The PQRs of Healthcare

Healthcare – The final frontier of innovation. Through contentious reform legislation, major consolidations among indemnifying and service providing organizations, the proliferation of new risk-bearing and service providing models of delivery, we are at long last inching towards a modern system.

Whether adapting business strategy, shifting operational practices to accommodate value-based and other alternative payment models, or simply informing yourself as a responsible consumer, decoding and comprehending healthcare reform parlance is an essential first step. Collected below are a number of the most common acronyms appearing in American healthcare reform discussions and documents; some old and some new, we hope you can benefit from this quick reference!

ACO

Accountable Care Organizations

An accountable care organization (ACO) is a network of healthcare organizations, principly composed of primary care physicians, specialty physicians and services, post- and sub-acute care services, and often acute care hospitals. ACOs organize to provide a full range of services for Medicare patients. The ACO’s payment structure is based upon applying quality metrics to this patient population’s care, and may fall under different risk-bearing models. See Pioneer ACO and MSSP.

ADT

Admit Discharge and Transfer data

ADT data feeds are generated in real time at most care facilities to track the admissions, discharges, and transfers of patients, and to synchronize IT systems. ADT data feeds are increasingly viewed as apposite for care event notifications.

AHIMA

American Health Information Management Association

With over 100,000 health information management professionals in membership, AHIMA seeks to advance utilization of electronic health records, and to promote innovative healthcare IT strategy.

AHIP

America’s Health Insurance Plans

AHIP is the national trade association representing the health insurance industry. AHIP’s members provide health and supplemental benefits to 200 million Americans through employer-sponsored coverage, the individual insurance market, and public programs such as Medicare and Medicaid.

ASC

Ambulatory Surgical Center

Facility established to conduct surgical procedures which require minimal inpatient rehabilitation, and which therefore may commonly discharge patients post-operatively on the day of surgery.

BHO

Behavioral Health Organization

Service providing and care management organizations specializing in the care of mental illness, substance abuse and behavioral health; often in partnership with indemnifying or other service providing organizations.

BPCI

Bundled Payment Care Initiative

Experimental payment program supported by CMS for reimbursement of certain services delivered to Medicare patients. Composed of 4 alternative payment and risk-sharing models, all based upon fixed episode of care based payments and care quality metrics. Currently 48 DRG based services are available for participation in bundled payment arrangements.

CEN

Clinical Event Notification

Automated alert programs distributing notifications upon initiation or change in care status of attributed patient or beneficiary populations.

CIN

Clinically Integrated Network

Contractual collaboration of hospitals, health systems, and provider groups to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.

CMS

Centers for Medicare and Medicaid Services

Subsidiary of Federal Dept of HHS. CMS supervises the care of the approx 100 million people who receive of Medicare, Medicaid, CHIP and other federally sponsored health plans.

CTN

Care Transition Notifications™

Real-time alerts sent to clinicians and care managers any time an attributed patient is admitted, discharged or transferred to a new care setting. CTNs enable real-time clinical and operational management of the patient.

DRG

Diagnosis Related Group

Healthcare services classification system often used to group services into billable and reportable “products” delivered to patients.

DSRIP

Delivery System Reform Incentive Payments

Federal financial waivers granted to state health departments to advance the shift toward value based and networked care for Medicaid patients. Program initiatives vary by state, but are founded in the triple aim of healthcare reform. DSRIP programs are currently underway in five states: New York, New Jersey, Kansas, Texas, and California.

eHI

eHealth Initiative

Researches, educates, and advocates for innovative solutions to improve the quality, safety and efficiency of care through information and technology.

EHR / EMR

Electronic Health Record / Electronic Medical Record

Healthcare IT record system for capturing, storing, and provisioning personal, clinical, and treatment data; viewed as essential component of healthcare delivery reform, supported by HITECH act and guided by meaningful use implementation stages.

EP

Eligible Professional

A category of service providers (including Physicians, Nurse Practitioners, and Physician Assistants) who have the opportunity to receive MU incentive payments.

ESCO

ESRD Seamless Care Organization

Accountable Care Organizations focused on optimizing the care and wellbeing of Medicare patients with ESRD – largely through networked care and value based financial models.

ESRD

End Stage Renal Disease

Clinical diagnosis assigned to individual with a rate of fluid filtration (metric of kidney function) below a minimum threshold to meet demands of daily living. Renal replacement therapy (dialysis) required.

FFS

Fee-for-service

Traditional payment model in which providers submit reimbursement claims for services provided to indemnifying and payer organizations. Believed to promote increasing volumes of services over value of services delivered.

HHS

U.S. Department of Health and Human Services

Federal organization with oversight of American healthcare quality and coverage.

HIE

Health Information Exchange

Healthcare data aggregator tasked with standardizing and purveying patient healthcare information across a region. HIEs are increasingly cited as cornerstones of healthcare data interoperability and availability.

HIMSS

Healthcare Information and Management Systems Society

Healthcare IT member organization promoting innovative and impactful use of IT in healthcare.

HIPAA

Health Information Portability and Accountability Act

Comprehensive privacy and security legislative act establishing standard for the storage and transmission of patient healthcare information.

HITECH

The Health Information Technology for Economic and Clinical Health Act

Component of the 2009 American Recovery and Reinvestment act providing a framework and funding mechanisms to support the adoption of Health IT broadly across the national healthcare delivery system.

HL7

Health Level 7

7 or HL7 refers to a set of international data encryption standards for transfer of clinical and administrative data between software applications used by various healthcare providers.

IDN

Integrated Delivery Network

A network of facilities and providers that cooperate to offer a continuum of care to a specific geographic area or market.

 

Interoperability

Ability of different information technology systems and software applications to communicate and to cooperatively perform operations.

IPA

Independent Physician Association

Contractual organization of physician groups, typically across specialties, allowing for pooled resource utilization, bargaining, and practice standardization.

MCO

Managed Care Organization

A managed care organization may be an HMO or other organization which seeks to oversee the provision of quality care while reducing costs. May indemnify patients directly or contract with risk-bearing organizations to share risk; may provide services to member or contract with services providers to compose care networks. Presently over 90% of insured Americans are in a managed care organization of some sort.

MSSP

Medicare Shared Savings Program

A care delivery transformation program available to ACOs which allows for varying levels of financial risk exposure and savings benefit, and ties financial savings and penalties to performance against pre-established cost and care quality benchmarks.

MU

Meaningful Use – EHR Incentive Program

Financial incentive program established in the HITECH act to promote the meaningful utilization of certified EHR technology.

MU2

Stage 2 Meaningful Use Rule

Stage 2 of the Meaningful Use program was issued publicly in August 2012. It differs from Stage 1 of the Meaningful Use role with is rules for information exchange and patient engagement.

NTOCC

National Transitions of Care Coalition

NTOCC is a group of concerned organizations and individuals who have joined together to address problems associated with transitions of care: the movement of patients from one practice setting to another.

ONC

The Office of the National Coordinator for Health Information Technology

Staff division of the Office of the Secretary, within the U.S. Department of Health and Human Services responsible for overseeing programs and policies to guide utilization of IT in healthcare – empowered by the HITECH act.

PCM

Patient Centric Messaging

Feature of the Cureatr platform which allows for quick visibility of care messages and event notifications on individual patients. Helps to manages the clutter in your inbox while directing you to the most relevant patient cases to manage clinical workflows.

PCMH

Patient Centered Medical Home

A care delivery model emphasizing regular interaction between patients and primary care teams to support care quality and financial reform initiatives. Recognition programs establish qualification criteria advancing provider availability, on-going care and health management, patient education, and IT connectivity to referral and acute care settings.

PHI

Protected Health information

PHI is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual, and can include any part of a patient’s medical record or payment history.

 

Pioneer ACO

A care delivery transformation program available to ACOs which exposes ACOs to high levels of financial risk or savings benefit, determined by their performance against pre-established cost and care quality benchmarks. Organizations chosen for this program must demonstrate experience with networked and coordinated care.

PPO

Preferred Provider Organization

A form on networked care delivery providing managed care organization which offers reduced rates to the insurer’s customers.

PPS

Performing Provider Systems

DSRIP-established care providing organization, offering networked and aligned services founded upon the triple aim of healthcare reform.

PQRS

Physician Quality Reporting System

PQRS is a quality reporting program for individual eligible professionals (EPs) and groups to report information on the quality of care to Medicare. PQRS gives EPs and groups the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time.

RHIO

Regional Health Information Organization

Governing body overseeing the operations of HIEs, often composed of major regional stakeholders cooperating to advance the goals of interoperability across systems.

SNF

Skilled Nursing Facility

A type of nursing home facility defined by Medicare as offering interim patient care until the patient reaches full independence once again.

 

Triple Aim of Healthcare Reform

Widely adopted framework to approach optimization of the healthcare delivery systems, advocating 1. improving the patient experience of care 2. improving the health of populations 3. reducing the per capita cost of healthcare.

TOC

Transitions of Care

The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.

VBC / VBP

Value-Based Care / Value-Based Purchasing

Financial service provider reimbursement schemes designed to transition away from fee-for-service to emphasizing quality and cost to patients and rewarding healthcare organizations for better health and treatment outcomes.

VNAA

Visiting Nurse Association of America

National trade organization that supports, promotes and advocates for mission-driven providers of home health, hospice and palliative care.

VNS

Visiting Nurse Service

Care service provider model with delivers nursing care to patient at their place of residence. Variable levels of capability, thought advocate to improve patient experience of care and to reduce costs of inpatient / facility based care.