医学课件healthcare delivery

1 Chapter1 HealthCareDeliverySystemsFeipeiLaiNationalTaiwanUniversity 2 HealthCareDeliverySystems HistoryofMedicineandHealthcareDeliveryContinuumofCareHealthCareFacilityOwnershipHealthCareFacilityOrganizationalStructureLicensure Regulation andAccreditation 3 Introduction Healthcaredeliveryhasbeengreatlyimpactedbyescalatingcosts resultinginmedicalnecessityrequirements reviewofappropriatenessofadmissions andrequirementforadministrationofqualityandeffectivetreatments 4 MRXO 在臨床醫學中 進行手術時同時使用磁振造影並整合各種影像技術是目前最熱門的醫療概念 新式的 未來手術室 中 安裝有全球首套MRXO解決方案 即完全整合磁振造影 MR 光及電腦斷層掃描 CT 系統 大幅減少病患危險並簡化醫師的手續 可望提高手術成功率 這項由日本東海大學 飛利浦醫療系統事業部合力推動的 未來手術室 已經由日本東海大學的松前教授 津具醫師 山本醫師共同在手術室同時使用MR 磁振造影 和X光影像技術 來進行神經外科手術 5 MRXO 在 未來手術室 中執行手術 可依執刀醫師與病患狀況 在數分鐘內將病患從手術台搬移到磁振造影 電腦斷層掃描或 光診斷系統 增加手術精密度與成功率 在磁振造影和電腦斷層掃描區域有拉門 6 HistoryofMedicine HealthCareDelivery HistoryofmedicineEvolutionofhealthcaredeliveryintheUnitedStates 7 Historyofmedicine In1994 scientistsdiscoveredthegenesresponsibleformanycasesofhereditarycoloncancer inheritedbreastcancer andthemostcommontypeofkidneycancer 8 EvolutionofhealthcaredeliveryintheUnitedStates 1991TheWorkgrouponElectronicDataInterchange WEDI wascreatedtoreducehealthcareadministrativecoststhroughimplementationoftheelectronicdatainterchange EDI whichusesnationalstandardstotransmitdataforreimbursementpurposes 9 EvolutionofhealthcaredeliveryintheUnitedStates 1996TheHealthInsurancePortabilityandAccountabilityAct HIPAA waspassed Itmandatesadministrativesimplificationregulationsthatgovernprivacy security andelectronictransactionstandardsforhealthcareinformation 10 EvolutionofhealthcaredeliveryintheUnitedStates 1996TheHealthcareIntegrityandProtectionDataBank HIPDB wascreatedwhichcombatsfraudandabuseinhealthinsuranceandhealthcaredeliverybyalertinguserstoconductacomprehensivereviewofapractitioner s provider s orsupplier spastactions 11 HealthcareIntegrityandProtectionDataBank AccesstoinformationintheHIPDBisavailabletoentitiesthatmeettheeligibilityrequirementsdefinedinSection1128EoftheSocialSecurityActandtheHIPDBregulations Inordertoaccessinformation eligibleentitiesmustfirstregisterwiththeDataBank HIPDBinformationisnotavailabletothegeneralpublic However informationinaformthatdoesnotidentifyanyparticularentityorpractitionerisavailable 12 HealthcareIntegrityandProtectionDataBank http www npdb hipdb hrsa gov Estimatesofannuallossesduetohealthcarefraudrangefrom3to10percentofallhealthcareexpenditures between 30billionand 100billionbasedonestimated1997expendituresofover 1trillionand2 5trillionfor2009 13 ContinuumofCare Acompleterangeofprogramsandservicesiscalledacontinuumofcare withthetypeofhealthcareindicatingthehealthcareservicesprovided PrimarycareSecondarycareTertiarycare 14 Primarycareservices Includepreventiveandacutecare arereferredtoasthepointoffirstcare andareprovidedbyageneralpractitionerorotherhealthprofessionalwhohasthefirstcontactwithapatientseekingmedicaltreatment includinggeneraldental ophthalmic眼科的 andpharmaceuticalservices 15 Primarycareservices AnnualphysicalexaminationsEarlydetectionofdiseaseFamilyplanningHealtheducationImmunizationsTreatmentofminorillnessesandinjuriesVisionandhearingscreening 16 Secondarycareservices Providedbymedicalspecialistsorhospitalstaffmemberstoapatientwhoseprimarycarewasprovidedbyageneralpractitionerwhofirstdiagnosedortreatedthepatient 17 Tertiarycareservices ProvidedbyspecializedhospitalsequippedwithdiagnosticandtreatmentfacilitiesnotgenerallyavailableathospitalsotherthanprimaryteachinghospitalorLevelI II IIIorIVtraumacenters 18 Traumacenters LevelI providesthehighestlevelofcomprehensivecareforseverelyinjuredadultandpediatricpatientswithcomplex multi systemtrauma LevelII broadrangeofsub specialistsareon callandpromptlyavailabletoprovideconsultationorcare 19 Traumacenters LevelIII physiciansareadvancedtraumalifesupport ATLS trainedandexperiencedincaringfortraumaticallyinjuredpatients nursesandancillarystaffarein houseandimmediatelyavailabletoinitiateresuscitativemeasures 20 Traumacenters LevelIV criticallyinjuredpatientswhorequirespecialtycarearetransferredtoahigherleveltraumasystemhospitalinaccordancewithpre establishedcriteria 21 Tertiarycare BurncentertreatmentCardiothoracicandvascularsurgeryInpatientcareforAIDSpatientsMagneticresonanceimaging MRI NeonatologylevelIIIunitservicesNeurosurgeryOrgantransplant 22 Tertiarycare PediatricsurgeryPositronemissionstomography PET RadiationoncologyServicesprovidedtoapersonwithahigh riskpregnancyServicesprovidedtoapersonwithcancerState designatedtraumacentersTraumasurgery 23 Positronemissionstomography PET buildsimagesbydetectingenergygivenoffbydecayingradioactiveisotopes Isotopesareatomsofanelementwiththesamenumberofprotons positivelychargedparticles inthenucleus butadifferentnumberofneutrons neutralparticles Becauseradioactiveisotopesareunstable astheydecay theythrowoffpositronsthatcollidewithelectronsandproducegammaraysthatshootoffinnearlyoppositedirections 24 PET PETsystemsusethepathsofthetwodetectedgammaraystodeterminetheoriginatingcollisionpoint aprocesscalledelectroniccollimation 瞄準 Thescannersuseacircularseriesofgammaray detectorstoenvelopethepatientsobothgammascanbedetectedsotheinstrumentcanuseelectroniccollimationtopredictwheretheenergysignaloriginated Thissignalisthenconvertedintoathree dimensionalimageslice 25 台灣醫院分類 診所地區醫院 497 2005 區域醫院 80 2005 65 2006 64 2007 醫學中心 23 2005 18 2006 19 2007 14 2009 26 醫學中心 在衛生局登記開放的急性一般病床與急性精神病床合計須達五百床以上至少應能提供家庭醫學 內 外 婦產 兒 骨 神經外 泌尿 耳鼻喉 眼 皮膚 神經 精神 復健 麻醉 放射線 病理 核醫 牙等十九科之診療服務 27 醫學中心 專任主治醫師人數 包括主任在內 每八床應有一名 專任護理人員每2床至少1名 加護病房 每床2 5名 手術室 每班每台2 5名 手術恢復室 每班每床0 5名 產房及待產室 每床2名 嬰兒室 每床0 4名 急診室 觀察室每床0 5名 診療室每12人次1名 門診 每班每診療室0 5名 血液透析室 每4人次1名 行政 教學 研究及其他護理人員 如院內感染控制 公衛 供應中心等護理人員 另計 應佔總人數百分之六 應有受過感染控制訓練之專任護理人員 每300床應設1名 28 醫學中心 藥事人員每40床至少1名 每60張門診處方至少1名 特殊藥品處方每15張至少1名 藥事人員總數至少四分之三為藥師 藥事人員至少有4名負責藥品管理諮詢及臨床等工作 29 區域醫院 應設置250床位以上急性病病床數每床所擁有的樓地板面積應在50平方公尺以上每9床至少應擁有一名主治醫師每2 5床至少應擁有一名護理人員等 至少應能提供家庭醫學 內 外 婦產 兒 骨 耳鼻喉 眼 精神 復健 麻醉 放射線 病理 牙等十四科之診療服務 30 區域醫院Nurse 加護病房 每床2名 手術室 每班每台2名 手術恢復室 每班每床0 5名 產房及待產室 每床1 2名 嬰兒室 每床0 4名 急診室 觀察室每床0 5名 診療室每12人次1名 門診 每班每診療室0 5名 血液透析室 每4人次1名 行政 教學 研究及其他護理人員 如院內感染控制 公衛 供應中心等護理人員 另計 應佔總人數百分之四 應有受過感染控制訓練之專任護理人員 每300床應設1名 31 區域醫院 藥事人員每50床至少1名 每70張門診處方至少1名 特殊藥品處方每15張至少1名 藥事人員總數至少四分之三為藥師 藥事人員中 至少有2名負責藥品管理諮詢及臨床等工作 32 地區醫院 在衛生局登記開放的急性一般病床需20床以上 急性一般病床及急性精神病床合計249床 含 以下 33 地區醫院 專任員工總人數每床應有1名 專任主治醫師人數以及專任護理人員應符合醫療機構設置標準 藥事人員每50床至少1名 每80張門診處方至少1名 每增加100張處方應增加1名 應有藥師1人以上 34 評鑑分級 設施總樓地板面積病房設施安全設備及一般設備保險病床比率 35 評鑑分級 人員員工總人數醫師總數麻醉科醫師放射線科醫師核醫科醫師病理科醫師復健科醫師精神科醫師護理藥事醫事檢驗醫用放射線技術復健技術精神科社會工作營養師病歷管理 36 評鑑分級 醫療業務及設備醫療業務急性病床數診療科別急診業務手術及麻醉作業產房嬰兒室加護病房藥事作業檢驗作業輸血作業放射線診療作業病理作業復健醫療作業精神科核子醫學牙科特殊醫療服務醫務社會服務工作營養部門病歷部門社區衛生服務員工健康檢查 37 評鑑分級 品質保證醫療品質審查感染控制人體試驗藥事作業品質護理服務品質檢驗作業品質管制輸血作業品質管制病理作業品質管制放射線診療品質管制核子醫學品質管制病歷管理醫院管理業務醫病關係之促進 38 評鑑分級 指定項目評估住院診斷處置用藥手術病歷寫作 39 評鑑分級 教學訓練教學師資教學訓練與研究設備教學訓練活動與其他醫院 醫學院 交流合作情形研究情形及論文發表教學進修研究經費 40 新制教學醫院評鑑基準 教學資源教學訓練計畫與成果研究執行與成果臨床師資培育及繼續教育學術交流與社區功能及角色管理行政 41 財團法人醫院評鑑暨醫療品質策進會 http www tjcha org tw Identify asp catid 23 42 HealthCareFacilityOwnership Government not for profit 25 Proprietary for profit 15 Voluntary not for profit 60 43 MedicalStaff Intern aphysicianinthefirstyearofgraduatemedicaleducation whichordinarilyimmediatelyfollowscompletionofthefour yearmedicalcurriculum Resident aphysicianwhohascompletedaninternshipandisengagedinaprogramoftrainingdesignedtoincreasehisorherknowledgeoftheclinicaldisciplinesofmedicine surgery oranyoftheotherspecialfieldsthatprovideadvancedtraininginpreparationforthepracticeofaspecialty 44 MedicalStaff Chiefresident aphysicianwhoisinhisfinalyearofresidencyorintheyearaftertheresidencyhasbeencompleted VisitingStaff VS 主治醫師 45 HealthCareFacilityOrganizationalStructure GoverningboardAdministrationMedicalstaffDepartments services andcommitteesContractedservices 46 Governingboard Thegoverningboard boardoftrustees boardofgovernors boardofdirectors serveswithoutpay anditsmembershipisrepresentedbyprofessionalsfromthebusinesscommunity 47 Administration Servesasliaisonbetweenthemedicalstaffandgoverningboardandisresponsiblefordevelopingastrategicplanforsupportingthemissionandgoalsoftheorganization CEO chiefexecutiveofficeCFO chieffinancialofficerCIO chiefinformationofficerCOO chiefoperatingofficer 48 Medicalstaff Consistsoflicensedphysiciansandotherlicensedprovidersaspermittedbylaw e g nursepractitionersandphysicianassistants whoaregrantedclinicalprivileges 49 physicianassistants Examine diagnose andtreatpatientsunderthedirectsupervisionofaphysician 50 Medicalstaffmembershipcategories Active deliversmosthospitalmedicalservices performssignificantorganizationalandadministrativemedicalstaffdutiesAssociate advancementtoactivecategoryisbeingconsideredConsultingCourtesy admitsanoccasionalpatienttothehospitalHonorary 51 52 Hospitaldepartments Services andCommittees 53 HealthInformationDepartment DepartmentadministrationCancerregistryCodingandabstractingImageprocessingIncompleterecordprocessingMedicaltranscriptionRecordcirculationReleaseofinformationprocessing 54 55 Coding Involvesassigningnumericandalphanumericcodestodiagnoses procedures andservices thisfunctionisusuallyperformedbycredentialedindividuals CodersassignICD 9 CMcodestoinpatientcasesandCurrentProceduralTerminology CPT HealthCareProcedureCodingSystem HCPCS LevelII National andICD 9 CMcodestooutpatient emergencydepartment andphysicianofficecases 56 Cancerregistry Performedbyindividualswhoarecredentialedascertifiedtumorregistrarsandincludeusingcomputerizedregistrysoftwaretoconductlifetimefollow uponeachcancerpatient electronicallytransmitdatatostateandnationalagenciesforuseatlocal regional state andnationallevels andgeneratereportsandinformationforrequestingentities 57 CurrentProceduralTerminology CPT PublishedannuallybytheAmericanMedicalAssociationandcodesare5 digitnumbersassignedtoambulatoryproceduresandservices E g 90663Influenzavirusvaccine pandemicformulation 58 ICD 9 CM TheInternationalClassificationofDiseases Ninthrevision ClinicalModificationisusedintheUnitedStatestocollectinformationaboutdiseasesandinjuriesandtoclassifydiagnosesandprocedures NationalCenterforHealthStatistics NCHS 59 1 INFECTIOUSANDPARASITICDISEASES 001 139 TUBERCULOSIS 010 018 Includes infectionbyMycobacterium分枝桿菌tuberculosis human bovine牛 Excludes congenitaltuberculosis 771 2 lateeffectsoftuberculosis 137 0 137 4 Thefollowingfifth digitsubclassificationisforusewithcategories010 018 0unspecified1bacteriologicalorhistological組織學的examinationnotdone2bacteriologicalorhistologicalexaminationunknown atpresent 3tuberclebacilli結核桿菌found insputum bymicroscopy4tuberclebacillinotfound insputum bymicroscopy butfoundbybacterialculture5tuberclebacillinotfoundbybacteriologicalexamination buttuberculosisconfirmedhistologically6tuberclebacillinotfoundbybacteriologicalorhistologicalexamination buttuberculosisconfirmedbyothermethods inoculation預防接種ofanimals 60 010PrimarytuberculousinfectionRequiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions 011PulmonarytuberculosisRequiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions Useadditionalcodetoidentifyanyassociatedsilicosis矽肺病 502 012OtherrespiratorytuberculosisRequiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions Excludes respiratorytuberculosis unspecified 011 9 013Tuberculosisofmeninges腦脊膜andcentralnervoussystemRequiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions 61 014Tuberculosisofintestines腸 peritoneum腹膜 andmesentericglands腸系膜腺Requiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions 015TuberculosisofbonesandjointsRequiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions Useadditionalcodetoidentifymanifestation as tuberculous Arthropathy關節病 711 4 Necrosis壞死ofbone 730 8 Osteitis骨炎 730 8 Osteomyelitis骨髓炎 730 8 Synovitis滑膜炎 727 01 Tenosynovitis腱鞘炎 727 01 62 016Tuberculosisofgenitourinary泌尿生殖器的systemRequiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions 017TuberculosisofotherorgansRequiresfifthdigit Seebeginningofsection010 018forcodesanddefinitions 018Miliary粟粒狀的tuberculosisIncludes tuberculosis Disseminated彌散性Generalized全身性的miliary whetherofasinglespecifiedsite multiplesites orunspecifiedsitePolyserositis漿膜炎 ICD 10 TheInternationalStatisticalClassificationofDiseasesandRelatedHealthProblems10thRevisionisacodingofdiseasesandsigns symptoms abnormalfindings complaints socialcircumstancesandexternalcausesofinjuryordiseases asclassifiedbytheWHO Thecodesetallowsmorethan14 400differentcodesandpermitsthetrackingofmanynewdiagnoses Usingoptionalsubclassifications thecodescanbeexpandedtoover16 000codes 63 USICD 10CM TheInternationalversionofICDshouldnotbeconfusedwithnationalClinicalModificationsofICDthatincludefrequentlymuchmoredetail andsometimeshaveseparatesectionsforprocedures sothenewUSICD 10CMhassome155 000codes 64 65 HCPCS TheHealthCareProcedureCodingSystemiscomprisedofLevelI CPT andLevelII National codes LevelIIHCPCScodesaredevelopedbytheCentersforMedicare MedicaidServices CMS andusedtoclassifyreportproceduresandservices 66 CPT CurrentProceduralTerminology anumericcodingsystemmaintainedbytheAmericanMedicalAssociation AMA TheCPTisauniformcodingsystemconsistingofdescriptivetermsandidentifyingcodesthatareusedprimarilytoidentifymedicalservicesandproceduresfurnishedbyphysiciansandotherhealthcareprofessionals 67 LevelIoftheHCPCS theCPTcodes doesnotincludecodesneededtoseparatelyreportmedicalitemsorservicesthatareregularlybilledbysuppliersotherthanphysicians 68 LevelIIHCPCS Codesarereportedtothird partypayers e g insurancecompanies forreimbursementpurposes 69 LevelIIHCPCS LevelIIoftheHCPCSisastandardizedcodingsystemthatisusedprimarilytoidentifyproducts supplies andservicesnotincludedintheCPTcodes suchasambulanceservicesanddurablemedicalequipment prosthetics假體 orthotics矯形器 andsupplies DMEPOS whenusedoutsideaphysician soffice 70 LevelIIHCPCS LevelIIalphanumericHCPCSprocedureandmodifiercodes theirlongandshortdescriptions andapplicableMedicareadministrative coverage andpricingdata TheLevelIIHCPCScodes whichareestablishedbyCMS sAlpha NumericEditorialPanel primarilyrepresentitemsandsuppliesandnon physicianservicesnotcoveredbytheAmericanMedicalAssociation sCurrentProceduralTerminology 4 CPT 4 codes Medicare Medicaid andprivatehealthinsurersuseHCPCSprocedureandmodifiercodesforclaimsprocessing 71 http www cms gov MedHCPCSGenInfo A1001007DRESSINGFORONEWOUNDDressingforonewoundC2002070120020701NA2001007DRESSINGFORTWOWOUNDSDressingfortwowoundsC02002070120020701NA3001007DRESSINGFORTHREEWOUNDSDressingforthreewoundsC02002070120020701N 72 Abstracting Performedtoentercodesandotherpertinentinformationutilizingcomputersoftware Togeneratestatisticalreportsanddisease procedureindexes whichareusedforadministrativedecision makingandquality managementpurposes 73 Incompleterecordprocessing Includestheassemblyandanalysisofdischargedpatientrecords Afterapatientisdischargedfromanursingunit therecordisretrievedandreportsareassembledaccordingtoahospital andmedicalstaff approvedorderofassembly 74 Medicaltranscription Involvestheaccurateandtimelytranscriptionofdictatedreports 75 Recordcirculation Includestheretrievalofpatientrecords forthepurposeof InpatientreadmissionScheduledandunscheduledoutpatientclinicvisitsAuthorizedquality managementstudiesEducationandresearch 76 Licensure RegulationandAccreditation CodeofFederalRegulations CFR FederalRegisterAlegalnewspaperpublishedeverybusinessdaybytheNationalArchivesandRecordsAdministration NARA inpa