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59 Cards in this Set
- Front
- Back
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The term "health information exchange" (HIE) refers to the
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electronic transmission of patients' health information and was recognized through the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 as being key to improving not only the health of the individual, but also the health of patient populations.
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Two types of HIT are
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electronic medical records (EMRs) and electronic health records (EHRs)
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An EMR is
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A digital version of a patient's paper medical chart, compiled by a single provider's practice.
used by the provider to diagnose and treat the patient and is not easily shared with other providers outside of the practice unless printed out. |
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EHRs
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"go beyond data collected in the provider's office and include a more comprehensive patient history."
are designed for sharing a patient's health information among multiple providers involved in the patient's care and are a means of coordinating care across settings. Unlike EMRs, "can be created, managed and consulted by authorized providers and staff from across more than one health care organization...and even across states."1 |
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The term "health information exchange" (HIE) refers to
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the electronic transmission of patients' health information and was recognized through the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 as being key to improving not only the health of the individual, but also the health of patient populations.
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While trying to determine an outcome, specific parameters must be set. These include
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setting the outcome measures in quantifiable terms and determining the appropriate time frame for the outcome to be achieved. (eg, "The patient will ambulate independently at a distance of 100 feet on a level surface, with the use of a quad cane, within two weeks.)
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information technology (IT) systems
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Are Critical to meeting Pressures from payers, providers, government officials, accreditation bodies, and the public continue to demand that the health care system find ways to contain escalating health care costs while, at the same time, provide quality, accessible care.
are effective, efficient, and have a universal design -- a common platform that allows a system used in one sector, such as the payer sector, to "talk" to the system in another sector, such as an integrated delivery system sort through a vast amount of data to extract pertinent, objective information that supports the work they are doing in terms of quality, cost, and access. allows payers and providers to reduce errors by improving documentation and enhancing communication use existing data to report outcomes, improve quality by objectively evaluating practice, and analyze and justify costs associated with a myriad of services delivered. |
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traditional outcomes relate to
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the areas of patient satisfaction, quality of life, clinical effectiveness, treatment response, quality and cost of services, efficiency and appropriateness of services delivered, and organizational performance
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nontraditional ways to measure outcomes may refer to:
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finding what works and what does not; finding ways to evaluate quality; finding ways to examine the value and quality of health care in relation to cost; disclosing information and analyzing results; and comparing health care providers by linking on clinical and financial data.
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An integrated data management system allows case management professionals to
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demonstrate clinical, financial, and quality outcomes.
have the opportunity to use their clinical knowledge and expertise by joining professionals called upon to design data management systems ensure that systems are designed to meet the needs of the end user, while delivering outcomes to support and improve the practice. |
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Collection of data in one setting can allow a cohesive plan of care to be followed by subsequent providers, creating continuity of care across the continuum for the following reasons.
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By collecting and building pertinent information from each episode of care, providers can gain a clear picture of each event that the patient has encountered.
On an aggregate level, the data gathered provide information that can be analyzed and reported according to the needs of the provider or payer. For example, many payers develop and manage educational programs for their plan members in order to promote wellness and minimize illness/injury. Data regarding an increase in diagnostic testing, such as mammograms, could indicate to the payer that educational efforts are being effective and showing positive results. Data can be useful in identifying problems early, to improve prognosis, ability to treat problems, and obtain successful outcomes. |
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the quality and effectiveness of decision-making depends on
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accurate, timely, and relevant information:
1) obtain accurate information, data must be entered accurately 2) Staff training is essential to ensure that each person understands the information that the data system provides to individual practice and to the organization. |
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Applications are
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tools used to integrate information to define standards of care, measure outcomes, examine variances, and make logical decisions and changes to the care process.
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Applications typically have three types of technical functions:
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presentation, business logic, and the database.
Presentation controls how the application looks and feels. Business logic contains rules, edits, and logic for processing and input of commercial applications that are available. These programs allow information to be collected and incorporated into charts or databases to analyze and present information in an organized manner. |
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Pertinent data generated every day by all involved in the health care system need to be analyzed because:
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• Case managers must take an active role in defining and communicating their unique needs when applications or systems decisions are being made.
• The marketplace is demanding that health care providers and payers develop and provide data to improve care, support/define costs, and demonstrate outcomes. • Computerized systems allow organizations to obtain information and generate reports on a variety of topics from the data collected. These include clinical information, logistical aggregate data, encounters with providers or payers, and financial information corresponding to services provided. • If a quality management team wants to evaluate the effectiveness of particular treatment guidelines or critical pathways, data generated from those using the pathway can be analyzed to determine variances in care and outcomes that may have occurred. • Information gathered from analysis of these areas allows the team to determine whether the guideline or pathway is being used, applied effective |
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Important questions to be asked include in data analysis:
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has length of stay been reduced;
has variation in care been decreased; are resources being used more; and can specific outcomes be captured in terms of cost, quality, and access to care? IMPORTANT: Answers to these questions are part of the analysis of continuous quality improvement (CQI) within an organization. |
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Through a careful evaluation of the data, changes, procedures, and policies can be implemented so that systems can be improved. Evaluative information that can be generated from the IT system can determine:
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The number of procedures performed within a given timeline
nformation concerning the type of patients selected for the procedure Outcomes of the procedure The benefit/complication rate of the procedure The cost of the procedure and the time to complete the procedure |
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Reports generated by an IT system should give the user adequate, objective information to review data critically. The data contained in the report should provide information that meets the stated goals of the analysis. Reports can include:
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Clinical and/or financial data to support outcomes
Activities (clinical and financial) that show service delivery to a specific population and whether the service was effective Objective information about overall services and care delivery within a specific population, and what outcomes were achieved |
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The process of evaluating data to report outcomes begins with
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determining the goals that are to be achieved.
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To determine how an organization or provider performs when compared with similar organizations, it is necessary to identify
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commonly used measures
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Benchmarking is an
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ongoing system of measuring products, services and practices against competitors or leaders in a given specialty.
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Benchmarking
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assists providers to improve their practice by measuring, evaluating, and comparing both results and processes that produce the best results.
is part of the continuous quality improvement process used to improve processes by identifying those areas that need improvement. allows organizations to remain competitive in terms of quality, cost effectiveness, and efficiency. |
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Best practice in the health care setting is viewed as a
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service, function, or process that has been fine-tuned, improved and implemented to produce superior outcomes.
result from benchmarks that allow organizations to meet or set new standards. |
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Best practices are used to:
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Improve clinical outcomes
Improve administrative efficiencies Reduce costs Provide supportive data in growing market shares and contracting |
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case management
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• is one process being used to promote best practices in health care delivery.
• Effectiveness improves the efficacy of care while promoting improved quality of care to gain patient satisfaction. • Efforts help organizations define and use best practices within the health care environment are an effective way to confront the changes and demands affecting health care organizations., • Needs to understand what consumers of health care want or expect to define and use best practices within the health care environment. • must listen to patients and families and work to develop practices that meet stated demands. As advocates, case managers can lead this effort through collaboration with providers and payers. • Incorporating best practices across the continuum of care will decrease fragmentation, maximize adherence, and improve quality of care, which will result in an overall reduction in health care costs and the assurance that precious resources reach those patients who have the great |
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Peer review became the norm in 1975 when
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the Social Security Act created a nationwide review agency known as the Professional Standards Review Organization (PSRO)
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Professional Standards Review Organization (PSRO)
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was formed to ensure that medical care provided to patients was of high quality and reflected the most appropriate and efficient use of health care services
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What various accrediting bodies have replaced the efforts that the PSRO started?
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Organizations such as the Joint Commission, the National Committee for Quality Improvement (NCQA), and the American Accreditation Health Care Commission/URAC (URAC) are major organizations that provide quality, peer review oversight for health plans and health care organizations
IMPORTANT: These accreditation bodies require policies and procedures to be established to ensure that the care provided to patients meets high standards, and that health care professionals who provide care maintain competencies that can be measured and reported to the public. |
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For any tools to be used effectively, several things must be put into place.
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To have buy-in from those who will use these tools, it is important that the entire team involved in the treatment or procedure is also involved in developing the tool(s).
Education for those who will be involved in using the tools is also essential to ensure the tools are used for the intended purpose(s). Education should be done prior to implementation of the tool and reinforced as part of the ongoing monitoring. It is important that the team understands that tools are not meant to replace clinical judgment but are used to guide and organize treatment decisions in specific situations. After the tools are developed, it is important to properly train staff about how to document the results generated from using the tools. For the tools to be viewed as a way to improve practice and not as a disciplinary measure, it is important that the tools are used to improve clinical practice and to decrease variation in care. |
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Case managers have many tools that enable them to evaluate how providers and other health care professionals within the health care system provide care to patients. For example, the Case Management Society of America (CMSA) implanted Case Management Adherence Guidelines (CMAG) in 2006 which have been widely used over recent years. CMAG Guidelines allow case managers to
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measure and track adherence as an outcome of case management intervention.
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Algorithms are
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systematic procedures that follow a logical progression based on additional information or a patient's response to an intervention to reach a solution for a specific problem.
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Like protocols, algorithms are
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a series of treatment steps, each of which is defined by the clinical response of the patient to the preceding step.
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unlike protocols, algorithms are
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research-based and have scientific support data.
IMPORTANT: One of the most recognized uses of algorithms is in advanced cardiac life support. Professionals use a specific algorithm that relates to specific cardiac rhythms. Corresponding treatment is designed to interrupt an abnormal rhythm in an attempt to normalize the rhythm. |
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Clinical guidelines are used in the health care industry to ensure that
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clinical interventions are less variable, are based on sound consistent practice, and optimize the management of limited resources.
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Clinical practice guidelines
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have emerged as a tool that health care professionals can use to improve the quality of care provided while controlling costs.
are defined as systematically developed statements that assist the practitioner, health care team, and patients in making decisions about appropriate health care for specific clinical circumstances should be practice-based, patient-specific, and user-friendly. |
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A clinical pathway
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is a tool that outlines all of the components of care for a patient with a particular diagnosis within a specific time frame
is a way of visualizing the process of care for a specific condition that a physician or nurse may encounter from day to day are also classified as critical pathways are interdisciplinary in that they provide written criteria to guide the care delivery of multiple disciplines delineate necessary treatment for a specified population of patients, facilitate appropriate resource use, and provide a standard for comparing actual with expected practice outcomes is illustrated on a grid outlining the treatment on one axis and the stated timeline with expected outcomes on the other axis Category can be listed include such items as assessment and evaluation, diagnostic tests, consults, treatments, medications, diet, teaching, and discharge planning. |
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A clinical pathway timeline
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is a specified period over which an event is expected to occur, and can vary according to where the the path is used.
EXAMPLE: In the emergency department, time may be measured in minutes or hours. In the acute care setting, where a diagnosis needs to be made, the length of stay can range from days to weeks. Usually, Diagnostic Related Groups (DRGs) are used as guides to determine length of stay. Months may be used to plot a course of treatment in areas such as the neonatal intensive care unit or a long-term care facility, where treatment is extended because of the nature of the problems and patients served. |
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For pathways to be accepted and used in clinical practice
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a multidisciplinary approach is important to use when designing a clinical path.
Health professionals who are involved in the treatment of patients and who use the pathway should be included in all aspects of the pathway design, implementation, and evaluation. an educational in-service should be held to introduce the path and explain to each department how the path is to be used, as well as documentation that accompanies the pathway |
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Decision trees
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are used to select the best course of action in situations where there are no clear decisions
allow for the able information to be inputted into a program that systematically factors all variables so that a decision can be made NOTE: Many IT systems feature decision trees as part of standard software |
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Regarding clinical pathways, the case manager
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can use this tool as a way to proactively identify problems, determine where the problems arose, and gather data that objectively provides information on how improvements to care or processes can be made
is able to objectively see how the patient is doing as a result of the use of clinical pathways, since the case manager has a broad view of the process, and does this by continuously assessing whether the patient is meeting the expected goals of the pathway. If goals are not achieved, the case manager documents this as a variance. Variances can occur at any time throughout the course of treatment. |
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Variances
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occur when the patient does not progress as outlined according to the clinical pathway
are usually classified according to who or what caused the variance can be caused by the patient, individual health care professionals, or because of a fault in the system |
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Regarding variances in clinical pathways:
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documentation shows that the variance occurred and what was done to correct the variance at the time
are a result of complex causes, interdisciplinary case consultation can be convened to discuss the events meeting should focus on determining whether the pathway is realistic for the individual patient, as well as whether the variance can be resolved |
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Standards of care help to operationalize
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patient care processes by providing a baseline for quality of care delivered to the patient
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The CMSA Standards of Practice for Case Managers, published by CMSA
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is an example of professional standards
set forth professional opinions regarding excellence in the field of case management serve to articulate the role and function of case managers to the public |
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HEDIS
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stands for Health Plan Employer Data and Information Set
scores were developed to rate the quality of managed care organizations is results- and effectiveness-oriented, with an emphasis on how well the managed care organization is preventing illnesses |
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The National Council on Quality Improvement (NCQA) has set the standard on outcomes reporting with its
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HEDIS scores since the early 1990s
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Medicare Advantage plans are mandated to report to NCQA any audited
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HEDIS data on Centers for Medicare and Medicaid Services identified measures
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In 2008, the Joint Commission published "Health Care at the Crossroads: Development of a National Performance Measurement Data Strategy," which was
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the result of a 2001 public policy initiative
NOTE: The idea behind this was to bridge performance measurement activities across the entire health care system |
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This was a 15-member group working to ensure that measurement-driven assessment processes were efficient, consistent and useful for the many parties that relied upon them in making health care decisions.
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the Joint Commission joined with the American Medical Accreditation Program (AMAP) and HEDIS to become the Performance Measurement Coordinating Council (PMCC)
NOTE: this was prior to the National Performance Measurement Data Strategy |
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Health assessment screening tools, also known as health risk assessments (HRA)
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are a means to evaluate risk and outcomes
cannot be used to evaluate process of practice can be descriptive or predictive and collect data about the characteristics of a population to identify and implement allow providers to proactively evaluate a patient's perception of his/her health status, and whether the patient understands the information given to him/her about a disease or injury and the ongoing prognosis are also used in demand management, where they are important to effectively triage patients/beneficiaries into appropriate settings at the appropriate time enables the practitioner to evaluate whether the patient understands, and can apply, the information to maximize patient adherence. If the screening tool shows that the patient did not understand the information well enough to self-manage and achieve optimal results, referral to case management is indicated for reinforcement and for monitoring the patient's adherence and outcomes over time |
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What is the most widely used of the Medical Outcomes Study (MOS) short-form screening tools and what is its purpose?
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The Short Form (SF)-36 Health Assessment Screening Tool
It includes eight multi-item measurement scales evaluating physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well being, social functioning, energy/fatigue and general health perception. is meant to measure the patient's perceived health status, and not the health care provider's assessment of the patient's health status. Why? An example of the effective use of a patient's perceived health status is in a DM model. In order to make disease management programs successful, a plan must be able to identify which of its members are at risk for repeat hospitalizations, over-utilization of services, nonadherence, and other issues. |
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More sophisticated health assessment screening tools use
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dynamic questioning so that an answer to one question triggers another set of questions that further attempts to define the member's health risk. Algorithms based on medical literature are then used to stratify health plan members into low-, medium- and high-risk categories.
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Health assessment screening tool Predictive tools
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are used to infer what may happen in a particular population, in particular disease conditions, or because of certain lifestyle behaviors
may be used to demonstrate factors among smokers. Results would show that smokers tend to develop more respiratory infections and chronic bronchitis than nonsmokers and recover more slowly from surgery |
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Health assessment screening tool Evaluative tools
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are survey tools that measure and weigh the effectiveness of a particular medical intervention or process
focus is on establishing and maintaining a streamlined process to make periodic health assessments a routine part of the care process, in both the inpatient and ambulatory settings an interdisciplinary team that includes physicians is needed |
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Patient care guidelines or clinical guidelines: case managers should know the five basic principles (fifth on separate card) that are crucial to follow in order for a delivery system to truly be resource-efficient:
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Principle 1: The provided services must not include any services that are not medically necessary/more intense than is medically necessary
Principle 2: Care should not be imparted by a provider with a greater level of expertise than is medically necessary to provide the medically appropriate care, unless the provider is willing to provide care at a cost that is equivalent to the cost for a less experienced provider. Principle 3: Care should not be delivered in a setting that is more costly or intensive than is medically necessary, recognizing that there are nonclinical factors that may make a more intense setting necessary. Principle 4: Health care resource prices should be directly correlated to the appropriate level of provider expertise and intensity of the service and setting. The prices should also be competitive with other contracts offered by providers . Principle 5: The administrative cost, added by those who provide financial and delivery of services should not be excessive. |
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Patient care guidelines should, at the minimum, include the following first four components:
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Diagnostic and therapeutic guidelines that provide a clinical description of appropriate care
Utilization review and case management templates that provide a way to monitor the care both concurrently and retrospectively Patient activity-modification guidelines that provide guidance regarding the activity expectations an employer, parent, friend or other interested party should have based on the patient's current health status Time duration of care guidelines that provide the key monitoring points required to appropriately chart a patient's recovery process and health status improvement |
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Patient care guidelines should, at the minimum, include the following last two components:
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Computerized medical records that provide all of the traditional information included in a patient's medical chart, but that allow real time comparisons with the four components above, as well as a comprehensive view of the patient's health care status historically, currently and prospectively
Course-of-care map/decision tree that provides the necessary information on alternatives and possibilities for both the current course of care and the possible interventions to effect health status improvement (or to minimize health status decline) |
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The following should be considered during the developmental and implementation phases of the guidelines:
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Selection of the diagnosis, procedure, or condition for the path
Definition of the scope (inpatient only; outpatient, etc.) Selection of a multidisciplinary team Inclusion of a physician champion (someone whose opinion is respected by his/her peers) A flowchart of the process and baseline data collection Identification of outcomes |
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According to the National Learning Consortium, continuous quality improvement (CQI) uses a
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structured planning approach to evaluate and improve current processes to achieve desired outcomes and enhance efficiency and effectiveness.
in case management strives to improve clinical performance, care delivery, and health outcomes with a focus on customer needs and desires |
