Comprehensive Guide to Healthcare IT, Telemedicine, and Health Insurance Models

Information Technology (IT)

The use of hardware, software, services and supporting infrastructure to manage and deliver information using voice, data, and video. It encompasses all computers with a human interface, all computer peripherals that will not operate unless connected to a computer or network, all voice, video, and data networks and the equipment/staff/purchased services needed to operate them, all technology services provided by vendors or contractors, and all functions associated with developing, purchasing, licensing, or maintaining software.

Telemedicine

Refers to the electronic delivery of treatment to patients, as an alternative to face-to-face (F2F) care.

E-health and Telehealth

More general terms that can refer to a variety of health-related services, including patient education.

mHealth

An important component of e-health, which pertains specifically to the use of mobile technologies.

Synchronous Telemedicine/Activities

Activities that occur in real time, such as F2F videoconferencing. The Office of the National Coordinator for Health Information Technology (ONC) defines it as 'live video-conferencing,' which is a 'two-way audiovisual link between a patient and a care provider'.

Asynchronous Telemedicine/Activities

Activities that do not occur in real time but rather involve the storage and forwarding of information (e.g., using an online educational module). ONC defines it as 'store-and-forward video-conferencing,' which is the 'transmission of a recorded health history to a health practitioner, usually a specialist'.

Electronic Medical Record (EMR)

Simply an electronic version of the kind of paper chart traditionally used by a healthcare organization. It is a single-facility system (not shared) but has digital capabilities such as the ability to track data over time and screen records easily for the purposes of improving care.

Electronic Health Record (EHR)

Goes beyond the clinical record of a single facility and includes information from all the providers treating the patient—potentially including hospitals, nursing homes, laboratories, all physicians and clinical specialists. It provides a longitudinal record with a broad view of the patient's treatment and health status over time.

Personal Health Record (PHR)

'An electronic application through which patients can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment'. It is intended to be used and managed by the patient or responsible party and contains similar information to the EHR and EMR.

Health Information Exchange (HIE)

Refers to the organization and sharing of electronic health-related information in a manner that protects the confidentiality, privacy, and security of the information.

Cloud Computing

Enables users to access data, resources, and computing power through a network of remote servers, rather than having to maintain the hardware and software themselves.

Software as a Service (SaaS)

The concept incorporated into cloud computing that allows for software to be accessed via the internet rather than installed locally.

Cybersecurity

The function needed to address the increasing risk of security breaches and computer-based crimes resulting from the growing connectedness and digitization of the healthcare world.

Phishing Attacks

Typically involve emails that are disguised so that they appear to be from a trusted party, asking the recipient to click on a link and enter personal information (e.g., name, passwords) to enable the sender to access accounts or systems.

Trojans and Malware

Special programs designed by hackers that enable the hacker to access information in systems on the affected computer and on the networks to which the computer is connected.

Ransomware

Programs designed by hackers that cause a computer to be infected by various viruses; data in the system become unavailable to the user unless a ransom is paid to the hacker for a code to unlock the data.

Passive Surveillance

Most routine surveillance systems, automatically routed to public health without action from the receiving agency, though they are limited by incompleteness of reporting and variability of quality (e.g., notifiable conditions).

Active Surveillance

When a public health entity contacts health providers seeking reports, used in conjunction with specific epidemiologic investigations (e.g., outbreak investigations) to ensure more complete reporting of conditions.

Third-Party Payer

An insurance company, government entity, or other party that provides the funding for medical care and health services for another person or group.

Self-Funded Model

An approach in which the individual or responsible party simply pays out-of-pocket (OOP) for the cost of medical care or other health services.

Bismarck Model

A funding model where everyone in the country is covered through an insurance-style, not-for-profit mechanism called a "sick fund," which is carefully regulated by the government.

Beveridge Model

A funding model where the government is the principal payer and owner of the healthcare system, and it tightly controls cost (e.g., the UK National Health System).

National Health Insurance (NHI) Model

A single-payer approach where the government is the principal payer for care, but the providers are mostly private (e.g., Canada).

Hybrid Model (Bis-Bev)

A model that has characteristics of both the Bismarck and Beveridge models; the US is a prime example of this approach.

Moral Hazard

Arises when people consume more medical services than necessary because they do not incur the full cost of those services (e.g., "no skin in the game").

Adverse Selection

Occurs when the purchaser of a health plan has knowledge that the health plan does not have concerning future needs, creating what economists call information asymmetry.

Price Elasticity

Refers to how demand for services changes with price; Health Care Expenditures (HCE) are generally inelastic.

Out of Pocket Costs (OOP)

The amount a patient pays that exceeds the amount insurance pays.

Deductible (Annual)

The amount the patient pays before the plan starts paying.

Co-insurance

The amount you pay as a percentage of the cost versus what the plan pays (e.g., 20% patient, 80% plan), usually for high-cost items.

Co-pay

A set flat amount the patient pays, usually for a lower cost item or service (e.g., $20 for a physician visit).

Balance Billing

When a patient receives a bill for all costs (charges) insurance did not pay, which is more likely if the provider is not in network.

Cost Sharing

When you pay part of the cost out of your own pocket.

Experience Rating

Looks at the person's previous medical history and considers preexisting conditions that might cause high utilization of healthcare (eliminated by the ACA).

Resource-Based Relative Value Scale (RBRVS)

A standardized formula for valuing medical services on a relative basis so different treatments and diseases can be compared.

High-Deductible Plans (Consumer-Directed Plans)

Plans that provide insurance protection but carry a significant deductible () that must be funded by the patient or responsible party; they are called 'consumer-directed plans' because they allow greater choice on how to spend healthcare dollars.

Health Savings Account (HSA)

An account into which the patient contributes money, tax free, for future medical expenses; it is owned by the patient, portable, and will never be taxed if used for medical/health services. Only allowed with high-deductible plans.

Health Reimbursement Account (HRA)

Similar to an HSA in that allowable medical and health services can be reimbursed using the funds. However, the HRA is owned by the employer, is not portable, and may be 'use it or lose it' each year. Only allowed with high-deductible plans.

Fee-for-service

An insurance payment method based on volume.

Managed Care Organizations (MCO)

Organizations that exercise formal control over patient utilization. They seek to streamline delivery and payment for care, offer behavioral incentives to providers and patients, use an insurance mechanism, and integrate the functions of financing through information.

Gatekeepers

A cost control method in managed care used to prevent self-referral to specialists.

Managed Competition

A strategy for efficiently buying health insurance, where the central idea is that individuals should be able to choose from among insurance companies based on the premiums and the benefits provided.

Medicare

A government-sponsored insurance program provided in four parts: Part A (inpatient care), Part B (outpatient services), Part C (Medicare Advantage/managed care option), and Part D (prescription drugs).

Indian Health Service (IHS)

An agency sponsored by the federal government that provides health services to American Indians and Alaska Natives.

TRICARE

A program sponsored by the federal government within the US Department of Defense (DoD) that provides services to active and retired members of the military and their families.

CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs)

A comprehensive healthcare benefits program in which the VA shares the cost of covered services and supplies with eligible beneficiaries.

Quality

Relates to meeting patient expectations for the service and is also related to clinic outcomes.

Safety

Relates to the absence of injury or harm to the patient.

Total Quality Management (TQM)

A state-of-the-art process improvement tool.

Lean

A process improvement approach defined by: defining value from the patient point of view, mapping value streams, and eliminating waste to create continuous flow.

Six Sigma

A set of techniques and tools for process improvement. A Six Sigma process is one in which 99.99966% of all opportunities to produce a service are expected to be free of defects. Strategies seek to improve the quality of the output of a process by identifying and removing the causes of defects, mainly using empirical, statistical methods.

Patient Experience

Reflects the full range of interactions the patient has with all components of the healthcare system, relying on an objective evaluation of whether something did or did not occur in the healthcare setting.

Patient Satisfaction

Reflects the full range of interactions the patient has with all components of the healthcare system, but is subjective, relying on the perspective of the individual patient.

Volatility

A component of the VUCA framework for adapting to and leading change.

Uncertainty

A component of the VUCA framework for adapting to and leading change.

Complexity

A component of the VUCA framework for adapting to and leading change.

Ambiguity

A component of the VUCA framework for adapting to and leading change.

Clarity

To know and declare your role in solving the problem.

Agility

To be flexible and persistent.