Transcript Introduction to Healthcare Information Technology

Introduction to Healthcare
Information Technology
Chapter Five
Medical Business Operations
Objectives
• Define frequently used healthcare terms
• Identify and describe the functions of certain
healthcare departments
• Describe the uses for clinical software
• List and describe the steps in the clinical process
or environment
• Identify and describe the functions of various
medical devices
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Healthcare IT: Challenges and
Opportunities
• Health care is one of the largest industries in the
US
– 14.2 million workers
• Bureau of Labor Statistics forecast:
– Over 3 million new jobs in healthcare between 2008
and 2018
• Home healthcare services
– One of the fastest growing areas until 2018
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Medical Terminology
• Healthcare
– Specialized terminology
– Numerous acronyms
• Imaging
– Often called radiology
– Use of technologies to provide visual representation
of internal body structures
– Can eliminate the need for biopsies or surgery in
some cases
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Medical Terminology (cont’d.)
• Major types of imaging technologies
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X-ray
CT scan
Fluoroscopy
Magnetic resonance imaging (MRI)
Ultrasound
Nuclear medicine
• Newer techniques
– Capsule endoscopy
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Figure 5-1 Modern x-ray machine
© Tyler Olson/www.Shutterstock.com
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Primary Care Physician
• Over 20 physician specialties in medicine
• Primary care physician specialties
– Family or general practice
• Broad range of ailments and chronic disorders
– Internal medicine
• Adult diseases and chronic disorders
– Pediatrics
• Diagnosis and treatment of children
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Stat
• Term meaning “immediately”
• Derived from Latin word statim
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Acuity
• Measure of the degree of patient disease or injury
• Can refer to:
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Severity
Time sensitivity
Physical effects
Psychological suffering
• High-acuity patient less healthy than low-acuity
patient, in general
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Code Blue
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Emergency code
Indicates patient needs immediate help
Can be announced over the public address system
Expedites correct staff moving to location where
patient needs help
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Trauma Levels
• Trauma
– Physical wound or injury to the body
– May be caused by accident or violence
– Commonly treated at hospital ERs
• Trauma center
– Centers classified according to their ability to handle
different types of trauma
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Table 5-1 Trauma center levels and resources
© Cengage Learning 2013
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Controlled Substances
• Controlled Substances Act of 1970
– Established government control of certain drugs and
chemicals known as controlled substances
• Classification scheme with five levels
• Schedule 1 substances
– High abuse potential
– No currently accepted medical use
• Schedule 2 substances
– Can cause dependence
– High abuse potential
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Controlled Substances (cont’d.)
• Schedule 3 substances
– Lower abuse potential than schedule 1 and 2
– Example: drugs containing less than 15mg
hydrocodone per dosage
• Schedule 4 substances
– Lower abuse potential than schedule 3
– Examples: diazepam, alprazolam, propoxyphene
• Schedule 5 substances
– Cough and cold preparations with limited quantities
of certain narcotics
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Controlled Substances (cont’d.)
• Healthcare providers that use controlled
substances:
– Have well-defined policies and procedures for use
• Example controlled substance policy components
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Locked storage
Staff authorization to access
Substance abuse protocol
Substance audits
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Electronic Medical Record
• Medical record (chart)
– Location where provider records aspects of
diagnosis and treatment
• Electronic medical record
– Can be viewed by authorized individuals anywhere
in the world
– Can be interfaced to other electronic systems
• Lab or radiology results can be instantly updated
– Controlling access can be more difficult than with
paper record
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Electronic Health Record
• Broader than an EMR
• Includes demographics, billing, and all historical
medical information
• Gives providers the widest possible perspective on
a patient
• Potential for abuse of information exists
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Medical Departments
• Ambulatory/day surgery
– Provides surgery on an outpatient basis
• Behavioral health
– Provides care for mental disorders
• Cardiac care units
– Treat patients requiring specialized cardiac
monitoring
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Medical Departments (cont’d.)
• Cardiovascular
– Includes advanced cardiac specialties
• Electrophysiology
• Heart failure
• Heart transplantation
• Dermatology
– Treats skin diseases:
• Usually on an outpatient basis
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Medical Departments (cont’d.)
• Ear, nose, and throat
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Also called otolaryngology
Facial plastic surgery
Laryngology (voice)
Neuro-otology (middle/inner ear, base of skull)
Otology (ear)
Rhinology (sinuses)
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Medical Departments (cont’d.)
• Emergency room
– Treats patients with life-threatening condition or
immediate need
– Certified to a specific trauma level
• Intensive care unit
– Treats patients needing high level of specialized
care
– Can include intensive monitoring with electronic
equipment
– Patient may need ventilator, feeding tubes, etc.
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Figure 5-3 Intensive care monitoring
© Edwin Verin/www.Shutterstock.com
Medical Departments (cont’d.)
• Laboratory
– Provides chemical, microbial, microscopic, and other
studies to diagnose and treat injury
• Medical/surgical
– Care for adult patients before and after surgery
• Nuclear medicine
– Uses radioactive decay of radiopharmaceuticals to
diagnose and treat disease
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Medical Departments (cont’d.)
• Obstetrics/gynecology
– Provides care for the female reproductive system
– Obstetrics provides care surrounding childbirth
• OB/GYN related departments
– Family birth center
– Labor and delivery
– Neonatal intensive unit
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Medical Departments (cont’d.)
• Occupational therapy
– Care for patients recovering from injury to regain
work-related skills
– Helping people with disabilities accomplish self-care
tasks
• Oncology
– Care for cancer patients
• Operating room
– Department where surgical operations are
conducted
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Medical Departments (cont’d.)
• Ophthalmology
– Diagnose and treat various eye conditions
• Pediatrics
– Specialized treatment for children
– Patients may be medium or high acuity
• Physical therapy
– Assists patients to regain lost range of motion
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Medical Departments (cont’d.)
• Plastic surgery
– Provides reconstruction of the human body
• Post-anesthesia care unit
– Provides care during recovery from anesthesia
• Radiology
– Provides imaging equipment using x-ray, ultrasound,
or nuclear isotopes to diagnose disease or injury
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Medical Departments (cont’d.)
• Respiratory
– Provides breathing treatments for inpatients or
outpatients
• Bronchodilators
• Pulmonary rehabilitation
• Mechanical ventilation
• Transitional/progressive care unit
– Provides transitional care between CCU/ICU and
standard care unit
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Clinical Software
• Software
– Set of instructions that helps hardware process data
into information
• Clinical software
– Used to manage data and information in a clinical
environment
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Patient Tracking
• Patient tracking software benefits
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Tracks services provided
Manages patient demographics
Manages patient visit history
Tracks time-specific illnesses like allergies
• Many patient tracking systems can interface with
scheduling, medical records, and lab software
packages
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Scheduling
• Scheduling software manages patient scheduling
process
• Capabilities
– Quickly scan for open appointments
– Track patient cancellations, no-shows, and
reschedules
– Track patient visits by time of check-in and departure
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Order Entry
• Computerized physician order entry (CPOE)
– Electronic systems transmit physician’s orders to
other healthcare professionals
• Advantages of CPOE
– Instant availability of patient’s medical history
– Current information helps prevent unwanted drug
interactions
– Statistical reports improve resource management
– Linking diagnoses to the order improves billing
management
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Billing/Coding/Auditing
• Billing software helps manage billing process
– Software decision engines can validate claims
– Submits claims to appropriate payer
• International Statistical Classification of Diseases
and Related Health Problems Codes (ICD-9)
– List of over 13,000 codes used in billing
• ICD-10
– Complete revision of the diagnosis code set
– Includes about 68,000 codes
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Table 5-2 ICD-9 and ICD-10 code examples
© Cengage Learning 2013
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Billing/Coding/Auditing (cont’d.)
• Audit software
– Computer algorithms determine whether correct
CPT and ICD codes are used
– Can use historical data for trending and analysis to
predict and improve performance
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Practice Management
• Practice management software (PMS) functions
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Patient tracking
Scheduling
Computerized physician order entry
Billing
Coding
Audit
• PMS can be interfaced with EMR systems
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The Clinical Environment
• Clinical process (clinical environment)
– Sequence of operations that must occur for the
patient to be examined, diagnosed, and treated
– May vary by environment
• Common features of the clinical environment
– Registration, consultation, examination, CPOE,
dictation/transcription, referrals
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Registration
• Patient must be registered or admitted:
– Prior to being seen by medical staff
• Examples of patient data collected during
registration
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Contact information
Billing information
Next of kin
Current medications
Other pertinent information
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Consultation
• Also known as medical history
• Questions about pain levels, location, and intensity
• Brief history of activity:
– To determine if behavior or actions contributed to the
illness
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Examination
• Checking the patient’s physical status
• Vital signs
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Body temperature
Blood pressure
Pulse rate
Respiratory rate
• Initial examination normally performed by nurse or
other medical professional
– Patient examined in more detail by a physician
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Physician Order Entry
• Process of storing and transmitting orders to other
healthcare providers
• Types of order entry
– Handwritten or typed paper orders
– Verbal orders
– CPOE
• Digital signatures
– Encrypted messages similar to handwritten
signatures
– Allow for electronic transmission and storage
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Dictation/Transcription
• Used with verbal orders
• Centralized voice-recording system shared among
physicians
• Transcriptionist transcribes orders to electronic,
paper, or film format
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Referrals/Consults
• Physician may refer (send) patient to another
professional for further diagnosis
• Consult
– Communication between physicians or specialists
regarding a patient’s diagnosis or treatment
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Medical Devices
• FDA regulates the manufacture and distribution of
medical devices in the US
• Definition of medical device
– Recognized in the official National Formulary or the
United States Pharmacopoeia
– Intended for use in the diagnosis or prevention of
disease
– Intended to affect the structure or function of the
body without chemical action
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Computerized Axial Tomography
Scanner
• Tomography
– Imaging technique in which sections are created by
a penetrating wave
• Computerized axial tomography (CAT or CT)
– X-ray system in which the tomography is created by
computer processing
• Advantages of CAT scans
– High contrast resolution
– Tissues that differ in density may be distinguished
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Electrocardiogram Machine
• Electrocardiogram (EKG or ECG)
– Two-dimensional representation of electrical heart
activity
– Read by trained professionals to detect heart
disease or abnormality
• EKG machines
– Commonly transported by hand or small cart
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Electroencephalograph Machine
• Measures ionic current flows within the brain’s
neurons
• Usually portable and transported by utility cart
• Trained professionals can read EEG:
– To determine disorders such as coma, epilepsy, and
brain death
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Glucose Monitor
• Portable electronic device that directly reads level
of glucose in the blood
• Results available in seconds
• Used in diagnosis of diabetes mellitus
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Magnetic Resonance Imaging
• Uses very strong magnetic fields to create image of
internal body structures
• Certain viewpoints more easily obtained than with
other imaging techniques
• Greater detail of internal body structures compared
with traditional techniques
• MRI machines
– Large (room-size)
– Complex
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Figure 5-6 Human brain scan from an MRI
© Donna Beeler/www.Shutterstock.com
Portable X-Ray Machine
• X-ray machine
– Uses x-rays to cast static shadows of internal body
structures on film or image sensor
– Large devices (typically room-size)
• Portable x-ray machine
– Can be transported to the patient:
• In cases where patient cannot be easily transported to
a traditional x-ray machine
– Machines are portable yet heavy
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Positron Emission Tomography
• Positronic emission tomography (PET) scans
– Certain radiopharmaceuticals behave in different
ways in different body organs
– Radiopharmaceutical administered to a patient emits
gamma rays
– PET scanner creates 3D image of tracer
concentration
• Scanners are large and complex
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Ultrasound
• Uses high-frequency sound waves to image soft
tissue structures
• Image quality less detailed than x-ray or other
technologies
• Ultrasound uses
– Evaluating fetal health during pregnancy
– Evaluating blood flow to the brain
– Diagnosis of heart abnormalities
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Vascular/Nuclear Stress Test
• Cardiac stress test
– Used to determine the heart’s response to physical
stress
• Vascular or nuclear stress test
– Uses radiopharmaceuticals that emit gamma rays
– Gamma camera captures detailed images of blood
flow in the heart
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Vitals Cuff
• Standard baseline measurements
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Body temperature
Blood pressure
Pulse rate
Respiratory rate
• Vitals cuff
– Device that integrates the entire vital sign
measurement process
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Medical Interfaces
• Standards for exchange of health information
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Health Level Seven
e-prescribing
Continuity of Care Document (CCD)
Continuity of Care Record (CCR)
International Statistical Classification of Diseases
and Related Health Problems, 10th Revision (ICD10)
– Current Procedural Terminology (CPT)
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Medical Interfaces (cont’d.)
• Standards for exchange of health information
(cont’d.)
– Systematized Nomenclature of Medicine (Snomed)
– National Drug Code ID (NDCID)
– Picture archiving and communication system
(PACS)
– Evaluation and Management Coding (E/M codes)
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Summary
• Health care has specialized terminology and
numerous acronyms
• Hospitals have different medical departments that
provide different types of patient care
• Clinical software is used to manage and
manipulate data and information in the clinical
environment
• The healthcare environment workflow may include
registration, consultation, examination, physician
order entry, dictation/transcription, and referrals or
consults
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Summary (cont’d.)
• Medical devices are used to diagnose and treat
patients and are regulated by the FDA
• There are many interfaces and standards that
support information sharing between devices and
systems
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