In part 1, I discussed how data is generated by patients and at the point of care and a few different ways that data can flow between the different processes that regulate the flow of clinical information. This post will outline three types of organization that exist outside of the patient/caregiver relationship but still have access to almost every piece of data that the healthcare system generates about you.
Healthcare providers rely on a variety of vendors to assist in delivering efficient care. These include outside labs, pharmacies, medical coders and transcribers, and technology providers. Each of these organizations touch a slice of the data.
Medical coders review the patient’s chart to translate the data generated by care providers into codes that are used to track patients through the diagnostic and billing process. Many health systems employ their own coders while some choose to outsource.
Technology providers get a wide range of access to data. Some work only with codes while others process the entirety of the medical record or handle all data transmissions, including emails, faxes, and telephone calls.
Labs and pharmacies both get orders that are relatively structured and tracked with a common set of codes. Labs get actual living samples from patients, a unique type of data in the system. This group of service providers also communicate directly with insurance companies or other payer organizations.
Health insurance companies and government payers (CMS and state-level payers) have the broadest view of a patient’s interactions with the system but, just like when you zoom out on a map, their view isn’t very detailed.
The most frequent kind of patient data that a payer will interact with are billing and diagnostic codes. Diagnostic codes are used to track the diagnoses a provider makes when a patient comes to them with a problem. When a doctor performs a procedure, such as an office visit or a mole removal, these are tracked with a procedure code. The payer uses the diagnostic and procedure codes to determine how the provider will get reimbursed.
Payers can also request additional data from the provider in support of a claim. They will also routinely audit patients using data collected from providers. Payers need to collect data from all of the providers who a patient sees, adding complexity to their data transmission process.
Along with the rapid adoption of EHRs due to the HITECH Act, health information exchanges began to spring up to address the need for information sharing between provider organizations and, in some cases, insurance companies. There have been varying levels of adoption when it comes to data sharing
Government agencies can also request access to health records. This includes law enforcement organizations in the course of investigating a crime or locating a suspect or as a part of a terrorist investigation. Government agencies responsible for handling disability claims, worker’s compensation, or Medicare/Medicaid will also have access to medical data.