Chapter 1 - Introduction to the Fundamentals

Question 1

HIPAA

Answer 1

acronym for: Health Insurance Portability and Accountability Act of 1996; it’s a federal law that deals with health information and health insurance

Question 2

health information technology

Answer 2

the electronic systems health care professionals – and increasingly, patients – use to store, share, and analyze health information

Question 3

health information exchange

Answer 3

the movement of health care information electronically across organizations within a region, community or hospital system

Question 4

ONC

Answer 4

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

Question 5

health information management professionals

Answer 5

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

Question 6

health informatics professionals

Answer 6

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

Question 7

public law

Answer 7

the part of the law that governs the relationship between the government and individuals

Question 8

private law

Answer 8

the part of the law that governs the relationship between individuals or entities that can act as individuals, such as corporations and organizations

Question 9

health information

Answer 9

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.)

Question 10

PHI

Answer 10

acronym for: protected health information; it refers to any and all types of health information

Question 11

health record

Answer 11

health information that contains data that can identify the patient

Question 12

hybrid health record

Answer 12

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

Question 13

electronic medical record

Answer 13

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

Question 14

electronic health record

Answer 14

an electronic record of an individual’s health information that can be shared by multiple healthcare organizations; it is maintained by healthcare staff

Question 15

personal health record

Answer 15

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

Question 16

HITECH

Answer 16

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

Question 17

American Recovery and Reinvestment Act of 2009

Answer 17

a stimulus package that President Barack Obama signed into law in 2009 to deal with the Great Recession

Question 18

privacy

Answer 18

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

Question 19

confidentiality

Answer 19

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

Question 20

security

Answer 20

in a healthcare context, it refers to the physical and electronic protection of health information from unauthorized access

Question 21

data security

Answer 21

the data protection measures that protect data from intentional or accidental destruction, unauthorized alteration, and unauthorized access

Question 22

system security

Answer 22

the safeguards that protect the systems that house and create health information; these systems include hardware, software, people, and buildings

Question 23

information security

Answer 23

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

Question 24

physical health record ownership

Answer 24

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

Question 25

custodian

Answer 25

in a healthcare context, the person who has responsibility for the development and maintenance of health records

Question 26

steward

Answer 26

in the context of healthcare, a custodian who is also responsible for ensuring the accuracy, completeness, and security of a health record

Question 27

information governance

Answer 27

the framework for managing information in an organization

Question 28

enterprise information management

Answer 28

the study of how to best use the information within an organization

Question 29

patient portal

Answer 29

a secure online website or app that gives patients convenient, 24-hour access to personal health information

Question 30

legal health record

Answer 30

in the context of healthcare, it refers to any and all health records

Question 31

business record

Answer 31

in the context of healthcare, it refers to any and all health records

Question 32

ASTM

Answer 32

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

Question 33

The Joint Commission

Answer 33

an independent, non-profit organization that evaluates and accredits over 21,000 healthcare organizations and programs in the United States

Question 34

privileged communication

Answer 34

information or communication shared by two people in a relationship that involves confidentiality

Question 35

metadata

Answer 35

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