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Fundamentals of Law for Health Informatics and Information Management 2nd edition -Chapter 1

The professional membership organization for managers of health information serivces and healthcare information sytems as well as coding services; provides accreditation, advocacy, certification, and educational services.
A national professional membership organization for physicians that distributes scientific information, informs members of legislations related to health and medicine and represents the medical profession’s interests in national legislative matters.
A professional organization of health informatics and information management personnel, biomedical informatics professionals, educators, and others.
ARRA – American Recovery and Reinvestment Act -2009
Federal legislation that included significant funding for health information technology and provided for significant changes to the HIPAA Privacy Rule
ASTM – American Society for Testing and Materials
A national organization whose purpose is to establish standards on materials, products, systems, and services
A core ethical principle centered on the indivdivual’s rights to self-determination that includes respect for the individual; in clinical applications, the patient’s rights to determine what does or does not happen to him or her in terms of healthcare
A legal term that means promoting good for others or providing services that benefit others, such as releasing health information that will help a patient receive care or will ensure payment for services received
Business Record
A record that is made and kept in the usual course of business, at or near the time of the event recorded
Code of Ethics (or code of ethical practice)
A statement of ethical principles that regarding business practices and professional behavior
A legal and ethincal concept that establishes the healthcare providers’ responsibilty for protecting health records and other personal and private information from unauthorized use or disclosure
Custodian of health records
The person designated as responsible for the operational functions of the vedelopment and maintenance of the health record and who may certify through affidavit or testimony the normal business practices used to create and maintain the record.
Data Security
The process of keeping data, both in transit and at rest, safe from unauthorized access, aleration, or desctruction
Designated Record Set
A group of records maintained by or for a covered entity encompassing medical records and billing records about individuals and enrollment, payment, claims adjudication, and case or medical managment record systems maintainted by or for a health plan use, in whole or in part, by or for the covered entity to make decisions about individuals
Electronic Health Record
A computerisze record health information and associated processes; an electronic record of health-related information on an indvidual that conforms to nationally recognized standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
Eletronic Medical Record
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization
A field of study that deals with moral priniciples, theories, and values; in healthcare, a formal decision-making process for dealing with the competing perspectives and obligations of the people who have interest in a common problem
Ethical Priniciples
Set of 4 principles to assist healthcare professionals in addressing healthcare related dilemas
Ethical priniciple
Ethical principle
Ethical principle
Ethical Principle
Health Information
The data generated and collected as a result of delivering care to a patient
Health Information Exchange (HIE)
Electronic movement of health-related information among organizations within a region or communicty that facilitates access to and retrieval of clinical data in support of safe, timely, efficeint, and effective patient-centered care; and organization or entity that forms to create and electronic framework to connect physicians to pharmacies, hopsitals, and other healthcare entities.
Health Information Technology
The techinal aspects of processing helath data and records including classification and coding, abstracting, registry development, storage, and so on
Health Information Technology for Economic and Clinical Health Act (HITECH)
Federal legistlation that was passed as a portion of the ARRA; contians changes to the HIPAA Privacy Rule
A law enacted by congress in 1996 , governing various aspects of health informationl federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the seucirt and privacy of health information
Health Record
Individually identifiable data, in any medium, that are collected, processed, stored, and displayed, and used by health care professionals; documents the care rendered to the patient and that patient’s healthcare status
Hybrid Health Record
A health record that uses a combination of paper and electronic formats
Information Governance
Strategic managmenet of enterprise electronic information, including the standards, policies and procedures for access, use and control of that information
The Joint commission
Agency that develops standards for healthcare organizations and certifies healthcare organizations on the basis of adherence to those standards
The impartial administration of policies or laws that takes into consideration the competing interests and limited resources of the indivduals or groups involved
Set of governing rules designed to protect citizens living in a civilized society, establish order, provides prarameters for conduct, and define the rights and obligations of the govt and its citizens
Legal Health Record
The form of a health record that is hte legal business record of the organization and serves as evidence in lawsuits or other legal actions.; what constitutes an organization’s legal health record varies depending on how the organization defines it
Moral Values
Principles formed through the influence of family, culture, religion, and society
National Alliance for Health Information Technology
A partnership of government and private sector leaders from various healthcare organizations that worked toward using technology to achieve improvements in patient safety, quality of care, and operating performance. Started in 2002 and ended 2009
A legal priniciple that means “first do no harm”
Office of National Coordinator for Health Technology
created in 2005 by the federal govt to “provide leadership for the development and nationwide implementation of an interoperable HIT infrastructure to improve the quality and efficiency of healthcare and the ability of consumers to manage their care and safety”.
In healthcare, the person to whom the health records belongs (traditionally, the provider)
Personal Health Record
An electronic or paper health record updated and maintained by the individual for him/herself
Privileged Communication
Communication shared between two parties – such as physician and patient, clergy and parishoner, husband and wife, , and attorney and client – that is considered privileged; may be defined by law
The quality of or state of being hidden from, or undisturbed by , the observation or activites of other people or freedom from unauthorized intrusion; in health-related context, the rights of a patient to control disclosure of personal information
The means to control access and protect information from accidental or intentional disclosure to unauthorized persons, and from unauthorized alteration, destruction, or loss.
The phyiscal protection of facilities and equipment from theft, damage, or unauthorized access, collectively, the poiciles procedures, and safeguards designed to protect the fonifdentiality of information, naintain the integrity and availablity of information systems, and control acces o the content of these systems.
the person responsible for ensuring the integrity and security of electronic information and records.
Custodian of health records
Refers to responsibility for ensuring the integrity (accuracy, completeness, and timeliness) and security (protection of privacy as well as protection from tampering, loss, or destruction) within the context of electronic information and records managment
System Security
Totality of safeguards including hardware, software, personnel policies, infomration proactice prolicies, disaster preparedness, and oversight of these components, protects both the system and the information contained within from unauthorized access from without and from misuse from within; enables the entity or system to protect the confidential information it stores unauthorized access, disclosure, or misues, there by protecting the privacy of the individuals, who are the subjects of the stored information
A hybrid record is a record that is totally electronic
An electrnoic health record can be managed across more than one healthcare organization
Confidentiallity refers to the right to be left alone
HITECH widens the scope of the privacy and security protections under HIPAA
Privileged communication is a legal concept designed to protect the communication between two parties
Ownership of a health record generated by a doctor on a patient belongs to the patient
A custodian of records is repsonsible for certifying that a record is what it purports to be
When a patient refuses treatment, he or she is exercising the ehtical principle of beneficence
In a malpractice case, a professional code of ethics may be used as a benchmark for what should be acceptable practice by a healthcare professional
The ethical prinicple of nonmaleficence refres to making sure rules are fairly and consistently applied to all

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