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Healthcare Overview2


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Healthcare Overview2

  1. 1. Who Helps the Healers?
  2. 2. The Players Payers Providers Patients Employers
  3. 3. General Overview <ul><li>Complex field involving many separate, colliding processes. </li></ul><ul><li>Systems are chosen to meet a single need. </li></ul><ul><li>Most health care organizations have low data maturity. </li></ul><ul><li>Regulatory requirements are now beginning to force data improvement. </li></ul>Payers Employers
  4. 4. Overall General Process: Pre Visit Process Managed Care <ul><li>Patient injures Knee (ouchie!) </li></ul><ul><li>Patient makes appointment </li></ul><ul><li>Medical Assistant or Nurse pulls chart </li></ul><ul><li>Financial Assistant verifies insurance coverage </li></ul>
  5. 5. Overall General Process: The Visit and Consultation Managed Care <ul><li>Patient arrives and checks in for appointment </li></ul><ul><li>Chart put in accessible area near examination room </li></ul><ul><li>Physician: </li></ul><ul><ul><li>Diagnoses patient </li></ul></ul><ul><ul><li>Orders medication </li></ul></ul><ul><ul><li>Orders physical therapy </li></ul></ul><ul><ul><li>Orders brace </li></ul></ul><ul><ul><li>Orders blood work </li></ul></ul><ul><ul><li>Orders x-rays </li></ul></ul><ul><ul><li>Adds information to patient chart </li></ul></ul><ul><ul><li>Requests follow up visit </li></ul></ul><ul><li>Follow up is scheduled at front desk </li></ul>
  6. 6. Overall General Process: The Visit and Consultation Post Visit <ul><li>Physician dictates any notes from the case </li></ul><ul><li>Medical Billers code the information from the visit to be sent to Financial Office </li></ul><ul><li>Transcriptionists type up the dictation and attach to patient record </li></ul><ul><li>Financial Office sends remaining charges to patient’s insurance </li></ul><ul><li>Insurance examines claim </li></ul><ul><li>Insurance readjudicates claim </li></ul><ul><li>Insurance remits payment to Provider </li></ul>
  7. 7. More and more Processes <ul><li>Every Organization Varies: </li></ul><ul><ul><li>Processes </li></ul></ul><ul><ul><li>Systems (including paper!) </li></ul></ul><ul><ul><li>Data Interest </li></ul></ul><ul><li>Managed care varies widely from Fee For Service </li></ul><ul><li>Every department in an organization may operate differently </li></ul>
  8. 8. Systems in Use <ul><li>Often systems are dictated by hardware. </li></ul><ul><li>In the case of grant-funded programs, systems are determined by the funding </li></ul><ul><li>Radiology </li></ul><ul><li>Laboratory </li></ul><ul><li>Patient Intake </li></ul><ul><li>Transcription </li></ul><ul><li>PACs </li></ul><ul><li>Prescription </li></ul><ul><li>EHR </li></ul><ul><li>Tumor Registry </li></ul><ul><li>Pathology </li></ul><ul><li>ICU </li></ul><ul><li>GL </li></ul><ul><li>Billing </li></ul>Sample System List for a Hospital – by No means complete!
  9. 9. About those systems <ul><li>The systems run on a variety of databases. </li></ul><ul><li>Since hardware often dictates the system, you can find several of one type within the same organization. </li></ul><ul><li>Often databases and applications are created in-house to cater to special reporting needs. </li></ul>
  10. 10. The struggle to combine data <ul><li>Each system uses different patient identifiers. </li></ul><ul><li>In some instances, even patient identifiers can be inaccurate. </li></ul><ul><li>In geographical locations with high probability of illegal immigration, incorrect data can be used. </li></ul><ul><li>Data entry quality varies wildly. </li></ul><ul><li>High instance of free-text fields </li></ul>
  11. 11. The EHR And Why It’s harder than it sounds <ul><li>Clinical Systems </li></ul><ul><li>Non-clinical systems </li></ul><ul><li>Process Issues </li></ul><ul><li>Reluctance of Medical Staff to learn “another program” </li></ul><ul><li>Difficulty and expense of implementation </li></ul><ul><li>High probability of implementation delay or failure. </li></ul>
  12. 12. Data Issues <ul><li>Data quality varies widely between departments. </li></ul><ul><li>Some systems have no internal ‘stop’ when necessary data is not entered and allows null information in key fields. </li></ul><ul><li>Quality of data structures varies between systems. </li></ul><ul><li>Vendors often do not allow specifications to be shared. </li></ul>
  13. 13. Regulatory Bodies <ul><li>The Joint Commission (Accreditation) </li></ul><ul><li>CMS </li></ul><ul><li>Payers </li></ul><ul><li>Employers (via Payer Influence) </li></ul>
  14. 14. What HIPAA really means <ul><li>Internal data security </li></ul><ul><li>Portability of insurance </li></ul><ul><li>Non-discrimination based on prior conditions </li></ul><ul><li>Privacy of Data </li></ul>
  15. 15. Healthcare Providers: The Future <ul><li>Pay for Performance </li></ul><ul><li>Health 2.0 </li></ul><ul><li>Electronic Health Record Legislation </li></ul><ul><li>Increased scrutiny by payers, employers, and patients </li></ul>
  16. 16. Questions?