Healthcare by George Hernandez

Exloring health, medicine, healthcare, and healthcare industry.

I've worked in the healthcare industry from the IT side (instead of the patient care side) but we should all take a good deal of personal responsibility for the health of our selves and others.

Summary

I wrote this summary of the healthcare industry in general in 2007 or 2008. I may tweak it over time.

General

Patient. Aka Health Consumer; Health Care Consumer: Any person who receives medical attention (aka health care; treatment; procedures; services; intervention). Typically, a patient has abnormal symptoms and seeks health care. An examination of the patient's medical history and signs ensues. A diagnosis of a medical condition (aka disorder; disease; illness) is hypothesized, and appropriate medical attention. When a patient has a visit (aka encounter) for health care, one or more services are performed.

Health Care Provider. Aka Service Provider. A person who provides medical attention, care, or treatment. This includes physicians, nurses, and allied health professions.

Physician. Aka Medical Practitioner; Medical Doctor. A person who practices medicine and in modern times holds the academic degree of doctor. Physicians initially acquire real-world experience via a residency. First-year residents are Interns. Physicians that have finished residency are Attending Physicians. Aka Attendings; Consultants; Staff Physicians.

Specialty. Physicians may or may not have a specialty.

General Practitioner (GP). Aka Primary Care Physician; Family Practitioner; Family Physician. A physician who provides general medical care for patients. For most patients, this is their "regular doctor". If the patient is a member of an HMO, then typically they must be referred by their GP in order to see a Medical Specialist.
Medical Specialist. Physicians who specialize in a particular branch of medicine. Medical Specialists are some times grouped as follows:
- Surgical Specialist. Aka Surgeon. Medical specialists in operative treatment.
- Internal Medicine. Aka Internist. Medical specialist in the diagnosis and non-surgical treatments of adults and internal organs.
- Diagnostic Specialist. Medical specialist in the examination and diagnosis of disorders (as opposed to the treatment of disorders).
- Neurologist. Medical specialist in neurological disorders.

Practice. The business of a practicing service provider, including one or more physicians, other service providers, practice staff (e.g. a Practice Manager), the location or facility, and the patients. A physician may practice at multiple locations. A practice is owned by/run by/works with the state (government), a health insurance company, a charity, a health organization, or some odd mix. Some practices include:

Private Practice. A practice with a solo physician and the physician's staff.
Clinic. A practice with few or several physicians.
Hospital. A practice institution with many physicians.

PO. Physician and practice organizations are often interchangeable and completely different from patients' organizations.

Patients' Organization (PO). An organization that represent a specific group of patients, sometimes with a common disease, that promotes patient-centered health care.
Physician Organization (PO). Aka Physician Group (PG). An organization that represents a specific group of physicians for economy of scale.
Practice Organization (PO). Aka Practice Group (PG). An organization that represents a specific group of practices for economy of scale.

Health Insurance

Health Care Insurer. Aka Payer; Insurer. In the US, most health care is not paid with cash, so health care is usually paid via health care insurance. Health care insurance is either public or private:

Public Health Care Insurance. Aka Social Health Care Insurance. Private health care insurance is sponsored by the government.
- Centers for Medicare and Medicaid Services (CMS) Formerly Health Care Financing Administration (HCFA). The federal agency that administers Medicare, HIPAA, quality standards for long-term care facilities (nursing homes), and clinical laboratory standards, as well as working with the state governments to administer Medicaid and SCHIP.
  - Medicare. Public health care insurance for those over 65 years of age.
  - Medicaid. Public health care insurance for those with low incomes.
  - State Children's Health Insurance Program (SCHIP). Public health care insurance for lower income families with children.
- Military health benefits. Includes the Department of Defense Military Health System (MHS), TRICARE, and the Veterans Health Administration (VHA).
- Indian Health Services (IHS). Public health care insurance for Native Americans.
- Federal Employees Health Benefits Program (FEHBP). Public health care insurance for federal employees.
Private Health Care Insurance. Private health care insurance is typically Employer Sponsored or Individually Purchased.
- Indemnity Insurance. Aka Fee-For-Service (FFS). If the patient receives health care services, then the patient pays the provider and the payer will reimburse (pay indemnity) to the patient if the health care was covered by the insurance plan.
  - High Deductible Health Plan (HDHP). Aka Catastrophic Health Insurance. An indemnity insurance plan with low premiums but high deductibles. Often required in order to set up a Health Savings Account (HSA), i.e. a tax-advantaged account that can be used to earn money and pay for medical expenses.
- Capitation Insurance. The payer pre-pays staff physicians/practices or specific hospitals or physician/practice organizations typical/estimated health care costs per capita (head or person).
- Pay for Performance (P4P). Aka Value Base Purchasing. Health care providers are given incentives if they meet performance standards in quality and efficiency. Health care providers are also given dis-incentives for medical errors and the like.
- Managed Care. The variety of techniques intended to reduce the costs while increasing the quality of health care.
  - Health Maintenance Organization (HMO). Capitation insurance that receives some federal funding and also sets some guidelines about the health care given. The Health Maintenance Organization Act of 1973 requires employers with 25 or more employees to offer HMO insurance. Usually the patient has a co-pay per visit.
    - Independent Physician Association (IPA). An HMO (or physician organization contracted by an HMO) whose physician members can work with other payers.
  - Preferred Provider Organization (PPO). Aka Participating Provider Organization (PPO). Capitation insurance that typically has no co-pay but has a higher deductible. If the patient wishes to see a provider outside of the PPO then the cost will be more or not covered at all if the PPO is an Exclusive Provider Organization (EPO).
  - Point of Service Plan (POS). Capitation insurance plan where the patient can choose to go either the HMO route or the PPO route depending upon the situation.

For example: As of 2008, the Blue Cross and Blue Shield Association (BCBSA) was composed of 39 insurance companies that covered over 99 million people. BCBSA manages private health insurance as well as portions of public health insurance (Medicare and FEHBP).

12.9 million FFS
15.8 million HMO
65.8 million PPO
4.8 million POS

Health Insurance Portability and Accountability Act (HIPAA). Passed by Congress in 1996. Title I provides protects health insurance for workers when they change or lose jobs. Title II sets standards for electronic health care transactions, established the NPI, and set standards for the right to privacy for patients.

National Provider Identifier (NPI). A 10 digit number uniquely identifying health care providers and organizations in the US by the CMS. The NPI was replaced the older Unique Provider Identification Number (UPIN) as of October 2006. An NPI may be validated by prefixing the NPI with "80840" and using the Luhn algorithm. The NPI is not to be mistaken with a Tax ID Number (TIN).

Guarantor. Aka Principal; Primary Obligor. The person responsible for paying the insurance. For example: In the Smith family, John Smith get health insurance through his work. He and his family members are covered by the insurance, but he is the guarantor.

Medical Coding

Medical Coding. Aka Medical Classification. Medical coding involves transforming medical classifications of areas like procedures, diagnoses, pharmaceutics, and anatomy into numbers or alphanumeric codes. Some medical coding systems, such as Systematized Nomenclature of Medicine (SNOMED), cover many areas, but others, such as the Anatomical Therapeutic Chemical Classification System for pharmaceutics, cover more specific areas. While there are many medical coding systems, only a few will be mentioned here.

Procedure Codes are numbers or alphanumeric codes used to identify specific medical interventions.

Current Procedural Terminology (CPT). Procedure codes maintained by the American Medical Association (AMA). There are three categories of CPTs: Category I is general, Category II is for performance measurement, and Category III is for emerging technologies.
Healthcare Common Procedure Coding System (HCPCS). Procedure codes based upon CPT. There are three levels of HCPCS: Level I is for CPT, Level II is for non-physician services, and Level III are local codes.

Diagnosis Codes are numbers or alphanumeric codes used to identify diagnoses.

International Statistical Classification of Diseases and Related Health Problems (ICD). Aka International Classification of Diseases (ICD). Codes (up to 5 characters long) and basic descriptions for diagnoses of known diseases and injuries. ICD is based upon the system introduced by French physician, Jacques Bertillon, in 1893. The World Health Organization (WHO) has the responsibility of updating the ICD roughly every 10 years. ICD-9 was published in 1977. ICD-10 was finished in 1992. ICD-11 is scheduled for 2011.
Diagnosis-Related Group (DRG). Groups ICD diagnoses into roughly 500 groups. Developed by Medicare.
Medical Diagnostic Category (MDC). Groups ICD diagnoses into 25 groups. Developed by Medicare.

Medical Record (MR). Aka Health Record; Medical Chart. A recording of a patient's medical history. A medical record typically consists of files and documents that kept in folders.

Physical Medical Record (PMR). Aka Paper Medical Record (PMR). Many medical records exist in physical format. PMRs have the advantage of immediacy if present. Paper Prompts can be used to facilitate the use of proper medical coding.
Electronic Health Record (EHR). Aka Electronic Medical Record (EMR). Many medical records exist in digital format. EHRs have many advantages including the facilitation of medical coding, Electronic Data Interchange (EDI) with other systems, and integration with Billing Systems. There are many bodies and standards that contribute to EHRs including: ASTM International, ANSI X12, CEN, DICOM, HL7, ISO TC 215, and openEHR.
Continuity of Care Record (CCR). A health record standard specification developed by multiple health informatics vendors (including ASTM International, MMS, HIMSS, AAFP, and AAP). A CCR is supposed to standardize the format of the most basic and recent information about a patient, including patient demographics, insurance information, diagnosis and problem list, medications, allergies and care plan.
Personal Health Record (PHR). A patient's medical record tracked by the patient as opposed to the physician.
Billing System. A billing system handles claims and charges for health care for a practice. A practice always uses some sort of billing system, whether a practice uses a PMR or an EMR. A billing system also captures medical coding. A billing system usually communicates with some sort of billing agency or clearing house.

Service Level. A service is the basic row of a medical data source. It is all of the vital information surrounding the performance of a procedure: What it was (CPT), who it was for (patient), when it happened (date of service), why it was performed (diagnosis), who did it (provider), where is happened (POS, facility, practice), and how much was charged for it (charges).

Sub-Service Level. Sometimes if a service is recorded as having a date of service that begins on one date and ends on another, then the service is often entered as multiple rows in the medical data source. Each of those rows may be referred to as a sub-services, i.e. one sub-service for each day.
Encounter Level. Aka Visit Level. An encounter may be composed of one or more services. A service cannot be considered to be in more than one Encounter. An encounter is a collection of services on a day, by a provider for a patient.
Episode Level. An episode may be composed of one or more related services. For example: An episode might be a service and several related follow up service, but exclude unrelated services that occurred during that time period.

Registry.

A set of patients collected together based on some defined criteria. Such criteria can include diagnostic histories, procedure histories, demographics, time window, provider or practice affiliations, or any other information that is collected across the patient population. For example: A registry of male patients. The criteria for a registry may be determined by a client or a major entity (such as CMS).
An organization, in the role of "Data Submission Vendor" collecting and aggregating Response data and passing it forward to CMS.

Master Patient Registry (MPR). Aka Master Patient Index (MPI); Patient Master Index (PMI). A registry for all the patients in a particular system.

Registry Measure. For a given registry (set of patients), different data may be collected about each patient. Each kind of data is a measure. For example: For a registry of male patients, measure smoking habits and weight. The measures for registry may be determined by a client or a major entity (such as CMS). Note that a similar measure for one registry may be subtly different from a measure for another registry. Common registry measure types include the following:

Quality Reporting Registry Measures. Like PQRI and CI.
Risk Indicator Registry Measures. A measure that may indicate a health danger.
Patient Fact Registry Measures. Universal measures like height and weight that can apply to nearly any registry.

Measure Response. Aka Quality Code. For a given registry measure, each patient will have their specific measure response (data point for that measure). A response is typically a medical code (like a CPT or ICD), or a custom value (like a clinical value), or some combination. For example: For a registry of male patients, and the weight measure, the measure responses for patient John Smith might br CPT F0002-PF and 160 pounds. The measure responses may be determined by a client or a major entity (such as CMS).

The Aggregated Measure Responses are typically compared against the patient count of a registry. For example: For a registry of male patients, and the weight measure, the measure responses are 10 at 160 pounds, 70 at 170 pounds, and 20 at 180 pounds. Aggregated measure responses are often charted or formed into a percentages. Most frequently the aggregated measure responses form the numerator, while the patient count of a registry forms the denominator. For example: For a registry of male patients, and the weight measure, 90% are over 165 pounds.

Physician Quality Reporting Initiative (PQRI). A physician quality reporting system implemented by CMS and mandated by the Tax Relief and Health Care Act of 2006. The PQRI is a voluntary program that provides financial incentive to health care providers if they successfully report quality related medical coding. In 2008 CMS is collecting PQRI data via specific EHRs and specific Registries.

Clinical Integration (CI). Clinical quality related medical coding to measure and improve health care quality and efficiency, and strengthen reimbursement negotiations especially for Pay for Performance (P4P).

Glossary

apoptosis: Cell suicide.
ASHICE: Aka Age, Sex, Height, Injuries/Illnesses, Condition, ETA. A mnemonic acronym for the important info to given when quickly transferring care.
borborygmus: boar bah rig muss. Stomach rumbling sounds made by the movement of gases in the intestine and stomach.
CatSper: A protein found in the tail of sperm cells that helps the sperm swim more strongly. CatSper may be used to develop unisex contraceptives that may be taken before or shortly after sex. [2001-10-11].
CMS [W]: Centers for Medicare & Medicaid Services. Formerly Health Care Financing Administration (HCFA). The federal agency within the United States Department of Health and Human Services (DHHS) that administers Medicare [http://www.hcfa.gov/medicare/medicare.htm], Medicaid [http://www.hcfa.gov/medicaid/medicaid.htm] and the State Children's Health Insurance [http://www.hcfa.gov/init/children.htm] Program (SCHIP). They are also responsible for other things such as the privacy of patient health data via Health Insurance Portability and Accountability Act (HIPAA).
CPT [W]: Current Procedural Terminology. Aka procedure code; billing code. Developed by the American Medical Association (AMA) in 1966, and maintained by the AMA. Each year, an annual publication is prepared, that makes changes corresponding with significant updates in medical technology and practice. CPT 2001 contains 7,928 codes and descriptors.
doctor: Physician.
DR ABC: Aka Danger, Response, Airway, Breathing, Circulation. A mnemonic used for the essential steps of providing first aid. Danger: Assess the danger to yourself; You can't help others if you're dead. Response: Check if they can respond to you and answer questions. Airway: Clear the airway. Breathing: Asses the patient's breathing; Apply artificial respiration if necessary. Circulation: Assess the patient's circulation; Apply chest compressions if necessary.
DSM [W]: Diagnostic and Statistical Manual of Mental Disorders. Published by the American Psychiatric Association (APA) since 1952.
DX: Diagnosis.
EHR: Electronic Health Record. Inter-hospital owned and controlled. See EMR and PHR.
EMR: Electronic Medical Record. Intra-hospital owned and controlled. See EHR and PHR.
EOB: Explanation of Benefits.
epicahus: Aka epicanthic fold. A vertical fold of skin from the upper eyelid that covers the inner corner of the eye. It is normal in Mongolian (Asian) races and also occurs in certain congenital conditions. EG: Down's syndrome.
HCFA: See CMS.
HCPCS [W]: Healthcare Common Procedure Coding System. HCPS was established in 1978 as a superset of the CPT.
HIPAA: Health Insurance Portability and Accountability Act. Passed by Congress in 1996. Concerned with the right to privacy for patients.
HMO: Health Maintenance Organization. Group medical insurance that entitles members to services of participating hospitals and clinics and physicians.
HSA: Health Savings Account. A tax-advantaged medical savings account similar to a 401(k) or Flexible Spending Account (FSA). A tax free account that can be used for medical expenses.
ICD [W]: International Statistical Classification of Diseases and Related Health Problems (officially) or International Classification of Diseases (easier to remember). Codes (up to 5 characters long) and basic descriptions for diagnoses of known diseases and injuries. ICD is based upon the system introduced by French physician, Jacques Bertillon, in 1893. The World Health Organization (WHO) has the responsibility of updating the ICD roughly every 10 years. ICD-9 was published in 1977. ICD-10 was finished in 1992.
IPA: Independent Physicians/Providers/Practices Association. Group of private practice physicians working together
managed care: Any system that manages healthcare delivery to control costs. Usually an insurance company or a doctor-hospital network acts an intermediate between the person seeking care and the physician.
Medicaid: A federal and state health insurance program designed to provide access to health services for persons below a certain income level. Provides health care to women and children who qualify for AFDC (Aid to Families with Dependent Children) and the impoverished elderly who are poor.
Medicare: A federal health insurance program designed to provide health care for the elderly and the disabled. People who qualify for Social Security benefits are automatically eligible for Medicare
MSP: Multi-Specialty Practice
NFP: Neighborhood Family Practice
NPI: National Provider ID
PCP: (1) Primary Care Provider

(2) Pneumocystis jiroveci pneumonia. A type of pneumonia often associated with HIV.
plu
(3) Phencyclidine. Aka Angeldust.
PHR: Personal Health Record. Patient owned & controlled. See also EHR and EHR.
PHO: Physician/Practice Hospital Organization.
Physician: A person who practices biological medicine. Aka doctor; practitioner; provider; medical doctor; medical practitioner; service provider;.

"Doctor" means "teacher" in Latin. A "doctorate" is the highest level of academic degree awarded (it's above a bachelor's and master's degree). Doctorates come in three varieties: Research doctorates (aka Doctor of Philosophy; Ph.D.; Philosophiæ Doctor in Latin) are for academic research of publishable quality in a large variety of fields. Professional doctorates (aka first professional degrees; licentiate) can do licensed work in specific fields like dentistry, human medicine, veterinary medicine, architecture, and psychology. Honorary doctorates are, well, honorary.

As far as human medicine in the US, two kinds of medical doctorates are licensed in all 50 states: Doctor of Medicine (aka M.D.; MD; Medicinæ Doctor in Latin) and Doctor of Osteopathic Medicine (aka O.D.; OD; D.O.; DO). "Alternative medicines" have met considerable resistance in the politics, economy, and science of American medicine and culture.

A medical specialist is a physician with additional expertise in a particular field of medicine.
POS: Place of Service.
PPO: Preferred Provider Organization. A group medical insurance plan in which members receive more coverage of services provided by participating hospitals and clinics and physicians.
Provider: Physician.
PX: Procedure
RBRVS: Resource-Based Relative Value Scale. 'In 1992, Medicare significantly changed the way it pays for physicians' services. Instead of basing payments on charges, the federal government established a standardized physician payment schedule based on a resource-based relative value scale (RBRVS). In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into three components: physician work, practice expense and professional liability insurance. Payments are calculated by multiplying the combined costs of a service by a conversion factor (a monetary amount that is determined by the Centers for Medicare and Medicaid Services). Payments are also adjusted for geographical differences in resource costs.' -http://www.ama-assn.org/ama/pub/category/2292.html
seratonin: 5- hydroxytryptamine. A neurotransmitter used at the ends of nerves. It is manufactured in your body using the amino acid tryptophan. At the meeting of one nerve with another there is a space. Release of seratonin (or other drugs, depending on the type of nerve) causes the other nerve to fire and continue the message along the "cable". It is also found in platelets. Release of seratonin by injured platelets is thought to cause blood vessels to contract. Prozac, the happy drug, generally boosts seratonin levels.
Service Provider: Physician.
SOAP note: Aka Subjective, Objective, Assessment, and Plan note. A method of documentation used by health care providers for writing notes about a patient in their chart.
SAMPLE history: Aka Symptoms/Signs, Allergies, Medications, Pertinent past history, Last oral intak, Events leading up to the emergency. A mnemonic acronym for key questions to ask when providing first aid.

Page Modified: (Hand noted: 2007-11-03 22:39:16Z) (Auto noted: 2010-12-24 22:53:57Z)