1. Continuum of Care
1.1. The range of healthcare services provided to patients
1.2. From ambulatory care to intensive acute care
1.3. The emphasis is on treating patients at the level of care required by their course of treatment
1.4. Assurance of communication between caregivers
2. Oversight
2.1. Federal regulators: DHHS, CMS, AHRQ, ONC, CDC, OIG, and NIH
2.2. State Regulators: Medicaid, CHIP
2.3. for the operation of any healthcare facility a licence must be obtained, the licencing process varies from state to state
2.4. local government may also become involved in healthcare, particularly in zoning
2.5. the Joint Commission- an organization located in Chicago that sets standards for acute care facilities, ambulatory networks, LCT facilities, and rehabilitation facilities as well as certain specialty facilitates like hospice and home care agencies
3. Secondary Health Record Data
3.1. Index- identifies data items within a set of parameters. Data that is abstracted or collected electronically allow for the creation of an index.
3.1.1. Indexes are used to connect and extract data from varied sources
3.1.2. Types of indexes
3.1.2.1. Master patient index or MPI
3.1.2.1.1. Used to identify patient with a Medical record number (MRN) and encounter numbers
3.1.2.1.2. Diagnosis, procedures, and physicians are connected to the patient via the MPI
3.1.2.1.3. electronic documentation is also indexed by the data from the MPI
3.1.2.2. Disease Index
3.1.2.2.1. Is maintained by facilities in order to produce lists of patients with a given disease/condition
3.1.2.2.2. Data in the index is derived from the diagnosis data entered during the coding and abstracting process
3.1.2.3. Procedure index
3.1.2.3.1. Is maintained by facilities in order to produce a list of patient who underwent a given procedure
3.1.2.3.2. Data in the index is derived from the diagnosis data entered during the coding and abstracting process
3.1.2.4. Physicians Index
3.1.2.4.1. Is maintained by facilities in order to produce a list of patient who received care from a given provider
3.1.2.4.2. Data in the index is derived from the diagnosis data entered during the coding and abstracting process
3.2. Registry- a systematic collection of data specific to serve a given purpose related to a specific health issue or diagnosis
3.2.1. Individual Monitoring, Surveillance, Incidence occurrence measure, and Prevention
3.3. Clinical Terminologies
3.3.1. Classification System-Used to group like concepts. category to subcategory to refinement
3.3.1.1. Examples include ICD-10-CM And ICD-10-PCS, MSDRG and APC
3.3.2. Nomenclature- is a standardized naming convention. In a nomenclature, each code has only one specific meaning, so it is a one code to one concept relationship.
3.3.2.1. HCPCS level I, II and III
3.3.3. Vocabulary goes beyond a nomenclature by providing contextual meaning to concepts.
3.3.3.1. SNOMED-CT and LOINC
4. Data Governance and Quality
4.1. Information Governance- an organizations framework for managing information throughout its life cycle, to support the organizations strategy, operations, regulatory, legal, risk and environmental requirements
4.1.1. Information governance principles include- Accountability, transparency, integrity, protection, compliance, availability, retention and disposition
4.2. Quality Data- the correctness of data collected at a health care facility
4.2.1. Data quality characteristics include- Accuracy, accountability, comprehensiveness, consistency, currency, definition, granularity, integrity, precision, relevancy and timeliness
5. Historical Evolution
5.1. Early 1900's- organized medicine begins
5.2. 1910's -Theodore Roosevelt campaigns on the issue of mandatory health insurance but efforts set side because WW1 begins
5.3. 1920's- medical attention becomes increasingly more difficult for the middle class to afford
5.4. 1930's- Despite resistance, Blue Cross begins offering insurance for hospital care in some states
5.5. 1940's- employers begin to offer health insurance coverage to compensate for wage controls placed on employers- the beginning of the employer-based system today
5.6. 1950's- Medicine continues to advance with more medications developed- The first successful organ transplant is performed- The price of hospital care doubles
5.7. 1960's-Lyndon Johnson signs Medicare into law providing health coverage for individuals age 65 and over. Medicaid covers long-term care for the poor and disabled. there is an increase in the number of companies offering private health insurance
5.8. 1970's- The cost of health care exponentially increases after the passage of Medicare and Medicaid- Richard Nixon signs the Health Maintenance Organization Act to help reduce costs
5.9. 1980's- Health care makes a move to become more privatized as health care businesses begin to consolidate creating larger hospital systems
5.10. 1990's-The cost of health care rises at a rate double the rate of inflation- Managed care groups increase to help mitigate cost
5.11. 2000's- Medicare's sustainability is called into question- Direct-to-consumer advertising takes off in the medical field
5.12. 2010's- Barack Obama signs the Affordable Care Act.
6. Health Care Professionals
6.1. Physician- licensed to practice medicine
6.2. Nurses- a clinical professional who has received post-secondary school training in caring for patients in a variety of health care settings
6.3. Allied Health Professionals- includes both clinical and nonclinical professionals who provide a variety of services to patients
6.4. Health Information Management- encompasses all the tasks, jobs, titles, and organizations involved in the administration of health information, including collection, storage, retrieval, securing/protecting, and reporting of that information
6.5. Interdisciplinary collaboration-clinical professionals work together to care for the patient
7. Primary Health Record
7.1. A Systematic documentation of a patients medical history, health, and care provded as recorded by the physicians and other health care providers throughout the course of care
7.2. Primary purpose of the health record
7.2.1. patent care- communication between providers, documents of legal evidence of care , and legal evidence of care give
7.2.2. Management of care- develop standards, research disease and treatment outcomes, and evaluate quality
7.2.3. Administrative- billing of services, strategic planning, monitoring performance and scheduling and staffing.
7.2.4. patient engagement- active participant in care planning and monitory, ex- patient portals like mychart.
7.3. Users of the Primary Health Record
7.3.1. Health Information Professionals
7.3.2. Physician
7.3.3. Nurses
7.3.4. Patient
7.3.5. Lab/Pathology/ Radiology technicians
7.4. Content of the Primary Health Record
7.4.1. Registration paper work- Face sheet and Advanced Directives, Consent for treatment or operation, and admission consent for if needed
7.4.2. Initial Assessment- History and Physical and vitals, any alerts
7.4.3. Plan of care
7.4.4. doctors orders, progress notes, medication documentation
7.4.5. Nurses notes such as progress notes and nurses assessment of patients
7.4.6. LAbratory and radiology data
7.4.7. Discharge notes and instructions for patients to take home