Chapter 1 Test 1

Question 1

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

Answer 1

Law

Question 2

What are the two types of laws?

Answer 2

Public and Private

Question 3

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

Answer 3

Public Law

Question 4

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

Answer 4

Private Law

Question 5

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

Answer 5

Law and Healthcare

Question 6

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

Answer 6

Health Information

Question 7

What are the two uses of health information?

Answer 7

Primary Use and Secondary Use

Question 8

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

Answer 8

Primary Use

Question 9

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

Answer 9

Secondary Use

Question 10

Protected under federal law—HIPAA

Answer 10

Protected Health Information

Question 11

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

Answer 11

HIPAA defining health information

Question 12

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

Answer 12

Health Information Technology

Question 13

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

Answer 13

Law and HIT

Question 14

roadmap to help states improve health information flow

Answer 14

National Governors Association

Question 15

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

Answer 15

Health Records

Question 16

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

Answer 16

Types of Health Records

Question 17

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

Answer 17

Hybrid Health Record

Question 18

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

Answer 18

Electronic Health Record(EHR)

Question 19

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

Answer 19

Electronic Medical Record(EMR)

Question 20

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

Answer 20

EHR, PHR, and EMR

Question 21

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

Answer 21

Personal Health Record

Question 22

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.

Answer 22

Patient Portal

Question 23

• 1996
• privacy rule in effect 2002
• security rule in effect 2003

Answer 23

Health Insurance Portability and Accountability Act (HIPAA)

Question 24

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

Answer 24

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

Question 25

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”

Answer 25

Privacy

Question 26

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

Answer 26

Confidentiality

Question 27

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

Answer 27

Security

Question 28

What are the two types of security?

Answer 28

Data and systems

Question 29

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

Answer 29

Data security

Question 30

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

Answer 30

system security

Question 31

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

Answer 31

US Code on Information Security

Question 32

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

Answer 32

Integrity

Question 33

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

Answer 33

Confidentiality

Question 34

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

Answer 34

Availability

Question 35

Who owns the health record?

Answer 35

healthcare provider who generates the record

Question 36

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

Answer 36

HIPAA Privacy Rule

Question 37

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

Answer 37

Custodian of Health Records

Question 38

Another name for Custodian of Health Records?

Answer 38

Gatekeeper

Question 39

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

Answer 39

Stewardship

Question 40

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”

Answer 40

Information Governance

Question 41

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

Answer 41

Stewardship and Governance

Question 42

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

Answer 42

Six Key Areas Where Electronic Records Differ from Paper Records