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http://www.csun.edu/~dn58412/IS531/IS531_SP15.html
Lecture 14Policy, Legal, and Regulatory Issues in
HIS (Chapters 18,19,20)
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Learning OutcomesLearning Outcomes
1. Status of current healthcare delivery system and related policies in US
2. Legal issues and their implementation3. Regulatory issues and agencies
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Status of U.S. Healthcare Status of U.S. Healthcare Delivery SystemDelivery System
• Higher expenditure• Standardization• Fragmented care• Unequal access to care• Less-than-optimal safety• Poor evaluation by patients• Payment for service rather than
maintaining wellness• Lack of rewards for primary care
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Healthcare ReformHealthcare Reform
• Health IT was seen as a tool to aid the reform process with HER, PHR, HIE
• President Bush’s executive orders in 2004, 2006 to create National Health Information Technology Coordinator
• President Obama’s ARRA 2009 supports 2014 goal for the EHRs
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National Health Information National Health Information Technology PolicyTechnology Policy
• Even with the creation many committees, taskforces, workgroups the United States has been very slow to follow.
• The American Recovery and Reinvestment Act (ARRA) of 2009 supported adoption of a nationwide health information infrastructure.
• Education of professionals and general public is needed.
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Our RolesOur Roles
• Public– Need greater awareness on benefits and
risks• Nurses
– Professional responsibility– Professional duty
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IssuesIssues
• Lack of motivation to share information across institutions
• Established constituencies are resistant to change
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LegislationLegislation• Electronic Signatures in Global and National
Commerce Act (ESIGN) in 2000: legal status for electronic signature
• Medicare Improvements for Patients and Providers Act (MIPPA) in 2008: financial incentive fro e-prescribing
• Health Insurance Portability and Accountability Act (HIPAA) in 1996: legal protection for personal health information
• American Recovery and Reinvestment Act (ARRA) in 2009: provision for IT in HIS
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HIPAAHIPAA
• The Health Insurance Portability and Accountability Act (1996) called for the establishment of an electronic patient records system and privacy rules.
• It also affects all aspects of health information management, including privacy and security of patient records, coding, and reimbursement.
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ARRAARRA
• The American Recovery and Reinvestment Act (2009) included provision for information technology in general and health information technology.
• HITECH Act makes changes to HIPAA and provides more funding for EHRs.
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EHR IncentivesEHR Incentives
• In 2011, Medicare and Medicaid will provide financial incentives to physicians and hospitals for meaningful use of health information technology.
• Negative incentives will begin in 2015.
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Privacy and Security ProvisionsPrivacy and Security Provisions
• Breaches in privacy and security are reportable to DHHS.
• Patients can restrict some disclosure of personal health information.
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Patient Protection and Patient Protection and Affordable Care Act (2010)Affordable Care Act (2010)
• Guarantees access to healthcare for all Americans
• Creates new incentives to change clinical practice and improve quality of care
• Gives practitioners more information to improve practice
• Give patients more information to make conscious decisions
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Regulatory AgenciesRegulatory Agencies
• Regulatory agencies are public authorities or government agencies responsible for exercising authority over some area in a regulatory or supervisory capacity.
• Health insurance regulation is visible at every government level.
• Each state determines how it will fill this regulatory role mandated at the federal level.
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Regulatory IssuesRegulatory Issues
• The ability to access sensitive health information in electronic patient records by many different sources generates growing concerns over privacy and confidentiality.
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MedicareMedicare
• Medicare:– Part A: facility-related expenses (no
premium, annual deductible)– Part B: medically necessary physician
and outpatient expenses (80% with annual deductible)
– Part C: Advantage Plan with some additional benefits (monthly premium)
– Part D: certain prescription drugs and medical supplies
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MedicaidMedicaid
• Medicaid eligibility is determined by income and regulated by state
• Medicaid covers approved expenses but not paid by Medicare
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State Health DepartmentsState Health Departments
• Public health conditions in marketplaces and workforces
• Schools, mental health facilities, rehabilitation hospitals
• Diseases , contamination• Regulated by federal, state, county
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Reimbursement IssuesReimbursement Issues
• Medicare, Medicaid, and other third-party payers dictate reimbursement criteria.
• Documentation is key to documenting the need for service and reimbursement.
• Automated systems enhance the quality of documentation, which can improve reimbursement, track claims status, report denials, and shorten the revenue cycle.
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• Adhere to a uniform format• Common terms:
– Common procedural Terminology– Healthcare Common Procedure Coding
System• National provider Identifier• Unique Physician Identification Number
Electronic Data Interchange in Electronic Data Interchange in ReimbursementReimbursement
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• Control for quality of healthcare services provided to patients by professional and facilities
• Hospital-based• Physician-based
Pay for PerformancePay for Performance
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ICD-10-CM codesICD-10-CM codes
• ICD-10-CM codes (WHO’s International Classification of Diseases)
• System of codes for diagnoses and procedures
• Provide reimbursement for services delivered in outpatient areas
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Healthcare Common Procedure Healthcare Common Procedure Coding System (HCPCS) Coding System (HCPCS)
• Level I (Current Procedural Terminology [CPT])—numeric system used for services and procedures furnished by physicians and other providers, maintained by the AMA
• Level II—products, supplies, durable medical equipment, prosthetics, and orthotics
• Medicare and Medicaid services maintain and distribute HCPCS Level II codes
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IssuesIssues
• Expansion of the “Do Not Pay” List for preventable complication
• Financial incentives for implementing technology– Adoption for certified HER Systems and
Medicare reimbursement– Meaningful use of EHR
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ReferencesReferences• Health IT Legislation and Regulationshttp://www.healthit.gov/policy-researchers-implementers/
health-it-legislation• Health Information Privacy (HIPAA, PSQIA)http://www.hhs.gov/ocr/privacy/• Medicarehttps://www.medicare.gov/• Medicaidhttp://medicaid.gov/• Medi-Cal (LA County)http://dhs.lacounty.gov/wps/portal/dhs/coverageoptions/
medical/
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