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a.Provide solutions for the case in roughly two to three pages.
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Case Study: Building a better MIS-Trap
You are the CEO of a large health services organization (HSO) in Florida. Your HSO has
inpatient and outpatient facilities, home health care services, and every other service your patient
population needs. You also have a world-renowned AIDS treatment center that has been
considered by many to be a model for the rest of the U.S. Your HSO has always enjoyed an
excellent reputation, and your quality of care is known to be excellent. You have been very
happy in your work, knowing that your HSO provides good care to people who truly need it in a
caring and cost-effective manner.
Your HSO has recently been featured in every media vehicle known to every man, woman,
and child in the U.S. and beyond. The reason: someone downloaded the names of 4,000 HIV+
patients who had been seen in your world-renowned HIV clinic and sent the list to newspapers,
magazines, and the Internet.
You and your board of trustees are completely blown away. The board is furious and wants
to fire you. You have been able to convince them that they need to keep you on to fix the HSO’s
management information system (MIS). Their last words to you were “You had better come
back with plans for building a better MIS, or you’re fired!”
You hire a computer security consultant, and she comes into your organization under
disguise as a nurse manager to help you determine where the security leak might be. She returns
to you in three days with the following report.
“While I was undercover in your organization for a mere three days, I observed the
following breaches in computer security. These are the highlights (or lowlights):
• Nurses log in with their passwords, walk away, and leave the system open and up and
running;
• Dr. Jones leaves his password taped to the PC on a piece of paper;
• Fax machines and printers are often in areas of high traffic and in rooms without locks;
• With my one password, I had remote access to every database in the hospital, including
Human Resources’ personnel files, from my home;
• There are no programs reminding people to change their passwords on a regular basis;
• When I pretended to forget my password, other nurses gave me theirs; and
• When I requested sensitive patient files on flash drive, even after this incident, people
rarely questioned me.
In short, you have a major problem with your MIS—and your staff!”
What should you do?
Discussion Questions
1. What law is being violated by the employees at this health services organization?
2. Why was this law enacted?
3. What are the penalties for violating this law?
4. If an employee shares confidential medical information about a celebrity and is caught,
what should the penalty be?
5. Do you think you should be updating your résumé and looking for a new job?
CHAPTER 8
HEALTH
INFORMATION
SYSTEMS AND
TECHNOLOGY
Objectives (1 of 3)
• Differentiate between the levels of
functionality in electronic health records
(EHR).
• Appraise key information systems used by
health care managers.
• Distinguish between information systems
common to all industries and those unique to
health care.
Objectives (2 of 3)
• Analyze the challenges to clinical information
system optimization.
• Examine the evolution of meaningful use and
its continued implications for health care
providers.
• Assess the future of health care information
systems (HIS) in the health care delivery
system and the health industry.
Objectives (3 of 3)
• Investigate sources of data for assessing the
active and passive use of EHRs.
• Critique the impact of HIS interoperability on
the health care manager.
• Examine the impacts of HIPAA and other
regulations, laws, and policies regarding
confidentiality of patient information.
Health Information Systems (HIS)
Defined
• All pieces of computer
systems, including:
– Software
– Hardware
– Operating systems
– End-user devices
connecting systems
• Networks: the electronic
connectivity between
system, people, and
organizations
• Data that systems
– Create
– Capture through the use
of software
– These become the
building blocks for all
functions and
applications.
Source: Balgrosky, 2015, p.13.
HIS Scope Model
Networks
• Networks can be categorized as intranets, which are internal
to an organization, or extranets, which are external and allow
users to share information.
• Networks also can be characterized as
– Local area networks (LANs)
– Wireless LANs (WLANs)
– Wide area networks (WANs)
– Wireless WANs (WWANs)
– Storage area networks (SANs)
• The Internet is a well-known WAN (Balgrosky, 2015, p .81).
Systems in Health Care (1 of 4)
• Standard office applications such as word
processing, spreadsheet management, and email and other administrative tools to enable
collaboration
• Budget systems to manage expenses and
income
• Cost accounting systems to model the profit
(or loss) of key services/products
Systems in Health Care (2 of 4)
• Enterprise resource planning (ERP) systems,
which include human resource, payroll,
accounts payable, materials management, and
general ledger functions
• Time and attendance, staffing and scheduling,
and productivity systems to manage a diverse
exempt and nonexempt, and in many health
care organizations a 24/7, 365-days-a-year
workforce
Systems in Health Care (3 of 4)
• Marketing systems including customer
relationship management (CRM) and typically
the organization’s website, Facebook and other
social media accounts
• For those health care entities that are nonprofit,
fund-raising systems that play a key role in
identifying and managing the contributions of
donors
Systems in Health Care (4 of 4)
• Billing and accounts receivable systems used
to bill clients and customers (e.g., patients and
insurance companies) for the goods or services
of the entity
Historical Uses of Information
Technology
• Health care settings include hospitals, physician
practices, nursing homes, home health care,
insurance companies
• Mainly used for administrative support
• To support regulatory requirements such as those
defined by JCAHO, CMS, and CAP
• Opportunity to reduce costs and increase patient
safety and treatment effectiveness has encouraged
use in more clinical settings.
Evolution of the Automation of
Health Care (1 of 2)
• Repetitive workloads lend themselves to automation:
– Filling prescriptions
– Resulting laboratory tests
– Completing radiology images
• Initial automation was in each clinical area and not
“hooked” together or integrated.
• Primary caregivers did not use computers as part of
their daily routines.
• Systems too cumbersome and time consuming
Evolution of the Automation of
Health Care (2 of 2)
• Medical devices are more sophisticated.
• Robotic use has increased, e.g., pharmacy
robots that fill prescriptions.
• Unification of medical devices and
information systems
• Systems more prevalent in the clinical setting
• Health care managers will need to use these
new systems in their daily routine.
The Electronic Medical Record
(EMR)
• 1991, Institute of Medicine (IOM) concluded
computer-based patient record to be an
essential technology
• 2000, IOM report, To Err is Human,
emphasized further need to increase the safety
of patient care through automation
• Clinicians have responded to call for safer
care, adoption of EMRs has accelerated.
• Now we are in the era of optimization.
What is EMR? (1 of 2)
• An EMR is a computer application that
includes:
– Clinical data repository
– Clinical decision support
– Controlled medical vocabulary
– Physician order entry
– Pharmacy and clinical documentation
• Used across inpatient and outpatient areas
What is EMR? (2 of 2)
• Used by all practitioners to document, monitor,
and manage health care delivery
• Legal record of care for a patient during their
encounter at a health services organization
(HSO)
Electronic Medical Record
Analytical Model (EMRAM)
• Developed by industry association of health care
information technology (HIT) professionals: The
Healthcare Information and Management Systems
Society (HIMSS)
• EMRAM = model to gauge hospital EMR
adoption
• Hospitals are scored in a national database
• Stages 0–7, indicating progressively higher and
more clinically sophisticated uses of HIT
Figure 8-2 EMRAM Model
Courtesy of HIMSS ANALYTICS.
EMRAM & O-EMRAM Models
Stages 0–1: very basic automation of individual
areas
Stages 2: ability to start bringing disparate data
together
Stages 3–6: implementation of advanced clinical
systems
Stage 7: ability to share or exchange data with
external entities
Table 8-2 Comparison of 2008 to 2017 EMRAM Scores for
American Hospitals, and Baseline O-EMRAM scores
Data from HIMSS Analytics. (2017a). Electronic Medical Record Adoption ModelSM (EMRAM). Retrieved from
https://www.himssanalytics.org/emram. HIMSS Analytics. (2017b). Outpatient Electronic Medical Record Adoption ModelSM
(OEMRAM). Retrieved from https://www.himssanalytics.org/oemram
Hospital EMR Adoption
• As of Q4 2017, 73% of all U.S. hospitals progressed
past stage 4.
• Only 6.4% (351) of over 5,487 hospitals have
progressed to stage 7.
• Slow progress due to:
– High cost of systems
– Slow development of data standards
– User unfriendliness of systems
– Patient lack of trust in the ability of the industry to hold
their information secure
EMR or EHR?
• Electronic health record (EHR) broader term
than EMR
• Refers to total health of patient, including
immunizations, allergies, medications, etc.
• Data in EHR accessible to many, including
patient and other health providers.
Physician EMR Adoption (1 of 2)
• Most patient care in the U.S. occurs in the
physician offices.
• Of all care settings – they have the LEAST
amount of automation due to the previously
defined barriers to adoption.
• 98.6% hospitals have “some” form of an EMR;
67.9% of physician practices have EMR.
Physician EMR Adoption (2 of 2)
• Larger practices with more staff adopt more
quickly due to more resources.
• Exceptions are growing where adoption and
use leading to better outcomes has begun.
Barriers to Adoption & Optimization
• Cost to deploy and sustain
• Major changes to clinical workflow
• Annual maintenance costs
• Complex use interface and experience
• Interoperability issues
• Lack of business education
• Lack of change management
Federal Response (1 of 2)
• Establishment of the Notice of Privacy
Practice (NOPP)
• While influential on the development and
enhancement of HIT, didn’t have any
immediate impact to increase adoption and
reduce other barriers
• By 2009, adoption continued to be very slow.
• Rising health care costs led the Obama
administration to intervene.
Federal Response (2 of 2)
• Legislation: American Recovery and
Reinvestment Act (ARRA)
• ARRA includes Health Information
Technology (HITECH) Act to increase
adoption through use incentives for hospitals
and physicians (among other care providers).
Beginning of Meaningful Use
• Concept of “meaningful use” criteria for EHRs
focused on achieving five health outcomes
policy priorities:
1. Improve quality, safety, and efficiency, and
reduce health disparities
2. Engage patients and families in their health
3. Improve care coordination
4. Improve population and public health
5. Ensure adequate privacy and security of patient
health information
Meaningful Use vs. EMRAM
• Stages of Meaningful • EMRAM vs. Meaningful
Use
Use
– Stage 1, 2011–2012: data Stage 4 = Stage 1
capture and sharing
Stage 6 = Stage 2
– Stage 2, 2014: advance
Stage 7 = Stage 3
clinical processes
• Physicians push back and
– Stage 3, 2016: improve
resistance
outcomes
• AMA/AHA call for changing
adoption time frames
• Issues remain unresolved
From Meaningful Use to MIPS (1 of 2)
• Under MU, providers expected to progress through
three stages of development, over the following 5
period:
• 2011–2012, Stage 1: data capture and sharing
• 2014, Stage 2: advance clinical processes
• 2016, Stage 3: improved outcomes (HealthIT, 2015).
From Meaningful Use to MIPS (2 of 2)
• Merit-Based Incentive Program (MIPS)
• Process evolved from defining goals of
utilizing EHRs to optimizing EHRs
• MIPS has four pillars that are weighted
– Quality (50%)
– Advancing care information (25%)
– Improvement activities (15%)
– Cost (10%)
Problems with EHRs
• Poor design
• Poor usability
• Time-consuming data entry
• Interference with face-to-face patient care
• Inefficient and less fulfilling work content
• Lack of interoperability
Solutions?
• Scribes: people trained in medical
terminology and pathophysiology who make
notes on EHR while physician speaks with the
patient
• Better training and more intuitive systems:
difficulty using EHR decreases productivity,
increasing provider frustration with hassle
factor
HIPAA
• 1996: Health Insurance Portability and
Accountability Act (HIPPA) established,
among other things:
– standardization of data, and
– regulations on its privacy.
• Heightened attention to measures to protect
personally identifiable health information
(PHI)
PHI
Individually identifiable health information (IIHI)
relates to:
• the individual’s past, present, or future physical or
mental health or condition;
• the provision of health care to the individual, or,
• the past, present, or future payment for the provision
of health care to the individual; and,
• that identifies the individual or for which there is a
reasonable basis to believe it can be used to identify
the individual.
HIPAA in 2018
• Fines for breaches range from $100 to
$50,000 per violation, with a cap of $1.5
million.
• HIPAA breaches with criminal intent have
penalties up to $250,000 and 10 years’
imprisonment.
PHI Breach Notification &
Enforcement
• Must consider the following factors:
– Nature and extent of PHI involved
– To whom the PHI may have been disclosed
– Whether that PHI was actually acquired or viewed
– The extent to which the risk to the PHI has been
mitigated (for example, assurances from recipient
that information has been destroyed or will not be
further used or disclosed) (APA Practice
Organization, 2013).
Business Associate Agreements
• Requirements of the law are extended to
include all groups that hospitals or other
covered entities do business with, as well as to
the subcontractors with whom those associates
do business.
• Contracts with business associates and subcontractors must address HIPAA requirements.
Future of Health Information
Technology (HIT)
• Portability: EMR in your pocket.
• There’s an app for that!
• Virtual health care: be “seen” without need for
physical exam
• Future uses of technology in health care include:
– Patients wearing computers to regulate and/or
monitor (smart vests)
– Embedded microchips
• Systems improvements for complex information
Potential Confounders
• Interoperability
• Optimizing existing vs. replacing EHRs
• Data integrity
• Promoting patient safety
• Cybersecurity
• Cloud-based Systems and Bring Your Own Device
(BYOD)
• Passive and active use of the EHR
Additional Areas
• E-health: electronic data transfer
• mHealth: mobile technologies for health-related
activities (look at your phone—there is probably
a health app on it!)
• Telemedicine & Telehealth: practicing at a
distant site
• Health informatics, analytics, & big data:
aggregating, analyzing, and sharing data trends
will inform research and policy.
HIT Impact on the Manager
• Complex and quickly evolving work
environment
• Effective managers must use technology
themselves and understand well enough to
manage effectiveness of their employees use.
• Dependency will create new norms around
computer competencies, processes during
“downtimes,” etc.
A Sampling of Research Sources
• Agency for Healthcare Research and Quality
Health Information Technology Tools and
Resources
• American Hospital Association
• Centers for Medicare and Medicaid Services
Electronic Health Records Incentive Programs
• HealthIT.gov
• Healthdata.gov
Conclusion
• HIT impact of health care/manager increasing
• Costs have risen, quality has not kept pace
• While many barriers, optimization of clinical
systems is increasing
• There are models to help, EMRAM & OEMRAM
CHAPTER 7
QUALITY AND
PERFORMANCE
IMPROVEMENT
BASICS
Objectives (1 of 2)
• Describe the risks inherent in the provision of
health care;
• Identify key quality and safety issues;
• Explain why constant vigilance, management,
and improvement are required in health care;
• Differentiate between health care system
failures and individual risky behavior;
Objectives (2 of 2)
• Apply overlapping quality and improvement
concepts and principles to everyday
management;
• Assess the leading models of quality
improvement methodology; and,
• Apply tools used in quality improvement.
Definition of Quality (1 of 2)
• Institute of Medicine
– “degree to which health services for individuals or
populations increase the likelihood of desired
health outcomes and are consistent with the current
professional knowledge”
• Donabedian conception of quality as:
– Structure: quality personnel and facilities
– Process: quality processes both in management and
production of health care
– Outcomes: quality resulting from the application of
structural and process variables
Definition of Quality (2 of 2)
• Donabedian’s four parts
– Technical management
– Interpersonal relationships
– Amenities of care
– Ethical principles guiding care
• Two quality questions
– Are the right things done? (effectiveness)
– Are things done right? (efficiency)
Patient-Centered Care
• Patient (person)-centered care
– Care centered around the individual
– Responsive to:
• The individual’s physical abilities
• Medical needs
• Social and psychological abilities, preferences,
and lifestyles
Why is Quality Important?
• Underuse: failure to provide a service whose
benefit is greater than its risk
– 54.9% of patients receive recommended care
• Overuse: use of service when risk outweighs its
benefits
– Uncritical use of antibiotics, especially in
consumer products
• Misuse: risk service is provided badly reducing
benefit to patient
– Medical errors, medication errors
The Complex Nature of Health
Care
• Health care
– Complex
– Dynamic
– Unpredictable
– Varying levels of ambiguity
• Health care delivery
– High number of human transactions that are at risk for
failures
– Interfaces with complicated information systems and
technology
– Many services are high risk and problem prone
Common Elements of Quality
Improvement Methodologies
• Measurement
– Definition (operational definition)
– Reliability
– Validity
• Process variation and statistical process control
– Special-cause variation
– Common-cause variation
Continuous Process Improvement
• “A structured organizational process for involving
personnel in planning and executing a continuous
flow of improvements to provide quality health care
that meets or exceeds expectations”
• Based on process part of Donabedian’s definition
• TQM/CQI’s five dimensions
– Process focus
– Customer focus
– Data-based decision making
– Employee empowerment
– Organization-wide scope
• FOCUS-PDCA
FOCUS/PDCA (1 of 2)
• Find: identify process problem
• Organize: put together a team to work on process
• Clarify: use techniques to clarify the problem
– Geographic mapping
– Flowcharting
• Understand: measure and collect data to
• Select: identify process improvements for
implementation
FOCUS/PDCA (2 of 2)
• Plan: create an implementation plan for taking
the process to the next level
• Do: implement and test the new process
• Check: evaluate the measures used and assess
outcomes
• Act: assure continuation of newly
implemented process, if successful, or redo the
process, if not successful
Six Sigma
• “Data-driven quality methodology that seeks
to eliminate variation from a process”
– Six Sigma Performance:
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