Chapter 2 EHRs, HIPPA, & HITECH Flashcards
File containing the documentation of a patient’s medical history and related information
medical record
Failure to use professional skill when giving medical services that results in injury or harm
malpractice
Recording of a patient’s health status in a medical record
documentation
State-specific performance measures for the delivery of healthcare
medical standards of care
Computerized lifelong healthcare records for an individual that incorporate date from all sources that treat an individual
Electronic health records (EHRs)
Computerized records of one physician’s encounters with a patient over time that are the physician’s legal record of patient care.
Electronic medical records (EMRs)
Private, secure electronic files that are created, maintained, and controlled by patients
Personal health records (PHRs)
Advantages of EHRs
- Immediate access to health information
- Computerized physician order entry management
- Clinical decision support
- Automated alerts and reminders
- Electronic communication and connectivity
- Patient support
- Administration and reporting
- Error reduction.
Visit between a patient and a medical professional
encounter
Provider’s evaluation of a patient’s condition and decision on a course of treatment to manage it
evaluation and management (E/M)
H & P documentation includes 4 types of info:
- The chief complaint
- the H&P examination
- the diagnosis
- the treatment plan
Process by which a patient authorizes medical treatment after a discussion with a physician
informed consent
3 other types of chart notes
- Progress Notes
- Discharge summary
- Procedural services documentation
Circle that explains how using EHRs is integrated with practice management programs
medical documentation and revenue cycle
CC
Chief complaint
Federal agency that runs Medicare, Medicaid, clinical laboratories, and other government health programs
Centers for Medicare and Medicaid Services (CMS)
What department is CMS a part of?
The Department of Health and Human Services (HHS)
Federal Act with guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse, and protecting PHI
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Law promoting the adoption and meaningful use of health information technology
Health Information Technology for Economic and Clinical Health Act (HITECH)
Utilization of certified EHR technology to improve quality, efficiency, and patient safety
meaningful use
Enables the sharing of health-related information among provider organizations
health information exchange (HIE)
Health system reform legislation that offers improved insurance coverage and other benefits
Affordable Care Act (ACA)
Network of doctors and hospitals that shares responsibility for managing the quality and cost of care provided to a group of patients
accountable care organization (ACO)
Computer-to-computer exchange of data in a standardized format
electronic data interchange (EDI)
Electronic exchange of healthcare information
transaction
3 parts of the Administrative Simplification provisions
- HIPAA Privacy Rule
- HIPAA Security Rule
- HIPAA Electronic Transaction and Code Sets Standards
Health plan, clearinghouse, or provider who transmits any health information in electronic form
covered entity (CE)
Company that converts nonstandard transactions into standard transactions and transmits the data to health plans, and the reverse process
clearinghouse
Person or organization that performs a function or activity for a covered entity
business associate (BA)
Law regulating the use and disclosure of patients’ protected health information
HIPAA Privacy Rule
Individually identifiable health information transmitted or maintained by electronic media
protected health information (PHI)
Legitimate reason for the sharing of patients’ protected health information without authorization
treatment, payment, and healthcare operation (TPO)
Principle that individually identifiable health information should be disclosed only to the extent needed
minimum necessary standard
Covered entity’s records that contain protected health information; for providers, the medical/financial patient record
designated record set (DRS)
Description of a covered entity’s principles and procedures related to the protection of patient’s health information
Notice of Privacy Practices (NPP)
Documentation of the disclosure of a patient’s PHI in that person’s medical record in unauthorized cases
accounting of disclosure
- Document signed by a patient to permit release of medical information; 2. health plan’s system of approving payment of benefits for appropriate services
authorization
Medical data from which individual identifiers have been removed
de-identified health information
Law requiring covered entities to establish safeguards to protect health information
HIPAA Security Rule
Method of converting a message into encoded text
encryption
Confidential authentication information
password
Impermissible use or disclosure of PHI that could pose significant risk to the affected person
breach
Document notifying an individual of a breach
breach notification
Rule governing the electronic exchange of health information
HIPAA Electronic Health Care Transactions and Code Sets (TCS)
Rules that improve interoperability between the data systems of different entities
operating rules
Alphabetic and/or numeric representations for data
code set
Identification systems for employers, healthcare providers, health plans, and patients
HIPAA National Identifiers
Unique ten-digit identifier assigned to each provider
National Provider Indentifier (NPI)
Set of regulations enhancing patients’ privacy protections and rights to information and the government’s ability to enforce HIPAA
Omnibus Rule
Government agency that enforces the HIPAA Privacy Act
Office for Civil Rights (OCR)
Part of CMS that helps to develop and coordinate the implementation of a comprehensive e-health strategy
Office of E-health Standards and Services (OESS)
Formal examination of a physician’s or a payer’s records
audit
Government program to uncover and prosecute fraud and abuse in federal healthcare programs
Health Care Fraud and Abuse Control Program
Government agency that investigates and prosecutes fraud
Office of the Inspector General (OIG)
Person who makes an accusation of fraud or abuse
relator
Intentional deceptive act to obtain benefit by taking advantage of another person
fraud
Action that improperly uses another’s resources
abuse
A medical practices written plan for complying with regulations
compliance plan
