Terminology in Health Care and Public Health Settings
Terminology in Health Care and Public Health Settings Unit 16 Definitions and Concepts in the EHR
Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 2
Electronic Medical Records • Electronic records that reside with an individual provider • Ambulatory: Physicians, Dentists, Pharmacist, Opticians, Public Health Clinics ect. • Acute Care: Hospitals, Emergency Care Centers, Surgical Centers Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 3
Personal Health Records “The Personal Health Record (PHR) is an Internet-based set of tools that allows people to access and coordinate their lifelong health information and make appropriate parts of it available to those who need it. ” Markle Foundation. Connecting Americans to their health care: A common framework for networked personal health information. 2006. Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 4
Functions of Personal Health Records • Information Sharing • Information Exchange • Information Selfmanagement Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 5
Personal Health Record Models • Payor tethered • Provider tethered • Third-Party tethered Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 6
Electronic Health Record • Record that consolidates multiple electronic medical and potentially personal health records • Across multiple providers • Across the life-span Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 7
Components of an Electronic Medical Record • • Clinical Systems Pharmacy Systems Laboratory Systems Admission/Discharge/Transfer Systems (ADT) • Billing Systems Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 8
Clinical Systems • Clinical Documentation • Clinical Decision Support (CDS) • Computerized Provider Order Entry (CPOE) • Bar-Code Medication Administration (BCMA) Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 9
Data Security and Confidentiality Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 10
Confidentiality The right of individuals to protect their information or records and refers to the situation of establishing a relationship and sharing private information Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 11
Security Protection of information from accidental or intentional access by unauthorized people, unauthorized modification, unauthorized accidental or intentional destruction Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 12
Legal Protections • Health Insurance Portability and Accountability Act (HIPAA) – HIPAA Privacy Rule – HIPAA Security Rule • Patient Safety Rule • Enforced by Office for Civil Rights Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 13
Maintaining Security • Back-ups • Mirror systems • Off-site data storage Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 14
Maintaining Confidentiality • Authentication Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 15
Maintaining Confidentiality • Authentication • Audit Trails Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 16
Maintaining Confidentiality • Authentication • Audit Trails • Firewalls Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 17
Maintaining Confidentiality • • Authentication Audit Trails Firewalls Encryption Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 18
Maintaining Confidentiality • • • Authentication Audit Trails Firewalls Encryption Confidentiality Statements Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 19
Hardware and Software Requirements for Electronic Records Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 20
Software • • • Legacy Off-the-shelf Vanilla systems Home grown Best of breed Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 21
Types of Networks • A network is a system of multiple computers that share information virtually and store and retrieve information from data repositories on computers called servers Component 3/ Unit 16 a • Smart terminals • Dumb Terminals • Wireless Health IT Workforce Curriculum 1. 0/Fall 2010 Version 22
Data Entry Devices Locations • Central Processing Units (CPU) • Tablets • Slim Clients • Personal Digital Assistants (PDA) • Nurses Station • Computers on Wheels • Point-of-care Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 23
Summary • Electronic record systems require a system network, application software, and data entry hardware • Confidentiality and security of patient data are maintained through a combination of legal, hardware, and software precautions Component 3/ Unit 16 a Health IT Workforce Curriculum 1. 0/Fall 2010 Version 24
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