EHR ch 2

HIPAA's seven core regulations /main rules:

* password management *unique user identification *access authorization *accounting of PHI disclosures *auditing abilities *code sets *data backup, storage, and security

Four notable functions, determined by the Institute of medicine.

*Health information and patient data * Results management * Order entry/management * Medical decision support

Modes of data entry into the EHR include

*Keyboard *touchscreen *voice recognition dictation *electronic handwriting recognition *templates *pick-lists

Benefits of the computerized provider order entry (CPOE) function in the EHR (3)

*more expedient order completion *reduction in hand writing related errors *opportunity to check for duplicate or incorrect tests

Three main components of meaningful use as specified by ARRA

1. The use of a certified EHR in a specified significant manner, such as e-prescribing. 2. The use of certified EHR technology for electronic exchange of health information to improve healthcare quality, such as transmitting lab results. 3. The use of certified EHR technology to submit clinical quality reports and other measures.

Drug formulary

A database of approved medications in drug therapy categories . Includes information on preparation, safety, effectiveness, and cost of the medications.

Server

A main computer designed to provide services to clients, workstations, or desktop computers over a local area network or the Internet.

Intranet

A privately maintained computer networks that provide secure accessibility to authorized people and enables sharing of software, databases, and files.

Test script

A test script in software testing is a set of instructions that is performed on the system to ensure the system functions as expected.

Template

An electronic file with the predesigned or set format and structure. It serves as a model for letters, faxes, and reports that need to be filled in to be completed.

ASP

Application server provider EHR is accessed via the Internet. The EHR software and databases HouseThe and maintained by a separate company in a remote location.

ATCB

Authorized testing and certification bodies.6 ATCBs sanctioned by the ONC to certify EHR programs against a set of ONC - established standards and features.

CCHIT

Certification commission for Health information technology

Encrypting

Changing data from its original form to unintelligible to unauthorized parties

CAAHEP

Commission on accreditation of Allied health education programs A nonprofit Allied health education organization that accredits entries - level, Allied health education programs.

Business associates

Companies such as accounting firms and billing agencies that work with and provide services to HIPAA-covered entities, including medical facilities, pharmacies, and healthcare providers.

CMC

Competency model clearinghouse Nonprofit, sponsored by the US Department of Labor employment and training administration. Provides official industry competency models. Has developed a list of critical work functions it believes are necessary to perform health informatics tasks using a certified EHR program.

COW/WOW

Computer on wheels/Workstation on wheels A computer is placed on a mobile desk or stand so that it can be moved around an office, unit, or patient room.

CPOE

Computerized provider order entry The means by which a physician/clinician electronically transmits instructions for a patient's treatment or the ordering of tests to a testing facility. One of the core objectives for stage one in meaningful use.

CHI

Consolidated health informatics Goal was to make federal agencies involved in healthcare, interoperable . 20 standards became the benchmark for how information would be coded or turns in each our programs. Primary focus: interoperability standards affecting health terminology and messaging.

CPT

Current procedural terminology Five digit code . Means for identifying common medical procedures.

Demographic fields must be recorded during the meaningful use.

Date of birth, gender/sex, ethnicity, preferred language, race

Meaningful use definition

Demonstrably effective use of an EHR program. Determined via tangible, ONC - established functionalities.

What did EPs or hospitals have to do to qualify for meaningful use into thousand 11 and 2012?

Demonstrate the use of a core set of 15 features in an EHR program, and the selection of five additional objectives from a menu set of 10 objectives, specified by the ONC.

Providers qualify for the Medicare and Medicaid incentives program by

Demonstrating meaningful use within ONC - ATCBs - certified EHR.

Code sets regulation

EHR must use national standard code sets, such as the ICD, CPT, end HCPCS one storing and transmitting information .

Password management regulation

EHR's must be able to change, create, and safeguard passwords . Eight or more characters. Expiration. Of 90-120 days is recommended for default passwords. Login attempts are monitored for auditing.

Access authorization regulation

Electronic PHI is protected by access levels to identifiable health information strata. Users must be assigned appropriate security access level , based on the minimal data necessary to perform their jobs. Covered entities such as medical practices may disclose PHI for payment purposes.

EP

Eligible professional

Unique user identification regulation

Every user is given a unique name/number for identification and tracking purposes and EHR's. Modifications made in the patient's record is logged with the unique identifier of the person who made the modifications. Log in/out history.

The high-tech act introduced the first federally mandated "data breach notification requirement" that did what?

Expanded the reach of HIPAA data privacy and security requirements to include business associates.

HIT

Health Information technology

HITECH

Health Information technology for Economic and Clinical Health

Accounting of PHI disclosures regulations

Health information disclosures from the patient's medical record is locked and kept for six years. Must be provided to the patient upon request. Patients must be allowed access to their medical record.

HIPAA

Health insurance portability and affordability act

HCPCS

Healthcare common procedure coding system Used by the CMS to identify medical supplies such as durable medical equipment and medical procedures.

The HITECH act provided measures to

Implement, use, and prove meaningful use of EHR's.

What does the high-tech act do with regards to PMS and EHR programs. ?

Increases compliance obligations and privacy regulations, and strengthens enforcement penalties related to the patient's health records and PMS and HR programs.

Structured data

Information that is organized in a coded manner so that it is identifiable, storable, retrievable, and analyzable in a computer system.

IOM

Institute of medicine Works outside the government to provide unbiased and authoritative medical advice to decision-makers and the public. Identified eight key capabilities, or functions, of EHR.

ICD

International classification of diseases

Two types of technologies that have increased the availability of medical databases and EHR access

Internet and intranet

LAN

Local area network A wired and/for wireless connection of computers on a single campus or facility. Enables multiple computers to communicate with one another , typically using a main server for the database, and can be customized to healthcare facilities needs.

MAERB

Medical assisting education review board Responsible for medical assisting educational program reviews, accreditation recommendations, and the development and revision of the core curricula for medical assistance as part of the CAAHEP.

NCVHS

National committee on vital and health statistics Advocate for uniform health data sets, especially for underrepresented populations. Makes recommendations on health information policy and standards to the Department of Health and Human Services.

ONC

Office if national coordinator for Health information technology

Tablet

Portable, handheld computer that allows users to document directly on the screen with a stylus pen or by touch.

Auditing abilities regulation

Prevention of inappropriate or on authorized intentional and unintentional disclosures and modifications to ePHI by tracking user access.

By 2004, CHI had set 20 standards to regulate information exchange between federal healthcare agencies. What did the standards regulate?

Promoted the adoption of interoperability standards for health vocabulary and messaging.

PHI

Protected health information Includes any information about health status, provision of healthcare, and payment of healthcare that can be linked to a specific individual. PHI is regulated under HIPAA.

With what was the IOM tasked by the HHS in the early development of the EHR industry?

Provide guidance on key EHR system capabilities. The four notable functions include: * Health information and patient data *results management *order entry/management *medical decision support

Data backup, storage, and security regulations

Retrievable, Xact copy of PHI should be electronically accessible from the back up of the medical database. Security measures must be taken such as controlled access, administrative passwords , server firewalls, and so on to reduce the risk and vulnerability of ePHI. Backup must be at an off-site location.

Two forms of data entry that has emerged as the most common

Templates and pick lists

Wireless connectivity

The ability to make and maintain a connection between two or more points in the telecommunication system without using hard wires or cables.

The government regulation known as HIPAA initially regulated PMS programs. What important role did HIPAA exserted in the early development of EHR's?

They required participants in the healthcare industry to use standardized transactions and code sets, and by extending the reach of HIPAA to protect medical information beyond the initial covered entity.

What was the purpose of the EHR certification program that the high-tech act authorized the ONC to establish?

To ensure a standard of features and functions and EHR programs , to provide financial incentives, assistance, online tools, and resources for providers to implement, use, and prove meaningful use of EHR.

What did the HITECH act authorized the ONC to do ?

To promote EHR adoption by means of financial incentive programs based on healthcare practitioners ability to use EHR technology in a meaningful manner.

USA PATRIOT Act abbreviation meaning

Uniting and strengthening America by providing appropriate tools required to intercept and obstruct terrorism.