Why is it important to understand who the consumers are before making patient information or patient portals available for them to access information? 2. ?What is the difference betwe
(1/2 page. APA format)
1. Why is it important to understand who the consumers are before making patient information or patient portals available for them to access information?
2. What is the difference between a digital immigrant and a digital native and what does this have to do with consumer health informatics?
Introduction to Healthcare Informatics, Second Edition
Chapter 14:
The Legal Electronic Health Record
© 2017 American Health Information Management Association
© 2017 American Health Information Management Association
Objectives
Explain the legal health record for disclosure
Compare and contrast a paper-based legal health record, a hybrid legal health record, and an electronic legal electronic health record
Determine the stakeholders and their roles for electronic legal health record definition projects
Relate the steps involved in defining the legal health record
© 2017 American Health Information Management Association
Objectives (continued)
Articulate the importance of developing a legal health record policy
Interpret the attributes that can impact the legal health record definition and e-discovery
Analyze patient record documentation regulations for correct utilization within legal health record policies and procedures
© 2017 American Health Information Management Association
Legal Health Records (LHRs)
Describes the data, documents, reports, and information that comprise the formal business record(s) of any healthcare organization that are to be utilized during legal proceedings
No standard terminology
Recommend using legal health record defined for disclosure
Dynamic process
© 2017 American Health Information Management Association
LHR Governance
Laws—passed by legislatures
Rules and Regulations—interpretations of laws
Judicial Decisions—courts interpreting the laws
Precedence—Previous decisions
© 2017 American Health Information Management Association
Legal Processes
e-discovery—processes related to electronically maintained information
Federal Rules of Civil Procedure (FRCP)
Govern the procedures for civil trials
Often also used to guide state court civil procedures
State laws vary for subpoenas, court orders, discovery, and similar processes
© 2017 American Health Information Management Association
Federal Rules of Evidence
Govern what and how electronic records may be used in a trial
Roles of record custodianship for purposes of evidence in a trial
Electronic records have many more requirements than paper records
© 2017 American Health Information Management Association
LHR Stakeholders
C-suite and practice managers
HIM professionals
Information technology staff
Record custodians
Privacy, compliance, and security officers: risk managers and quality managers
Clinicians
Legal counsel
© 2017 American Health Information Management Association
Legal Health Records
Format:
Paper
Electronic
Hybrid
Health record custodian
Designated record set
© 2017 American Health Information Management Association
Purpose of LHR Definition
Clarifies the roles of all records and their uses
Sets foundational policy for record management operations
Must be continually reviewed and updated as their constituent record components evolve
© 2017 American Health Information Management Association
LHR Definition Project Steps
Determine the LHR stakeholder team
Determine strategy and plan; get executive sponsorship and empowerment
Gather LHR-related knowledge
Develop a master source system matrix
Create a document matrix of LHR components
© 2017 American Health Information Management Association
LHR Definition Project Steps (continued)
Assess and catalog EHR systems for their LHR attributes
Determine the need for new and revised related policies and procedures
Determine the LHR maintenance plan
Create a presentation and conduct education and training for appropriate workforce members
© 2017 American Health Information Management Association
LHR Defined for Disclosure
Determine what business records or components of records will be released upon legal request
Use a spreadsheet or other tool to keep track of source systems and documents
HIPAA Designated Record Set is a good starting point for the LHR
© 2017 American Health Information Management Association
LHR Policy Imperative
Determines what data and information can or should be released pursuant to a request from a third party
No policy leaves the organization at risk related to request for data and information that the organization is not prepare to release
© 2017 American Health Information Management Association
Litigation Response Policy
The processes invoked if the potential for lawsuits or litigation is detected
Maximize defensive posture
Responses to subpoenas and court orders
Protecting against spoliation (malicious alteration, concealment, or destruction of evidence)
© 2017 American Health Information Management Association
Uniform Rules for e-Discovery
Amendments to the FRCP specifically designed for electronically store information
Apply to federal courts, but can be followed as guidance
© 2017 American Health Information Management Association
Litigation Response Policies and Procedures
Failure to define these can increase liability and financial risk
Starts with documentation of the steps and personnel already performing these tasks
Customize practices to fit your specific requirements
© 2017 American Health Information Management Association
EHR System Functionality Relevant to the LHR
Audit logs
Authorship and authentication of entries and electronic signatures
Business continuity
Business rules
Data, document management, and nonrepudiation
Retention, data permanence, and migration plans
© 2017 American Health Information Management Association
EHR System Functionality Relevant to the LHR (continued)
Interfaces
Legal hold
Metadata
Electronic health record output
Rendition
Snapshots and screen views
Privacy attributes
Version controls
© 2017 American Health Information Management Association
Patient Record Documentation
Accuracy
Patient-requested amendments
Corrections
Deletions
Copy and paste forward
Late entries
Resequencing and reassignment
Templates, boilerplates, canned text, and structured input
© 2017 American Health Information Management Association
e-Discovery Overview
LHR needs to be defined
Disclosure—output and release upon request of appropriate health record documents
E-discovery—process of discovering the relevant parts of a patient’s record that may be used for litigation
© 2017 American Health Information Management Association
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Introduction to Healthcare Informatics, Second Edition
Chapter 15:
Consumer Health Informatics
© 2017 American Health Information Management Association
© 2017 American Health Information Management Association
Objectives
Define consumer health informatics
Describe characteristics of the online health information consumer
Identify current and past consumer health informatics technology
Discuss ubiquitous computing
Characterize the differences between validity and reliability
Explain privacy and security issues for online health information
© 2017 American Health Information Management Association
Introduction
Concept of Consumer Health Informatics
Consumer Involvement
ONC
Online Diagnosers
Patient Portal
Meaningful use
© 2017 American Health Information Management Association
Consumer Health Informatics
Standardized definition
Consumer
Health
Informatics
Mindmap
Explicit Themes
Implicit Themes
© 2017 American Health Information Management Association
Mindmap
© 2017 American Health Information Management Association
Explicit Themes
Types of consumers
The term health as opposed to disease or illness
Tools and applications
Rationale for CHI
Nondependency on a healthcare professional for health information
Intersection with other disciplines
© 2017 American Health Information Management Association
Implicit Themes
Content is created by experts
Information is available in a searchable repository
The acquisition of health information is a solitary and personal activity
Consumers do not seek health information from other consumers
The desired information is pulled or retrieved by the consumer
There is no push of information to the consumer
Limited to staying healthy; not about finding information about disease or illness
© 2017 American Health Information Management Association
Literacy
Health literacy
Computational literacy
Visual literacy
e-Health literacy
Computer literacy
Technology literacy
Health People 2020
Digital Immigrant or Digital Native
© 2017 American Health Information Management Association
Online Health Consumer
Characteristics
Use of Internet
Demographics
Cell Phone/Smart Phone
Educational Level
© 2017 American Health Information Management Association
Initial Topics of Interest
A specific disease or medical problem
A specific medical treatment or procedure
Doctors or other health professionals
Hospitals or other medical facilities
Health insurance, including private insurance, Medicare, or Medicaid
Environmental health hazards
© 2017 American Health Information Management Association
Current Topics of Interest
Food safety or recalls
Drug safety or recalls
Pregnancy and childbirth
Memory loss and dementia or Alzheimer’s
Medical test results
Management of chronic pain
Long-term care for an elderly or disabled person
End of life decisions
© 2017 American Health Information Management Association
CHI Technology
Self-help books
Online health articles or sites
Bulletin boards and online discussion groups
Automated appointment reminders
Automated systems for learning more about health conditions
Wearable sensors, such as glucose monitors
Social media sites such as Facebook and Twitter
© 2017 American Health Information Management Association
Ubiquitous Computing of Online Health Information
WebMD
Healthcare Organizations and Hospitals
Medical Libraries
Disease Societies and Associations
Pharmacies
Mobile Technology
Social Networking Sites
© 2017 American Health Information Management Association
Personal Health Records
Definition
Barriers to Adoption
Disparities in Access to Health Information
Cost
Benefits
© 2017 American Health Information Management Association
Barriers to Adoption
Physicians question reliability of patient-reported data
Question of who would pay for the costs of the PHRs
Interoperability needed to exchange data
Patient privacy and security
Encryption and problems of authentication
Legal implications of health provider relying on inaccurate patient-entered PHR data
Providers concern for use of electronic PHR to elicit prescriptions for narcotics
© 2017 American Health Information Management Association
15
Personal Health Record (PHR)
Maintained and updated by the patient
Paper or electronic format (USB, CD, and such)
Microsoft Health Vault
Barriers to implementation
Benefits to the PHR
Patient generated data
© 2017 American Health Information Management Association
Blue Button
Veterans Administration
Patient Portals
Veterans, Uniformed Service Members, Medicare Beneficiaries
Information Available
Current Medicines
Drug Allergies
Treatments
Laboratory Results
Uses
© 2017 American Health Information Management Association
Patient Portal
HIPAA mandate for access to information
Meaningful Use Stages 1 and 2
Features and functionalities
© 2017 American Health Information Management Association
Validity and Reliability
Validity
Reliability
HON Code of Conduct (HONcode)
Sources for Determining Validity and Reliability
© 2017 American Health Information Management Association
The Current HONcode
Authoritative—expertise of the authors
Complementarily—uphold the doctor-patient bond
Privacy—ensure privacy and security of personal data
Attribution—give credit to sources of information
Justifiable—corroborate assertions of improvement and betterment
Transparency—clarity of content and inclusion of webmaster’s e-mail address
Financial disclosure—disclosure of
Advertising policy—a clear distinction between advertising and verifiable content (HON 2011)
© 2017 American Health Information Management Association
Trusted Sources for Determining Validity and Reliability Online Information
MedlinePlus Guide to Healthy Web Surfing
Finding Reliable Health Information Online
Finding Reliable Health Information Online
MedlinePlus Quality Guidelines
Medical Library Association List of 100 Websites You can Trust
© 2017 American Health Information Management Association
Privacy and Security
Privacy Policy Statement
Type of information collected
Cookies
Personally identifiable information (PII)
Links to other sites
Security
Third-party websites and applications
Challenges
Mobile and Online Health Information
© 2017 American Health Information Management Association
Summary
Consumer Empowerment
Validity and Reliability
Privacy and Security
Patient Portal Requirements
© 2017 American Health Information Management Association
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