HEALTH INFORMATION MANAGEMENT

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TODAY’S

HEALTH INFORMATION MANAGEMENT AN INTEGRATED APPROACH, SECOND EDITION

by Dana C. McWay, JD, RHIA

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Today’s Health Information Management: An Integrated Approach, Second Edition Dana C. McWay

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BRIEF CONTENTS

iii

PA R T 1 INTRODUCTION TO HEALTH INFORMATION MANAGEMENT

1 Health Care Delivery Systems 3 2 The Health Information Management Profession 29 3 Legal Issues 47 4 Ethical Standards 87

CLINICAL DATA MANAGEMENT

5 Health Care Data Content and Structures 121 6 Nomenclatures and Classification Systems 147 7 Quality Health Care Management 169 8 Health Statistics 199 9 Research 231

TECHNOLOGY

10 Database Management 259 11 Information Systems and Technology 279 12 Informatics 299

MANAGEMENT

13 Management Organization 321 14 Human Resource Management 355 15 Financial Management 387 16 Reimbursement Methodologies 405

Appendix A Common HIM Abbreviations 423

Appendix B Web Resources 433

Appendix C Sample HIPPA Notices of Privacy practices 443

Appendix D Selected Laws Affecting HIM 451

Appendix E Selected HIPAA Regulations 455

Glossary 499

Index 527

PA R T 2

PA R T 3

PA R T 4

CONTENTS

1 Preface xv

PART INTRODUCTION TO HEALTH INFORMATION MANAGEMENT 1

Health Care Delivery Systems 3

Introduction 5 Historical Development 5

Early History 5 Health Care in the United States 6 Public Health 11 Mental Health 12 Occupational Health 14

Health Care Delivery Systems 15 Professional Associations 15 Voluntary Health Agencies 16 Philanthropic Foundations 17 International Health Agencies 17 Variety of Delivery Systems 17

Settings 17 Health Care Professionals 20

Medical Staff 22 Medical Staff Organization 22 Bylaws, Rules, and Regulations 23 Privileges and Credentialing 23

Conclusion 25 Chapter Summary 25 Case Study 25 Review Questions 25 Enrichment Activity 26 Web Sites 26 References 26 Notes 26

C H A P T E R 1

vi C O N T E N T S

The Health Information Management Profession 29

Introduction 31 Health Information 31

Historical Development of the Profession 31 Educational and Certification Requirements 33

Careers 37 Traditional Settings 39 Nontraditional Settings 41

Direct Patient Care Settings 42 Settings Not Involving Direct Patient Care 43

Conclusion 44 Chapter Summary 44 Case Study 44 Review Questions 44 Enrichment Activities 45 Web Sites 45 References 45 Notes 45

Legal Issues 47

Introduction 49 Overview of External Forces 49

Roles of Governmental Entities 50 Roles of Nongovernmental Entities 52 Role Application 53

Understanding the Court System 53 The Court System 53 Administrative Bodies 55

Health Records as Evidence 58 Hearsay 58 Privilege 59 Exclusions 60 Legal Procedures 60 e-Discovery 61 Additional Steps in Litigation 63

Principles of Liability 64 Intentional Torts 64 Nonintentional Torts 65 Social Media 67

Legal Issues in HIM 67 HIPAA 68

Administrative Simplification 68 Fraud and Abuse 71

Privacy and Confidentiality 71 Access to Health Care Data 73

Ownership and Disclosure 73 Identity Theft 75

Informed Consent 76 Judicial Process 77

Fraud and Abuse 78 Fraud and Abuse Laws 79 Resources to Combat Fraud and Abuse 80

C H A P T E R 2

C H A P T E R 3

C O N T E N T S vii

Conclusion 82 Chapter Summary 82 Case Study 83 Review Questions 83 Enrichment Activities 83 Web Sites 83 References 84 Notes 84

Ethical Standards 87

Introduction 89 Ethical Overview 89

Ethical Models 90 Ethical Concepts 90 Ethical Theories 93

Ethical Decision Making 94 Influencing Factors 95

Codes of Ethics 95 Patient Rights 103 Other Factors 104

Decision-Making Process 104 Bioethical Issues 106

Related to the Beginning of Life 106 Family Planning 106 Abortion 107 Perinatal Ethics 108 Eugenics 108

Related to Sustaining or Improving the Quality of Life 108 HIV/AIDS 109 Organ Transplantation 109 Genetic Science 110

Related to Death and Dying 110 Planning for End of Life 111 Euthanasia 111 Withholding/Withdrawing Treatment 111

Ethical Challenges 112 General Challenges 112 Role of Ethics in Supervision 113 Health Care Challenges 114 Health Information Management Challenges 115

Conclusion 116 Chapter Summary 116 Case Study 116 Review Questions 116 Enrichment Activities 116 Web Sites 117 References 117 Notes 117

C H A P T E R 4

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2 PART CLINICAL DATA MANAGEMENT 119

Health Care Data Content and Structures 121

Introduction 123 Types, Users, Uses, and Flow of Data 123

Types of Data 123 Users and Uses of Data 127

Patient Users 128 Data Flow 129

Forms Design and Control 131 Data Storage, Retention, and Destruction 132

Data Storage 134 Data Retention and Destruction 136

Indices and Registries 139 Indices 139 Registries 140

Registry Types 142 Conclusion 143 Chapter Summary 143 Case Study 143 Review Questions 143 Enrichment Activities 144 Web Sites 144 References 144 Notes 144

Nomenclatures and Classification Systems 147

Introduction 149 Languages, Vocabularies, and Nomenclatures 149

Nomenclature Development 150 Classification Systems 152

History and Application of Classification Systems 152 Diagnosis-Related Groups 155

HIM Transformation 157 Other Classification Systems 163

Emerging Issues 164 Conclusion 166 Chapter Summary 166 Case Study 166 Review Questions 167 Enrichment Activity 167 Web Sites 167 References 167 Notes 168

C H A P T E R 6

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C H A P T E R 5

C O N T E N T S ix

Quality Health Care Management 169

Introduction 171 Data Quality 171

Historical Development 171 Federal Efforts 175 Private Efforts 176

Tools 178 Performance Improvement and Risk Management 187

Performance Improvement 187 Risk Management 189

Utilization Management 191 Utilization Review Process 192

Conclusion 195 Chapter Summary 195 Case Study 196 Review Questions 196 Enrichment Activity 196 Web Sites 197 References 197 Notes 197

Health Statistics 199

Introduction 201 Overview 201

Statistical Types 202 Statistical Literacy 203

Statistical Basics 204 Measures of Central Tendency 205 Other Mathematical Concepts 206 Data Collection 208 Statistical Formulas 209

Data Presentation 212 Regression Analysis 215

Regression Analysis Models 217 Health Information Management Statistics 221

Productivity 221 Statistical Tools 223

Conclusion 226 Chapter Summary 226 Case Studies 226 Review Questions 229 Enrichment Activities 229 Web Sites 230 References 230 Notes 230

C H A P T E R 7

C H A P T E R 8

x C O N T E N T S

Research 231

Introduction 233 Research Principles 233

Historical Overview 233 Methodology 234

Qualitative and Quantitative Research 234 Study Types 235

Research Study Process 239 Research Design 239 Publication Process 240

Institutional Review Boards 241 Historical Overview 241 Review Process 243

Review of Research on Animals 246 Emerging Trends 247

Epidemiology 248 Historical Overview 249 Epidemiological Basics 250

Disease Progression 251 Types of Epidemiology 252 Descriptive Epidemiology 252 Analytic and Experimental Epidemiology 253

Conclusion 254 Chapter Summary 254 Case Study 254 Review Questions 254 Enrichment Activities 255 Web Sites 255 References 255 Notes 255

PART TECHNOLOGY 257

Database Management 259

Introduction 261 Concepts and Functions 261

Database Design 263 Controls 265 Data Standards 265 Retrieval and Analysis Methods 267

Data Sets 268 Data Exchange 272

State and Local Data Exchange Efforts 274 Conclusion 275 Chapter Summary 276 Case Study 276 Review Questions 276 Enrichment Activities 276 Web Sites 276 References 277 Notes 277

C H A P T E R 9

C H A P T E R 1 0

C O N T E N T S xi

Information Systems and Technology 279

Introduction 281 Information Systems 281

Computer Concepts 281 Hardware 282 Software 285 Units of Measure and Standards 285

Information Systems Life Cycle 286 Communication Technologies 288 Security 290

HIPAA Security Rule 291 Systems Architecture 293

Systems Architecture Specifics 293 Conclusion 295 Chapter Summary 295 Case Study 295 Review Questions 296 Enrichment Activity 296 Web Sites 296 References 296 Notes 297

Informatics 299

Introduction 301 Overview 301 Electronic Health Records 302

Meaningful Use 305 Legal Health Record 310

Technology Applications and Trends 311 Role of Social Media in Health Care 313

Conclusion 316 Chapter Summary 316 Case Study 316 Review Questions 317 Enrichment Activity 317 Web Sites 317 References 317 Notes 317

C H A P T E R 1 1

C H A P T E R 1 2

xii C O N T E N T S

4C H A P T E R 1 3PART MANAGEMENT 319Management Organization 321Introduction 323Principles of Management 323Planning 323Strategic Planning 323Management Planning 325 Operational Planning 326 Disaster Planning 326 Planning Tools 329

Organizing 329 Design and Structure 330 Organizing People 331 Organizing the Type of Work 335 Organizing Work Performance 335 Organizing the Work Environment 335

Directing 336 Decision Making 336 Instructing Others 337 Work Simplification 338

Controlling 338 Types of Controls 338 Setting Standards 339 Monitoring Performance 339

Leading 340 Motivating 340 Directing Others 341 Resolving Conflicts 342 Effective Communication 342

Management Theories 343 Historical Overview 343 Specialized Management Theories 344

Change Management 344 Project Management 345 Process Improvement 346 Knowledge Management 348 Effective Meeting Management 351

Conclusion 351 Chapter Summary 352 Case Study 352 Review Questions 352 Enrichment Activities 352 Web Sites 353 References 353 Notes 353

xii C O N T E N T S

C O N T E N T S xiii

Human Resource Management 355

Introduction 357 Employment 357 Staffing 358

Recruitment 358 Selection 358 Compensation 364 Orientation and Training 364 Retention 365 Separation 366

Employee Rights 367 Overview 367 Employment Law Application 368

Discrimination 368 Sex Discrimination 368 Racial, Religious, and National Origin Discrimination 369 Age Discrimination 370 Disability Discrimination 370 Genetic Discrimination 372 Workplace Protections 372 Social Media 375

Supervision 376 Performance Evaluations 376 Problem Behaviors 377 Discipline and Grievance 378 Developing Others 379

Career Development 379 Coaching 379 Mentoring 380

Team Building 380 Telework 381

Workforce Diversity 383 Conclusion 384 Chapter Summary 384 Case Study 384 Review Questions 384 Enrichment Activities 384 Web Sites 385 References 385 Notes 385

C H A P T E R 1 4

xiv C O N T E N T S

Financial Management 387

Introduction 389 Overview 389 Accounting 391

Managerial Accounting 391 Financial Accounting 393

Budgets 395 Procurement 399

Procurement Requests 400 Conclusion 402 Chapter Summary 402 Case Study 402 Review Questions 402 Enrichment Activities 402 Web Sites 403 References 403

Reimbursement Methodologies 405

Introduction 407 Third-Party Payers 407

Governmental Payers 408 Nongovernmental Payers 409

Managed Care Organizations 411 Health Insurance Exchanges 413

Payment Methodologies 414 Fee for Service 414 Prospective Payment Systems 415 Resource-Based Relative Value Systems 416 Capitation 416

Revenue Cycle Management 417 Conclusion 419 Chapter Summary 419 Case Study 420 Review Questions 420 Enrichment Activities 420 Web Sites 420 References 421 Notes 421

Common HIM Abbreviations 423

Web Resources 433

Sample HIPPA Notices of Privacy Practices 443

Selected Laws Affecting HIM 451

Selected HIPAA Regulations 455

Glossary 499

Index 527

C H A P T E R 1 5

C H A P T E R 1 6

A P P E N D I X A

A P P E N D I X B

A P P E N D I X C

A P P E N D I X D

A P P E N D I X E

BRIEF CONTENTS

Over the past quarter century, new developments in technology, law, and organizational management have changed the profession of health information management (HIM). Once seen as the guardian of a paper-based health record, the health information management profession has evolved as health care has evolved, expanding to include the development and implementation of the electronic health record and management of the data contained within it. As the need for health information has grown, so has the need to manage that information. The health information profes- sional plays a more central role in the delivery of health care than ever before.

For those interested in learning about health information management, this text provides a comprehensive discussion of the principles and practices presented in a user-friendly manner. It is designed to serve as a broad text for the health information man- agement discipline and does not presume that the learner is already versed in the subject matter. The text is designed to incor- porate the model curriculum of the American Health Information Management Association for both the health information admin- istrator and health information technician programs. Although differences exist in curricula between the programs, it is my belief that the content of this book is applicable to students in both groups because it is written with multiple levels of detail. Instruc- tors may determine the emphasis level of each chapter as it is taught during the semester. This text also serves as a reference point for professionals in the health care field who need to acquire a general understanding of health information manage- ment, and as a research tool for other allied health and medical disciplines.

Although this text is intended to be comprehensive, one text- book could not possibly encompass all of the details of the broad discipline of health information management. Long past is the time when one textbook could cover all matters and issues associ- ated with a single discipline—the evolution of the HIM profession is such that other specialized texts are needed to complement this text. Every effort has been made to capture the significant changes

and trends that the HIM field and profession have undergone in recent years.

Two things set this text apart from others in the field. First, the book is authored by only one person, allowing for a consistent voice and tone across the chapters. It also means that one chapter will not contradict the contents of another chapter within the same book, and that the difficulty level will not vary from one chapter to the next. Second, the text integrates into each chapter, as applica- ble, five areas that are significant to health information manage- ment: the American Recovery and Reinvestment Act (ARRA), including HITECH; the Health Insurance Portability and Account- ability Act (HIPAA); electronic health information management (e-HIM); the Genetic Information Nondiscrimination Act (GINA); and informatics. This approach is taken so that while the student is learning the substantive matter, he or she can also understand the interplay between these three areas and the sub- stantive matter. Boxes for each of these five areas are found near the text discussion to highlight this interplay.

BOOK STRUCTURE This text offers a comprehensive, sequential approach to the study of health information management. Although each chapter is designed to stand alone, it is grouped with related chapters to form units of study. Four major units of study are presented in this text:

Part 1 serves as an introduction to health information man- agement. This unit of study comprises four chapters, beginning with a discussion of health care delivery systems, both historically and in the present day, and the health information management profession, including various career paths. These chapters are fol- lowed by a discussion of legal issues, including an overview of the court systems, the principles of liability, HIPAA, and health care fraud and abuse. The last chapter addresses ethical standards,

PREFACE

xvi C O N T E N T S

outlining the basis for ethical concepts and theories and their role in decision making, explaining various ethical challenges, and highlighting bioethics issues.

Part 2 serves as an overview of clinical data management. This unit of study consists of six chapters and begins with a dis- cussion of health data content and structures, including types and uses; forms design and control; data storage, retention, and destruction; and indices and registries. Nomenclatures and classification systems make up the next chapter, and a discus- sion of emerging issues completes the chapter. Quality manage- ment, performance improvement, risk management, and utilization management form the basis of the next chapter. Health statistics is the focus of the next chapter, addressing sta- tistical literacy in general, and regression analysis and HIM sta- tistics in particular. Research issues complete the unit, with sections addressing research principles, the research study pro- cess, the role of institutional review boards, and the discipline of epidemiology.

Part 3 serves as an overview of information technology issues. This unit of study is comprised of three chapters and begins with a discussion of database management, including con- cepts and functions, data sets, and data exchange efforts. Informa- tion systems and technology is the subject of the next chapter, including a discussion of various information systems and sys- tems architecture. New to this edition, informatics completes the unit, with sections addressing electronic health records and tech- nological applications and trends, including the role of social media in health care.

Part 3 serves as an overview of management issues. This unit of study consists of four chapters, beginning with management principles and theories, including change, project, and knowledge management. A discussion of human resource management follows, focusing on staffing, employee rights, supervision, and workforce diversity. The financial management chapter addresses the fundamental concepts that drive financial management, including accounting, budgets, and procurement. The last chapter provides a basis in reimbursement methodologies, including how third-party payers and the revenue cycle function in the health care world.

Wherever the term health information manager is used in this text, I refer to both registered health information administrators (RHIA) and registered health information technicians (RHIT). I make this choice consciously, because the experience of the health information management profession during the last two decades has shown that professionals at both levels hold a variety of posi- tions within the discipline. Additionally, care has been exercised to use the terms health record and health information management in lieu of medical record and medical record management, because these are the terms in use in the 21st century. Each chapter alter- nates in the use of the male and female pronouns. Information contained in the text boxes within the chapter provides a quick grasp of concepts that may be new to the learner.

PEDAGOGICAL FEATURES Each chapter contains:

An integration of ARRA, HIPAA, e-health information management, GINA, and informatics throughout the subject matter as appropriate

Learning objectives

A listing of key concepts that are further explained in the text

Figures and tables that provide details to illustrate the content of the text

Case studies to apply concepts learned

Review questions designed to test comprehension

Enrichment activities designed to assist critical thinking

A list of Web sites that relate to the chapter’s subject matter for the learner’s easy reference

Additionally, appendices contain:

An extensive glossary of terms

A list of abbreviations commonly used in HIM

Web site resources, organized by subject matter and in alphabetical order

Sample HIPAA privacy notices

A table of selected federal laws applicable to HIM

Selected HIPAA regulations

TEACHING AND LEARNING RESOURCES FOR TODAY’S HEALTH INFORMATION MANAGEMENT Additional textbook resources for students and instructors can be found online by going to www.cengagebrain.com and typing in the book’s ISBN. The available resources are also listed as follows for your convenience. Please note: all instructor resources can be accessed by going to www.cengagebrain.com. You will need to create a unique login. If you need assistance, please contact your sales representative.

Student Workbook The Student Workbook contains additional application-based exer- cises to help reinforce the essential concepts presented in the textbook. Test your knowledge through activities such as abbreviations and key terms review, chapter quiz material, case explorations, and more.

ISBN: 9781133592495

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C O N T E N T S xvii

CourseMate Go beyond the textbook and complement your text and course content with study and practice materials through CourseMate. CourseMate includes:

Interactive eBook with highlighting, note taking, and an interactive glossary

Additional assignable chapter quizzes, flashcards, and games

Engagement Tracker tool that monitors student engage- ment in the course

Want to give CourseMate a try? Go to www.cengagebrain.com, enter the ISBN of this textbook (978-1-1335-9247-1), and you can access a free sample of the CourseMate available with this textbook.

ISBN: 9781133595243

Instructor’s Manual The Instructor’s Manual provides answer keys for the text and workbook; a curriculum crosswalk for each chapter with links to the AHIMA domains, subdomains, and knowledge clusters; and additional enrichment activities.

ISBN: 9781133592488

Instructor Resources (Online) All instructor resources can be accessed by going to www.cengagebrain.com to create a unique user login. Contact your sales representative for more information. Online instruc- tor resources are password-protected and include all resources found on the Instructor Resources CD-ROM, including the test bank, PowerPoint presentations, and the electronic Instructor’s Manual.

Use the electronic Instructor’s Manual files to help prepare for class.

Customizable instructor support slide presentations in PowerPoint® format focus in on key points for each chapter.

The testbank written In ExamView® makes generating tests and quizzes a snap.

ISBN: 9781133595786

Web Tutor™ Course Cartridges WebTutor™ is a course management and delivery sys-

tem designed to accompany this textbook. It is available to supplement on-campus course delivery or to serve as the course management platform for an online course. The WebTutor for this title contains:

Online quizzes for each chapter

Discussion topics and learning links

Online glossary

Instructor support slides using PowerPoint™

Computerized test bank

Communication tools, including a course calendar, chat, e-mail, and threaded discussions

Web Tutor on Blackboard ISBN: 9781133595861 Web Tutor on Angel ISBN: 9781133595878

InfoHealth Connect Community Site InfoHealth Connect is a Cengage Learning community Web site that gathers resources for educators, professionals, and students working in the Health Information and Insurance, Billing & Coding arenas.

Need a research topic? Get news from the cutting edge via our Healthcare news links and video newsfeed

Have a burning question? Post your question to our dis- cussion board

Looking for pearls of wisdom? Read blogs from sea- soned professionals

Want to network? Create a member profile to connect with other members

Too busy to visit regularly? Add the site RSS feed to your reader or follow us on Twitter @infohlthconnect

Go to http://community.cengage.com/Site/infohealthconnect/ to join our community today!

P R E FA C E xvii

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ACKNOWLEDGMENTS Many persons have played a role in the creation of this text- book, including family, friends, and colleagues. A special thank you is warranted for my family, who showed patience, under- standing, and support for the long hours spent on this, my sec- ond textbook. My children, Conor, William, and Ryan, spent many hours at libraries, learning the intricacies of research and authorship. My husband, Patrick, whose patience and encouragement sustained me throughout the development of this text, deserves my unending love. Two HIM professionals, Sharon Farley, RHIA, and Patt Petersen, MA, RHIA, provided valuable assistance in the subjects of quality management and statistics, respectively. My appreciation is extended to the reviewers of my manuscript. Your comments aided in strength- ening this text.

Dana C. McWay, JD, RHIA

CONTRIBUTORS The author and publisher would like to acknowledge the following health information management educators for their contributions to the content of this text:

Sharon Farley, RHIA Contributing material to Chapter 7

Patt Peterson, MA, RHIA Contributing material to Chapter 9

REVIEWERS The following health information management educators provided invaluable feedback and suggestions during the development of this text:

Julie Alles, RHIA Adjunct Instructor Health Administration Programs Ferris State University Big Rapids, MI 49307

Marie A. Janes, MEd, RHIA Associate Lecturer University of Toledo Toledo, OH

Rachel Minatee, MBA, RHIA Professor of Health Information Technology Rose State College Midwest City, OK

Kelly Rinker, MA, RHIA, CPHIMS Faculty Regis University Denver, CO

Jeanne Sands, MBA, RHIT Adjunct Professor Herzing University Online Milwaukee, WI

xviii P R E FA C E

C O N T E N T S xix

ABOUT THE AUTHOR Dana C. McWay, JD, RHIA, is both a lawyer and a health informa- tion management professional. With training and experience in both disciplines, experience as a member of the Institutional Review Board at Washington University Medical School from 1992 to present, and experience in converting a paper-based record management system to an electronic record management system, she brings a wide-ranging perspective to this textbook.

Ms. McWay serves as the Court Executive/Clerk of Court for the U.S. Bankruptcy Court for the Eastern District of Missouri, an executive position responsible for all operational, administrative, financial, and technological matters of the court. In this capacity, she organized the court’s conversion to an electronic case filing system, resulting in widespread acceptance by end users. This suc- cess led to her appointment as member and, later, chair of the Case Management/Electronic Case Filing (CM/ECF) Working Group, an entity within the federal judiciary responsible for providing guidance and assistance in all phases of the development of bank- ruptcy CM/ECF software releases. She serves on numerous national committees and working groups within the judiciary, including those involved in identifying the impact of new legisla- tion upon judicial operations and those involved in advising on the education and training needs of court staff. Prior to this posi- tion, she worked as the Chief Deputy Clerk of Court for the U.S. Court of Appeals for the Eighth Circuit, responsible for daily operations of the court.

Ms. McWay began her legal career as a judicial law clerk to the Honorable Myron H. Bright of the U.S. Court of Appeals for the Eighth Circuit. She then became an associate with the law firm of Peper, Martin, Jensen, Maichel, & Hetlage, a multi-specialty firm located in St. Louis, Missouri. Ms. McWay’s legal practice encompassed a variety of health law topics, including contracts, medical records, and physician practice issues. She is admitted to practice in both Illinois and Missouri.

Prior to her legal career, Ms. McWay worked in health infor- mation management as both a director and assistant director of

medical records in a large teaching hospital and a for-profit psy- chiatric and substance abuse facility. She continues to participate in the HIM profession, having served as a project manager for the Missouri Health Information Management Association (MHIMA) and as a member of MHIMA’s Legislative Committee. On the national level, she serves as a director on the Board of Directors of AHIMA and has served as faculty for AHIMA con- tinuing education seminars, a peer reviewer of AHIMA book pro- posals and texts, a contributing author to AHIMA’s HIM Practice Standards, chair and former member of the Professional Ethics Committee, and a member of both the Committee for Profes- sional Development and the Triumph Awards Committee of AHIMA.

Ms. McWay is both an author and an editor. Her textbook, Legal Aspects of Health Information Management, is in its second edition. With the Peper Martin law firm, she revised The Legal Manual to Medical Record Practice in Missouri in 1991. She has authored numerous other publications and served as coeditor of several online continuing education modules presented by the American Health Information Management Association. She has also presented numerous seminars, serving as faculty and panel presenter. She has served as an adjunct faculty member in a mas- ter’s program in health informatics and a pre-law studies program, and as a guest lecturer at several area colleges and universities, focusing on the intersection of legal issues and health care practices.

Ms. McWay is a magna cum laude graduate of the St. Louis University School of Allied Health Professions, with a degree in medical record administration, and a cum laude graduate of the St. Louis University School of Law. While in law school, Ms. McWay served as the health law editor of the St. Louis University Law Jour- nal and as a faculty research fellow. She is a recipient of the Alumni Merit Award from the School of Allied Health Professions and a Triumph Award (the Legacy Award) from the American Health Information Management Association for her textbook, Legal Aspects of Health Information Management. She is one of three recipients of the 2010 Outstanding Leadership Award from the Federal Judiciary.

P R E FA C E xix

HOW TO USE THE TEXTBOOK

Learning Objectives at the beginning of each chapter list the theoretical and practical goals of the chapter. The Certification Connection ties the chapter material to the RHIA and RHIT exam outlines.

Important terms, ideas, and acro- nyms are presented in the Key Concepts list, and they are high- lighted the first time they appear in the chapter content. The Outline lists major headings to provide a roadmap for the chapter content.

At the end of each chapter, reinforce your understanding of the covered concepts using the Summary and Review Questions.

Enrichment Activities and Case Studies provide opportunities to use critical thinking skills to reflect on the material and relate the concepts to real-life situations.

The book highlights the interplay of informatics, electronic health information (e-HIM), the Health Insurance Portability and Accountability Act (HIPAA), American Recovery & Reimbursement Act (ARRA), and Genetic Information Nondiscrimination Act (GINA) with the sub- ject matter of each chapter in special boxes.

P A R T 1

1 Health Care Delivery Systems

2 The Health Information Management Profession

3 Legal Issues

4 Ethical Standards

INTRODUCTION TO HEALTH INFORMATION MANAGEMENT

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Health Care Delivery Systems

LEARNING OBJECTIVES After reading this chapter, the learner should be able to:

1. Trace the historical development of the health care delivery system in early times.

2. Describe the four-stage progression of the health care delivery system in the United States.

3. Describe the increase in stature of hospitals after World War II.

4. Explain the standardization movement of the early 20th century.

5. Define the term accreditation and explain its significance to health care organizations.

6. Compare and contrast the federal government’s role in health care during stages three and four.

7. Define the concept of managed care and dif- ferentiate between the three main types.

8. Trace the historical development of public, mental, and occupational health.

9. Compare and contrast professional associa- tions, voluntary health agencies, philan- thropic foundations, and international health agencies.

10. Differentiate between the variety of settings where health care is delivered.

11. Compare and contrast physicians, dentists, chiro- practors, podiatrists, optometrists, physician as- sistants, nurses, and allied health professionals.

12. Understand the organization of a hospital’s medical staff, the importance of its bylaws, and the use of the credentialing process in granting clinical privileges.

1C H A P T E R > > CERTIFICATION CONNECTION

RHIA

Accreditation, licensure, and certification Continuum of health care services Health care delivery systems Organizational compliance Regulatory and licensure requirements

RHIT

Accreditation, licensure, and certification Health care delivery systems Health care organizations and structure Provider roles and disciplines Public health

T H E H E A LT H I N F O R M AT I O N M A N A G E M E N T P R O F E S S I O N

Outline Key ConceptsOutline Key Concepts

Accountable care organization

Accreditation

Adult day care services

Allied health professional

Ambulatory health care

Block grants

Board certified

Bylaws

Capitation

Chiropractor

Clinical privileges

Community mental health care

Complementary and alternative medicine

Continuum of care

Credentialing process

Dentist

Fee for service

Fringe benefits

Generalists

Health insurance exchange

Health savings accounts

HMO

Home health agency

Hospice care

Hospital

IPA

International health agencies

Licensing

Long-term care facility

Managed care

Medicaid

Medicare

Medical staff

Medical staff coordinator

Mental health

Mental illness

Mobile diagnostic services

Nurse

Nurse practitioner

Occupational health

Optometrist

Outsourcing

Palliative care

Philanthropic foundations

Physician

Physician assistant

Podiatrist

PPO

Primary care

Professional associations

Public health

Quaternary care

Registration

Regulations

Rehabilitation care facility

Respite care

Rules

Secondary care

Specialists

Surgical assistant

Tertiary care

Tracer methodology

Voluntary health agencies

Historical Development Early History

Health Care in the United States

Public Health

Mental Health

Occupational Health

Health Care Delivery Systems Professional Associations

Voluntary Health Agencies

Philanthropic Foundations

International Health Agencies

Variety of Delivery Systems

Medical Staff Medical Staff Organization

Bylaws, Rules, and Regulations

Privileges and Credentialing

4 PA R T 1 I N T R O D U C T I O N T O H E A LT H I N F O R M AT I O N M A N A G E M E N T

INTRODUCTION

C H A P T E R 1 H E A LT H C A R E D E L I V E R Y S Y S T E M S 5

HISTORICAL DEVELOPMENT The number and quality of professionals, organizations, and enti- ties involved in health care has varied significantly over time. In large measure, this variety is attributable to the knowledge of dis- eases and their causes possessed by individuals and communities. With the advent of technology and advancements in medicine, an ever-expanding knowledge base has resulted in more, rather than less, complexity in health care.

Early History To understand the development of health care in the United States, one must first look to the development of health care in earlier times and in other regions of the world. Anthropological studies have helped to trace health care back thousands of years. Table 1-1 illustrates the early history of health care.

In primitive times, human society responded to disease in one of three ways. First, humans looked to nature for answers, determin- ing that disease was a result of offended forces of nature such as storms, volcanic eruptions, and earthquakes. Second, they looked to the supernatural for answers, determining that disease may be a way

of “possessing” human beings. Third, they looked to the offended spirits of gods or the dead, concluding that disease was a logical result of any offense incurred. In response to any of these three ways, primitive peoples treated disease with prayers, offerings, religious ceremonies, diet, or medicinal herbs. Furthermore, they attempted to frighten demons—and, therefore, disease—away with dancing, drumming, and fearful masks. They employed resources such as amulets, charmed stones, and songs in efforts to banish disease.

As humans made the connection between cause and effect, treatments evolved to improve or cure disease. A medicine man or shaman employed methods such as applying warm ashes to induce sweating, applying a tight band around the head to treat a head- ache, and bandaging the chest to the point of partial immobiliza- tion to treat tuberculosis. Man incised wounds to remove foreign bodies such as stones and splinters, doing so by sucking out the foreign body. Fractured bones were splinted with stiffened mud bandages or tree branches. Midwives became recognized figures among primitive peoples.

As civilization emerged, instructions relating to health care were written down. The earliest known written materials—stone tablets, papyri, and inscriptions on monuments and tombs—have been found in Egypt, dating to 2700 b.c. These materials recognize the existence

INTRODUCTION

The health care delivery system of the 21st century is both varied and complex. No one organization or entity is respon- sible for delivering all health care in the United States. It is important to understand the origins of the health care delivery system in the United States so that the relationships between organizations, entities, and health care professionals be- comes clear. This chapter provides that understanding through an overview of the historical development of the health care delivery system, both in the United States and other regions of the world. Some focus is given to specified areas of health care, including public health, mental health, and occupational health. A discussion of the organizations, entities, and professionals who deliver health care services and the settings in which they work follows, allowing the learner to better understand the complexity of health care. A section concerning a hospital’s medical staff explains its organization, its governing mechanisms, and the credentialing process. Integrated as appropriate within the entire chapter is a discus- sion of the influences of technology, financing concerns, and the role of the federal government in the health care delivery system.

6 PA R T 1 I N T R O D U C T I O N T O H E A LT H I N F O R M AT I O N M A N A G E M E N T

of physicians and dentists working under the authority of gods. As such, physicians were considered priests who received training in temple schools in areas such as diagnosis and treatment. Priests fol- lowed the case approach beginning with a preliminary diagnosis, examination of the patient, diagnosis and prognosis, and indication of treatment measures to be employed. An example of such an approach can be found in the famous Ebers Papyrus illustrated in Figure 1-1.

Although this description speaks to a rational approach to med- icine, a magical approach to medicine was involved as well. Because of the prevailing belief that disease was caused by demons and evil spirits, curing of disease could only occur through the intervention of the gods. Accordingly, physicians in ancient Egypt recognized one god over all others as the most important with regard to healing— Imhotep, who they referred to as the god of medicine.

As Egyptian civilization declined, other civilizations adopted and expanded the Egyptians’ knowledge of medicine. Arabians refined the concept of pharmacology, and, in another part of the world, the Chinese did the same. The Jewish people became pre- eminent in the area of public hygiene. The Babylonians codified fees for physician practice and punishments for malpractice in the Hammurabi Code. Eventually, each of these civilizations declined or dispersed.

The next notable civilization to make an impact on medicine was the Greeks, the forerunners of modern Western medicine. The Greeks were the first to reduce and then shed the supernatural view of disease and approach medicine from a rational and scien- tific point of view. Among the greatest Greek physicians was Hippocrates, from whom the famous oath originates (see Figure 1-2). Hippocrates is famous for codifying medicine through the publication of numerous books, promoting medicine as one of the highest ethical and spiritual endeavors, and establishing the principle that knowledge of disease can be obtained from careful observation and notation of symptoms.

Between the 6th century and the 16th century, little advance- ment in medicine occurred. Alchemy, magic, and astronomy were prominently identified with medicine. To the extent that medicine existed as we now understand it, the clergy were its practitioners. Religious orders established hospitals to offer hospitality and refuge to old, disabled, and homeless pilgrims. Soon a vast network of hos- pitals emerged, mainly offering rest and shelter rather than treatment.

Toward the end of the 16th century, a renaissance occurred in many areas of culture, including medicine. Advancements were made in understanding the anatomy of the human body, clinical observations of diseases, and bedside teaching methods. Efforts were made to not only identify disease but to discover specific remedies that could be applied to the patient. The concept of vacci- nations was introduced, along with the microscope. Although pos- itive developments were made, medicine still used ineffective methods such as bloodletting, induced vomiting, and the adminis- tration of large doses of toxic drugs.

Health Care in the United States The delivery of health care in the United States has progressed in four stages, as illustrated in Table 1-2. Until 1900, health care delivery was primarily a loose collection of efforts made by

Table 1-1 | Early History of Health Care

Characteristics Primitive Times Early Civilization Greek Civilization

Health Care Providers Medicine man or shaman Physicians/dentists working under authority of gods

Physicians such as Hippocrates

Communication Methods Drawings Early writings Codification of early medical practice

Societal Views of Health Care Nature/supernatural/offended spirits

Magical/religious approach Rational/scientific approach

Figure 1-1 | A page of the Ebers Papyrus; the lower part is a prescription

Courtesy of the United States National Library of Medicine, National Institutes of Health, www.nlm.nih.gov

C H A P T E R 1 H E A LT H C A R E D E L I V E R Y S Y S T E M S 7

individual physicians who worked independently of one another. These physicians were by and large poorly trained, often obtaining their skills through an apprenticeship with an older physician. Gradually, they began taking courses at medical colleges, which grew in number but varied in quality and sophistication. The majority of a physician’s time was spent at patients’ homes or in the office, with very limited time spent at hospitals.

During this same time frame, hospitals were established, providing the first visible institutions around which health care services could be organized. Early examples include the Pennsyl- vania Hospital in Philadelphia, Bellevue General in New York City, Charity Hospital in New Orleans, and Massachusetts Gen- eral in Boston. These hospitals and others primarily served the sick poor who could not be cared for at home. They were funded by private beneficiaries, endowments, and donations. For those

patients with financial means, the optimum place for treatment was one’s home, because hospitals were seen as dirty, crowded, and disease ridden.

During this time, two organizations formed that resulted in long-term improvements in the delivery of health care. The American Medical Association (AMA), created in 1847, began with efforts to improve the poor quality of medical education and exam- ine the questionable ethics of practicing physicians. Although no longer involved in the accreditation of medical schools, the AMA continues to center its efforts on promoting the art and science of medicine, improving public health, influencing and creating health care policy, and serving the professional needs of its members, including continuing medical education. Similarly, the American Hospital Association (AHA) began in 1848 with efforts to improve the public welfare by providing better health care in hospitals.

Figure 1-2 | Hippocratic Oath

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

I will apply dietetic measures for the benefit of the sick, according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injuries, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must noise abroad, I will keep to myself holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Courtesy of the United States National Library of Medicine, National Institutes of Health, www.nlm.nih.gov

Table 1-2 | Stages in the Delivery of Health Care in the United States

Characteristics 1776–1900 1900–WWI WWII–1980 1980–Present

Health Care Providers Physicians who worked independently of one another/limited number of hospitals, primarily serv- ing the sick poor

Improved scientific knowledge of physicians; new hospital services; increased hospital use

Development of medical specializations

Rapid growth of allied health professionals

Influence of Technology Limited Beginning growth in science and technology

Major advances in science and technology

Use of sophisticated tech- nology in diagnostic and therapeutic procedures

Organizational/Societal Efforts to Improve Health Care

Limited in number and scope

Reform of medical schools/standardization movements in hospitals

Role of federal govern- ment in financing bio- medical research and hospital facilities

Role of federal govern- ment in containing costs; emergence of managed care industry

Role of Patient Little factual knowledge Beginning steps in patient education

Awareness of health care as a political issue; increased use of health insurance

Advent of consumer culture

8 PA R T 1 I N T R O D U C T I O N T O H E A LT H I N F O R M AT I O N M A N A G E M E N T

It continues those efforts to this day, representing hospital interests in legal and legislative matters, funding and conducting research and educational programs, and maintaining data on hospital profiles.

In addition to formal organizations, a new movement swept through the country at the end of the 19th century: mental health reform. This movement posited that insanity was a medical or mental disorder that could be managed through the provision of health care services. The mentally ill were no longer housed in poorhouses or prisons but rather in institutions often funded and managed at the state level. Unfortunately, these state-run institu- tions fell into disrepute as inadequate funding caused overcrowd- ing and deplorable living conditions.

The second stage of medical improvements began in the early 1900s, with exciting changes emerging from research laboratories and medical school reform. Major scientific advances were achieved in the research lab, including the discoveries of insulin, penicillin, and the role vitamins play in disease prevention. Signifi- cant advances were achieved in obstetrics and surgery, making these areas of medicine safer for patients.

Reforms of medical schools occurred as the result of the Flexner Report, a study undertaken by Abraham Flexner and funded by the Carnegie Foundation for the Advancement of Teaching in 1910. This report indicated serious deficiencies in medical education and recommended revisions of medical school curricula and affiliation with universities. As a result, numerous proprietary medical schools closed and the remaining schools increased university affiliation. In the remaining medical schools, emphasis was placed on training physicians to be scientists in addition to practitioners.

Licensing of physicians in large numbers also started during this time period. Licensing refers to a right conferred by a govern- mental entity to practice an occupation or provide a service. Licensing controls the number of individuals who are permitted to practice an occupation or provide a service. Licenses are generally granted to individuals who present proof of specified educational requirements and pass an examination administered by an appro- priate state board. Those individuals who practice an occupation or provide a service that is subject to licensure but do not possess a license do so at their own risk, as that practice or provision of ser- vice is considered illegal. Each state determines which occupation or service is subject to licensure; occupations commonly subject to licensure include medicine, osteopathy, nursing, dentistry, and podiatry, among others.

Although physicians spent a majority of their time with patients in their offices or patients’ homes, a trend toward the use of hospitals emerged in the first three decades of the twentieth century. Technology began to influence the science of medicine. Because tech- nology was relatively expensive, it became important to concentrate it in hospitals so that a large number of physicians and their patients could gain access to it. As a result, hospitals began to change, offering services unavailable to patients at home or anywhere else.

A movement toward standardization of hospital care soon ensued. This movement was led by the American College of Sur- geons (ASC), an organization formed in 1913 to improve patient care. The ASC began its Hospital Standardization Program four years later, resulting in the adoption of the Minimum Standards document in 1919. This document identified the standards deemed essential to proper care and treatment of hospital patients. Among the standards were the requirement of an organized medi- cal staff, the existence of certain diagnostic and therapeutic facili- ties, and the creation of a written health record for every patient.

The standardization movement also led to expansion of the licensing process beyond individuals to health care facilities. State regulatory bodies developed basic minimum standards for health care facilities to meet. Those health care facilities that met the established standards could obtain a license and provide health care services to the public. As with individuals, health care facili- ties that provided services to the public without a license did so at their own risk; their actions were illegal.

As World War II began, health care in the United States moved into its third stage. Initially, the focus rested on the need for massive mobilization of health care workers to treat the wounded and solve war-related problems. Soon, wartime developments— such as the treatment of patients with antibiotics, new surgical techniques to treat burns and trauma, and new approaches to the transportation of the sick and wounded—were adopted by physi- cians treating the civilian population.

As direct patient care services improved, so did the stature of hospitals. A combination of factors influenced this increase in stature: advances in medicine and technology, the abandonment of the public’s view that hospital care was mainly for those too poor to afford home care, the role of the federal government in financing biomedical research and hospital facilities, and the influx in availability of private health insurance. With this change in stature came a change in expectations. It was no longer merely enough that a hospital emphasized caring for the patient. Rather, the public expected hospitals to integrate advances in medicine and technology made in research laboratories into their daily work so that patients were both cared for and cured. This improvement in stature and increase in expectations resulted in the hospital becoming the central institution of the health care delivery system.

As scientific advances increased rapidly, the knowledge required of health care providers to practice competently soared. Accordingly, a new trend emerged among physicians: the need for specialty practice. Whereas before World War II, the vast majority of physicians were general practitioners, after World War II the vast majority of physicians specialized in some area of medicine or surgery. Nurses and other health professionals were similarly affected by scientific advances. Training became more oriented to a scientific basis and many training programs were affiliated with universities. For all health care providers, the availability of new technologies resulted in a more complex knowledge base from which to practice.

C H A P T E R 1 H E A LT H C A R E D E L I V E R Y S Y S T E M S 9

Significant developments affecting the stature of hospitals merit further discussion. During the 1950s, factors such as the increased specialization of physicians and health professionals, the increased use of technology, advances in medical science, and the sophistication of hospitals impacted the efforts to standardize medical care. In recognition, a new concept emerged: accreditation.

Accreditation is the process by which an external entity reviews an organization or program of study to determine if the organization or program meets certain predetermined standards. In recognition of meeting those standards, the organization or program is said to be accredited. The process used is the survey method, and a wide variety of health care functions considered crucial to patient care are surveyed. Health care organizations and programs have strong incentives to become accredited, because accreditation status is linked with the ability to receive financial reimbursement for services and recognition of the delivery of high quality services.

Two organizations played the largest roles in health care accreditation during this period: the Joint Commission (JC), for- merly known as the Joint Commission on Accreditation of Health- care Organizations (JCAHO), and the American Osteopathic Association’s (AOA) Healthcare Facilities Accreditation Program (HFAP). The JC adopted the Hospital Standardization Program of the ACS and played a major role in the improvement of the quality of health care; similarly, the HFAP played a crucial role in accredit- ing osteopathic hospitals. Both the JC and the AOA accredit health care entities beyond the hospital setting, such as behavioral health, home health, long-term care, critical access hospitals, clinical labo- ratories, and ambulatory care settings. Additional information concerning the role of accrediting organizations can be found in Chapter 3, “Legal Issues.”

Equally important was the rise of the private health insurance industry. Among the most prominent was the development and pro- gression of the Blue Cross Blue Shield (BCBS) insurance companies. These nonprofit, community-based health plans insured against hos- pital costs (Blue Cross) and physician and related services costs (Blue Shield). These plans were offered to employers and industry as fringe benefits, meaning that the benefits were supplemental to the wage and salary offered to the employee. As the BCBS programs increased in popularity, commercial insurance carriers entered the market, and a majority of Americans were soon covered by some form of health insurance.1 This rise in insurance coverage in the 1940s/1950s time frame resulted in a majority of Americans receiving health care ser- vices in an economical fashion. It also resulted in the emergence of the health care sector as a significant part of the American economy.

During this same time period, the federal government began to assume major responsibility for combating health problems. It did so through a series of initiatives designed to organize and finance health care.

In 1946, Congress passed the Hospital Survey and Construc- tion Act, commonly known as the Hill-Burton Act, named after

the two sponsors of the legislation. The Hill-Burton Act provided funding for construction of hospitals and other health care facili- ties throughout the United States. It was passed in response to the realization that existing hospitals required substantial moderniza- tion and that new hospitals were needed in the rural and suburban communities located outside the urban core areas. Administered through a joint federal-state process, the Hill-Burton Act resulted in a wave of hospital construction and, later, renovation.

The government began to respond to political pressures that charged that the public’s health, education, and welfare were the responsibility of the federal government. In 1953, Congress created a cabinet-level department called the Department of Health, Edu- cation, and Welfare (DHEW). Congress charged this department with coordinating federal efforts in these three areas and provided it with the authority to promulgate rules and regulations imple- menting federal legislation.

Prior to the 1960s, those portions of the general population who had health insurance obtained it as a fringe benefit of their employment. Two segments of the general population were excluded from this development: the elderly who were no longer employed, and the poor who were unemployed or employed with- out fringe benefits such as health insurance. In response, the fed- eral government amended the Social Security Act in 1965 to provide two government-subsidized health care programs: Medi- care and Medicaid. Formally known as the Health Insurance Act for the Aged, Medicare is the program designed to provide financ- ing for health care for all persons over the age of 65, regardless of financial need. It is not limited to health care treatment for the aged, but serves the population under age 65 with certain disabili- ties and those suffering from end-stage renal disease, regardless of age. Formally known as the Medical Assistance Program, Medicaid is the program designed to provide financing for health care for poor or impoverished persons. Medicaid coverage is con- sidered broader than Medicare coverage and includes services for pregnant women, parents with dependent children who have no way to pay for health care, low-income families, the elderly need- ing long-term care, and the disabled population. Medicare and Medicaid markedly changed the face of health care in that these were the first broad-scale efforts to recognize the receipt of health care as a right of Americans.

As a result of increased access to medical care, the rise and complexity of private health insurance, and the Medicare and Medicaid programs, an ever-increasing flow of private and public funds moved into the health care arena. As health care costs esca- lated, it became more difficult to finance the delivery of health care at prior levels. The strain on the American economy was such that changes were needed by the end of the 1970s. Accordingly, the fourth stage in the delivery of health care emerged, one associated with restrictions in growth, resource limitations, and reorganiza- tion of the systems used to finance and provide health care.

The first recognized effort to control health care costs came from the federal government, the largest financier of health care in the United States. In 1982 Congress passed the Tax Equity and

10 PA R T 1 I N T R O D U C T I O N T O H E A LT H I N F O R M AT I O N M A N A G E M E N T

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