Health Care Information Systems A Practical Approach for Health

Health Care Information Systems

Health Care Information Systems A Practical Approach for Health

Care Management

Fourth Edition

Karen A. Wager

Frances Wickham Lee

John P. Glaser

Cover design by Wiley

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Library of Congress Cataloging-in-Publication Data Library of Congress Cataloging-in-Publication Data has been applied for and is on fi le with the Library of Congress.

9781119337188 (paperback) 9781119337126 (ePDF) 9781119337089 (ePub)

Printed in the United States of America

FOURTH EDITION

PB Printing 10 9 8 7 6 5 4 3 2 1

Contents

Tables, Figures, and Exhibits …………………………………………………………………….. xi Preface …………………………………………………………………………………………………. xv Acknowledgments ……………………………………………………………………………….. xxiii The Authors ………………………………………………………………………………………… xxv

Part 1 Major Environmental Forces That Shape the National Health Information System Landscape ………………………………………………. 1

1 The National Health Information Technology Landscape …………………………………………………………… 3 Learning Objectives 1990s: The Call for HIT 2000–2010: The Arrival of HIT 2010–Present: Health Care Reform and the Growth of HIT Summary Key Terms Learning Activities References

2 Health Care Data …………………………………………………………………. 21 Learning Objectives Health Care Data and Information Defi ned Health Care Data and Information Sources Health Care Data Uses Health Care Data Quality Summary Key Terms Learning Activities References

3 Health Care Information Systems …………………………………………. 65 Learning Objectives Review of Key Terms Major Health Care Information Systems History and Evolution Electronic Health Records Personal Health Records Key Issues and Challenges

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Summary Key Terms Learning Activities References

4 Information Systems to Support Population Health Management ……………………………………………………………. 99 Learning Objectives PHM: Key to Success Accountable Care Core Processes Data, Analytics, and Health IT Capabilities and Tools Transitioning from the Record to the Plan Summary Key Terms Learning Activities References

Part 2 Selection, Implementation, Evaluation, and Management of Health Care Information Systems ………………………………………………………….. 139 5 System Acquisition …………………………………………………………….. 141

Learning Objectives System Acquisition: A Defi nition Systems Development Life Cycle System Acquisition Process Project Management Tools Things That Can Go Wrong Information Technology Architecture Summary Key Terms Learning Activities References

6 System Implementation and Support …………………………………. 179 Learning Objectives System Implementation Process Managing Change and the Organizational Aspects System Support and Evaluation Summary Key Terms Learning Activities References

7 Assessing and Achieving Value in Health Care Information Systems ………………………………………………………….. 215 Learning Objectives Definition of IT-Enabled Value

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The IT Project Proposal Ensuring the Delivery of Value Analyses of the IT Value Challenge Summary Key Terms Learning Activities References

8 Organizing Information Technology Services ………………………. 251 Learning Objectives Information Technology Functions Organizing IT Staff Members and Services In-House versus Outsourced IT Evaluating IT Effectiveness Summary Key Terms Learning Activities References

Part 3 Laws, Regulations, and Standards That Affect Health Care Information Systems ………….. 285

9 Privacy and Security …………………………………………………………… 287 Learning Objectives Privacy, Confidentiality, and Security Defi ned Legal Protection of Health Information Threats to Health Care Information The Health Care Organization’s Security Program Beyond HIPAA: Cybersecurity for Today’s Wired Environment Summary Key Terms Learning Activities References

10 Performance Standards and Measures ………………………………… 323 Learning Objectives Licensure, Certification, and Accreditation Measuring the Quality of Care Federal Quality Improvement Initiatives Summary Key Terms Learning Activities References

11 Health Care Information System Standards ………………………… 357 Learning Objectives HCIS Standards Overview Standards Development Process

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Federal Initiatives Affecting Health Care IT Standards Other Organizations Influencing Health Care IT Standards Health IT Standards Vocabulary and Terminology Standards Data Exchange and Messaging Standards Health Record Content and Functional Standards Summary Key Terms Learning Activities References

Part 4 Senior-Level Management Issues Related to Health Care Information Systems Management ………………………………………………….. 393 12 IT Alignment and Strategic Planning ………………………………….. 395

Learning Objectives IT Planning Objectives Overview of Strategy The IT Assest A Normative Approach to Developing Alignment and IT Strategy IT Strategy and Alignment Challenges Summary Key Terms Learning Activities References

13 IT Governance and Management ……………………………………….. 427 Learning Objectives IT Governance IT Budget Management Role in Major IT Initiatives IT Effectiveness The Competitive Value of IT Summary Key Terms Learning Activities Notes References

14 Health IT Leadership Case Studies ………………………………………. 467 Case 1: Population Health Management in Action Case 2: Registries and Disease Management in the PCMH Case 3: Implementing a Capacity Management

Information System Case 4: Implementing a Telemedicine Solution Case 5: Selecting an EHR For Dermatology Practice Case 6: Watson’s Ambulatory EHR Transition

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Case 7: Concerns and Workarounds with a Clinical Documentation System

Case 8: Conversion to an EHR Messaging System Case 9: Strategies for Implementing CPOE Case 10: Implementing a Syndromic Surveillance System Case 11: Planning an EHR Implementation Case 12: Replacing a Practice Management System Case 13: Implementing Tele-psychiatry in a Community Hospital

Emergency Department Case 14: Assessing the Value and Impact of CPOE Case 15: Assessing the Value of Health IT Investment Case 16: The Admitting System Crashes Case 17: Breaching The Security of an Internet Patient Portal Case 18: The Decision to Develop an IT Strategic Plan Case 19: Selection of a Patient Safety Strategy Case 20: Strategic IS Planning for the Hospital ED Case 21: Board Support for a Capital Project Supplemental Listing of Related Case Studies and Webinars

Appendixes A. Overview of the Health Care IT Industry …………………………….. 525

The Health Care IT Industry Sources of Industry Information Health Care IT Associations Summary Learning Activities References

B. Sample Project Charter, Sample Job Descriptions, and Sample User Satisfaction Survey ………………………………….. 539 Sample Project Charter Sample Job Descriptions Sample User Satisfaction Survey

Index ………………………………………………………………………………………………….. 559

Tables, Figures, and Exhibits

TABLES

1.1 Stages of Meaningful Use ……………………………………………………….. 9 1.2 Differences between Medicare and Medicaid EHR

incentive programs ……………………………………………………………….. 11 1.3 MIPS performance categories…………………………………………………..13 2.1 Ten common hospital statistical measures ………………………………….47 2.2 Terms used in the literature to describe the fi ve common

dimensions of data quality ……………………………………………………..52 2.3 Excerpt from data dictionary used by AHRQ surgical site infection

risk stratifi cation/outcome detection …………………………………………56 3.1 Common types of administrative and clinical information systems ….68

3.2 Functions defining the use of EHRs ………………………………………….76 3.3 Sociotechnical dimensions ………………………………………………………92 4.1 Key attributes and broad results of current ACO models …………….. 106 5.1 Sample criteria for evaluation of RFP responses ……………………….. 161 7.1 Financial analysis of a patient accounting document

imaging system …………………………………………………………………..227 7.2 Requests for new information system projects ………………………….. 230 9.1 HIPAA violation categories …………………………………………………… 302 9.2 Top ten largest fines levied for HIPAA violations as of

August 2016 ………………………………………………………………………. 303 9.3 Resources for conducting a comprehensive risk analysis …………….. 309 9.4 Common examples of vulnerabilities and mitigation strategies …….. 310

10.1 2015 approved CMS accrediting organizations …………………………..329 10.2 Major types of quality measures …………………………………………….336 10.3 Excerpt of CQMs for 2014 EHR Incentive Programs ……………………338 10.4 MIPS performance categories…………………………………………………349 11.1 Relationships among standards-setting organizations …………………. 361 11.2 Excerpt from CVX (clinical vaccines administered) …………………….374 11.3 Excerpt from NCPDP data dictionary ……………………………………… 380 11.4 X12 TG2 work groups …………………………………………………………. 381 11.5 Excerpt from the HL7 EHR-S Functional Model …………………………386

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12.1 IT initiatives linked to organizational goals ………………………………397 12.2 Summary of the scope of outpatient care problems …………………… 402 12.3 Assessment of telehealth strategic opportunities ……………………….. 413 12.4 Summary of IT strategic planning ………………………………………….. 414 13.1 Target increases in an IT operating budget ……………………………….442 14.1 List of cases and corresponding chapters …………………………………469 A.1 IT interests of different health care organizations ………………………526 A.2 Health care provider market: NAICS taxonomy …………………………527 A.3 Changes in application focus resulting from changes

in the health care business model ………………………………………….528 A.4 Major health care IT vendors, ranked by revenue ……………………… 530 B.1 Revision history …………………………………………………………………. 541 B.2 Issue management ………………………………………………………………549

FIGURES

1.1 Milestones for a supportive payment and regulatory environment ….15 2.1 Health care data to health care knowledge …………………………………23 2.2 Sample EHR information screen ………………………………………………33 2.3 Sample EHR problem list ……………………………………………………….34 2.4 Sample EHR progress notes …………………………………………………….34

2.5 Sample EHR lab report …………………………………………………………..35 2.6 Sample heart failure and hypertension query screen …………………….45

3.1 History and evolution of health care information systems (1960s to today) …………………………………………………………………..70

3.2 Sample drug alert screen ………………………………………………………..73 3.3 Sample patient portal …………………………………………………………….74 3.4 Percent of non-federal acute care hospitals with adoption of at

least a basic EHR with notes system and position of a certifi ed EHR: 2008–2015 ……………………………………………………………………75

3.5 Office-based physician practice EHR adoption since 2004 ……………..77 3.6 The ONC’s roadmap to interoperability ……………………………………..84 4.1 Percent of nonfederal acute care hospitals that electronically

exchanged laboratory results, radiology reports, clinical care summaries, or medication lists with ambulatory care providers or hospitals outside their organization: 2008–2015 ……………………. 118

5.1 Systems development life cycle ………………………………………………144 5.2 System usability scale questionnaire ……………………………………….163

5.3 Cost-benefi t analysis ……………………………………………………………164 5.4 Example of a simple Gantt chart ……………………………………………167

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6.1 Project timeline with project phases ……………………………………….189 7.1 IT investment portfolio …………………………………………………………237 7.2 Days in accounts receivable ………………………………………………….239 7.3 Digital intensity versus transformation intensity ………………………..246 8.1 IT organizational chart: Large health system …………………………….257

10.1 Screenshot from NQF ………………………………………………………….. 341 10.2 Projected timetable for implementation of MACRA ……………………. 350 12.1 Overview of IT strategy development ……………………………………… 400 12.2 IT initiative priorities ………………………………………………………….. 415 12.3 IT plan timetable and budget ……………………………………………….. 416 12.4 Hype cycle for emerging technologies, 2014 …………………………….. 422 13.1 IT budget decision-making process …………………………………………443 13.2 Gross margin performance differences in high IT–use industries ….. 461 13.3 Singles and grand slams ……………………………………………………….463

EXHIBITS

2.1 Excerpt from ICD-10-CM 2016 ………………………………………………….38 2.2 Excerpt from ICD-10 PCS 2017 OCW …………………………………………40 2.3 Patient encounter form coding standards …………………………………..41 5.1 Overview of System Acquisition Process …………………………………. 147 9.1 Sample release of information form ………………………………………..294 9.2 Cybersecurity framework core ………………………………………………. 318

10.1 Medical Record Content: Excerpt from South Carolina Standards for Licensing Hospitals and Institutional General Infi rmaries ……….326

10.2 Medical Record Content: Excerpt from the Conditions of Participation for Hospitals …………………………………………………….328

11.1 Excerpt from ONC 2016 Interoperability Standards Advisory ………..366 11.2 X12 5010 professional claim standard……………………………………… 382 12.1 IT initiatives necessary to support a strategic goal for a provider …. 410 12.2 IT initiatives necessary to support a strategic goal for a

health plan ……………………………………………………………………….. 411 12.3 System support of nursing documentation ………………………………. 412

In memory of our colleague Andy Pasternack

Preface

Health care delivery is in the early stages of a profound shift in its core strat­ egies, organization, financing, and operational and care processes.

Reactive sick care is being replaced by proactive efforts to keep people well and out of the hospital. Fragmented care delivery capabilities are being supplanted by initiatives to create and manage cross-continuum systems of care. Providers that were rewarded for volume are increasingly being rewarded for quality and effi ciency.

New forms of reimbursement, such as bundles and various types of cap­ itation, are causing this shift. To thrive in the new era of health care delivery, providers are creating health systems, such as accountable care organizations, that include venues along the care spectrum.

In addition providers are introducing new processes to support the need to manage care between encounters, keep people healthy, and ensure that utilization is appropriate. Moreover, as reimbursement shifts to incent- improved provider performance these organizations will have a common need to optimize operational efficiency, improve financial management, and effectively engage consumers in managing their health and care.

These changes in business models and processes follow on the heels of the extraordinary increase in electronic health record adoption spurred by the Meaningful Use program of the US federal government.

On top of a foundation of electronic health records, the industry will add population health management applications, systems that support extensive patient engagement, broader interoperability, and more significant use of analytics. Providers involved in patient care will need immediate access to electronic decision-support tools, the latest relevant research findings on a given topic, and patient-specific reminders and alerts. Health care executives will need to be able to devise strategic initiatives that take advantage of access to real-time, relevant administrative and clinical information.

In parallel with the changes in health care, information technology (IT) innovation continues at a remarkable pace. The Internet of Things is creating a reality of intelligent homes, cars, and equipment, such as environmental sensors and devices attached to patients. Social media use continues to grow

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and become more sophisticated and capable. Mobile personal devices have become the device of choice for personal and professional activities. Big data has exceptional potential to help identify new diagnostic and therapeutic algorithms, conduct most market surveillance, and assess the comparative effectiveness of treatments.

For providers to prosper in this new era they must be very effective in developing IT strategies, implementing the technology, and leveraging the technology to improve organizational performance. They must understand the nature of health care data and the challenges of privacy and security. Clinicians and managers must appreciate the breadth of health care IT and emerging health care IT trends.

The transformation of the health care industry means that IT is no longer a necessary back-office evil—it is an essential foundation if an organization is to survive. That has not been true in the past; provider organizations could do quite well in a fee-for-service world without computerized physician order entry and other advanced IT applications.

Having ready access to timely, complete, accurate, legible, and rele­ vant information is critical to health care organizations, providers, and the patients they serve. Whether it is a nurse administering medication to a comatose patient, a physician advising a patient on the latest research findings for a specific cancer treatment, a billing clerk filing an electronic claim, a chief executive officer justifying to the board the need for build­ ing a new emergency department, or a health policy analyst reporting on the cost-effectiveness of a new prevention program to the state’s Medicaid program, each individual needs access to high-quality information with which to effectively perform his or her job.

The need for quality information in health care, already strong, has never been greater, particularly as this sector of our society strives to provide quality care, contain costs, and ensure adequate access.

PURPOSE OF THIS BOOK

The purpose of this book is to prepare future health care executives with the knowledge and skills they need to manage information and information systems technology effectively in this new environment. We wrote this book with the graduate student (or upper-level undergraduate student) enrolled in a health care management program in mind.

Our definition of health care management is fairly broad and includes a range of academic programs from health administration, health infor­ mation management, and public health programs to master of business

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administration (MBA) programs with an emphasis in health to nursing administration and physician executive educational programs. This book may also serve as an introductory text in health informatics programs.

The first (2005), second (2009), and third (2013) editions have been widely used by a variety of health care management and health information systems programs throughout the United States and abroad. Although we have maintained the majority of the chapters from the third edition, this edition has gone through significant changes in composition and structure reflecting feedback from educators and students and the need to discuss topics such as population health and recent changes in payment reform ini­ tiatives. We have removed the section on the international perspective on health care information technology and updated the case studies of organi­ zations experiencing management-related information system challenges. We also added a new chapter on the role of information systems in managing population health.

ORGANIZATION OF THIS BOOK

The chapters in this book are organized into four major parts:

• Part One: “Major Environmental Forces That Shape the National Health Information System Landscape” (Chapters One through Four)

• Part Two: “Selection, Implementation, Evaluation, and Management of Health Care Information Systems” (Chapters Five through Eight)

• Part Three: “Laws, Regulations, and Standards That Affect Health Care Information Systems” (Chapters Nine through Eleven)

• Part Four: “Senior-Level Management Issues Related to Health Care Information Systems Management” (Chapters Twelve through Fourteen)

In addition Appendix A provides an overview of the health care IT indus­ try. Appendix B provides a compendium of a sample project charter, sample job descriptions, and a sample user satisfaction survey.

The purpose of Part One (“Major Environmental Forces That Shape the National Health Information System Landscape”) is to provide the reader with the foundation needed for the rest of the book. This foun­ dation includes an overview of the major environmental forces that are shaping the national health IT landscape, such as Medicare’s alternative payment programs. The reader will gain insight into the different types of clinical, administrative, and external data used by health care provider

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organizations. Additionally, the reader will gain an understanding of the adoption, use, and functionality of health care information systems with focus on electronic health records (EHRs), personal health records (PHRs), and systems need to support population health management (e.g., data analytics, telehealth).

Specifically Part One has four chapters:

• Chapter One: National Health Information Technology Landscape. This chapter discusses the various forces and activities that are shaping health information systems nationally. The chapter reviews the HITECH Act, the Affordable Care Act, HIPAA, and national efforts to advance interoperability.

• Chapter Two: Health Care Data. This chapter examines the range of health care data and issues with data quality and capture. This examination is conducted from a cross-continuum, health system perspective.

• Chapter Three: Health Care Information Systems. This chapter provides an overview of clinical and administrative information systems. The chapter focuses on the electronic health record and personal health record and describes in greater detail the major initiatives that have led to current adoption and use of EHRs by hospitals and physician practices (e.g., Meaningful Use and health information exchanges). The chapter also includes discussion on the state of EHRs in settings across the care continuum (e.g., behavioral health, community care, long-term care). It concludes with a discussion on important health care information system issues including interoperability, usability, and health IT safety.

• Chapter Four: Information Systems to Support Population Health Management. This is a new chapter. Its purpose is to focus on the key data and information needs of health systems to effectively manage population health. Key topics include population health, telehealth, patient engagement (including social media), data analytics, and health information exchange (HIE).

The purpose of Part Two (“Selection, Implementation, Evaluation, and Management of Health Care Information Systems”) is to provide the reader with an overview of what is needed to effectively select, implement, evaluate, and manage health care information systems. This section discusses issues mid- and senior-level managers are likely to encounter related to managing

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change and managing projects. The reader will also gain insight into the role and functions of the IT organization or department.

Specifically Part Two has four chapters:

• Chapter Five: System Acquisition. This chapter discusses the processes that organizations use to

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