Functions and Protections of the Health Record

Flashcards covering administrative, clinical, and legal aspects of health record management, including telehealth, interoperability, and documentation standards.

Telehealth

The use of electronic information and telecommunications technologies to extend care when you and the patient aren't in the same place at the same time.

Artificial Intelligence ($AI$)

A field of computer science focused on creating machines able to perform tasks that would typically require human intelligence.

Natural Language Processing ($NLP$)

A specialized branch of $AI$ that enables computers to understand and interpret human speech by focusing on the interaction between computers and humans through natural language.

Predictive Modeling

A technique that analyzes historical and current data to predict the future, often utilized in healthcare to predict disease states, hospital readmissions, or sepsis survival.

$$ICD-10$$

International Classification of Diseases, Tenth Revision; a code set adopted by $HIPAA$ for reporting diagnoses.

$$HCPCS$$

Healthcare Common Procedure Coding System; a code set used for reporting procedures in billing transactions.

$$CPT$$

Current Procedural Terminology; a code set used for reporting clinical procedures on claims and encounter forms.

$$CDT$$

Code on Dental Procedures and Nomenclature; a standardized code set for dental services.

$$NDC$$

National Drug Codes; a code set used for identifying drugs in healthcare transactions.

$$NCVHS$$

National Committee on Vital and Health Statistics; a public policy advisory board that recommends standards to promote interoperability of $EHRs$.

$$NHIN$$

Nationwide Health Information Network; a group of federal and nonfederal organizations working to improve patient care through secure and interoperable health information exchange.

$HL7$ International

A not-for-profit organization that develops standards for the exchange, integration, sharing, and retrieval of electronic health information.

$$FHIR$$

Fast Healthcare Interoperability Resources; a standard set of rules and specifications developed by $HL7$ for exchanging electronic health data using resources.

$$SNOMED\text{ }CT$$

Systematized Nomenclature of Medicine Clinical Terms; a comprehensive, machine-readable clinical terminology used for indexing and aggregating clinical data.

$$NCPDP$$

National Council for Prescription Drug Programs; a not-for-profit organization that develops standards for exchanging prescription and payment information.

Longitudinal Health Record

A record that includes all of the health-related information generated for an individual during their lifetime.

Data

Objective descriptions of processes, procedures, people, and other observable things and activities; representing facts.

Information

The result of the analysis of data for a specific purpose which conveys meaning.

Data Elements

Individual facts or measurements that are the smallest unique subset of a database.

Administrative Data

Elements used for patient identification, billing, or other administrative functions.

Demographic Data

Characteristics of an individual or population, such as age, sex, race, ethnicity, and language.

Financial Data

Facts collected to identify the parties responsible for payment for healthcare services, including insurance policy numbers and employer information.

Clinical Data

Information relevant to a patient's medical condition and treatment used to support clinical decision-making.

Master Patient Index ($MPI$)

A database that uniquely identifies patients across various healthcare systems and links their information to maintain a longitudinal record.

Face Sheet

A form in the $EHR$ containing patient identification, demographics, admission date, insurance, and diagnoses, usually becoming the first page of the printed record.

Episode of Care

The healthcare services given during a certain period of time, usually during a hospital stay.

Clinical Decision Support

The use of technology to process data elements to make comparisons, trend results, deliver clinical reminders, and issue alerts.

Utilization Management ($UM$)

A process focusing on how healthcare organizations use their resources to provide appropriate care in the most efficient manner.

Case Management

The ongoing, concurrent review of the appropriateness and effectiveness of clinical services provided to a patient.

Quality Management

The evaluation of the quality of healthcare services and delivery using standards and guidelines developed by government or accreditation bodies.

Performance Improvement ($PI$)

The continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired outcomes.

Continuous Quality Improvement ($CQI$)

A component of total quality management that emphasizes meeting patient needs and relying on data for process performance improvement.

Accreditation Organization

A professional organization that establishes standards and conducts periodic assessments to measure the performance of healthcare organizations.

The Joint Commission

A private, voluntary, not-for-profit organization that evaluates and accredits hospitals based on predefined performance standards.

Credentialing

The process of reviewing and validating the qualifications (degrees, licenses) of physicians to grant medical staff membership.

Clinical Privileges

The specific clinical activities a professional is qualified and approved to perform within a healthcare organization.

Risk Management ($RM$)

A process designed to prevent or minimize injuries and adverse events while managing liability for those that do occur.

Liability

The legal responsibility to compensate individuals for injuries and losses sustained as the result of negligence.

Sentinel Event

A serious incident that results in severe temporary harm, permanent harm, or death.

Incident Report

An internal document that describes an unforeseen event with factual details to collect information for root cause analysis.

Privilege

A legal protection that can relieve a healthcare organization from the burden of producing internal risk management documentation during discovery.

Vital Statistics

Data on births, illnesses ($\text{morbidity}$), and deaths ($\text{mortality}$).

Morbidity

A term referring to illness or the incidence of disease.

Mortality

A term referring to death or the incidence of death.

Licensure

The mandatory legal authority or formal permission from authorities to carry on healthcare activities.

Accreditation

A voluntary process where an independent third-party entity evaluates an organization to determine if it meets predetermined criteria.

Certification

The act of granting approval for a healthcare organization to provide services to specific beneficiaries or for a professional to practice.

Clinical Trial

An investigation of the safety and effectiveness of new treatments and tests conducted according to a protocol.

Evidence

The means by which the facts of a case are proved or disproved in legal proceedings.

Hearsay

Statements made outside of the discovery process, which are generally not admissible as evidence unless an exception applies.

Business Record Exception

An exception to the hearsay rule that allows records created in the normal course of business, like health records, to be admissible as evidence.

Record Custodian

An individual designated by a healthcare organization to be responsible for the policies and procedures that ensure business record principles are met.

Discovery

The legal process of exchanging information between parties to reveal relevant facts about a dispute before trial.

e-Discovery

The discovery and production of electronically stored information, such as metadata or audit trails.

Legal Hold

A communication issued to suspend the normal disposition of records when litigation is reasonably anticipated.

Court Order

An official direction issued by a judge or court officer requiring or forbidding a person to perform certain actions.

Subpoena

A command to appear in court or to present documents or other evidence.

Subpoena duces tecum

A command directing a record custodian to produce all or part of a business record, such as a health record.

Redisclosure

The process of disclosing health record documentation that was originally created by a different healthcare provider.

Statute of Limitations

A specific time frame allowed by law for bringing litigation/legal action.

Certificate of Destruction

A document that permanently proves a health record was destroyed in the normal course of business.

Prevalence Rate

$$\text{The proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time.}$$

Incidence Rate

$$\text{The number of people who contracted the same disease during a specific time period compared to the number of people who could have contracted the disease.}$$

Census

A report of the number of inpatients present in a healthcare facility at any given time.

Rate

$$\text{A comparison of an event taking the number of times it happened divided by the number of times it could have happened.}$$

Ratio

$$\text{A number found by dividing one quantity by another.}$$

Percentages

$$\text{Values computed on the basis of a whole being divided into 100 parts.}$$