What does this stand for?
ERH
Electronic Health Record.
MIPPA
Medicare improvements for patients and providers act of 2008
Demographic information
First and Last Name
Middle initial
DOB
Health Record number or Medical Record Number
Partial Social Security Number
Define Security, Confidentiality and Privacy
Security - the protective measures and tools for safeguarding information in the information systems
Confidentiality - The expectation that information shared with a healthcare provider will be used only for its intended purpose
Privacy - The right of the individual to limit access of information about themselves
Professional email should include
Subject, verbs, and punctuation. Correctly spelled words.
HIE
Health Information Exchange
In the year ____ IOM called for the elimination of paper by year _____
1991, 2001
EMAR
Electronic Medication Administration Record
Covered entity of HIPAA
Transmits any health information in electronic for for one of the covered transactions
Includes - health plan, healthcare provider (transmits health information), Healthcare clearinghouse
SOAP format
Subjective
Objective
Assessment
Plan
ARRA
American Recovery and Reinvestment Act
Barriers
Prohibitive cost of many EHR systems and limited access to capital and infrastructure
Limited access to EHR vendor information and technical assistance
Suitability of ERH products for practice and rural health care settings
Difficulty connecting to or obtaining broadband service
Telehealth issues
Privacy, confidentiality, and security must be ensured during the telemedicine event
Liability is usually shared between referring provider and consulting provider, but for telemedicine vendors and technical staff there is no legal precedent yet
Licensure and accreditation rules differ by states for both licensure and accreditation; there is no federal legislation for telemedicine at this time
HIPPA -Penalties
Individuals can now be prosecuted
Penalties now apply to BAs
Tiered penalties - unknowing violations, due to reasonable cause, willful neglect (corrected and uncorrected)
Appropriate etiquette
Clinician to patient: Eye contact, Listening skills, Non verbal communication.
Clinician to Clinician: No badmouthing, legal record
HITECH Act
Health Information Technology for Economic and Clinical Health Act
Benefits
Easier to access clinical information
Provides current information
Tools such as reminders and health alerts
Enhance the documentation captured
Allows healthcare providers to spend more time with patients
Test results can also be available immediately upon completion
Supports various data analytics functions
Economic and administrative benefits
Importance of CPOE
Preventing lost orders
Eliminating ambiguities caused by illegible handwriting
Reducing medication errors of dose and frequency, drug-allergy, and drug-drug interactions
Monitoring for duplicate orders
Reducing the time to fill orders
Security threats
Internal: Hardware, Environment, Employees (honest mistakes/human error, exploit access, use access for malice or gain)
External: People who access data or steal hardware, Natural Disasters
Effective communication includes
Clarified ideas, Decide on the purpose of the message, Choose Concreate words and appropriate symbols
HIPPA
Health Insurance Portability and Accountability Act
Unanticipated Issues
Increased work for clinicians
Unfavorable work flow changes
Ongoing demands for system changes
Conflicts between electronic and paper-based systems
Unfavorable changed in communication
Negative user emotions
Generation of new kinds of errors
Overdependence on technology
Lack of customization
ERH Data forms
Digital images - xrays, ct scans, pathology, annotated drawings
Text files - word processing files transcribed exam notes
Discrete Data - Fielded data, Coded data
PHI Identifiers
Name, Address, phone numbers, fax numbers, SS number, Medical record number, Health plan beneficiary numbers, Account Numbers, Certificate/license numbers, Vehicle identifiers, Device identifiers, URLS, IP address numbers, Biometrics, Full-Face photos.
Pros and Cons of Email communication
Pros - Fast, Easy to use, Avoid phone tag, Rapid communication, Allows for reminders, Saves Money, Reduces staff time
Cons - No control of forwarding of emails, Legal issues, Misaddressed emails - HIPAA issue, Risk of miscommunication, Too lengthy messages