Management and Decision Support Systems 12 Management and Decision Support Systems

Pretest (True/False) Integrated systems require HL7 to exchange information with other healthcare systems. The ADT system registers patients before they are treated or scheduled for treatment. In a general ledger that uses a double-entry bookkeeping system, expenses are amounts that are owed, but not yet paid.

Pretest (True/False) (continued) Accounts payable systems control the outflow of money from a healthcare facility for all expenses except payroll. Rent, insurance, and utilities are all examples of direct costs a department must pay.

Interfaced or Integrated? Interfaced systems Consist of separate software and databases linked into computer network Exchange information with other healthcare systems using HL7 or proprietary transaction standard Software may be from same or different vendor

Interfaced or Integrated? (continued) Integrated systems Share common database Data records read and updated without need for HL7 Same vendor also supplies software programs such as registration and billing to work together seamlessly

Administrative Systems Include financial, human resource, scheduling, and quality management systems Include hospital registration system (ADT system) and billing system (A/R system) Two systems on either end of patient care Provide secondary data that may be used for various purposes

Eight Financial Systems Financial information systems Track income, expenses, assets, liabilities General ledger Overall accounting system used to produce financial statements and monitor organization’s overall financial health Accounts receivable Money owed to the business

Eight Financial Systems (continued) Purchasing Used to order supplies and services Accounts payable Manages payments for facility purchases, recurring expenses (rent, utilities) and nonrecurring expenses (maintenance, repairs)

Eight Financial Systems (continued) Inventory and materials management Works with purchasing, deducting from quantity on hand supplies used and adding to quantity on hand supplies received Payroll Administration of employee payroll information and payment of wages, employer taxes, benefits

Eight Financial Systems (continued) Budgeting Used to predict annual expected income and expenses Cost accounting Used to attribute direct and indirect costs to various departments

HR Management System Functions Employee evaluations Training Education and continuing education Employee health

Patient Scheduling Systems Outpatient Scheduling Allows for examination and treatment of patients Predicts labor and resource needs Involves making appointments for length of time appropriate to reason for appointment Relies on schedule templates

Figure 12-5 Appointment schedule screen Figure 12-5 Appointment schedule screen. (© 2009 Sage Software Healthcare, Inc. All rights reserved.)

Patient Scheduling Systems (continued) Inpatient scheduling Includes processing doctors’ orders for tests or services, coordinating with respective department, arranging for assistant to transport patient within hospital Requires schedule coordinator who handles several different departments

Staff Scheduling Systems Employee scheduling systems used to determine which employees are working when Human resources tracks and manages vacation schedules, employee sick days, holidays

Staff Scheduling Systems (continued) Provider scheduling includes blocking doctors’ appointment schedule when doctors are not in the office and arranging for another doctor to “cover” patients; maintains on-call schedule Surgery scheduling includes preop, surgery, and postop, plus cleaning of operating room

Facility and Equipment Maintenance Systems Many administrative systems maintain facilities and equipment, including: Systems to track requests for repairs and upgrades to building, rooms, departments Systems to control heat, air, energy usage Systems for fire control, security, employee tracking, and timekeeping

Facility and Equipment Maintenance Systems (continued) Repair orders for systems that require outside service are tracked and reported to purchasing and accounts payable

Facility and Equipment Maintenance Systems (continued) Biomedical, surgical, radiological, laboratory, and other medical equipment must be serviced and tested regularly Joint Commission, CAP, other regulatory agencies require facilities to keep testing maintenance records

Quality Management (QM) Covers many areas related to hospital operation and patient care provided to patients Produces data and reports used for risk analysis and decision support that allow facilities to evaluate appropriateness and effectiveness of medical care

Quality Management (QM) (continued) Tracks and maintains data entered by QM department Uses and analyzes data abstracted from patient health records and other departmental systems

QM Data Includes Case management and utilization management Tracks certification, authorization, concurrent review of the case, avoidable days, denials, appeals Infection control Tracks and reports communicable diseases, hospital-acquired infections, diagnoses that must be reported to CDC

QM Data Includes (continued) Incident tracking Tracks both patient and nonpatient incidents Patient relations handles patient complaints to improve care and patient satisfaction, reduce risk

Figure 12-8 MIDAS risk management screen records a patient fall Figure 12-8 MIDAS risk management screen records a patient fall. (Courtesy of MidasPlus, Inc.)

QM Data Includes (continued) Risk management Minimizes loss by reducing risk through preventive policies and measures Peer review Involves patient, employee, or audit that calls attention to issue relevant to patient care; other providers review to determine appropriateness, make recommendations

QM Data Includes (continued) Comparative performance measure systems Compares performance measures to those of other similar facilities May use NHQM and CMI information available from Medicare, or download data from vendors

Risk Assessment Versus Risk Management Risk assessment involves analyzing processes and measuring statistical data to identify preventable losses and minimizing their occurrences Example: assessing computer security to minimize security risks to EPHI data

Risk Assessment Versus Risk Management (continued) Risk management provides organizations with information needed to improve performance and processes and provide safer environment for employees, patients, volunteers, visitors Basic functions: risk identification, risk analysis, loss prevention/reduction, claims management

CMS RAC Program Identifies improper payments made on healthcare claims provided for Medicare beneficiaries and obtaining repayment to Medicare

CMS RAC Program (continued) Affects healthcare providers including hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers, and any provider/supplier that bills Medicare Parts A and B Reviews handled by private companies with financial incentives to identify and recoup overpayments

RAC Risk Management Strategy Establish committee to handle RAC issues Create procedure to track RAC requests and ensure they’re handled within permitted timelines Conduct internal assessment to ensure submitted claims meet Medicare rules

RAC Risk Management Strategy (continued) Prepare and provision HIM department to comply with RAC requests Create policies and procedures for deciding which RAC denials to appeal

Role of HIM Department Ensure claims are as accurate as possible when first submitted Ensure requests from recovery audit contractor are handled efficiently, effectively, and according to existing procedures and policies