Definitions/Glossary of Terms

Transcription

1 Definitions/Glossary of Terms Submitted by: Evelyn Gallego, MBA EgH Consulting Owner, Health IT Consultant Bethesda, MD Date Posted: 8/30/2010 The following glossary is based on the Health Care Quality Glossary published by the Agency for Health Care Policy and Research and the National Quality Measures Clearinghouse (NQMC) Glossary sponsored by the Agency for Healthcare Research and Quality (AHRQ). Health Care Quality Glossary. Overview. The Russia-United States of America Joint Commission on Economic and Technological Cooperation, The Health Committee, Access to Quality Health Care, Agency for Health Care Policy and Research, Rockville, MD. Glossary. (2010, 07 14). Retrieved 2010, from National Quality measures Clearinghouse: Health and related factors and conditions Health status: The characterization of the condition of health or ill health of an individual or group, or of a population as a whole, graded through studies of special indicators which characterize level of health (or ill health). Health status indicators include population mortality and morbidity rates, prevalence of specific diseases, trauma rates, anthropometric data, self assessment and average expected years of life. Quality of Life: The value assigned to duration of life as modified by impairments, physical, social and psychological functional states, perceptions and opportunities that are influenced by disease injury, treatment, or policy. Quality of life can be measured in terms of quality adjusted life years (QALY), disability adjusted life years (DALY), and other indices.

2 Health Policy: A statement of a decision regarding a goal in health care and a plan for achieving that goal. Alternatively, it is a field of study and practice in which the priorities and values underlying health resource allocation are determined. Health promotion: The efforts to change people s behavior in order to promote healthy lives and to help prevent illnesses and accidents. Health Outcomes: The changes in current or future health status of individuals or groups of personas that are attributable to previously provided medical care. Health outcomes include mortality and morbidity, physical, mental and social functioning, costs of care, and quality of life. Health care Health services system: All formal and informal activities, medical, economic and organizational, aimed at rendering medical and other health services to individuals. Health technology: The application of scientific knowledge to solving health problems. Health technologies include pharmaceuticals, medical devices, procedures or surgical techniques, and management and information systems innovations. Public Health: The science and art of disease prevention, life prolongation, promotion and maintenance of mental, physical and social health and occupational rehabilitation through organized efficient efforts of the society on its various levels. Patient centered care: An approach to care that consciously adopts a patent s perspective. This perspective can be characterized around dimensions such as respect for patients values, preferences, and expressed needs; coordination and integration of care: information, communication and education; physical comfort; emotional support and alleviation of fear and anxiety; involvement of family and friends; transition and continuity. Access: Identifies the ability to utilize needed health services by a patient or population in terms of: health services delivery system characteristics such as availability, organization, and financing of services; characteristics of the population such as demographics, income, care seeking behavior; and whether or not the care sought adequately met the individual or group s basic medical needs. Access to care: a performance dimension addressing the degree to which an individual or a defined population can approach, enter, and make use of needed health services. Disease management: A comprehensive, integrated approach to care and reimbursement based fundamentally on the natural course of a disease, with treatment designed to address the chronic illness and maximum effectiveness and efficiency. Its emphasis is commonly on prevention of acute exacerbations or episodes of illness and to implement aggressive interventions at those times and in those patients where it will have the greatest positive impact. Clinical Information System: An information system that collects, stores, and transmits information that is used to support clinical care (e.g., transmission of laboratory test results, radiology results,

3 prescription drug orders). Electronic medical records (EMR) and electronic health records (EHR) are examples of systems designed to store and manage electronic information used for clinical care. ICD 10 CM (International Classification of Diseases, 10 th Edition): A system for classifying diseases, trauma and causes of death based on etiological and pathogenic mechanisms. DRG (Diagnosis Related Group) system: The classification of hospitalized patients into any of approximately 495 clinically cohesive categories having homogeneous levels of resource utilization. Each patient is assigned a DRG based on pricing and comorbid diagnoses, and modified by the principal and secondary procedures obtained during the hospitalization, as well as age, sex and discharge status. Each DRG may be either surgical or medical in nature, depending on the care provided in hospital. In the U.S., the Health Care Financing Administration (HCFA) uses the DRG system to determine hospital reimbursement as part of its Prospective Payment system (PPS) for all Medicare beneficiaries. Major diagnostic categories (MDC): HCFA has assigned each DRG to one of twenty five MDCs based on its principal diagnosis or procedure. No DRG may appear in more than one MDC, and each MDC focuses on a major body system or is associated with a specific medical specialty. Health care organization Prevention: Actions directed toward decreasing the probability of occurrence of diseases or accidents, or the negative health consequences associated with such occurrences. Primary prevention: decreasing the probability of an individual developing a disease or having an accident. Examples include childhood immunizations, and programs to reduce the likelihood that teenagers start smoking. Secondary prevention: actions designed to detect disease at a sufficiently early stage so that the likelihood of optimal outcomes is increased. Examples include screening for cancer, or management of high blood pressure, or high cholesterol to prevent cardiovascular disease. Tertiary prevention: actions designed to reduce the consequences of chronic disease, such as managing diabetes to reduce the likelihood of complications such as amputation of an extremity or prescribing beta blockers after a heart attack to reduce the likelihood of subsequent cardiovascular events or death. Diagnosis: The process of recognizing the presence of a disease or condition from its symptoms, signs, laboratory findings or other data, such as response to therapy in accordance with accepted disease classifications. Treatment: A process designed to achieve the desired health status for a patient. Visit: A patient s visit to a physician.

4 Consultation (encounter): Contact between a patient and a health professional in which a health service is provided. A consultation may take place over the phone, in a provider setting or electronically (via between patient and health professional). Admission: In general, this is the initiation of inpatient care (including day care within a clinical environment). Readmission: The re entry of a patient to a hospital within a specified interval after discharge with the same diagnosis. Readmission rate: A performance measure showing the proportion of a hospital s patients who are readmitted to the hospital following discharge with the same diagnosis. A higher rate could indicate lower quality of care. Inpatient: An individual who occupies a hospital bed and who has been admitted to a hospital for examination, diagnosis, care, or treatment. Hospitals include both inpatient health care facilities and other health care facilities where a patient is provided with non permanent accommodation (rehabilitation centers). Discharge: The official termination of a patient s stay in a hospital or other medical facility to which one has been admitted. Ambulatory care: All types of health services provided to patients who are not confined to an institutional bed as inpatients during the time services are rendered. Ambulatory care services are provided in many settings ranging from freestanding ambulatory surgical facilities to cardiac catheterization centers to physicians offices. Emergency care: The urgent provision of primary or specialized medical care according to emergency (vital) indications. Specialized care: Secondary qualified medical care provided by a medical specialist. Long term care: The health and personal care services provided to chronically ill, aged, disabled, or otherwise handicapped persons in an institution or place of residence. Cost Cost: Actual expenses incurred to provide a health care product or service. Variable cost: Costs that vary with changes in output volume, such as the direct labor required to provide a service. Direct costs: The cost that is explicitly identifiable with a particular service or area. Examples of direct medical costs are hospital supplies, labor costs for medical personnel, and pharmaceuticals. Indirect costs: A cost that cannot be easily identified in the product or service (e.g., electricity, executive salaries, insurance). Also referred to as overhead costs. Indirect cost may also be used to refer to lost

5 or reduced productivity resulting from morbidity or premature mortality due to a medical condition or treatment. Costing: Methods and processes for calculating costs (actual or estimated) required to achieve certain goals, obtain certain products, processes or for maintenance of health services. Price Reporting: The availability of financial information to a specific audience where the value is based on the perspective of the specific user of the information. Financial information includes cost, charge, payment, resource utilization, and rate, and can be presented as: Resources applied to an episode of care: Presented in terms of volume counts (no dollar value attached) of healthcare services (like pharmaceuticals) providers use to diagnose and treat an illness. An example of a report would include counts of a surgical procedure. Negotiated price for a unit of service: Presented in terms of the contracted or allowable charges a health plan pays for goods and services by provider. Negotiated price for an episode of care: Presented in terms of the contracted price a health plan pays for the resources applied to treat an episode of care. An example would be the total allowable cost for an episode of care such as with a cholecystectomy. This also applies in the ambulatory setting if a visit consists of only a procedure such as a radiology test or a cardiovascular stress test. Patient (consumer) out of pocket costs: Presented in cost terms such as co pays, deductibles and exclusions. Health Care Quality Quality: A character, characteristic, or property of anything that makes it good or bad, commendable or reprehensible; thus, the degree of excellence that a thing possesses. Quality of medical care: The understanding of quality applied to health care; the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality characteristics: Appropriateness: The degree by which the care provided is right for the need. Availability: A measure of the degree of a healthcare system which is in the operable and committable state. Continuity: Addresses the degree over time to which the care/intervention for a patient is coordinated among practitioners and organizations. Efficacy: The degree to which a health care intervention, procedure, regimen, or service produces a beneficial result under rigorously controlled and monitored circumstances, such as randomized controlled clinical trials.

6 Effectiveness: A performance dimension that assess the degree to which a health care intervention is provided in the correct manner, given the current state of knowledge, in order to achieve desired outcomes under usual care conditions. It addresses the relationship between the outcomes (results of the care/intervention) and the resources used to deliver the care/intervention). Safety: Relates to actual or potential bodily harm caused by an intervention or absence of an intervention. Timeliness: The rate by which you obtain needed care while minimizing delays (Patient) Satisfaction: a measurement that obtains reports of opinions or ratings from patients about services received from a provider or payer (health plan organization). Stability: refers to the reliability (i.e., the ability to collect, manage, and provide data properly without failure) and availability (the ability to be operational when it is needed) of the quality system. Improvement: The attainment of (or process of attaining), a new level of performance or quality that is superior to any previous level of quality. Quality indicator: An agreed upon process or outcome measure that is used to assess quality of care. Quality indicators include hospital readmission rates, providers rates of adherence to clinical guidelines, and ratings of patient satisfaction with care. Continuous quality improvement: A management approach to the continuous study of improvement of the processes of providing health care services to meet the needs of patients and other persons. CQI focuses on making an entire system s outcomes better by constantly adjusting and improving the system itself instead of searching out and removing persons or processes whose practices or results are outside of established norms. Adverse drug event: Negative medical occurrence experienced by a subject or patient following clinical use of a drug. Adverse event: An undesirable and usually unanticipated event, such as death of an inpatient. Incidents such as patient falls or improper administration of medications are also considered adverse events even if there is no permanent effect on the patient. Quality Measurement HEDIS (Health Plan Employer Data and Information Set): A standardized set of measures for evaluating the performance of managed care organizations. Measures are divided into six domains: effectiveness of care, access to care, satisfaction with care, utilization and costs, informed choices, and health plan descriptive information. Clinical Outcome: A consequence of the use of health care products, services, or programs that affect patients clinical well being. Mortality and functional status are examples of commonly used outcomes.

7 Performance Measurement: Measurement of adherence to recognized standards of quality. Performance measurement may take place at the national, system, institution, or individual provider level. Performance measures include: Patient Experience Measures: Also referred to as Customer Satisfaction Measures, these measures are used to determine how patients feel about the care they received. The information is usually collected by random surveys. Structural Measures: These measures determine whether a provider has systems or resources available to deliver appropriate care or improve the quality of care. Examples include measures on whether a provider has invested in an electronic health record (EHR) or electronic medical record (EMR) to improve the quality of care. Process Measures: Also referred to as Quality Indicators, these measures are used to determine whether specific services are available and provided depending on the needs of a patient. Measures focus on individual patient clinical interactions at a single point in time. An example of a process measure quality report would include information detailing a diabetic receiving an annual eye exam. Outcome Measures: Used to determine whether there has been a change in a patient s health status as a result of an intervention. An example of an outcome measures quality report would include information detailing a diabetic monitored to determine whether a preventive service (i.e., an annual eye exam) reduced the risk of the patient developing blindness. Access Measures: Used to determine whether a patient attained timely and appropriate care. An example of an access measure would be information on patient wait times for an outpatient surgery. Population Health: Population health is the state of health of a group of persons defined by geographic location, organizational affiliation or non clinical characteristics. Use of Services: A use of service is the provision of a service to, on behalf of, or by a group of persons defined by geographic location, organizational or non clinical characteristics without determination of the appropriateness of the service for the specified individuals. Use of service measures can assess encounters, tests, interventions as well as the efficiency of the delivery of these services. Quality Reporting: The availability of quality information to a specific audience that allows for comparison between a healthcare provider s quality of care and a community standard. Information is made available through various forms of reports including: Authorized Reports: These reports are available only to registered or authorized users of a Web site, portal or organization. Such examples include Physician Quality Reporting Initiative (PQRI) reports available only to Centers for Medicare & Medicaid Services (CMS) registered providers and health plans. In general, organizations have developed fairly sophisticated Web sites that

8 provide access to standard reports, but also allow the requestor to create their own ad hoc reports via the Web site, thereby providing the user the ability to print the report for their own use. Public Reports: Several healthcare organizations provide regularly published reports available through public libraries, Web sites or through requests for information. Examples include the CMS Hospital Compare Report and the CMS Nursing Home Compare Report. Ad Hoc Reports: Reports produced upon request and sent to the requesting agencies only. In most cases, these requests are done for a fee. The majority of these reports are paper based and sent via postal mail. Target Audiences (for reporting initiatives): Target audiences of the information obtained through quality and price reporting initiatives vary as a result of the perceived benefits of this type of information. In general, four main audiences are identified for purposes of this project that either use or benefit from quality and price reports: purchasers, consumers, providers and policymakers. Purchaser Groups: Reflects both individual and group purchasers. Examples of group purchasers include those who purchase healthcare coverage (either in whole or in part) for their employees as well as the health plans that pay for healthcare services on behalf of the patient and their employer. These groups benefit from information that details if providers are providing quality care at the same, lower or higher price than other providers. These data may influence their admission of providers to their panels. This type of information also assists purchasers to negotiate and establish provider contracts. Price reporting is especially important to the employer who offers health insurance as part of their employee benefit package. Employers record the expense of health insurance purchase on their profit/loss statement. Consumer Groups: Reflects the patient and their families seeking information on how a particular service is rated across providers and ultimately, their out of pocket costs for receiving that particular service. Consumers use these reports to select where to receive the best possible care at the best price. This group also includes employees that pay some portion of their healthcare insurance. The health plan that employees select directly affects their out of pocket expenses for healthcare services. Price reporting includes direct cost for healthcare insurance and the eventual out of pocket expenses employees pay based on their healthcare needs. A general caveat for price reporting is that information must be made available prior to receiving the service. The use of information in this manner has been popularized by the term transparency, which implies in this context that information is accessible by consumers who will use it to make healthcare decisions. Provider Groups: Reflects physician and affiliated groups (physicians, nurses, pharmacists, dentists, physical therapists and many other specialized practitioners) hospitals and other health care facilities. Providers use quality and price information to benchmark the quality and cost of the care they provide, as well as a basis of comparison with other providers. They also use these

9 reports to select referrals. In addition, hospitals may use this information in conjunction with their medical staff members to monitor the quality of credentialed providers. Policymakers: Reflects the lawmakers across federal, state and local levels. It also includes accrediting organizations such as The Joint Commission (TJC). Ultimately policymakers use quality and price information to drive change in the market either through legislation, executive orders or incentives. Examples include pay for reporting, pay for performance and accreditation.