Health Information Management: Key Concepts and Regulatory Frameworks

A set of vocabulary-style flashcards covering key terms and definitions from the lecture notes on health care history, regulation, and health information management.

Flexner Report

A 1910 Carnegie Foundation–commissioned evaluation of U.S. medical education that emphasized hospital-based training and led to higher hospital standards.

Carnegie Foundation

The private foundation that commissioned the Flexner Report to reform medical education.

American College of Surgeons (ACS)

Founded to set standards for hospitals and improve care for surgical patients; initiated hospital standardization.

The Joint Commission (TJC)

A voluntary accrediting body that promotes quality and safety by setting standards, including those for medical records.

Health Information Manager (HIM)

Professional who manages health information, ensuring data quality, privacy, and compliance across care settings.

Medical record librarian

Early term for health information professionals who maintained and organized patient records.

Hill-Burton Act

1946 legislation authorizing hospital construction and funding; included need assessments for new facilities.

Medicare (Title XVIII)

Federal health program for Social Security beneficiaries, with four parts: A, B, C, and D.

Medicare Part A

Hospital Insurance; covers inpatient hospital care, some home health, skilled nursing, and hospice.

Medicare Part B

Medical Insurance; covers physician services, outpatient services, medical equipment, and more.

Medicare Part C

Medicare Advantage; private plans that may offer additional coverage beyond Parts A and B.

Medicare Part D

Prescription drug coverage; optional for beneficiaries.

CHIP (Title XXI)

Children’s Health Insurance Program; provides insurance for uninsured children up to age 19 who don’t qualify for Medicaid.

Medicaid (Title XIX)

Joint federal–state medical assistance program for low-income individuals and families.

CMS (Centers for Medicare & Medicaid Services)

Federal agency in HHS that administers Medicare and Medicaid and oversees payment and quality programs.

Medicare Administrative Contractors (MACs)

Private organizations contracted by CMS to administer Medicare benefits.

Inpatient Prospective Payment System (IPPS)

Medicare payment method that pays a fixed amount per case based on DRGs, not per day.

Per diem

Payment method that reimburses a fixed amount for each day of a patient’s inpatient stay.

Capitation

Payment model where providers are paid a set amount per patient, incentivizing fewer services and prevention.

Health Maintenance Organization (HMO)

A managed care model using capitation and emphasis on preventive care.

Recovery Audit Contractor (RAC)

CMS program to recover improper Medicare payments through audits.

Medicaid Integrity Program (MIP)

Program focused on detecting Medicaid overpayments and improper payments.

Zone Program Integrity Contractor (ZPIC)

CMS contractors that identify and investigate provider fraud within geographic zones.

Quality Improvement Organization (QIO)

CMS contractors that monitor Medicare services and improve care quality; conduct audits.

Beneficiary and Family-Centered Care QIOs (BFCC-QIOs)

Reorganized QIOs (2014) focusing on beneficiary-centered care with case reviews and quality activities.

Clinical Documentation Improvement (CDI)

Programs to improve documentation quality, coding accuracy, and data quality.

Pay-for-Performance (P4P)

Reimbursement approach rewarding quality outcomes and producer performance.

Hospital Value-Based Purchasing (HVBP)

ACA program that ties hospital payments to quality/performance outcomes.

Hospital Inpatient Quality Reporting (IQR)

CMS program collecting inpatient quality data used for public reporting and payment adjustments.

Hospital Outpatient Quality Data Reporting Program (HOP QDRP)

CMS program requiring outpatient quality data reporting.

Physician Quality Reporting System (PQRS)

CMS program that penalizes providers who do not report quality measures; promotes quality reporting.

Affordable Care Act (ACA)

2010 health reform law expanding coverage, promoting quality and value, and enabling new delivery/payment models.

American Recovery and Reinvestment Act (ARRA)

2009 stimulus act funding health IT adoption, EHRs, and health information exchange.

Health Information Technology for Economic and Clinical Health (HITECH) Act

Title XIII of ARRA; promoted meaningful use of EHRs and strengthened privacy/security rules.

Electronic Health Record (EHR)

Longitudinal digital record of a patient’s health information across settings.

Personal Health Record (PHR)

Patient-controlled, internet-based tools for accessing and coordinating lifelong health information.

Health Information Exchange (HIE)

Process/organization for secure electronic sharing of health information across providers.

Regional Health Information Organization (RHIO)

Geographic network to govern and facilitate health information exchange (older term largely replaced by HIE).

HIPAA

Health Insurance Portability and Accountability Act (1996); establishes privacy, security, and administrative simplification standards for health information.

Protected Health Information (PHI)

Any individually identifiable health information protected by HIPAA.

Privacy Rule

HIPAA rule governing the use/disclosure of PHI; requires authorization for many disclosures and provides patient rights.

Notice of Privacy Practices (NPP)

Written notice describing how a covered entity may use/disclose PHI; required under HIPAA.

Treatment, Payment, and Health Care Operations (TPO)

HIPAA allowances that permit use/disclosure of PHI without patient authorization for care, billing, and operations.

Security Rule

HIPAA rule requiring safeguards to protect PHI in electronic form; includes risk analyses and access controls.

Business Associate (BA)

Entity that handles PHI on behalf of a covered entity; must comply with HIPAA security/privacy rules.

Deemed status

Recognition by CMS that an accrediting organization meets federal Conditions of Participation, avoiding separate state surveys.

State Operations Manual (SOM)

CMS manual with survey procedures and guidance for state survey agencies.