If you read my health data book recommendations you saw 'Hacking Healthcare' on there, but I wanted to give it a full, proper review to give a sense of what I find so valuable about this book.
First off, at face value this book has some apparent negatives relative to data science: it's not new (my copy is from October 2012; it's about EHR's as software applications more than as databases; it's about Meaningful Use (the authors actually state they wrote the book to educate and prepare IT staff on Meaningful Use). And despite those apparent shortcomings, this book, in my opinion, actually teaches more about healthcare and how it produces data than any of the modern healthcare data science books I've looked at so far.
Preface:
"This book, so far as we know, is the first candid attempt to bridge the gap between clinicians and IT staff. It explains the factors that make healthcare settings different from other jobs and academic settings..."
I agree - this statement from the authors basically sets the tone for the best chapters of this book, to me. This really is the only book I've found that attempts to actually get the reader to understand the clinical healthcare process and the ramifications for the resulting data. These concepts are just as valuable, or more valuable, for data scientists as they are for health IT staff.
Chapter 1: Introduction
A good overview of the context of the EHR in America in the early 2010's following ARRA & HITECH, but before EHR's became the expectation. It's interesting from a historical perspective to read this in 2020, when the paradigm has flipped and electronic records really are the expectation, and paper records feel like the outlier. Also interesting to read the authors' summary of the issues that prevented the earlier digitization of healthcare:
- complexity of healthcare (still an issue in 2020)
- constantly changing landscape of the field (still an issue in 2020)
- inability to do full electronic installs resulting in hybrid EHR / paper scenarios (there may be small pockets of this, but haven't seen this as a largescale situation in a long time)
- provider discontent (probably a larger issue today than in 2012)
- expense of systems disincentivizing EHRs (Meanigful Use incentives certainly changed the dynamics of this issue, but expense of major EHR software still certainly seems like an issue to me)
Chapter 2: Anatomy of Medical Practice
This is where we start to get to the really good stuff. Even though some of the content is dated (in 2020, how many practices are still using paper or non-enterprise software for tasks like scheduling & patient registration?) and we've moved past some of the Meaningful Use details focused on this chapter does a great job explaining the basics of providing healthcare to a patient in America. There's a focus on distinguishing between inpatient and outpatient care, which makes sense, especially as an introduction to understanding American health care, but it's not explained in the most intuitive way focusing instead on how long care is provided for. I also found myself thinking during certain sections, like patient admission and relationships with labs or other 3rd parties, that a section would be clearer with a diagram than just text. Some sections also went a little deeper on the legal aspects than necessary, in my opinion.
Sections in chapter 2:
How patients reach Healthcare Organizations - could use a diagram to clarify flow
Lab sample Collection before a visit - could use a diagram to clarify relationships
HIPAA and patient identification (patient registration)
Intake, demographics, visits and admissions
Precertification and prior authorization
Emergency admissions
Prioritization and triage
Outpatient care
Inpatient care
Labs
Imaging
Administration and billing
Chapter 3: Medical Billing
The first 3 sentences of this chapter, verbatim: "Medical billing in the United States ranks, in our experience, with nuclear physics and rocket design in challenges to mastery. These fields all have incredibly steep learning curves and require years of study, patience, and experience. We are not joking about this." That resonates with me, and I suspect with many of us willingly or unwillingly involved in US medical billing. It's also maddeningly difficult to proactively learn about these billing systems: from my experience the limited, organized, books or content on this topic is either Marianas Trench deep or stratospherically high-level. This chapter tends towards the latter, but it's hard to fault an introductory book intended for IT workers that fact - the chapter still has good information and introduces many crucial big topics and some more esoteric, important concepts. I'll try to give a brief synopsis of the major sections of this chapter:
Who Pays, and How: Very, very high level introduction to the concept of 'payers' in the billing system. Also, kudos for at least mentioning the existence of specialized payers, such as worker's comp, FECA/Black Lung, and the Ryan White program. Even if these payment programs don't come up everday, it's helpful to know they exist and not be confused when you see something like them in your payer list.
Claims: Very high level on the concept of recording information about medical services in a standardized way to transmit for payment. Kudos here for mentioning the CMS/HCFA 1500 and the UB-04. In the modern world, it's common to only think of a claim from an electronic perspective and you tend not to hear these names outside of billing/coding & HIM areas, but, again, nice to know those names for context.
Eligibility: A more in-depth discussion of the steps of the eligibility process from a provider perspective, along with some thoughts on how this process effects subsequent patient care. Although the authors don't describe this section using these words, this is basically a very high level overview of how revenue cycle works & the different paths revenue collection might take depending on the eligibility assessment and patient/insurance ability to pay.
Treatment: This section actually focuses, to me, on two concepts: how is medical care priced and how is medical care recorded for the purposes of billing. There's only a bit on the former, but they do get into important concepts like considering non-chargeable costs, regional variation, and weighting factors. It's nice to see a reference to 'fee schedule' to understand what that is, but it would have been nicer to see a reference/explanation of the 'charge master' or the role of accounting (cost & activity-based) in medical pricing.
This book is originally from 2013, so the treatment of coding systems is a bit dated (they were still pre-ICD10 conversion), but overall the explanations on coding systems for recording medical services is reasonably good. It's high level, but includes some more nuanced concepts like using some codes to justify other billed services.
The Billing Process: This is focused on the out-of-provider processing done by billing services and clearinghouses. Personally, this has never been particularly interesting or important to anyone outside of a rev cycle function.
Complexities in Billing / Adjudication: These two sections really focus on the true revenue cycle processing, either in-provider or outsourced.
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