Chapter 1 - Introduction to the Fundamentals Flashcards
HIPAA
acronym for: Health Insurance Portability and Accountability Act of 1996; it’s a federal law that deals with health information and health insurance
health information technology
the electronic systems health care professionals – and increasingly, patients – use to store, share, and analyze health information
health information exchange
the movement of health care information electronically across organizations within a region, community or hospital system
ONC
acronym for: Office of the National Coordinator for Health Information Technology; it is a division within the U.S. Department of Health and Human Services that manages health information technology
health information management professionals
individuals responsible for protecting the privacy and security of health information within a healthcare organization; they also must keep up to date on the current law and make sure they are in compliance with it
health informatics professionals
individuals responsible for protecting the privacy and security of health information within a healthcare organization; they also must keep up to date on the current law and make sure they are in compliance with it
public law
the part of the law that governs the relationship between the government and individuals
private law
the part of the law that governs the relationship between individuals or entities that can act as individuals, such as corporations and organizations
health information
data generated and collected as a result of delivering care to a patient; it can be in any medium (e.g. handwritten, electronic, audio recording, video recording, etc.)
PHI
acronym for: protected health information; it refers to any and all types of health information
health record
health information that contains data that can identify the patient
hybrid health record
a health record that consists of both paper and electronic records and media (e.g. film, video, or images); it is typically created both by using a computer and by doing things manually without a computer
electronic medical record
an electronic record of an individual’s health information that is used by authorized staff within a single healthcare organization; it is maintained by healthcare staff
electronic health record
an electronic record of an individual’s health information that can be shared by multiple healthcare organizations; it is maintained by healthcare staff
personal health record
an electronic record of an individual’s health information that can be shared by multiple healthcare organizations; it is maintained by the individual in question
HITECH
acronym for: Health Information Technology for Economic and Clinical Health Act; it was part of the American Recovery and Reinvestment Act of 2009; it is a law that promotes health information management while also increasing the scope of the privacy and security protections offered by HIPAA
American Recovery and Reinvestment Act of 2009
a stimulus package that President Barack Obama signed into law in 2009 to deal with the Great Recession
privacy
the right of individuals to be left alone and not be bothered or spied on by others; in a health information context it also refers to the right to maintain control over certain personal information
confidentiality
the ethical principle or legal right that a health professional will hold secret all information relating to a patient, unless the patient gives consent permitting disclosure or the government makes a legal demand for information
security
in a healthcare context, it refers to the physical and electronic protection of health information from unauthorized access
data security
the data protection measures that protect data from intentional or accidental destruction, unauthorized alteration, and unauthorized access
system security
the safeguards that protect the systems that house and create health information; these systems include hardware, software, people, and buildings
information security
the practice of protecting information systems from improper modification or destruction, ensuring the confidentiality of information, and making sure the data in the system is available for use
physical health record ownership
a term that refers to the traditional ownership of the health record by the healthcare provider that generated it; however, state and federal laws uphold the right of the patient to control information within the record
custodian
in a healthcare context, the person who has responsibility for the development and maintenance of health records
steward
in the context of healthcare, a custodian who is also responsible for ensuring the accuracy, completeness, and security of a health record
information governance
the framework for managing information in an organization
enterprise information management
the study of how to best use the information within an organization
patient portal
a secure online website or app that gives patients convenient, 24-hour access to personal health information
legal health record
in the context of healthcare, it refers to any and all health records
business record
in the context of healthcare, it refers to any and all health records
ASTM
acronym for: American Society for Testing and Materials; now more commonly called ASTM International; they are an organization that develops technical standards for a variety of materials, products, systems, and services; they have developed a definition of privacy for the health information field
The Joint Commission
an independent, non-profit organization that evaluates and accredits over 21,000 healthcare organizations and programs in the United States
privileged communication
information or communication shared by two people in a relationship that involves confidentiality
metadata
a set of data that describes and gives information about other data; in the context of healthcare, it can refer to data about when the health record was created, when it was edited, who created or edited it, and its edit history
