Florida National University
HAS-6197 Health Information System and Electronic Health Record: Assignment Week 5
Administrative and Structural Analysis of an Electronic Health Claim Management: Chapters
9 &10
Objective: In this assignment you are request to you will describe, analyze and apply process of
creating claims, locating specific claim, methods used to submit electronic claims, and the claim
determination process used by health plans.
ASSIGNMENT GUIDELINES (10%):
Students will judgmentally evaluate the readings from Chapter 9 and 10 on your textbook and
from the article assigned for week 5. The Purpose of this Administrative and Structural Analysis
of an Electronic Health Claim Management is to describes the potential benefits of EHRs that
include clinical outcomes (eg, improved quality, reduced medical errors), organizational
outcomes (eg, financial and operational benefits), and societal outcomes (eg, improved ability to
conduct research, improved population health, reduced costs). Despite these benefits, studies in
the literature highlight drawbacks associated with EHRs, which include the high upfront
acquisition costs, ongoing maintenance costs, and disruptions to workflows that contribute to
temporary losses in productivity that are the result of learning a new system. Moreover, EHRs
are associated with potential perceived privacy concerns among patients, which are further
addressed legislatively in the HITECH Act. Overall, experts and policymakers believe that
significant benefits to patients and society can be realized when EHRs are widely adopted and
used in a “meaningful” way.
You need to develop a 4-5-page paper long including title page and references page reproducing
your understanding and capability to relate the readings to claim management. Each paper must
be typewritten with 12-point font and double-spaced with standard margins. Follow APA style
7th format when referring to the selected articles and include a reference page.
EACH PAPER SHOULD INCLUDE THE FOLLOWING:
1. Introduction (25%) Provide a brief synopsis of the meaning (not a description) of each
Chapter and articles you read, in your own words.
2. Your Strategies (50%)
a. Briefly compare the CMS-1500 paper claim and the 837 electronic.
b. Discussion the information contained in the claim management dialog box
c. Analyze the method used to submit electronic claims.
d. Discuss the use of the PM/HER to monitor claims.
3. Conclusion (15%)
Briefly summarize your thoughts & conclusion to this assignment and your appraisal of the
Chapter you read. How did these articles and Chapters impact your thoughts about Claim
Management? How this Administrative Analysis help you in relation to Claim management in
Medisoft.
Evaluation will be based on how clearly you respond to the above, in particular:
a) The clarity with which you present and analyzed the strategies;
b) The depth, scope, and organization of your Administrative Analysis paper; and,
c) Your conclusions, including a description of the impact of these articles and Chapters on any
Healthcare Organization.
ASSIGNMENT RUBRICS
Assignments Guidelines
Introduction
Your Strategies
Conclusion
Total
1 Points
2.5 Points
5 Points
1.5 Points
10 points
ASSIGNMENT GRADING SYSTEM
A
B+
B
C+
C
D
F
Dr. Gisela LLamas
90% – 100%
85% – 89%
80% – 84%
75% – 79%
70% – 74%
60% – 69%
50% – 59% Or less.
10%
25%
50%
15%
100%
Chapter 9:
Adopting New
Technologies
Introduction
• HIS and technologies play a significant role in
embracing innovation
• To innovate, the industry must seize opportunities to
improve on current, mainstream technologies and
build them better
• New technologies and HIS must be anticipated,
piloted, tested, and adapted to
• Most new HIS must fit in with existing HIS
• Discussion of innovation explores why it is needed,
the risks and benefits adoption brings, and the tools
and mind-sets that help it succeed
The Context of HIS Innovation
• Innovation is borne of forces driving change to health
care
– Unsustainable costs
– Move to value-based care and reimbursement
– Patient-centric consumerism
• These trends push healthcare organizations providers,
and payers to seek tech-driven solutions
• Healthcare organizations and provider must ascend
steep learning curves as they try new methods and find
ones that work
• A lot is at stake as they try, fail, and learn
The Context of HIS Innovation
• New technologies and existing problems
– Avoid the love of new technology for newness sake
– Issues for healthcare organizations
• Security breaches and ransoming
• Wasted clinician time and goodwill as a result of tech that
is difficult to use and systems dominated by assembly-line
workflows and profit-minded vendors rather than the
end-user in mind
• Patients remain on the outskirts of the activities and
information intended to help them
• The costs of HIS and technologies are a hefty burden for
organizations and society to bear
The Value of Adopting New
Technologies
• MU criteria of the HITECH Act of 2009 for EHR
implementations and incentive payments were
expected to spawn achievement of HIS benefits in
three categories
1. Improving accuracy, timeliness, and availability of health
information to care providers
2. Improving access to information, thereby allowing
providers to better anticipate the diagnostic and health
needs of their patients and share this information among
other providers as appropriate
3. Empowering patients to more actively participate in their
health care and wellness and have access and input to their
health data
The Value of Adopting New
Technologies
• Realizing value
– Four areas critical to value realization
• Strategic alignment
• Architectural considerations
• Post-implementation evaluation
• Excellence in HIS service delivery
The Value of Adopting New
Technologies
• The HIS value proposition
– U.S. Department of Veterans Affairs (VA) has implemented a
very successful EHR and established a track record of
leadership in HER adoption
– 2010 comparison showed VA spent proportionately more
than private-sector health systems but achieved high
adoption and quality of care
– Realizing benefits depends on creating a deliberate,
organized system implementation
– Each benefit or goal must have measurable, realistic
objectives
– Keep targeted objectives realistic and within reach
The Value of Adopting New
Technologies
• Use technology to simplify processes and access to
information
– Increasing complexity of information requires key subject
matter experts (SMEs) and key stakeholders in introducing
any new technology
– Informatics techniques can improve the process of evaluating
and dissecting the work and processes of decision making
– Great deal of work has been done in the field of informatics
to improve the quantity and quality of available information
– The more complex options are, the more likely the decision
maker will choose the status quo
Rogers’s Theory of Diffusion of Innovation:
Adoption of New HIS and Technology
• Health care has been markedly slower than other
industries to use IT to accomplish its work
– Use of HIS and tech is called adoption
– Adoption of disruptive HIS and tech means that organizations
adapt to automated work processes
– Adoption of HIS and tech occurs amidst a busy and stressful
healthcare environment
– Health care and the adoption of HIS and tech are more
complex than the environments found in other industries or
lines of work
Rogers’s Theory of Diffusion of Innovation:
Adoption of New HIS and Technology
• Adoption patterns
– Innovators
• Initiators of the change; always want to try something new
– Early Adopters
• Respected opinion leaders of the organization; use the experience of
the Innovators to inform their decisions
– Early Majority
• Careful, cooperative, attentive; embrace the innovation as part of a
move toward positive change
– Late Majority
• Eventually adjust to change, usually after most others have done so
– Laggards
• Traditionalists; resistant to change
Rogers’s Theory of Diffusion of Innovation:
Adoption of New HIS and Technology
• Adoption patterns
– Adoption of HIS and tech is thought to follow the pattern of the
diffusion of innovation and adoption of disruptive technologies
(Rogers, 1962, Diffusion of Innovations)
– The adoption curve has five groups or segments that play roles in
the adoption of disruptive new technologies
Rogers’s adoption/ innovation curve
Data from Rogers, E. M. (1963). Rogers’ adoption/innovation curve. In: Diffusion of innovations. New York: Free Press.
Historical Sources of HIS and
Technology Innovation
• Early innovations and documented advancements in
use of HIS and tech over 25 years occurred at a small
number of noteworthy healthcare organizations
– HIS innovation occurs in a handful of organizations whose
cultures and capacities are fertile grounds for trying new HIS
and tech and applications
– Four organizations published 25 percent of all studies of HIS
from 1995 through 2007
– Their cultures and bottom lines are better suited to tackle
these types of high-risk research and development efforts
The History of HIS Innovation
• Since the 1960s, the origin points of innovation have been
hospital data processing departments, clinical computer labs,
home offices, garages
• The few hospitals able to afford expensive mainframe hardware
and programmers developed the early healthcare computer
application software
• In the 1970s, air-cooled minicomputers made it possible for the
first vendors to emerge to support hospital financial software
• Early HIS work gave rise to the first HIS professional
organizations
– Hospital Information Systems Sharing Groups (HISSG)
– Electronic Computing Hospital Organization (ECHO)
The History of HIS Innovation
• First HIS were extensions of charge-capture systems for patient
billing
• First comprehensive medical information system was designed
and built through a federal grant from Lockheed Martin
• 1980s brought the mini-computer and competitive air-cooled
minicomputers that required less infrastructure and made the
business of HIS more affordable
• Some vendors created their own software packages, but this was
not common
• Early adopters among healthcare providers began to buy and
implement computer systems to support their financial systems
and increasingly some ancillary clinical and practice
management
The History of HIS Innovation
• Innovation in clinical systems and the EHR
– Clinical HIS have roots in charge-capture systems rather than
systems with functionality grounded in clinical care purposes
– Technicon developed first comprehensive medical
information system in the mid-1970s.
• Requirements document for this systems reads like requirements
documentation for a modern EHR system
– Niche systems competed to be “best-of-breed”
– Physician practice management systems for large practices
– In the 1990s, the Internet transformed healthcare computing
– Federal government enacted the HIPPA to protect the
security and privacy of citizens’ data
Role of Professional Organizations in
Adopting New Technologies
• Health Information Management Systems Society
(HIMSS)
– Roots in an organization established in 1962 for management
engineering professionals in health care – Hospital
Management Systems Society (HMSS)
– Morphed into HIMSS in 1986 as focus changed to information
systems
– HIMSS is not the primary HIS and tech professional
organization in the U.S., with growing international reach
– Not-for-profit philosophy
– Commitment to objectivity
– Maintains analytics database and publishes reports
Role of Professional Organizations in
Adopting New Technologies
• American Health Information Management Association
(ARLNA)
– Aims to “elevate the standards of clinical records in hospitals
and other medical institutions”
– Provides strict accreditation and certification tests and
processes for achieving and maintaining Registered Health
Information Administrator (RHIA) accreditation for health
information professionals and Registered Health Information
Technicians (RHITs) certifications for coders
– As computerization of health records grows, AHIMA has
evolved to provide education, training, certification, and
accreditation
Role of Professional Organizations in
Adopting New Technologies
• American Medical Informatics Association (AMIA)
– Promotes and develops the science and practice of
informatics in health care
– Offers conferences, education, meetings, research, and policy
• Alliance for Nursing Informatics (ANI)
– Supported by both AIA and HIMSS
– Brings together 18 independent nursing informatics groups
– Devoted to professional development, leadership, and
collaboration among those in the HIS and tech-related
disciplines
Impact of New Technologies on Existing HIS
• Adoption of new technologies affects existing HIS plans and
architectures
• Must take care to analyze how innovation will fit in with existing
technology and HIS
• Do not plop additional technologies atop the core systems; they
must be carefully connected
• New technology should augment and enrich what already exists
• Great expansion is possible by building upon cost systems
• EHR system provides levels of capabilities leading up to
paperless clinical environments
Impact of New Technologies on Existing HIS
• Electronic Medical Record Adoption Model
HER adoption stages
Reproduced from Healthcare Information and Management Systems Society (HIMSS). EMRAM A strategic roadmap for effective EMR adoption and maturity. Retrieved from
https://www.himssanalytics.org/sites/himssanalytics/files/HIMSS percent20Analytics percent20EMRAM percent20- percent20web_2.pdf
Impact of New Technologies on Existing HIS
• Market forces
– Trends in investments in the health information
technology market are indicators of where interest
and progress lie
• Patient-centric technologies used to engage patients in
management of their own health is a growing market
• More settled disciplines of provider-centric technologies
and clinical analytics are diminishing in levels of new
money as markets are more saturated
Impact of New Technologies on Existing HIS
• Unintended consequences of adoption of new
technologies
– Detection of all the effects of automation has lagged behind
implementation
– Customization creates difficulty in drawing cause and effect
relationships
– Vendor contracts favor the vendor and prohibit open
disclosure of system problems
– Crossing the Quality Chasm
– 2012 study reported 56% of errors were computer system
related and 44% were human error
– Combination of paper and electronic records is particularly
problematic
Case Example: Challenging Financial
Effects of EHR Implementations
• Background
• The challenges needing a solution
• The solution
• Anticipated outcomes of the new approaches
Case Example: Blockchain: To Adopt or
Not to Adopt
• Background
• The challenges needing a solution
• The solution
• Anticipated outcomes of the new approaches
Impact of New Technologies on Existing HIS
• Provider dissatisfaction with EHR systems
– Physician burnout is one of the most pronounced unintended
consequences
– 2018 survey by Medscape
• Three of the four top complaints were time spent in bureaucratic,
clerical tasks; too much time spent at work; and increased
computerization of their practices
– September 2018 Stanford Report
• Physicians spend 62% of their time with a patient documenting in the
EHR system
• Physicians report EHR systems get in the way of provider-patient
interaction and turn them into data-entry clerks
Impact of New Technologies on Existing HIS
• Provider dissatisfaction with EHR systems
– It is underestimates how much professional angst and moral
distress the EHR system has created for physicians
– KLAS
• Less than half of physicians feel their EHR systems enable quality care
• In six organizations 75% of physicians feel their EHR systems enable
quality care
– Digital health and future uses of new ways of emerging
technologies call for additional education of all health
professionals and health administration professionals
Building HIS and Technology into Education
and Health Professionals
• HIS and technology must be built into the curricula of
professional schools
– Medicine, nursing, therapies, management, policy
– Discipline and ability to oversee activities of organizations
and vendors of HIS products and services is essential
– Vast majority of clinicians and managers in health care have
little experience and no education in this arena
– HITECH Act of 2009 granted funding mostly to community
colleges for rapid training of health IT professional
– Nursing informatics and medical informatics degrees
Cultural Change Comes with New
Technology and HIS
• Health care lags behind other knowledge-based,
connected industries in adoption of new technologies
to streamline and advance how work is done
• Value migration from visible, tangible assets to
intangible knowledge resources
• Intellectual capital is gaining importance as means of
improving organizational performance and market
position
• Performance and productivity are not enough
• Problems and capabilities of the modern world
requires innovative thought
Cultural Change Comes with New
Technology and HIS
• Emergency of the knowledge-based economy
– Patients will no longer be passive recipients of medical
services
– Goes beyond hope for absence of disease or injury; extends
to achieving and maintaining optimal health and wellbeing
– Digital technology is “dematerializing” information
– It is enabling separation of information from the physical
structures and objects used to carry it
– Takes geography out of the equation
– Huge change from the central records room or corporate
office mentality that implies all important information (and
intelligence) was housed in one physical location
Cultural Change Comes with New
Technology and HIS
• Changing organizational models
– Organizational configurations are transitioning from
strict, define, and hierarchical to fluid, social,
adaptable networks
– Organizations can now be called “flat”
• Information sharing and collaboration occur between any
and all “team members” who need to interact
• Hierarchy still exists, but function and process is changing
due to automation of information
Cultural Change Comes with New
Technology and HIS
• Facilitating organizational evolution
– Hospitals can no longer be treated as the center of
the healthcare universe
• Changing demographics
• Increasing rates of chronic illness
• Focus is being placed on primary, personalized care
• Prevention rather than acute care (the arena of hospitals)
• Medical homes and accountable care organizations
(ACOs)
• Lifetime patient record
Case Example: Binders Versus
Automation
• Background
• The challenges needing a solution
• The solution
• Anticipated outcomes of the new approaches
Case Example: ACO Versus a Hospital
for a Patient with Diabetes
• Background
• The challenges needing a solution
• The solution
• Anticipated outcomes of the new approaches
Case Example: Human-Centered
Process
• Background
• The challenges needing a solution
• The solution
• Anticipated outcomes of the new approaches
Cultural Change Comes with New
Technology and HIS
• Management of information resources
– Knowledge management is an essential part of the
evolutionary process
– Quadrants III and IV of the HIS planning framework comprise
clinical and business intelligence systems
– These systems add an entire layer of HIS and tech to the
architectures and mix of systems supporting healthcare
management
– Environmental or marketing analysis is an essential
component of strategic management of knowledge resources
Summary
• Adopting new technologies is steeped in theory and based on
the earthly reality of solutions
• The adoption of HIS and technology can be seen as rooted in
Rogers’s diffusion of innovation
• HIS and technology adoption originated mostly within
hospitals and other healthcare delivery organizations
• Vendors emerged as a result of hospital software
development innovations
• Successful HIS and tech adoption faces numerous challenges
• HITECH financial incentives have encouraged adoption of EHR
systems
• Unintended negative consequences must be considered
Chapter 10:
Data
Data Definition
• Data is base-level computer information that
may consist of numerical or word elements,
facts, values, or combinations of stored
information that can be either qualitative or
quantitative, and from which knowledge is
derived and decision making may be made
better and more logical.
Data Sources
• Clinical
• Transactional/Operations
• Payer
• Third Party
• External
• Government
Data Sources – Clinical
• Electronic health records/electronic medical records
personal health records (EHRs/EMRs/PHRs)
• Images and image management systems (e.g., picture
archiving and communication systems [PACSs],
digitized X-rays, CT scans, PET scans)
• Case mix, care management, and disease management
systems
• Independent laboratory and other clinical results (e.g.,
blood, tissue, fluids)
• Monitoring systems (e.g., maternity, cardiology, ICU)
Data Sources –
Transactional/Operations
• Hospital information systems (e.g., admissions, emergency
department visits)
• Hospital departmental systems (e.g., radiology, laboratory,
pharmacy, surgery, emergency department, order entry)
• Materials management, supplies, and cost accounting
systems
• Physician practice management systems (e.g., scheduling,
billing)
• Revenue-cycle processes (e.g., provider billing, claims,
patient accounting)
• Post-acute clinical and billing systems (e.g., skilled nursing,
home care)
Data Sources – Payer
• Payer claims and contracting systems (e.g.,
benefit rules, risk calculations, claims
[adjudication])
• Care management systems (for coordinating
transitions of care and discharge to home or
other facilities)
Data Sources – Third Party
• Research systems (e.g., universities, human,
animal)
• Clinical trials systems (e.g., pharmaceutical
companies, universities)
• Satisfaction surveying systems (e.g., patients,
providers, staff)
Data Sources – External
• Internet resources
• Registries, population management, statistics,
and risk adjustments
• Industry reporting (e.g., benchmarks, score
cards, report cards)
• Cellular devices and applications
• Personal monitors and watches
Data Sources – Government
• Federal government programs (e.g., Centers for
Medicare and Medicaid Services [CMS], State
Children’s Health Insurance Program [SCHIP],
Department of Defense TRICARE and TRICARE for Life
programs, Veterans Health Administration [VHA]
program, and Indian Health Service [IHS] program)
• State and local government programs (e.g., Medicaid,
MediCal, State Health Insurance Assistance Program
[SHIP], Children’s Health Insurance Program [CHIP],
Health Resources and Services Administration Primary
Care: The Health Center Program, healthcare
marketplace regulatory programs)
Three Big Data Sources
• Electronic Health Record (EHR) Systems
• Mobile Communication and Devices
• Imaging
Data Technology
• Data dictionary
• Interoperability
• Metadata
• Data modeling
• Democratization of data
• Data visualization
Data Security
• The security, veracity and granularity of data is
particularly important in the healthcare
industry. This data is used in life and death
decision making.
• The Health Insurance Portability and
Accountability Act (HIPAA)
• Protected Health Information (PHI)
• The Health Information Technology for
Economic and Clinical Health (HITECH) Act
Data Ownership
• Patient
• Providers: Hospital & Physicians
– IT Department
– RCM (Revenue Cycle Management)
– Executives
• Software Vendors
• Government
Data Flow
Transactional Flow and Data Creation from an ED Visit
Courtesy of Ric Speaker.
Medicare Access and CHIP
Reauthorization Act (MACRA)
• Federal legislation for the Department of Health
and Human Services (HHS) and CMS is applying
efforts to measure the quality of care and to
create incentives to compensate providers for
their respective compliance and energies to affect
this.
• Medicare
• MIPS: Merit Based Incentive Payment System
• MU: Meaningful Use
• APM: Alternative Payment Models
Big and Thick Data
• Big Data refers to the contemporary phenomena
of having a massive amount of discrete data
elements, thoughts, audio/video, social media,
transactional applications, and more.
• Thick Data is by nature more subjective, visceral,
and intuitive. Quality measures will involve
anthropological and ethnographical intelligence.
• Healthcare is principally vast amounts of BIG
objective data, yet to fully perfect quality
outcomes and value based care THICK must be
empathized and integrated.
3 Vs
• Velocity
– Suggests that data have momentum through
applications, consumer uses, and business uses
• Volume
– Suggests similar exponential growth of accessible and
seemingly necessary data Data growth in the future
will likely be larger in health care than in any sector
other than global security and social media.
• Variety
– Suggests that data are associated with, and will
continue to take on, seemingly limitless descriptions
Challenges for Data and Best Practices
• Disparate Data
• Financial Risk Associated with High Volume of
Data
• Clinician Time and Patient Experience
• Privacy and security
• “Data can either be useful or perfectly
anonymous but never both.”
Summary
• Data provide an increasingly essential resource
for healthcare organizations and providers. Data
support clinical work and business processes and
they offer the necessary tools for information
creation and analytical opportunities.
• Healthcare data continue to exponentially
increase.
• Critical technology standards, disparate source
systems, and silo processes continue to challenge
healthcare organizations and it will be many years
before this disintegration is overcome.