OBJECTIVES
• To be able to discuss some of the most significant influences
shaping the current and future health information technology
landscapes in the United States.
• To understand the roles national private sector and government
initiatives have played in the advancement of health information
technology in the United States.
• To be able to describe major events since the 1990s that have
influenced the adoption of health information technologies and
systems.
3
4 · C H A P T E R 1: T H E N AT I O N A L H E A LT H I N F O R M AT I O N T E C H N O L O G Y L A N D S C A P E
Since the early 1990s, the use of health information technology (HIT)
across all aspects of the US health care delivery system has been increasing.
Electronic health records (EHRs), telehealth, social media, mobile applica
tions, and so on are becoming the norm—even commonplace—today. Today’s
health care providers and organizations across the continuum of care have
come to depend on reliable HIT to aid in managing population health effec
tively while reducing costs and improving quality patient care. Chapter One
will explore some of the most significant influences shaping the current and
future HIT landscapes in the United States. Certainly, advances in infor
mation technology affect HIT development, but national private sector and
government initiatives have played key roles in the adoption and application
of the technologies in health care. This chapter will provide a chronologi
cal overview of the significant government and private sector actions that
have directly or indirectly affected the adoption of HIT since the Institute of
Medicine landmark report, The Computer-Based Patient Record: An Essential
Technology for Health Care, authored by Dick and Steen and published in 1991.
Knowledge of these initiatives and mandates shaping the current HIT national
landscape provides the background for understanding the importance of the
health information systems that are used to promote excellent, cost-effective
patient care.
1990s: THE CALL FOR HIT
Institute of Medicine CPR Report
The Institute of Medicine (IOM) report The Computer-Based Patient Record:
An Essential Technology for Health Care (Dick & Steen, 1991) brought
international attention to the numerous problems inherent in paper-based
medical records and called for the adoption of the computer-based patient
record (CPR) as the standard by the year 2001. The IOM defi ned the
CPR as “an electronic patient record that resides in a system specifi
cally designed to support users by providing accessibility to complete and
accurate data, alerts, reminders, clinical decision support systems, links
to medical knowledge, and other aids” (Dick & Steen, 1991, p. 11). This
vision of a patient’s record offered far more than an electronic version of
existing paper records—the IOM report viewed the CPR as a tool to assist
the clinician in caring for the patient by providing him or her with remind
ers, alerts, clinical decision–support capabilities, and access to the latest
research findings on a particular diagnosis or treatment modality. CPR
systems and related applications, such as EHRs, will be further discussed
20 0 0 – 2010 : T HE A R RI VA L O F H I T · 5
in Chapter Three. At this point, it is important to understand the IOM
report’s impact on the vendor community and health care organizations.
Leading vendors and health care organizations saw this report as an
impetus toward radically changing the ways in which patient information
would be managed and patient care delivered. During the 1990s, a number
of vendors developed CPR systems. However, despite the fact that these
systems were, for the most part, reliable and technically mature by the
end of the decade, only 10 percent of hospitals and less than 15 percent
of physician practices had implemented them (Goldsmith, 2003). Needless
to say, the IOM goal of widespread CPR adoption by 2001 was not met.
The report alone was not enough to entice organizations and individual
providers to commit to the required investment of resources to make the
switch from predominantly paper records.
Health Insurance Portability and Accountability Act (HIPAA)
Five years after the IOM report advocating CPRs was published, President
Clinton signed into law the Health Insurance Portability and Account
ability Act (HIPAA) of 1996 (which is discussed in detail in Chapter Nine).
HIPAA was designed primarily to make health insurance more affordable
and accessible, but it included important provisions to simplify adminis
trative processes and to protect the security and confidentiality of personal
health information. HIPAA was part of a larger health care reform effort and
a federal interest in HIT for purposes beyond reimbursement. HIPAA also
brought national attention to the issues surrounding the use of personal
health information in electronic form. The Internet had revolutionized the
way that consumers, providers, and health care organizations accessed health
information, communicated with each other, and conducted business, creat
ing new risks to patient privacy and security.
2000–2010: THE ARRIVAL OF HIT
IOM Patient Safety Reports
A second IOM report, To Err Is Human: Building a Safer Health Care System
(Kohn, Corrigan, & Donaldson, 2000), brought national attention to research
estimating that 44,000 to 98,000 patients die each year because of medical
errors. A subsequent related report by the IOM Committee on Data Stan
dards for Patient Safety, Patient Safety: Achieving a New Standard for Care
(Aspden, 2004), called for health care organizations to adopt information
6 · C H A P T E R 1: T H E N AT I O N A L H E A LT H I N F O R M AT I O N T E C H N O L O G Y L A N D S C A P E
technology capable of collecting and sharing essential health information on
patients and their care. This IOM committee examined the status of stan
dards, including standards for health data interchange, terminologies, and
medical knowledge representation. Here is an example of the committee’s
conclusions:
• As concerns about patient safety have grown, the health care
sector has looked to other industries that have confronted similar
challenges, in particular, the airline industry. This industry learned
long ago that information and clear communications are critical to
the safe navigation of an airplane. To perform their jobs well and
guide their plane safely to its destination, pilots must communicate
with the airport controller concerning their destination and current
circumstances (e.g., mechanical or other problems), their fl ight
plan, and environmental factors (e.g., weather conditions) that
could necessitate a change in course. Information must also pass
seamlessly from one controller to another to ensure a safe and
smooth journey for planes flying long distances, provide notification
of airport delays or closures because of weather conditions, and
enable rapid alert and response to extenuating circumstance, such as
a terrorist attack.
• Information is as critical to the provision of safe health care—which
is free of errors of commission and omission—as it is to the safe
operation of aircraft. To develop a treatment plan, a doctor must have
access to complete patient information (e.g., diagnoses, medications,
current test results, and available social supports) and to the most
current science base (Aspden, 2004).
Whereas To Err Is Human focused primarily on errors that occur in hospi
tals, the 2004 report examined the incidence of serious safety issues in other
settings as well, including ambulatory care facilities and nursing homes. Its
authors point out that earlier research on patient safety focused on errors
of commission, such as prescribing a medication that has a potentially fatal
interaction with another medication the patient is taking, and they argue
that errors of omission are equally important. An example of an error of
omission is failing to prescribe a medication from which the patient would
likely have benefited (Institute of Medicine, Committee on Data Standards
for Patient Safety, 2003). A significant contributing factor to the unacceptably
high rate of medical errors reported in these two reports and many others is
poor information management practices. Illegible prescriptions, unconfi rmed
20 0 0 – 2010 : T HE A R RI VA L O F H I T · 7
verbal orders, unanswered telephone calls, and lost medical records could all
place patients at risk.
Transparency and Patient Safety
The federal government also responded to quality of care concerns by pro
moting health care transparency (for example, making quality and price
information available to consumers) and furthering the adoption of HIT. In
2003, the Medicare Modernization Act was passed, which expanded the
program to include prescription drugs and mandated the use of electronic
prescribing (e-prescribing) among health plans providing prescription drug
coverage to Medicare beneficiaries. A year later (2004), President Bush called
for the widespread adoption of EHR systems within the decade to improve
efficiency, reduce medical errors, and improve quality of care. By 2006, he
had issued an executive order directing federal agencies that administer or
sponsor health insurance programs to make information about prices paid
to health care providers for procedures and information on the quality of
services provided by physicians, hospitals, and other health care providers
publicly available. This executive order also encouraged adoption of HIT
standards to facilitate the rapid exchange of health information (The White
House, 2006).
During this period significant changes in reimbursement practices also
materialized in an effort to address patient safety, health care quality, and
cost concerns. Historically, health care providers and organizations had
been paid for services rendered regardless of patient quality or outcome.
Nearing the end of the decade, payment reform became a hot item. For
example, pay for performance (P4P) or value-based purchasing pilot
programs became more widespread. P4P reimburses providers based on
meeting predefined quality measures and thus is intended to promote
and reward quality. The Centers for Medicare and Medicaid Services
(CMS) notified hospitals and physicians that future increases in payment
would be linked to improvements in clinical performance. Medicare also
announced it would no longer pay hospitals for the costs of treating certain
conditions that could reasonably have been prevented—such as bedsores,
injuries caused by falls, and infections resulting from the prolonged use of
catheters in blood vessels or the bladder—or for treating “serious prevent
able” events—such as leaving a sponge or other object in a patient during
surgery or providing the patient with incompatible blood or blood prod
ucts. Private health plans also followed Medicare’s lead and began denying
payment for such mishaps. Providers began to recognize the importance
8 · C H A P T E R 1: T H E N AT I O N A L H E A LT H I N F O R M AT I O N T E C H N O L O G Y L A N D S C A P E
of adopting improved HIT to collect and transmit the data needed under
these payment reforms.
Office of the National Coordinator for Health
Information Technology
In April 2004, President Bush signed Executive Order No. 13335, 3 C.F.R.,
establishing the Office of the National Coordinator for Health Information
Technology (ONC) and charged the office with providing “leadership for
the development and nationwide implementation of an interoperable health
information technology infrastructure to improve the quality and efficiency
of health care.” In 2009, the role of the ONC (organizationally located within
the US Department of Health and Human Services) was strengthened when
the Health Information Technology for Economic and Clinical Health
(HITECH) Act legislatively mandated it to provide leadership and oversight
of the national efforts to support the adoption of EHRs and health informa
tion exchange (HIE) (ONC, 2015).
In spite of the various national initiatives and changes to reimbursement
during the first decade of the twenty-first century, by the end of the decade
only 25 percent of physician practices (Hsiao, Hing, Socey, & Cai, 2011) and
12 percent of hospitals (Jha, 2010) had implemented “basic” EHR systems.
The far majority of solo and small physician practices continued to use paperbased medical record systems. Studies show that the relatively low adoption
rates among solo and small physician practices were because of the cost of
HIT and the misalignment of incentives (Jha et al., 2009). Patients, payers,
and purchasers had the most to gain from physician use of EHR systems, yet
it was the physician who was expected to bear the total cost. To address this
misalignment of incentives issue, to provide health care organizations and
providers with some funding for the adoption and Meaningful Use of EHRs,
and to promote a national agenda for HIE, the HITECH Act was passed as a
part of the American Recovery and Reinvestment Act in 2009.
2010–PRESENT: HEALTH CARE REFORM AND
THE GROWTH OF HIT
HITECH and Meaningful Use
An important component of HITECH was the establishment of the Medicare
and Medicaid EHR Incentive Programs. Eligible professionals and hospitals
that adopt, implement, or upgrade to a certified EHR received incentive pay
ments. After the first year of adoption, the providers had to prove successfully
2 0 1 0 – P R E S E N T: H E A L T H C A R E R E F O R M A N D T H E G R O W T H O F H I T · 9
that they were “demonstrating Meaningful Use” of certified EHRs to receive
additional incentive payments. The criteria, objectives, and measures for
demonstrating Meaningful Use evolved over a five-year period from 2011 to
2016. The first stage of Meaningful Use criteria was implemented in 2011–2012
and focused on data capturing and sharing. Stage 2 (2014) criteria are
intended to advance clinical processes, and Stage 3 (2016) criteria aim to show
improved outcomes. Table 1.1 provides a broad overview of the Meaningful
Use criteria by stage.
Through the Medicare EHR Incentive Program, each eligible professional
who adopted and achieved meaningful EHR use in 2011 or 2012 was able
to earn up to $44,000 over a five-year period. The amount decreased over
the period, creating incentives to providers to start sooner rather than later.
Table 1.1 Stages of Meaningful Use
Stage 1:
Meaningful Use criteria
focus
Stage 2:
Meaningful Use criteria
focus
Stage 3:
Meaningful Use criteria
focus
Electronically capturing
health information in a
standardized format
More rigorous HIE
Improving quality, safety,
and efficiency leading
to improved health
outcomes
Using that information
to track key clinical
conditions
Increased requirements
for e-prescribing and
incorporating lab
results
Decision support for
national high-priority
conditions
Communicating that
information for care
coordination processes
Electronic transmission
of patient summaries
across multiple settings
Patient access to selfmanagement tools
Initiating the reporting
of clinical quality
measures and public
health information
More patient-controlled
data
Access to comprehensive
patient data through
patient-centered HIE
Using information to
engage patients and
their families in their
care
Source: ONC (n.d.a.).
Improving population
health
10 · C H A P T E R 1 : T H E N A T I O N A L H E A L T H I N F O R M A T I O N T E C H N O L O G Y L A N D S C A P E
Eligible hospitals could earn over $2 million through the Medicare EHR
Incentive Program, and the Medicaid program made available up to $63,500
for each eligible professional (through 2021) and over $2 million to each
eligible hospital. As of December 2015, more than 482,000 health care pro
viders received a total of over $31 billion in payments for participating in the
Medicare and Medicaid EHR Incentive Programs (CMS, n.d.). See Table 1.2
for primary differences between the two incentive programs.
Within the ONC, the Office of Interoperability and Standards oversees
certification programs for HIT. The purpose of certification is to provide
assurance to EHR purchasers and other users that their EHR system has the
technological capability, functionality, and security needed to assist them in
meeting Meaningful Use criteria. Eligible providers who apply for the EHR
Medicare and Medicaid Incentive Programs are required to use certified EHR
technology. The ONC has authorized certain organizations to perform the
actual testing and certification of EHR systems.
Other HITECH Programs
Many small physician practices and rural hospitals do not have the in-house
expertise to select, implement, and support EHR systems that meet certifica
tion standards. To address these needs, HITECH funded sixty-two regional
extension centers (RECs) throughout the nation to support providers in adopt
ing and becoming meaningful users of EHRs. The RECs are primarily intended
to provide advice and technical assistance to primary care providers, espe
cially those in small practices, and to small rural hospitals, which often do not
have information technology (IT) expertise. Furthermore, HITECH provided
funding for various workforce training programs to support the education
of HIT professionals. The education-based programs included curriculum
development, community college consortia, competency examination, and
university-based training programs, with the overarching goal of training an
additional forty-five thousand HIT professionals. Funding was also made avail
able to seventeen Beacon communities and Strategic Health IT Advanced
Research Projects (SHARP) across the nation. The Beacon programs are
leading organizations that are demonstrating how HIT can be used in innova
tive ways to target specific health problems within communities (HealthIT.gov,
2012). These programs are illustrating HIT’s role in improving individual and
population health outcomes and in overcoming barriers such as coordination
of care, which plagues our nation’s health care system (McKethan et al., 2011).
Achieving Meaningful Use requires that health care providers are able to
share health information electronically with others using a secure network
for HIE. To this end, HITECH provided state grants to help build the HIE
2 0 1 0 – P R E S E N T: H E A L T H C A R E R E F O R M A N D T H E G R O W T H O F H I T · 11
Table 1.2 Differences between Medicare and Medicaid EHR incentive programs
Medicare EHR Incentive Program
Medicaid EHR Incentive Program
Federally implemented and available
nationally
Implemented voluntarily by states
Medicare Advantage professionals have
special eligibility accommodations.
Medicaid managed care professionals
must meet regular eligibility
requirements.
Open to physicians, subsection (d)
hospitals, and critical access hospitals
Open to five types of professionals and
three types of hospitals
Same definition of Meaningful Use
applied to all participants nationally
States can adopt a more rigorous
definition of Meaningful Use.
Must demonstrate Meaningful Use in
fi rst year
Adopt, implement, or upgrade option in
fi rst year
Maximum incentive for eligible
Maximum incentive for eligible
professionals is $63,750.
professionals is $44,000; 10 percent
for HPSA (health professional shortage
area).
2014 is the last year in which a
professional can initiate participation.
2016 is the last year in which a
professional can initiate participation.
Payments over five years
Payments over six years
In 2015 fee reductions (penalties) begin
for those who do not demonstrate
Meaningful Use of a certified HER.
No fee reductions (penalties)
2016 is the last incentive payment year.
2021 is the last incentive payment year.
No Medicare patient population
minimum is required.
Eligible professionals must have a
30 percent Medicaid population
(20 percent for pediatricians) to
participate; this must be demonstrated
annually.
Source: Carson, Garr, Goforth, and Forkner (2010).
infrastructure for exchange of electronic health information among provid
ers and between providers and consumers. Nearly all states have approved
strategic and operational plans for moving forward with implementation of
their HIE cooperative agreement programs.
12 · C H A P T E R 1 : T H E N A T I O N A L H E A L T H I N F O R M A T I O N T E C H N O L O G Y L A N D S C A P E
Affordable Care Act
In addition to the increased efforts to promote HIT through legislated pro
grams, the early 2010s brought dramatic change to the health care sector as
a whole with the passage of significant health care reform legislation. Amer
icans have grappled for decades with some type of “health care reform” in
an attempt to achieve the simultaneous “triple aims” for the US health care
delivery system:
• Improve the patient experience of care
• Improve the health of populations
• Reduce per capita cost of health care (IHI, n.d.)
Full achievement of these aims has been challenging within a health care
delivery system managed by different stakeholders—payers, providers, and
patients—whose goals are frequently not well aligned. The latest attempt at
reform occurred in 2010, when President Obama signed into law the Patient
Protection and Affordable Care Act (PPACA), now known as the Affordable
Care Act (ACA).
Along with mandating that individuals have health insurance and
expanding Medicaid programs, the ACA created the structure for health
insurance exchanges, including a greater role for states, and imposed
changes to private insurance, such as prohibiting health plans from
placing lifetime limits on the dollar value of coverage and prohibiting
preexisting condition exclusions. Numerous changes were to be made to
the Medicare program, including continued reductions in Medicare pay
ments to certain hospitals for hospital-acquired conditions and excessive
preventable hospital readmissions. Additionally, the CMS established an
innovation center to test, evaluate, and expand different payment struc
tures and methodologies to reduce program expenditures while main
taining or improving quality of care. Through the innovation center and
other means, CMS has been aggressively pursuing implementation of
value-based payment methods and exploring the viability of alternative
models of care and payment.
The final assessment of the success of ACA is still unknown; however,
what is certain is that its various programs will rely heavily on quality HIT
to achieve their goals. A greater emphasis than ever is placed on facilitating
patient engagement in their own care through the use of technology. On the
other end of the spectrum, new models of care and payment include improved
health for populations as an explicit goal, requiring HIT to manage the sheer
volume and complexity of data needed.
2 0 1 0 – P R E S E N T: H E A L T H C A R E R E F O R M A N D T H E G R O W T H O F H I T · 13
Value-Based Payment Programs
Shortly after the ACA was passed, CMS implemented several value-based
payment programs in an effort to reward health care providers with incentive
payments for the quality of care they provide to Medicare patients. In 2015,
the Medicare Access and CHIP Reauthorization Act (MACRA) was signed
into law. Among other things, MACRA outlines a timetable for the 2019
implementation of a merit-based incentive payment system (MIPS) that will
replace other value-based payment programs, including the EHR Incentive
Programs. MIPS will use a set of performance measures, divided into catego
ries, to calculate a score (between 0 and 100) for eligible professionals. Each
category of performance will be weighted as shown in Table 1.3.
Health care providers meeting the established threshold score will receive
no adjustment to payment; those scoring below will receive a negative adjust
ment, and those above, a positive adjustment. Exceptional performers may
receive bonus payments (CMS, n.d.).
Alternate Payment Methods
Providers who meet the criteria to provide an alternate payment method
(APM) will receive bonus payments and will be exempt from the MIPS.
Although there are likely to be other APMs identified over time, three types
are receiving a great deal of attention currently: accountable care organi
zations (ACOs), bundled payments, and patient-centered medical homes
(PCMHs). ACOs are “networks of . . . health care providers that share respon
sibility for coordinating care and meeting health care quality and cost metrics
for a defined patient population” (Breakaway Policy Strategies for FasterCures,
2015, p. 2). Bundled payments aim to incentivize providers to improve care
coordination, promote teamwork, and lower costs. Payers will compensate
Table 1.3 MIPS performance categories
Category
Weight (%)
Quality
50
Advancing care information
25
Clinical practice improvement activities
15
Resource use
10
14 · C H A P T E R 1 : T H E N A T I O N A L H E A L T H I N F O R M A T I O N T E C H N O L O G Y L A N D S C A P E
providers with a single payment for an episode of care. PCMHs are APMs
that are rooted in the private sector. In 2007, four physician societies pub
lished a joint statement of principles emphasizing a personal physician–led
coordination of care. All of the APMs rely heavily on HIT. ACOs and PCMHs,
in particular, require that HIT support the organization and its providers in
the carrying out the following functions:
• Manage and coordinate integrated care.
• Identify, manage, and reduce or contain costs.
• Adhere to evidence-based practice guidelines and standards of care;
ensure quality and safety.
• Manage population health.
• Engage patients and their families and caregivers in their own care.
• Report on quality outcomes.
HIT Interoperability Efforts
Despite efforts dating back to the first reports on the need for adoption of
computerized patient records, complete interoperability among HIT systems,
which is key to supporting an integrated health care delivery system that
provides improved care to individuals and populations while managing costs,
remains elusive. The federal government, along with other provider, vendor,
and professional organizations, however, recognize this need for interopera
bility. The ONC defines interoperability as “the ability of a system to exchange
electronic health information with and use electronic health information from
other systems without special effort on the part of the user” (ONC, n.d.a).
Interoperability among HIT encompasses far more than just connected EHRs
across systems. Home health monitoring systems are becoming common
place, telehealth is on the rise, and large public health databases exist at
state and national levels. True interoperability will encompass any electronic
sources with information needed to provide the best possible health care.
Some of the more notable efforts toward HIT interoperability include
the efforts by the government under the direction of the ONC and several
other national public and private organizations. In 2015, the ONC published
“Connecting Health and Care for the Nation: A Shared Nationwide Interop
erability Roadmap,” a ten-year plan for achieving HIT interoperability in the
United States. Figure 1.1 summarizes the key milestones identified in the ONC
road map. The ultimate goal for 2024 is “a learning health system enabled
by nationwide interoperability.” The goal of the learning health system is to
2 0 1 0 – P R E S E N T: H E A L T H C A R E R E F O R M A N D T H E G R O W T H O F H I T · 15
Figure 1.1 Milestones for a supportive payment and regulatory environment
Source: ONC (2015).
improve the health of individuals and populations by “generating information
and knowledge from data captured and updated over time . . . and sharing and
disseminating what is learned in timely and actionable forms that directly
enable individuals, clinicians, and public health entities to . . . make informed
decisions” (ONC, 2015, p. 18).
Health Level Seven International (HL7), a not-for-profit, ANSI (American
National Standards Institute)–accredited, standards-developing organization,
is focused on technical standards for HIE. The HL7 Fast Healthcare Interop
erability Resources (FHIR) standards were introduced in 2012 and are under
development to improve the exchange of EHR data. About this same time
Healtheway, now the Sequoia Project, was chartered as a nonprofit organi
zation to “advance the implementation of secure, interoperable nationwide
health information exchange” (Sequoia Project, n.d.a). The Sequoia Project
supports several initiatives, including the eHealth Exchange, a group of
government and nongovernment organizations devoted to improving patient
care through “interoperable health information exchange” (Sequoia Project,
n.d.a). Unlike HL7, which focuses on technical standards, eHealth Exchange’s
primary focus is on the legal and policy barriers associated with nationwide
interoperability. Another Sequoia initiative, Carequality, strives to connect
private HIE networks. Another private endeavor, Commonwell Health Alli
ance, is a consortium of HIT vendors and other organizations that are com
mitted to achieving interoperability. Commonwell began in 2013 with six
EHR vendors. In 2015, their membership represented 70 percent of hospitals.
Provider members of Commonwell register their patients in order to exchange
easily information with other member providers (Jacob, 2015).
Although HIT has become commonplace across the continuum of care,
seamless interoperability among the nation’s HIT systems has not yet been
realized. One author describes the movement toward HIT interoperability in
the United States not as a straight path but rather as a jigsaw puzzle with
multiple public and private organizations “working on different pieces”
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(Jacob, 2015). Interoperability requires not only technical standards but also
a national health information infrastructure, along with an effective gov
erning system. Concerns about the misalignment of incentives for achiev
ing interoperability remain. Most experts agree that technology is not the
barrier to interoperability. Governance and alignment of agendas among
disparate organizations are cited as the most daunting barriers. Because of
its potential to affect seriously the progress of interoperability, in 2015, the
ONC reported to Congress on the phenomenon of health information block
ing, which is defined as occurring “when persons or entities knowingly and
unreasonably interfere with the exchange or use of electronic health infor
mation” (ONC, 2015). The report charged that current economic incentives
were not supportive of information exchange and that some of the current
market practices actually discouraged sharing health information (DeSalvo
& Daniel, 2015).
SUMMARY
Chapter One provides a brief chronological overview of the some of the most
significant national drivers in the development, growth, and use of HIT in
the United States. Since the 1990s and the publication of The Computer-Based
Patient Record: An Essential Technology for Health Care, the national HIT
landscape has certainly evolved, and it will continue to do so. Challenges
to realizing an integrated national HIT infrastructure are numerous, but the
need for one has never been greater. Recognizing that the technology is not
the major barrier to the national infrastructure, the government, through
legislation, CMS incentive programs, the ONC, and other programs, will
continue to play a significant role in the Meaningful Use of HIT, pushing for
the alignment of incentives within the health care delivery system.
In a 2016 speech, CMS acting chief Andy Slavitt summed up the govern
ment’s role in achieving its HIT vision with the following statements:
The focus will move away from rewarding providers for the use of tech
nology and towards the outcome they achieve with their patients.
Second, providers will be able to customize their goals so tech compa
nies can build around the individual practice needs, not the needs of the
government. Technology must be user-centered and support physicians,
not distract them.
Third, one way to aid this is by leveling the technology playing field for
start-ups and new entrants. We are requiring open APIs . . . that allow
apps, analytic tools, and connected technologies to get data in and out of
an EHR securely.
K E Y T E R M S · 17
We are deadly serious about interoperability. We will begin initiatives . . .
pointing technology to fill critical use cases like closing referral loops and
engaging a patient in their care.
Technology companies that look for ways to practice “data blocking” in oppo
sition to new regulations will find that it won’t be tolerated. (Nerney, 2016)
Many of the initiatives discussed in Chapter One will be explored more
fully in subsequent chapters of this book. The purpose of Chapter One is
to provide the reader with a snapshot of the national HIT landscape and
enough historical background to set the stage for why health care managers
and leaders must understand and actively engage in the implementation of
effective health information systems to achieve better health for individuals
and populations while managing costs.
KEY TERMS
Accountable Care Organizations (ACOs)
Affordable Care Act (ACA)
Alternate payment methods (APM)
American Recovery and Reinvestment
Act
ANSI (American National Standards
Institute)
Beacon communities
Bundled payments
Centers for Medicare and Medicaid
Services (CMS)
Commonwell Health Alliance
Computer-based patient record (CPR)
Coordination of care
eHealth Exchange
Electronic health records (EHRs)
e-prescribing
Fast Healthcare Interoperability
Resources (FHIR) standards
Health information blocking
Health information exchange (HIE)
Health information technology (HIT)
Health Information Technology for
Economic and Clinical Health
(HITECH) Act
Health Insurance Portability and
Accountability Act (HIPAA)
Health Level Seven International
(HL7)
HIT interoperability
Meaningful Use of EHR
Medicare Access and CHIP
Reauthorization Act (MACRA)
Medicare Modernization Act
Merit-based incentive payment system
(MIPS)
Nationwide Interoperability
Roadmap
Office of the National Coordinator
for Health Information Technology
(ONC)
Patient-centered medical homes
(PCMHs)
Patient safety
Pay for performance (P4P)
Regional extension centers (RECs)
Strategic Health IT Advanced
Research Projects (SHARP)
The Sequoia Project
Value-based payment
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LEARNING ACTIVITIES
1. Investigate the latest Meaningful Use criteria for eligible professionals
or eligible hospitals. Visit either a physician practice or hospital in
your community. Have they participated in the Medicare or Medicaid
EHR Incentive Program? Why or why not? If the organization or
provider has participated in the program, what has the experience
been like? What lessons have they learned? Find out the degree to
which the facility uses EHRs and what issues or challenges they have
had in achieving Meaningful Use.
2. Evaluate different models of care within your local community or
state. Did you find any examples of accountable care organizations
or patient-centered medical homes? Explain. Working as a team, visit
or interview a leader from a site that uses an innovative model of
care. Describe the model, its use, challenges, and degree of patient
coordination and integration. How is HIT used to support the delivery
of care and reporting of outcomes?
3. Investigate one of the Beacon communities to find out how they
are using HIT to improve quality of care and access to care within
their region. Be prepared to share with the class a summary of your
findings. Do you think the work that this Beacon community has
done could be replicated in your community? Why or why not?
4. Explore the extent to which health information exchange is occurring
within your community, region, or state. Who are the key players?
What types of models of health information exchange exist? To
what extent is information being exchanged across organizations for
patient care purposes?
5. Investigate the CMS website to determine their current and proposed
value-based or pay-for-performance programs. Compare one or more
of the programs to the traditional fee-for-service payment method.
What are the advantages and disadvantages of each to a physician
provider in a small practice?
REFERENCES
Aspden, P. (2004). Patient safety: Achieving a new standard for care. Washington,
DC: National Academies Press.
Breakaway Policy Strategies for FasterCures. (2015). A closer look at alternative
payment models. FasterCures value and coverage issue brief. Retrieved August 4,
2016, from http://www.fastercures.org/assets/Uploads/PDF/VC-Brief-Alternative
PaymentModels.pdf
R E F E R E N C E S · 19
Carson, D. D., Garr, D. R., Goforth, G. A., & Forkner, E. (2010). The time to hesitate
has passed: The age of electronic health records is here (pp. 2–11). Columbia,
SC: South Carolina Medical Association.
Centers for Medicare & Medicaid Services (CMS). (n.d.). The merit-based incen
tive payment system: MIPS scoring methodology overview. Retrieved August
4, 2016, from https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/
MIPS-Scoring-Methodology-slide-deck.pdf
DeSalvo, K., & Daniel, J. (2015, April 10). Blocking of health information undermines
health system interoperability and delivery reform. HealthIT Buzz. Retrieved
August 4, 2016, from https://www.healthit.gov/buzz-blog/from-the-onc-desk/
health-information-blocking-undermines-interoperability-delivery-reform/
Dick, R. S., & Steen, E. B. (1991). The computer-based patient record: An essential
technology for health care. Washington, DC: National Academy Press.
Goldsmith, J. C. (2003). Digital medicine: Implications for healthcare leaders.
Chicago, IL: Health Administration Press.
HealthIT.gov. (2012). The Beacon community program improving health through
health information technology [Brochure]. Retrieved August 3, 2016, from
https://www.healthit.gov/sites/default/fi les/beacon-communities-lessons
learned.pdf
Hsiao, C., Hing, E., Socey, T., & Cai, B. (2011, Nov.). Electronic medical record/
electronic health record systems of office-based physicians: United States, 2009
and preliminary 2010 state estimates. NCHS Data Brief (79). Washington, DC:
US Department of Health and Human Services, National Center for Health
Statistics, Division of Health Care Statistics.
Institute for Healthcare Improvement (IHI). (n.d.). The IHI triple aim. Retrieved
September 22, 2016, from http://www.ihi.org/Engage/Initiatives/TripleAim/
Pages/default.aspx
Institute of Medicine, Committee on Data Standards for Patient Safety. (2003).
Reducing medical errors requires national computerized information systems:
Data standards are crucial to improving patient safety. Retrieved from http://
www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=10863
Jacob, J. A. (2015). On the road to interoperability, public and private organizations
work to connect health care data. JAMA, 314(12), 1213.
Jha, A. K. (2010). Meaningful use of electronic health records. JAMA, 304(15),
1709. doi:10.1001/jama.2010.1497
Jha, A. K., Desroches, C. M., Campbell, E. G., Donelan, K., Rao, S. R., Ferris,
T. G. . . . Blumenthal, D. (2009). Use of electronic health records in US hos
pitals. New England Journal of Medicine, 360(16), 1628–1638. doi:10.1056/
nejmsa0900592
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a
safer health system. Washington, DC: National Academy Press.
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McKethan, A., Brammer, C., Fatemi, P., Kim, M., Kirtane, J., Kunzman, J. . . .
Jain, S. H. (2011). An early status report on the Beacon Communities’ plans
for transformation via health information technology. Health Affairs, 30(4),
782–788. doi:10.1377/hlthaff.2011.0166
Nerney, C. (2016, January). CMS acting chief Slavitt on interoperabil
ity. Retrieved August 3, 2016, from http://www.hiewatch.com/news/
cms-acting-chief-slavitt-interoperability
Office of the National Coordinator for Health Information Technology (ONC).
(2015). Connecting health and care for the nation: A shared nationwide interop
erability roadmap. Retrieved August 3, 2016, from https://www.healthit.gov/
sites/default/fi les/nationwide-interoperability-roadmap-draft-version-1.0.pdf
Office of the National Coordinator for Health Information Technology (ONC).
(n.d.a). EHR incentives & certification. Retrieved September 21, 2016, from
https://www.healthit.gov/providers-professionals/how-attain-meaningful-use
Office of the National Coordinator for Health Information Technology (ONC).
(n.d.b). Interoperability. Retrieved September 21, 2016, from https://www
.healthit.gov/policy-researchers-implementers/interoperability
The Sequoia Project. (n.d.a). About the Sequoia Project. Retrieved August 4, 2016,
from http://sequoiaproject.org/about-us/
The Sequoia Project. (n.d.b). What is eHealth exchange. Retrieved from http://
sequoiaproject.org/ehealth-exchange/
The White House. (2006, August). Fact sheet: Health care transparency: Empowering
consumers to save on quality care. Retrieved September 22, 2016, from https://
georgewbush-whitehouse.archives.gov/news/releases/2006/08/20060822.html
CHAPTER 2
Health Care Data
LEARNING OBJECTIVES
• To be able to define health care data and information.
• To be able to understand the major purposes for maintaining
patient records.
• To be able to discuss basic patient health record and claims
content.
• To be able to discuss basic uses of health care data, including big
and small data and analytics.
• To be able to identify common issues related to health care data
quality.
21
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Central to health care information systems is the actual health care data
that is collected and subsequently transformed into useful health care infor
mation. In this chapter we will examine key aspects of health care data. In
particular, this chapter is divided into four main sections:
• Health care data and information defined (What are health data and
health information?)
• Health care data and information sources (Where does health data
originate and why? When does health care data become health care
information?)
• Health care data uses (How do health care organizations use data?
What is the impact of the trend toward analytics and big data on
health care data?)
• Health care data quality (How does the quality of health data affect its
use?)
HEALTH CARE DATA AND INFORMATION DEFINED
Often the terms health care data and health care information are used inter
changeably. However, there is a distinction, if somewhat blurred in current
use. What, then, is the difference between health data and health informa
tion? The simple answer is that health information is processed health data.
(We interpret processing broadly to cover everything from formal analysis to
explanations supplied by the individual decision maker’s brain.) Health care
data are raw health care facts, generally stored as characters, words, symbols,
measurements, or statistics. One thing apparent about health care data is that
they are generally not very useful for decision making. Health care data may
describe a particular event, but alone and unprocessed they are not particu
larly helpful. Take, for example, this figure: 79 percent. By itself, what does
it mean? If we process this datum further by indicating that it represents the
average bed occupancy for a hospital for the month of January, it takes on
more meaning. With the additional facts attached, is this figure now infor
mation? That depends. If all a health care executive wants or needs to know
is the bed occupancy rate for January, this could be considered information.
However, for the hospital executive who is interested in knowing the trend
of the bed occupancy rate over time or how the facility’s bed occupancy rate
compares to that of other, similar facilities, this is not yet the information
he needs. A clinical example of raw data would be the lab value, hematocrit
(HCT) = 32 or a diagnosis, such as diabetes. These are single facts, data at
the most granular level. They take on meaning when assigned to particular
H E A L T H C A R E D A T A A N D I N F O R M A T I O N D E F I N E D · 23
patients in the context of their health Figure 2.1 Health care data to
care status or analyzed as components health care knowledge
of population studies.
Knowledge is seen by some as
the highest level in a hierarchy with
data at the bottom and information in
the middle (Figure 2.1). Knowledge is
defined by Johns (1997, p. 53) as “a
combination of rules, relationships,
ideas, and experience.” Another way
of thinking about knowledge is that it
is information applied to rules, expe
riences, and relationships with the
result that it can be used for decision
making. Data analytics applied to
health care information and research
studies based on health care information are examples of transforming health
care information into new knowledge. To carry out our example from previ
ous paragraphs, the 79 percent occupancy rate could be related to additional
information to lead to knowledge that the health care facility’s referral strat
egy is working.
Where do health care data end and where does health care information
begin? Information is an extremely valuable asset at all levels of the health care
community. Health care executives, clinical staff members, and others rely on
information to get their jobs accomplished. The goal of this discussion is not
to pinpoint where data end and information begins but rather to further an
understanding of the relationship between health care data and information—
health care data are the beginnings of health care information. You cannot
create information without data. Through the rest of this chapter the terms
health care data and health care information will be used to describe either the
most granular components of health care information or data that have been
processed, respectively (Lee, 2002).
The first several sections of this chapter focus primarily on the health
care data and information levels, but the content of the section on health care
data quality takes on new importance when applied to processes for seeking
knowledge from health care data. We will begin the chapter exploring where
some of the most common health care data originate and describe some of the
most common organizational and provider uses of health care information,
including patient care, billing and reimbursement, and basic health care
statistics. Please note there are many other uses for health information that
go beyond these basics that will be explored throughout this text.
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HEALTH CARE DATA AND INFORMATION SOURCES
The majority of health care information created and used in health care
information systems within and across organizations can be found as an
entry in a patient’s health record or claim, and this information is readily
matched to a specific, identifiable patient.
The Health Insurance Portability and Accountability Act (HIPAA), the
federal legislation that includes provisions to protect patients’ health informa
tion from unauthorized disclosure, defines health information as any information,
whether oral or recorded in any form or medium, that does the following:
• Is created or received by a health care provider, health plan, public
health authority, employer, life insurer, school or university, or health
care clearinghouse
• Relates to the past, present, or future physical or mental health
or condition of an individual, the provision of health care to an
individual, or the past, present, or future payment for the provision of
health care to an individual
HIPAA refers to this type of identifiable information as protected health
information (PHI).
The Joint Commission, the major accrediting agency for many types of
health care organizations in the United States, has adopted the HIPAA defi ni
tion of protected health information as the definition of “health information”
listed in their accreditation manuals’ glossary of terms (The Joint Commis
sion, 2016). Creating, maintaining, and managing quality health information
is a significant factor in health care organizations, such as hospitals, nursing
homes, rehabilitation centers, and others, who want to achieve Joint Commis
sion accreditation. The accreditation manuals for each type of facility contain
dozens of standards that are devoted to the creation and management of
health information. For example, the hospital accreditation manual contains
two specific chapters, Record of Care, Treatment, and Services (RC) and Infor
mation Management (IM). The RC chapter outlines specific standards govern
ing the components of a complete medical record, and the IM chapter outlines
standards for managing information as an important organizational resource.
Medical Record versus Health Record
The terms medical record and health record are often used interchangeably
to describe a patient’s clinical record. However, with the advent and subse
quent evolution of electronic versions of patient records these terms actually
describe different entities. The Office of the National Coordinator for Health
H E A L T H C A R E D A T A A N D I N F O R M A T I O N S O U R C E S · 25
Information Technology (ONC) distinguishes the electronic medical record
and the electronic health record as follows.
Electronic medical records (EMRs) are a digital version of the paper
charts. An EMR contains the medical and treatment history of the patients
in one practice (or organization). EMRs have advantages over paper records.
For example, EMRs enable clinicians (and others) to do the following:
• Track data over time
• Easily identify which patients are due for preventive screenings or
checkups
• Check how their patients are doing on certain parameters—such as
blood pressure readings or vaccinations
• Monitor and improve overall quality of care within the practice
But the information in EMRs doesn’t travel easily out of the practice (or
organization). In fact, the patient’s record might even have to be printed out
and delivered by mail to specialists and other members of the care team. In
that regard, EMRs are not much better than a paper record.
Electronic health records (EHRs) do all those things—and more. EHRs
focus on the total health of the patient—going beyond standard clinical
data collected in the provider’s office (or during episodes of care)—and is
inclusive of a broader view on a patient’s care. EHRs are designed to reach
out beyond the health organization that originally collects and compiles
the information. They are built to share information with other health care
providers (and organizations), such as laboratories and specialists, so they
contain information from all the clinicians involved in the patient’s care
(Garrett & Seidman, 2011). Another distinguishing feature of the EHR (dis
cussed in more detail in Chapter Three) is the inclusion of decision-support
capabilities beyond those of the EMR.
Patient Record Purposes
Health care organizations maintain patient clinical records for several key
purposes. As we move into the discussion on clinical information systems in
subsequent chapters, it will be important to remember these purposes, which
remain constant regardless of the format or infrastructure supporting the
records. In considering the purposes listed, the scope of care is also important.
Records support not only managing a single episode of care but also a patient’s
continuum of care and population health. Episode of care generally refers to
the services provided to a patient with a specific condition for a specific period
26 · C H A P T E R 2 : H E A L T H C A R E D A T A
of time. Continuum of care, as defined by HIMSS (2014), is a concept involving
a system that guides and tracks patients over time through a comprehensive
array of health services spanning all levels and intensity of care. Population
health is a relatively new term and definitions vary. However, the concept
behind managing population health is to improve health outcomes within
defined communities (Stoto, 2013). The following list comprises the most
commonly recognized purposes for creating and maintaining patient records.
1. Patient care. Patient records provide the documented basis for
planning patient care and treatment, for a single episode of care and
across the care continuum. This purpose is considered the numberone reason for maintaining patient records. As our health care
delivery system moves toward true population health management
and patient-focused care, the patient record becomes a critical tool for
documenting each provider’s contribution to that care.
2. Communication. Patient records are an important means by which
physicians, nurses, and others, whether within a single organization
or across organizations, can communicate with one another about
patient needs. The members of the health care team generally
interact with patients at different times during the day, week, or
even month or year. Information from the patient’s record plays an
important role in facilitating communication among providers across
the continuum of care. The patient record may be the only means
of communication among various providers. It is important to note
that patients also have a right to access their records, and their
engagement in their own care is often reflected in today’s records.
3. Legal documentation. Patient records, because they describe and
document care and treatment, are also legal records. In the event
of a lawsuit or other legal action involving patient care, the record
becomes the primary evidence for what actually took place during the
care. An old but absolutely true adage about the legal importance of
patient records says, “If it was not documented, it was not done.”
4. Billing and reimbursement. Patient records provide the
documentation patients and payers use to verify billed services.
Insurance companies and other third-party payers insist on clear
documentation to support any claims submitted. The federal
programs Medicare and Medicaid have oversight and review
processes in place that use patient records to confirm the accuracy
of claims filed. Filing a claim for a service that is not clearly
documented in the patient record may be construed as fraud.
H E A L T H C A R E D A T A A N D I N F O R M A T I O N S O U R C E S · 27
5. Research and quality management. Patient records are used in many
facilities for research purposes and for monitoring the quality of
care provided. Patient records can serve as source documents from
which information about certain diseases or procedures can be taken,
for example. Although research is most prevalent in large academic
medical centers, studies are conducted in other types of health care
organizations as well.
6. Population health. Information from patient records is used to
monitor population health, assess health status, measure utilization of
services, track quality outcomes, and evaluate adherence to evidencebased practice guidelines. Health care payers and consumers are
increasingly demanding to know the cost-effectiveness and efficacy of
different treatment options and modalities. Population health focuses
on prevention as a means of achieving cost-effective care.
7. Public health. Federal and state public health agencies use
information from patient records to inform policies and procedures to
ensure that they protect citizens from unhealthy conditions.
Patient Records as Legal Documents
The importance of maintaining complete and accurate patient records cannot
be underestimated. They serve not only as a basis for planning patient care
but also as the legal record documenting the care that was provided to
patients. The data captured in a patient record become a permanent record
of that patient’s diagnoses, treatments, response to treatments, and case
management. Patient records provide much of the source data for health
care information that is created, maintained, and managed within and across
health care organizations.
When the patient record was a file folder full of paper housed in the health
information management department of the hospital, identifying the legal
health record (LHR) was fairly straightforward. Records kept in the usual
course of business (in this case, providing care to patients) represent an
exception to the hearsay rule, are generally admissible in a court, and there
fore can be subpoenaed—they are legal documentation of the care provided
to the patients. With the implementation of comprehensive EHR systems
the definition of an LHR remains the same, but the identification of the
boundaries for it may be harder to determine. In 2013, the ONC’s National
Learning Consortium published the Legal Health Record Policy Template to
guide health care organizations and providers in defi ning which records and
record sets constitute their legal health record for administrative, business, or
28 · C H A P T E R 2 : H E A L T H C A R E D A T A
evidentiary purposes. The media on which the records are maintained does
not determine the legal status; rather, it is the purpose for which the record
was created and is maintained. The complete template can be found at www
.healthit.gov/sites/default/fi les/legal_health_policy_template.docx.
Because of the legal nature of patient reco…