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Policy, Legal, and Regulatory Issues in HIS

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Lecture 14 Policy, Legal, and Regulatory Issues in HIS (Chapters 18,19,20) * * * * * * * * * * * * Learning Outcomes Status of current healthcare delivery system and ... – PowerPoint PPT presentation

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Title: Policy, Legal, and Regulatory Issues in HIS


1
  • Lecture 14
  • Policy, Legal, and Regulatory Issues in HIS
  • (Chapters 18,19,20)

2
Learning Outcomes
  1. Status of current healthcare delivery system and
    related policies in US
  2. Legal issues and their implementation
  3. Regulatory issues and agencies

3
Status of U.S. Healthcare Delivery 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

4
Healthcare Reform
  • Health IT was seen as a tool to aid the reform
    process with HER, PHR, HIE
  • President Bushs executive orders in 2004, 2006
    to create National Health Information Technology
    Coordinator
  • President Obamas ARRA 2009 supports 2014 goal
    for the EHRs

5
National Health Information Technology 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.

6
Our Roles
  • Public
  • Need greater awareness on benefits and risks
  • Nurses
  • Professional responsibility
  • Professional duty

7
Issues
  • Lack of motivation to share information across
    institutions
  • Established constituencies are resistant to change

8
Legislation
  • 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

9
HIPAA
  • 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.

10
ARRA
  • 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.

11
EHR 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.

12
Privacy and Security Provisions
  • Breaches in privacy and security are reportable
    to DHHS.
  • Patients can restrict some disclosure of personal
    health information.

13
Patient Protection and 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

14
Regulatory Agencies
  • Regulatory agencies are public authorities or gove
    rnment 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.

15
Regulatory Issues
  • The ability to access sensitive health
    information in electronic patient records by many
    different sources generates growing concerns over
    privacy and confidentiality.

16
Medicare
  • 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

17
Medicaid
  • Medicaid eligibility is determined by income and
    regulated by state
  • Medicaid covers approved expenses but not paid by
    Medicare

18
State Health Departments
  • Public health conditions in marketplaces and
    workforces
  • Schools, mental health facilities, rehabilitation
    hospitals
  • Diseases , contamination
  • Regulated by federal, state, county

19
Reimbursement 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.

20
Electronic Data Interchange in Reimbursement
  • Adhere to a uniform format
  • Common terms
  • Common procedural Terminology
  • Healthcare Common Procedure Coding System
  • National provider Identifier
  • Unique Physician Identification Number

21
Pay for Performance
  • Control for quality of healthcare services
    provided to patients by professional and
    facilities
  • Hospital-based
  • Physician-based

22
ICD-10-CM codes
  • ICD-10-CM codes (WHOs International
    Classification of Diseases)
  • System of codes for diagnoses and procedures
  • Provide reimbursement for services delivered in
    outpatient areas

23
Healthcare Common Procedure 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 IIproducts, supplies, durable medical
    equipment, prosthetics, and orthotics
  • Medicare and Medicaid services maintain and
    distribute HCPCS Level II codes

24
Issues
  • 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

25
References
  • Health IT Legislation and Regulations
  • http//www.healthit.gov/policy-researchers-impleme
    nters/health-it-legislation
  • Health Information Privacy (HIPAA, PSQIA)
  • http//www.hhs.gov/ocr/privacy/
  • Medicare
  • https//www.medicare.gov/
  • Medicaid
  • http//medicaid.gov/
  • Medi-Cal (LA County)
  • http//dhs.lacounty.gov/wps/portal/dhs/coverageopt
    ions/medical/
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