Modernizing Payer System A Practical Guide To Healthcare Interoperability Compliance And Data Integration
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Modernizing Payer System A Practical Guide To Healthcare Interoperability Compliance And Data Integration
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Author : Parth Jani
language : en
Publisher: Libertatem Media Private Limited
Release Date : 2024-05-11
Modernizing Payer System A Practical Guide To Healthcare Interoperability Compliance And Data Integration written by Parth Jani and has been published by Libertatem Media Private Limited this book supported file pdf, txt, epub, kindle and other format this book has been release on 2024-05-11 with Computers categories.
In an era where healthcare transformation is both a regulatory necessity and a digital imperative, Modernizing Payer Systems by Parth Jani delivers a masterclass in rebuilding the core of U.S. healthcare administration. This book is a vital guide for architects, IT leaders, and healthcare executives striving to create scalable, interoperable, and compliant payer platforms. Drawing on real-world experience across Medicaid, Medicare, ACA, and commercial plans, Jani offers deep insights into integrating legacy systems with cloud-native architectures, aligning with CMS interoperability mandates, and leveraging HL7, FHIR, and EDI for seamless data exchange. Readers will learn how to manage complex workflows spanning claims, PBMs, enrollment, provider data, and compliance reporting, while building secure, analytics-ready data ecosystems using tools like OMOP CDM, SSIS, and Informatica. The book also tackles mission-critical topics such as HIPAA compliance, No Surprises Act adherence, pharmacy integration, and AI-driven claims automation. With detailed architectural frameworks, vendor integration strategies, and lessons from real-world projects, Modernizing Payer Systems empowers stakeholders to navigate healthcare’s most complex IT challenges. Whether you're planning a modernization roadmap or tackling a full-scale payer system transformation, this book is your blueprint for delivering agile, compliant, and intelligent healthcare platforms—designed not just to meet today’s standards, but to shape the future of payer innovation.
Registries For Evaluating Patient Outcomes
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Author : Richard E. Gliklich
language : en
Publisher:
Release Date : 2014
Registries For Evaluating Patient Outcomes written by Richard E. Gliklich and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2014 with Diseases categories.
Integrating Social Care Into The Delivery Of Health Care
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Author : National Academies of Sciences, Engineering, and Medicine
language : en
Publisher: National Academies Press
Release Date : 2019-12-30
Integrating Social Care Into The Delivery Of Health Care written by National Academies of Sciences, Engineering, and Medicine and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2019-12-30 with Medical categories.
Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health was released in September 2019, before the World Health Organization declared COVID-19 a global pandemic in March 2020. Improving social conditions remains critical to improving health outcomes, and integrating social care into health care delivery is more relevant than ever in the context of the pandemic and increased strains placed on the U.S. health care system. The report and its related products ultimately aim to help improve health and health equity, during COVID-19 and beyond. The consistent and compelling evidence on how social determinants shape health has led to a growing recognition throughout the health care sector that improving health and health equity is likely to depend â€" at least in part â€" on mitigating adverse social determinants. This recognition has been bolstered by a shift in the health care sector towards value-based payment, which incentivizes improved health outcomes for persons and populations rather than service delivery alone. The combined result of these changes has been a growing emphasis on health care systems addressing patients' social risk factors and social needs with the aim of improving health outcomes. This may involve health care systems linking individual patients with government and community social services, but important questions need to be answered about when and how health care systems should integrate social care into their practices and what kinds of infrastructure are required to facilitate such activities. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health examines the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes. This report assesses approaches to social care integration currently being taken by health care providers and systems, and new or emerging approaches and opportunities; current roles in such integration by different disciplines and organizations, and new or emerging roles and types of providers; and current and emerging efforts to design health care systems to improve the nation's health and reduce health inequities.
Procuring Interoperability
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Author : National Academy of Medicine
language : en
Publisher:
Release Date : 2023-09-03
Procuring Interoperability written by National Academy of Medicine and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2023-09-03 with categories.
Realizing the promise of digital technology will depend on the ability to share information across time and space from multiple devices, sources, systems, and organizations. The major barrier to progress is not technical; rather, it is in the failure of organizational demand and purchasing requirements. In contrast to many other industries, the purchasers of health care technologies have not marshaled their purchasing power to drive interoperability as a key requirement. Better procurement practices, supported by compatible interoperability platforms and architecture, will allow for better, safer patient care; reduced administrative workload for clinicians; protection from cybersecurity attacks; and significant financial savings across multiple markets. With funding support from the Gordon and Betty Moore Foundation, this National Academy of Medicine Special Publication represents a multi-stakeholder exploration of the path toward achieving large-scale interoperability through strategic acquisition of health information technology solutions and devices. In this publication, data exchanges over three environments are identified as critical to achieving interoperability: facility-to-facility (macro-tier); intra-facility (meso-tier); and at point-of-care (micro-tier). The publication further identifies the key characteristics of information exchange involved in health and health care, the nature of the requirements for functional interoperability in care processes, the mapping of those requirements into prevailing contracting practices, the specification of the steps necessary to achieve system-wide interoperability, and the proposal of a roadmap for using procurement specifications to engage those steps. The publication concludes with a series of checklists to be used by health care organizations and other stakeholders to accelerate progress in achieving system-wide interoperability.
Engineering A Learning Healthcare System
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Author : National Academy of Engineering
language : en
Publisher: National Academies Press
Release Date : 2011-06-14
Engineering A Learning Healthcare System written by National Academy of Engineering and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2011-06-14 with Medical categories.
Improving our nation's healthcare system is a challenge which, because of its scale and complexity, requires a creative approach and input from many different fields of expertise. Lessons from engineering have the potential to improve both the efficiency and quality of healthcare delivery. The fundamental notion of a high-performing healthcare system-one that increasingly is more effective, more efficient, safer, and higher quality-is rooted in continuous improvement principles that medicine shares with engineering. As part of its Learning Health System series of workshops, the Institute of Medicine's Roundtable on Value and Science-Driven Health Care and the National Academy of Engineering, hosted a workshop on lessons from systems and operations engineering that could be applied to health care. Building on previous work done in this area the workshop convened leading engineering practitioners, health professionals, and scholars to explore how the field might learn from and apply systems engineering principles in the design of a learning healthcare system. Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary focuses on current major healthcare system challenges and what the field of engineering has to offer in the redesign of the system toward a learning healthcare system.
Patient Safety
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Author : Institute of Medicine
language : en
Publisher: National Academies Press
Release Date : 2003-12-20
Patient Safety written by Institute of Medicine and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2003-12-20 with Medical categories.
Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.
Race Ethnicity And Language Data
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Author : Institute of Medicine
language : en
Publisher: National Academies Press
Release Date : 2009-11-30
Race Ethnicity And Language Data written by Institute of Medicine and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2009-11-30 with Medical categories.
The goal of eliminating disparities in health care in the United States remains elusive. Even as quality improves on specific measures, disparities often persist. Addressing these disparities must begin with the fundamental step of bringing the nature of the disparities and the groups at risk for those disparities to light by collecting health care quality information stratified by race, ethnicity and language data. Then attention can be focused on where interventions might be best applied, and on planning and evaluating those efforts to inform the development of policy and the application of resources. A lack of standardization of categories for race, ethnicity, and language data has been suggested as one obstacle to achieving more widespread collection and utilization of these data. Race, Ethnicity, and Language Data identifies current models for collecting and coding race, ethnicity, and language data; reviews challenges involved in obtaining these data, and makes recommendations for a nationally standardized approach for use in health care quality improvement.
Artificial Intelligence In Healthcare
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Author : Adam Bohr
language : en
Publisher: Academic Press
Release Date : 2020-06-21
Artificial Intelligence In Healthcare written by Adam Bohr and has been published by Academic Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2020-06-21 with Computers categories.
Artificial Intelligence (AI) in Healthcare is more than a comprehensive introduction to artificial intelligence as a tool in the generation and analysis of healthcare data. The book is split into two sections where the first section describes the current healthcare challenges and the rise of AI in this arena. The ten following chapters are written by specialists in each area, covering the whole healthcare ecosystem. First, the AI applications in drug design and drug development are presented followed by its applications in the field of cancer diagnostics, treatment and medical imaging. Subsequently, the application of AI in medical devices and surgery are covered as well as remote patient monitoring. Finally, the book dives into the topics of security, privacy, information sharing, health insurances and legal aspects of AI in healthcare. - Highlights different data techniques in healthcare data analysis, including machine learning and data mining - Illustrates different applications and challenges across the design, implementation and management of intelligent systems and healthcare data networks - Includes applications and case studies across all areas of AI in healthcare data
Improving The Quality Of Health Care For Mental And Substance Use Conditions
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Author : Institute of Medicine
language : en
Publisher: National Academies Press
Release Date : 2006-03-29
Improving The Quality Of Health Care For Mental And Substance Use Conditions written by Institute of Medicine and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2006-03-29 with Medical categories.
Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are seriousâ€"for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substanceâ€"use conditions will benefit from this guide to achieving better care.
Better Ehr
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Author : Jiajie Zhang (Professor of biomedical informatics)
language : en
Publisher:
Release Date : 2014-10-01
Better Ehr written by Jiajie Zhang (Professor of biomedical informatics) and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2014-10-01 with categories.
Electronic Health Records (EHR) offer great potential to increase healthcare efficiency, improve patient safety, and reduce health costs. The adoption of EHRs among office-based physicians in the US has increased from 20% ten years ago to over 80% in 2014. Among acute care hospitals in US, the adoption rate today is approaching 100%. Finding relevant patient information in electronic health records' (EHRs) large datasets is difficult, especially when organized only by data type and time. Automated clinical summarization creates condition-specific displays, promising improved clinician efficiency. However, automated summarization requires new kinds of clinical knowledge (e.g., problem-medication relationships).