Electronic Health Records
What type of documentation organization do we teach here in the program?
SOAP
Name the main federal government agency that is responsible for healthcare
CMS (Centers for Medicare and Medicaid Services)
Make is possible for providers and health plans to exchange data using a standard format and standard code sets
Define covered entity
Define clearing house
healthplan, clearinghouse, or provider who transmits any PHI in electronic format.
company that converts nonstandard transactions into standard transactions and transmits the data to health plans and the reverse process.
What does it mean if something has been de-identified?
neither identifies nor provides a reasonable basis to identify and individual
Documentation is defined as?
means of organizing a patient's health record in chronological order, using a systemic, logical, and consistent method
What does HIPAA stand for?
Health Insurance Portability and Accountability Act of 1996
Who required the interoperability between the different data systems know as the operating rules?
ACA
Regulates use and disclosure of patient's protected health information
What is the purpose of the HIPAA Security Rule?
Requires entities to establish safeguards to protect PHI.
Define medical professional liability
the responsibility of licensed healthcare professionals
How many provisions/titles does HIPAA have?
5
HIPPA National Identifiers are for whom?
What is an NPI?
Employers
Healthcare Providers
Health Plans
Patients
National Provider Identifier (predetermined length)
Define TPO and whether or not authorization is needed
Treatment, payment, and healthcare operations
Define backing up
the activity of copying files to another medium so that they will be preserved in case the originals are no longer available
Define minimum necessary standard and what it means
taking reasonable safeguards to protect PHI from incidental disclosure
Define EDI,
and transaction is equivalent to what?
Electronic data interchange (computer to computer exchange of information)
a business document
Define OIG and what its purpose is?
Office of the Inspector General, directed by HIPAA law to combat fraud and abuse
HealthCare Fraud and Abuse Program
Define business associate and give an example
people or organizations that work for CEs but are not themselves a CE
law firms
medical biller/coder
accountants
collection agency
What is a breach and what must be sent when this occurs?
Breach-impermissable use or disclosure under the Privacy Rule that compromises the security or privacy of PHI.
A breach notification document must be sent out notifying the individual of the breach.
List 3 advantages of EHRs
Define NPP and when does it need to be given?
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
Notice of Privacy Practices, on first encounter
What is the purpose of HITECH
To create additional provisions concerning the standards for electronic transmission of healthcare data
Created meaningful use
Fraud is the intentional deception of taking advantage of a person. Billing for procedures that were not performed.
Abuse is misusing money that the government has allocated such as Medicare funds. Billing for an unnecessary ambulance ride.
Define PHI and give 3 examples
Protected health information
Name
Address
Birth date
Telephone number
Fax number
Social security number
Name 3 tips for creating a safe password
Use combination of letters/numbers/and symbols
Do not use your user ID
Select a mixture of upper/lowercase letters