Chapter 1 Flashcards
Discuss why protecting the privacy and confidentiality of health information is a challenge.
Health information is more easily accessible than ever before
Describe primary and secondary uses of health information
Primary-clinical care, secondary-public health reporting, public safety, population health studies, third party reimbursement, and patient safety
Discuss the difference b/n a paper health record, a hybrid record, and an electric record
Paper- all files are printed, hybrid is a mix of electronic and paper, and electronic is all on computer or system
Define privacy
The right to be left alone
Define confidentiality
Protecting private thoughts shared with one another
Define security
Physical protection of information that preserves confidentiality
Explain the theoretical concepts behind privacy, confidentiality, and security
Private information is the most sensitive and can affect the patient if leaked
Discuss ownership and control of the health record.
Traditionally owned by physician, however the individual has rights to view or prohibit
Discuss the role and responsibilities of the custodian of health records
They are responsible for care, control, safekeeping, disclosure, evidence for legal cases, may be called to testify, inspection, and duplication of records.
Who may serve as the custodian of health records?
The director of the him dept traditionally, or another individual who can verify
Describe the role of professional codes of ethics in protecting health information
They provide a framework and set of standards for protecting health information.
AHIMA
American health information management association-provides accreditation, advocacy, certification, and education to health information technologists and managers including coding services
AMA
American medical association-association of physicians that distributes scientific information, represents in legal proceedings, and advises legal issues
AMIA
American medical informatics association-association of health informatics and health information management personnel, biomedical informatics professionals, and educators.
ARRA
American recovery and reinvestment act of 2009-federal legislation that funded HIT and changes to HIPAA privacy rule
ASTM
American society for testing and materials-organization dedicated to creating standards for materials, products, systems and services
Autonomy
Individual’s right to self determination, in charge of what happens to him, or information
Business record
A record kept for normal business
Code of ethics/code of ethical practice
Reflects the values and principles defined by a professional setting as acceptable behavior
Designated record set
A defined group of information that may consist of medical and billing records, information about payments, case management systems, and other information used to make health care decisions.
Electronic health record
An electronic record that can be utilized by more than one organization.
Electronic medical record
Electronic record used by only one healthcare organization.
Ethics
Standards of behavior regarding right and wrong.
Ethical principles
Set of four principles for healthcare professionals - autonomy, beneficence, nonmaleficence, and justice.
Health information
Data generated and collected as a result of caring for a patient
Health information exchange
Electronic movement of health information, or an entity that forms to create links between physicians to pharmacies, hospitals, and other health entities
Health information technology
The technical aspects of processing health data and records, including coding,abstracting, registry devmt, and storage
HITECH
Health information technology for economic and clinical health act
HIPAA
Health insurance portability and accountability act of 1996
Health record
Individually identifiable data that documents the care of an individual.
Information governance
Management of electronic information including standards for access, use, and control of the information.
The joint commission
Agency that develops standards for healthcare organizations and certifies them based on their adherence to those standards
Law
A set of governing rules used to protect the public.
Legal health record
LHR- the record that is the legal business record that serves as evidence in legal actions
Moral values
Principles formed through family, culture, religion, and society
NAHIT
National alliance for health information technology-2002-2009, formed to improve safety, quality of care, and operating performance through the use of technology
Nonmaleficence
Legal principle of first do no harm
ONC
Office of the national coordinator for health info technology-2004, created by fed govt to create health information technology to improve the quality and efficiency of healthcare
Personal health record
Electronic or paper record managed by the individual patient
Privileged communication
Communication between two parties such as a doctor and patient, or husband and wife that is considered privileged by law.
Steward
Person responsible for integrity and security
Stewardship
Responsibility for integrity (accuracy, completeness, timeliness) and security
System security
Protection of the hardware, software, access, prevention of misuse, protection of privacy
Ownership of a health record generated by a doctor belongs to whom?
Generally considered dr property, but patient has rights to it
What is the role of the custodian of records?
He or she is responsible for the care, custody, control, proper safekeeping, legal proceedings, and verify the record is what it purports to be
Autonomy
Recognizing the pt right to make their own choices
Beneficence
Doing good, promoting health and welfare, kindness, compassion, helping others
Nonmaleficence
Doing no harm
Justice
Obligation to be fair in the distribution of benefits and risks
