Chapter 1 Test 1 Flashcards by Renee Glaser

set of governing rules designed to protect citizens living in a civilized society
Establishes order, provides parameters for conduct, and defines rights and obligations of government and its citizens
Controls behavior that threatens public safety and sets penalties for disobedience

Law

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What are the two types of laws?

Public and Private

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Involves federal, state, and local governments
Defines, regulates, and enforces rights and duties among individuals and businesses as related to government.
Example: federal and state laws which define access, use and disclosure of patient healthcare
-example: criminal law and civil law

Public Law

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Involves rules and principles that defines rights and duties among individuals and private businesses
Example: contract between HER vendor and a hospital system

Private Law

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US healthcare is a trillion-dollar business regulated by federal and state laws, accrediting bodies, practice standards, and codes of ethics
Serves to protect consumers and providers by requiring accountability for services and privacy, confidentiality, and security of health information

Law and Healthcare

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Data generated and collected as a result of delivering care to a patient

Health Information

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What are the two uses of health information?

Primary Use and Secondary Use

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clinical care
Example: Patients weight for medication administration
Example: Whatever the doctor needs the information for delivery of care

Primary Use

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public health reporting, population health management, third-party reimbursement(insurance), quality improvement(whether or not the condition was here on admission), and patient safety
Used as evidence in legal cases in which conflict arises and resolutions is sought through the court system
Example: overweight patient population monitoring for quality improvement
• Example: billing/insurance claims
• Example: cancer registries
• Example: legal use of the medical record in court

Secondary Use

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Protected under federal law—HIPAA

Protected Health Information

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It is any information, whether oral or recorded in any form or medium, that: (1) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (2) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual

HIPAA defining health information

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Push to decrease healthcare costs and improve quality and safety of healthcare through use of health information technology (HIT)
Movement from paper to electronic health records (EHRs) and health information exchanges (HIE) that enable the sharing of information with multiple parties and across multiple boundaries

Health Information Technology

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Public and private collaborations are working together to eliminate legal barriers for sharing electronically stored health information

Law and HIT

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roadmap to help states improve health information flow

National Governors Association

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Individually identifiable data, in any medium, that are collected, processed, stored, displayed, and used by healthcare professionals

Health Records

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Hybrid health record
Electronic health record (EHR)
Electronic medical record (EMR)
Personal health record (PHR)

Types of Health Records

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Record that consists of both paper and electronic records and media (for example, film, video, or imaging system) and uses both manual and electronic processes
Data in the record may be handwritten, direct voice entry captured in a word-processing system, or from provider wireless devices such as handheld personal computers

Hybrid Health Record

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization

Electronic Health Record(EHR)

An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization

Electronic Medical Record(EMR)

National Alliance for Health Information Technology(NAHIT) wrote the definitions for what?

EHR, PHR, and EMR

An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual

Personal Health Record

Allow patients to electronically access their personal health record (PHR) and schedule appointments, communicate with their providers via email messaging, and perform other functions as offered by the organization.

Patient Portal

1996
privacy rule in effect 2002
security rule in effect 2003

Health Insurance Portability and Accountability Act (HIPAA)

Widened the scope of privacy and security protections under HIPAA
Promoted national infrastructure through MU for EHR’s and established HIE
Increased potential liability for noncompliance

Health Information Technology for Economic and Clinical Health Act (HITECH) part of the American Reinvestment and Recovery Act of 2009 (ARRA)

is an important social value; it means “a right to be left alone.” " is a right of individuals to be let [sic] alone and to be protected against physical or psychological invasion or the misuse of their property. It includes freedom from intrusion or observation into one's private affairs, the right to maintain control over certain personal information, and the freedom to act without outside interference” “Right to limit the disclosure of personal information”

Privacy

Results from sharing private thoughts with someone else in confidence Definitions “Status accorded to data or information indicating that it is sensitive for some reason, and therefore it needs to be protected against theft, disclosure, or improper use, or both, and must be disseminated only to authorized individuals or organizations with a need to know” “Protection of data or information from being made available or disclosed to an unauthorized person(s) or process(es)” As recognized by law, stems from a relationship where information is shared between two parties such as attorney and client, clergy and parishioner, husband and wife, or physician and patient. The information or communication shared in these relationships is considered “privileged.” obligates healthcare providers (individuals and organizations) to protect patient information

Confidentiality

Pertains to the physical and electronic protection of information that preserves these concepts Prevent unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system 2 types

Security

What are the two types of security?

Data and systems

The result of effective data protection measures; the sum of measures that safeguard data and computer programs from undesired occurrences and exposure to accidental or intentional access or disclosure to unauthorized persons, or a combination thereof; accidental or malicious alteration; unauthorized copying; or loss by theft or destruction by hardware failures, software deficiencies, operating mistakes; physical damage by fire, water, smoke, excessive temperature, electrical failure or sabotage; or a combination thereof. exists when data are protected from accidental or intentional disclosure to unauthorized persons and from unauthorized or accidental alteration

Data security

The totality of safeguards including hardware, software, personnel policies, information practice policies, disaster preparedness, and oversight of these components. Security protects both the system and the information contained within from unauthorized access from without and from misuse from within. Security enables the entity or system to protect the confidential information it stores from unauthorized access, disclosure, or misuse, thereby protecting the privacy of the individuals who are the subjects of the stored information

system security

Protecting information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction in order to provide integrity, confidentiality, and availability

US Code on Information Security

which means guarding against improper information modifications or destruction, and includes ensuring information non-repudiation and authenticity -you have to have authorized access to change things in a patient record

Integrity

which means preserving authorized restrictions on access and disclosure, including means for protecting personal privacy and propriety information - Not sharing passwords/usernames, and just being able to get into the system - Examples: Nurses/Doctors can only see their patients - You can only see what you need to see to do your job

Confidentiality

ensuring timely and reliable access to and use of information - when physician needs info it has to be available

Availability

Who owns the health record?

healthcare provider who generates the record

grants a patient the right to access, view, copy, or amend the record.

HIPAA Privacy Rule

Individual who has been designated as having responsibility for the care, custody, control, and proper safekeeping and disclosure of health records for such persons or institutions that prepare and maintain records of healthcare

Custodian of Health Records

Another name for Custodian of Health Records?

Gatekeeper

Similar to role of custodianship Goes beyond physical record to include: Responsibilities for ensuring integrity (accuracy, completeness, timeliness) and security (protection of privacy as well as from tampering, loss or destruction) within the context of electronic information and records management

Stewardship

Stewardship as a component of _______ which is the “strategic management of enterprise electronic information including the standards, policies, and procedures for access, use, and control of that information”

Information Governance

Role of steward requires leadership, responsibility and governance to ensure consistent application of, and compliance with policies across organization-wide distributed information systems.

Stewardship and Governance

1) Volume and Duplicability 2) Persistence 3) Dynamic Changeable Content 4) Metadata 5) Environment Dependence and Obsolescence 6) Dispersion and Search-ability

Six Key Areas Where Electronic Records Differ from Paper Records