HEALTH INFORMATION MANAGEMENT AN INTEGRATED APPROACH, SECOND EDITION

TODAY’S

by Dana C. McWay, JD, RHIA

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Today’s Health Information Management: An Integrated Approach, Second Edition Dana C. McWay

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BRIEF CONTENTS

iii

PA R T 1 INTRODUCTION TO HEALTH INFORMATION MANAGEMENT

1 Health Care Delivery Systems 3 2 The Health Information Management Profession 29 3 Legal Issues 47 4 Ethical Standards 87

CLINICAL DATA MANAGEMENT

5 Health Care Data Content and Structures 121 6 Nomenclatures and Classification Systems 147 7 Quality Health Care Management 169 8 Health Statistics 199 9 Research 231

TECHNOLOGY

10 Database Management 259 11 Information Systems and Technology 279 12 Informatics 299

MANAGEMENT

13 Management Organization 321 14 Human Resource Management 355 15 Financial Management 387 16 Reimbursement Methodologies 405

Appendix A Common HIM Abbreviations 423

Appendix B Web Resources 433

Appendix C Sample HIPPA Notices of Privacy practices 443

Appendix D Selected Laws Affecting HIM 451

Appendix E Selected HIPAA Regulations 455

Glossary 499

Index 527

PA R T 2

PA R T 3

PA R T 4

CONTENTS

1 Preface xv

PART INTRODUCTION TO HEALTH INFORMATION MANAGEMENT 1

Health Care Delivery Systems 3

Introduction 5 Historical Development 5

Early History 5 Health Care in the United States 6 Public Health 11 Mental Health 12 Occupational Health 14

Health Care Delivery Systems 15 Professional Associations 15 Voluntary Health Agencies 16 Philanthropic Foundations 17 International Health Agencies 17 Variety of Delivery Systems 17

Settings 17 Health Care Professionals 20

Medical Staff 22 Medical Staff Organization 22 Bylaws, Rules, and Regulations 23 Privileges and Credentialing 23

Conclusion 25 Chapter Summary 25 Case Study 25 Review Questions 25 Enrichment Activity 26 Web Sites 26 References 26 Notes 26

C H A P T E R 1

vi C O N T E N T S

The Health Information Management Profession 29

Introduction 31 Health Information 31

Historical Development of the Profession 31 Educational and Certification Requirements 33

Careers 37 Traditional Settings 39 Nontraditional Settings 41

Direct Patient Care Settings 42 Settings Not Involving Direct Patient Care 43

Conclusion 44 Chapter Summary 44 Case Study 44 Review Questions 44 Enrichment Activities 45 Web Sites 45 References 45 Notes 45

Legal Issues 47

Introduction 49 Overview of External Forces 49

Roles of Governmental Entities 50 Roles of Nongovernmental Entities 52 Role Application 53

Understanding the Court System 53 The Court System 53 Administrative Bodies 55

Health Records as Evidence 58 Hearsay 58 Privilege 59 Exclusions 60 Legal Procedures 60 e-Discovery 61 Additional Steps in Litigation 63

Principles of Liability 64 Intentional Torts 64 Nonintentional Torts 65 Social Media 67

Legal Issues in HIM 67 HIPAA 68

Administrative Simplification 68 Fraud and Abuse 71

Privacy and Confidentiality 71 Access to Health Care Data 73

Ownership and Disclosure 73 Identity Theft 75

Informed Consent 76 Judicial Process 77

Fraud and Abuse 78 Fraud and Abuse Laws 79 Resources to Combat Fraud and Abuse 80

C H A P T E R 2

C H A P T E R 3

C O N T E N T S vii

Conclusion 82 Chapter Summary 82 Case Study 83 Review Questions 83 Enrichment Activities 83 Web Sites 83 References 84 Notes 84

Ethical Standards 87

Introduction 89 Ethical Overview 89

Ethical Models 90 Ethical Concepts 90 Ethical Theories 93

Ethical Decision Making 94 Influencing Factors 95

Codes of Ethics 95 Patient Rights 103 Other Factors 104

Decision-Making Process 104 Bioethical Issues 106

Related to the Beginning of Life 106 Family Planning 106 Abortion 107 Perinatal Ethics 108 Eugenics 108

Related to Sustaining or Improving the Quality of Life 108 HIV/AIDS 109 Organ Transplantation 109 Genetic Science 110

Related to Death and Dying 110 Planning for End of Life 111 Euthanasia 111 Withholding/Withdrawing Treatment 111

Ethical Challenges 112 General Challenges 112 Role of Ethics in Supervision 113 Health Care Challenges 114 Health Information Management Challenges 115

Conclusion 116 Chapter Summary 116 Case Study 116 Review Questions 116 Enrichment Activities 116 Web Sites 117 References 117 Notes 117

C H A P T E R 4

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2 PART CLINICAL DATA MANAGEMENT 119

Health Care Data Content and Structures 121

Introduction 123 Types, Users, Uses, and Flow of Data 123

Types of Data 123 Users and Uses of Data 127

Patient Users 128 Data Flow 129

Forms Design and Control 131 Data Storage, Retention, and Destruction 132

Data Storage 134 Data Retention and Destruction 136

Indices and Registries 139 Indices 139 Registries 140

Registry Types 142 Conclusion 143 Chapter Summary 143 Case Study 143 Review Questions 143 Enrichment Activities 144 Web Sites 144 References 144 Notes 144

Nomenclatures and Classification Systems 147

Introduction 149 Languages, Vocabularies, and Nomenclatures 149

Nomenclature Development 150 Classification Systems 152

History and Application of Classification Systems 152 Diagnosis-Related Groups 155

HIM Transformation 157 Other Classification Systems 163

Emerging Issues 164 Conclusion 166 Chapter Summary 166 Case Study 166 Review Questions 167 Enrichment Activity 167 Web Sites 167 References 167 Notes 168

C H A P T E R 6

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C H A P T E R 5

C O N T E N T S ix

Quality Health Care Management 169

Introduction 171 Data Quality 171

Historical Development 171 Federal Efforts 175 Private Efforts 176

Tools 178 Performance Improvement and Risk Management 187

Performance Improvement 187 Risk Management 189

Utilization Management 191 Utilization Review Process 192

Conclusion 195 Chapter Summary 195 Case Study 196 Review Questions 196 Enrichment Activity 196 Web Sites 197 References 197 Notes 197

Health Statistics 199

Introduction 201 Overview 201

Statistical Types 202 Statistical Literacy 203

Statistical Basics 204 Measures of Central Tendency 205 Other Mathematical Concepts 206 Data Collection 208 Statistical Formulas 209

Data Presentation 212 Regression Analysis 215

Regression Analysis Models 217 Health Information Management Statistics 221

Productivity 221 Statistical Tools 223

Conclusion 226 Chapter Summary 226 Case Studies 226 Review Questions 229 Enrichment Activities 229 Web Sites 230 References 230 Notes 230

C H A P T E R 7

C H A P T E R 8

x C O N T E N T S

Research 231

Introduction 233 Research Principles 233

Historical Overview 233 Methodology 234

Qualitative and Quantitative Research 234 Study Types 235

Research Study Process 239 Research Design 239 Publication Process 240

Institutional Review Boards 241 Historical Overview 241 Review Process 243

Review of Research on Animals 246 Emerging Trends 247

Epidemiology 248 Historical Overview 249 Epidemiological Basics 250

Disease Progression 251 Types of Epidemiology 252 Descriptive Epidemiology 252 Analytic and Experimental Epidemiology 253

Conclusion 254 Chapter Summary 254 Case Study 254 Review Questions 254 Enrichment Activities 255 Web Sites 255 References 255 Notes 255

PART TECHNOLOGY 257

Database Management 259

Introduction 261 Concepts and Functions 261

Database Design 263 Controls 265 Data Standards 265 Retrieval and Analysis Methods 267

Data Sets 268 Data Exchange 272

State and Local Data Exchange Efforts 274 Conclusion 275 Chapter Summary 276 Case Study 276 Review Questions 276 Enrichment Activities 276 Web Sites 276 References 277 Notes 277

C H A P T E R 9

C H A P T E R 1 0

C O N T E N T S xi

Information Systems and Technology 279

Introduction 281 Information Systems 281

Computer Concepts 281 Hardware 282 Software 285 Units of Measure and Standards 285

Information Systems Life Cycle 286 Communication Technologies 288 Security 290

HIPAA Security Rule 291 Systems Architecture 293

Systems Architecture Specifics 293 Conclusion 295 Chapter Summary 295 Case Study 295 Review Questions 296 Enrichment Activity 296 Web Sites 296 References 296 Notes 297

Informatics 299

Introduction 301 Overview 301 Electronic Health Records 302

Meaningful Use 305 Legal Health Record 310

Technology Applications and Trends 311 Role of Social Media in Health Care 313

Conclusion 316 Chapter Summary 316 Case Study 316 Review Questions 317 Enrichment Activity 317 Web Sites 317 References 317 Notes 317

C H A P T E R 1 1

C H A P T E R 1 2

xii C O N T E N T S

4C H A P T E R 1 3PART MANAGEMENT 319Management Organization 321Introduction 323Principles of Management 323Planning 323Strategic Planning 323Management Planning 325 Operational Planning 326 Disaster Planning 326 Planning Tools 329

Organizing 329 Design and Structure 330 Organizing People 331 Organizing the Type of Work 335 Organizing Work Performance 335 Organizing the Work Environment 335

Directing 336 Decision Making 336 Instructing Others 337 Work Simplification 338

Controlling 338 Types of Controls 338 Setting Standards 339 Monitoring Performance 339

Leading 340 Motivating 340 Directing Others 341 Resolving Conflicts 342 Effective Communication 342

Management Theories 343 Historical Overview 343 Specialized Management Theories 344

Change Management 344 Project Management 345 Process Improvement 346 Knowledge Management 348 Effective Meeting Management 351

Conclusion 351 Chapter Summary 352 Case Study 352 Review Questions 352 Enrichment Activities 352 Web Sites 353 References 353 Notes 353

xii C O N T E N T S

C O N T E N T S xiii

Human Resource Management 355

Introduction 357 Employment 357 Staffing 358

Recruitment 358 Selection 358 Compensation 364 Orientation and Training 364 Retention 365 Separation 366

Employee Rights 367 Overview 367 Employment Law Application 368

Discrimination 368 Sex Discrimination 368 Racial, Religious, and National Origin Discrimination 369 Age Discrimination 370 Disability Discrimination 370 Genetic Discrimination 372 Workplace Protections 372 Social Media 375

Supervision 376 Performance Evaluations 376 Problem Behaviors 377 Discipline and Grievance 378 Developing Others 379

Career Development 379 Coaching 379 Mentoring 380

Team Building 380 Telework 381

Workforce Diversity 383 Conclusion 384 Chapter Summary 384 Case Study 384 Review Questions 384 Enrichment Activities 384 Web Sites 385 References 385 Notes 385

C H A P T E R 1 4

xiv C O N T E N T S

Financial Management 387

Introduction 389 Overview 389 Accounting 391

Managerial Accounting 391 Financial Accounting 393

Budgets 395 Procurement 399

Procurement Requests 400 Conclusion 402 Chapter Summary 402 Case Study 402 Review Questions 402 Enrichment Activities 402 Web Sites 403 References 403

Reimbursement Methodologies 405

Introduction 407 Third-Party Payers 407

Governmental Payers 408 Nongovernmental Payers 409

Managed Care Organizations 411 Health Insurance Exchanges 413

Payment Methodologies 414 Fee for Service 414 Prospective Payment Systems 415 Resource-Based Relative Value Systems 416 Capitation 416

Revenue Cycle Management 417 Conclusion 419 Chapter Summary 419 Case Study 420 Review Questions 420 Enrichment Activities 420 Web Sites 420 References 421 Notes 421

Common HIM Abbreviations 423

Web Resources 433

Sample HIPPA Notices of Privacy Practices 443

Selected Laws Affecting HIM 451

Selected HIPAA Regulations 455

Glossary 499

Index 527

C H A P T E R 1 5

C H A P T E R 1 6

A P P E N D I X A

A P P E N D I X B

A P P E N D I X C

A P P E N D I X D

A P P E N D I X E

BRIEF CONTENTS

Over the past quarter century, new developments in technology, law, and organizational management have changed the profession of health information management (HIM). Once seen as the guardian of a paper-based health record, the health information management profession has evolved as health care has evolved, expanding to include the development and implementation of the electronic health record and management of the data contained within it. As the need for health information has grown, so has the need to manage that information. The health information profes- sional plays a more central role in the delivery of health care than ever before.

For those interested in learning about health information management, this text provides a comprehensive discussion of the principles and practices presented in a user-friendly manner. It is designed to serve as a broad text for the health information man- agement discipline and does not presume that the learner is already versed in the subject matter. The text is designed to incor- porate the model curriculum of the American Health Information Management Association for both the health information admin- istrator and health information technician programs. Although differences exist in curricula between the programs, it is my belief that the content of this book is applicable to students in both groups because it is written with multiple levels of detail. Instruc- tors may determine the emphasis level of each chapter as it is taught during the semester. This text also serves as a reference point for professionals in the health care field who need to acquire a general understanding of health information manage- ment, and as a research tool for other allied health and medical disciplines.

Although this text is intended to be comprehensive, one text- book could not possibly encompass all of the details of the broad discipline of health information management. Long past is the time when one textbook could cover all matters and issues associ- ated with a single discipline—the evolution of the HIM profession is such that other specialized texts are needed to complement this text. Every effort has been made to capture the significant changes

and trends that the HIM field and profession have undergone in recent years.

Two things set this text apart from others in the field. First, the book is authored by only one person, allowing for a consistent voice and tone across the chapters. It also means that one chapter will not contradict the contents of another chapter within the same book, and that the difficulty level will not vary from one chapter to the next. Second, the text integrates into each chapter, as applica- ble, five areas that are significant to health information manage- ment: the American Recovery and Reinvestment Act (ARRA), including HITECH; the Health Insurance Portability and Account- ability Act (HIPAA); electronic health information management (e-HIM); the Genetic Information Nondiscrimination Act (GINA); and informatics. This approach is taken so that while the student is learning the substantive matter, he or she can also understand the interplay between these three areas and the sub- stantive matter. Boxes for each of these five areas are found near the text discussion to highlight this interplay.

BOOK STRUCTURE This text offers a comprehensive, sequential approach to the study of health information management. Although each chapter is designed to stand alone, it is grouped with related chapters to form units of study. Four major units of study are presented in this text:

Part 1 serves as an introduction to health information man- agement. This unit of study comprises four chapters, beginning with a discussion of health care delivery systems, both historically and in the present day, and the health information management profession, including various career paths. These chapters are fol- lowed by a discussion of legal issues, including an overview of the court systems, the principles of liability, HIPAA, and health care fraud and abuse. The last chapter addresses ethical standards,

PREFACE

xvi C O N T E N T S

outlining the basis for ethical concepts and theories and their role in decision making, explaining various ethical challenges, and highlighting bioethics issues.

Part 2 serves as an overview of clinical data management. This unit of study consists of six chapters and begins with a dis- cussion of health data content and structures, including types and uses; forms design and control; data storage, retention, and destruction; and indices and registries. Nomenclatures and classification systems make up the next chapter, and a discus- sion of emerging issues completes the chapter. Quality manage- ment, performance improvement, risk management, and utilization management form the basis of the next chapter. Health statistics is the focus of the next chapter, addressing sta- tistical literacy in general, and regression analysis and HIM sta- tistics in particular. Research issues complete the unit, with sections addressing research principles, the research study pro- cess, the role of institutional review boards, and the discipline of epidemiology.

Part 3 serves as an overview of information technology issues. This unit of study is comprised of three chapters and begins with a discussion of database management, including con- cepts and functions, data sets, and data exchange efforts. Informa- tion systems and technology is the subject of the next chapter, including a discussion of various information systems and sys- tems architecture. New to this edition, informatics completes the unit, with sections addressing electronic health records and tech- nological applications and trends, including the role of social media in health care.

Part 3 serves as an overview of management issues. This unit of study consists of four chapters, beginning with management principles and theories, including change, project, and knowledge management. A discussion of human resource management follows, focusing on staffing, employee rights, supervision, and workforce diversity. The financial management chapter addresses the fundamental concepts that drive financial management, including accounting, budgets, and procurement. The last chapter provides a basis in reimbursement methodologies, including how third-party payers and the revenue cycle function in the health care world.

Wherever the term health information manager is used in this text, I refer to both registered health information administrators (RHIA) and registered health information technicians (RHIT). I make this choice consciously, because the experience of the health information management profession during the last two decades has shown that professionals at both levels hold a variety of posi- tions within the discipline. Additionally, care has been exercised to use the terms health record and health information management in lieu of medical record and medical record management, because these are the terms in use in the 21st century. Each chapter alter- nates in the use of the male and female pronouns. Information contained in the text boxes within the chapter provides a quick grasp of concepts that may be new to the learner.

PEDAGOGICAL FEATURES Each chapter contains:

An integration of ARRA, HIPAA, e-health information management, GINA, and informatics throughout the subject matter as appropriate

Learning objectives

A listing of key concepts that are further explained in the text

Figures and tables that provide details to illustrate the content of the text

Case studies to apply concepts learned

Review questions designed to test comprehension

Enrichment activities designed to assist critical thinking

A list of Web sites that relate to the chapter’s subject matter for the learner’s easy reference

Additionally, appendices contain:

An extensive glossary of terms

A list of abbreviations commonly used in HIM

Web site resources, organized by subject matter and in alphabetical order

Sample HIPAA privacy notices

A table of selected federal laws applicable to HIM

Selected HIPAA regulations

TEACHING AND LEARNING RESOURCES FOR TODAY’S HEALTH INFORMATION MANAGEMENT Additional textbook resources for students and instructors can be found online by going to www.cengagebrain.com and typing in the book’s ISBN. The available resources are also listed as follows for your convenience. Please note: all instructor resources can be accessed by going to www.cengagebrain.com. You will need to create a unique login. If you need assistance, please contact your sales representative.

Student Workbook The Student Workbook contains additional application-based exer- cises to help reinforce the essential concepts presented in the textbook. Test your knowledge through activities such as abbreviations and key terms review, chapter quiz material, case explorations, and more.

ISBN: 9781133592495

xvi P R E FA C E

C O N T E N T S xvii

CourseMate Go beyond the textbook and complement your text and course content with study and practice materials through CourseMate. CourseMate includes:

Interactive eBook with highlighting, note taking, and an interactive glossary

Additional assignable chapter quizzes, flashcards, and games

Engagement Tracker tool that monitors student engage- ment in the course

Want to give CourseMate a try? Go to www.cengagebrain.com, enter the ISBN of this textbook (978-1-1335-9247-1), and you can access a free sample of the CourseMate available with this textbook.

ISBN: 9781133595243

Instructor’s Manual The Instructor’s Manual provides answer keys for the text and workbook; a curriculum crosswalk for each chapter with links to the AHIMA domains, subdomains, and knowledge clusters; and additional enrichment activities.

ISBN: 9781133592488

Instructor Resources (Online) All instructor resources can be accessed by going to www.cengagebrain.com to create a unique user login. Contact your sales representative for more information. Online instruc- tor resources are password-protected and include all resources found on the Instructor Resources CD-ROM, including the test bank, PowerPoint presentations, and the electronic Instructor’s Manual.

Use the electronic Instructor’s Manual files to help prepare for class.

Customizable instructor support slide presentations in PowerPoint® format focus in on key points for each chapter.

The testbank written In ExamView® makes generating tests and quizzes a snap.

ISBN: 9781133595786

Web Tutor™ Course Cartridges WebTutor™ is a course management and delivery sys-

tem designed to accompany this textbook. It is available to supplement on-campus course delivery or to serve as the course management platform for an online course. The WebTutor for this title contains:

Online quizzes for each chapter

Discussion topics and learning links

Online glossary

Instructor support slides using PowerPoint™

Computerized test bank

Communication tools, including a course calendar, chat, e-mail, and threaded discussions

Web Tutor on Blackboard ISBN: 9781133595861 Web Tutor on Angel ISBN: 9781133595878

InfoHealth Connect Community Site InfoHealth Connect is a Cengage Learning community Web site that gathers resources for educators, professionals, and students working in the Health Information and Insurance, Billing & Coding arenas.

Need a research topic? Get news from the cutting edge via our Healthcare news links and video newsfeed

Have a burning question? Post your question to our dis- cussion board

Looking for pearls of wisdom? Read blogs from sea- soned professionals

Want to network? Create a member profile to connect with other members

Too busy to visit regularly? Add the site RSS feed to your reader or follow us on Twitter @infohlthconnect

Go to http://community.cengage.com/Site/infohealthconnect/ to join our community today!

P R E FA C E xvii

xviii C O N T E N T S

ACKNOWLEDGMENTS Many persons have played a role in the creation of this text- book, including family, friends, and colleagues. A special thank you is warranted for my family, who showed patience, under- standing, and support for the long hours spent on this, my sec- ond textbook. My children, Conor, William, and Ryan, spent many hours at libraries, learning the intricacies of research and authorship. My husband, Patrick, whose patience and encouragement sustained me throughout the development of this text, deserves my unending love. Two HIM professionals, Sharon Farley, RHIA, and Patt Petersen, MA, RHIA, provided valuable assistance in the subjects of quality management and statistics, respectively. My appreciation is extended to the reviewers of my manuscript. Your comments aided in strength- ening this text.

Dana C. McWay, JD, RHIA

CONTRIBUTORS The author and publisher would like to acknowledge the following health information management educators for their contributions to the content of this text:

Sharon Farley, RHIA Contributing material to Chapter 7

Patt Peterson, MA, RHIA Contributing material to Chapter 9

REVIEWERS The following health information management educators provided invaluable feedback and suggestions during the development of this text:

Julie Alles, RHIA Adjunct Instructor Health Administration Programs Ferris State University Big Rapids, MI 49307

Marie A. Janes, MEd, RHIA Associate Lecturer University of Toledo Toledo, OH

Rachel Minatee, MBA, RHIA Professor of Health Information Technology Rose State College Midwest City, OK

Kelly Rinker, MA, RHIA, CPHIMS Faculty Regis University Denver, CO

Jeanne Sands, MBA, RHIT Adjunct Professor Herzing University Online Milwaukee, WI

xviii P R E FA C E

C O N T E N T S xix

ABOUT THE AUTHOR Dana C. McWay, JD, RHIA, is both a lawyer and a health informa- tion management professional. With training and experience in both disciplines, experience as a member of the Institutional Review Board at Washington University Medical School from 1992 to present, and experience in converting a paper-based record management system to an electronic record management system, she brings a wide-ranging perspective to this textbook.

Ms. McWay serves as the Court Executive/Clerk of Court for the U.S. Bankruptcy Court for the Eastern District of Missouri, an executive position responsible for all operational, administrative, financial, and technological matters of the court. In this capacity, she organized the court’s conversion to an electronic case filing system, resulting in widespread acceptance by end users. This suc- cess led to her appointment as member and, later, chair of the Case Management/Electronic Case Filing (CM/ECF) Working Group, an entity within the federal judiciary responsible for providing guidance and assistance in all phases of the development of bank- ruptcy CM/ECF software releases. She serves on numerous national committees and working groups within the judiciary, including those involved in identifying the impact of new legisla- tion upon judicial operations and those involved in advising on the education and training needs of court staff. Prior to this posi- tion, she worked as the Chief Deputy Clerk of Court for the U.S. Court of Appeals for the Eighth Circuit, responsible for daily operations of the court.

Ms. McWay began her legal career as a judicial law clerk to the Honorable Myron H. Bright of the U.S. Court of Appeals for the Eighth Circuit. She then became an associate with the law firm of Peper, Martin, Jensen, Maichel, & Hetlage, a multi-specialty firm located in St. Louis, Missouri. Ms. McWay’s legal practice encompassed a variety of health law topics, including contracts, medical records, and physician practice issues. She is admitted to practice in both Illinois and Missouri.

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