Fluent Essays

From a health information system perspective, there are federal laws relative to information management, data authentication, health exchange, standards, and end user needs. Additionally, organizations can choose to become accredited or certified. Accrediting organizations endorse, facilitate, and provide standards to protect patient health information. Meanwhile, laws are in place to ensure the safety and security of patient health information. The standards of patient’s health information safety and security within organizations are clearly outlined and widely adopted by all legitimate health care organizations. Introduction to Standard IM.01.01.03 The primary goal of the information continuity process is to return the hospital to normal operations as soon as possible with minimal downtime and no data loss. The hospital needs to be prepared for events that could impact the availability of data and information regardless of whether interruptions are scheduled or unscheduled (due to a local or regional disaster or an emergency). Interruptions to an organization’s information system can potentially have a devastating impact on its ability to deliver quality care and continue its business operations. Planning for emergency situations helps the organization mitigate the impact that interruptions, emergencies, and disasters have on its ability to manage information. The hospital plans for interruptions by training staff on alternative procedures, testing the hospital’s Emergency Operations Plan, conducting regularly scheduled data backups, and testing data restoration procedures. Justify two information management standards from the list below as outlined by The Joint Commission. You are required to expand upon the Elements of Performance. The hospital plans for managing information. The hospital plans for continuity of its information management process. Regardless of whether an organization uses a paper-based system or an electronic system, a plan to address the process for information continuity, including knowledge-based information, should be in place. Hospitals that plan for maintaining access to electronic information systems by using various electronic backup and restoration procedures can quickly recover from interruptions with minimal downtime and data loss.Chapter 11 Health Care Information System Standards Throughout this text we have examined a variety of different types of standards that affect, directly or indirectly, the management of health information systems. In Chapter Ten we examined health care performance standards; Chapter Two looked at data quality standards, Chapter Nine at security standards, and so on. In this chapter we will examine yet another category of standards that affect healthcare data and information systems: health care information system (HCIS) standards. In all cases the standards examined represent the measuring stick or set of rules against which an entity, such as an organization or system, will compare its structures, processes, or functions to determine compliance. In the case of the HCIS standards discussed in this chapter the aim is to provide a common set of rules by which health care information systems can communicate. Systems that conform to different standards cannot possibly communicate with one another. Portability, data exchange, and interoperability among different health information systems can be achieved only if they can “communicate.” For a simple analogy, think about traveling to a country where you do not speak the language. You would not be able to communicate with that countrys citizens without a common language or translator. Think of the common language you adopt as the standard set of rules to which all parties agree to adhere. Once you and others agree on a common language, you and they can communicate. You may still have some problems, but generally these can be overcome. By nature HCIS standards include technical specifications, which make it less easy for the typical health care administrator to fully understand them. In addition, a complex web of public and private organizations create, manage, and implement HCIS standards, resulting Chapter 10 Performance Standards and Measures This chapter examines public and private organizations and processes that establish standards for ensuring that health records are maintained accurately and completely and that they contain the data and information needed to define and report a wide range of measures to determine the quality and efficiency of health care. These activities are very important and have a significant influence on providers and HIT capabilities, significant enough for us to devote an entire chapter to them. Health care organizations and health plans use data and information to measure performance against internal and external standards; to compare performance to other like organizations; to demonstrate performance to licensing, certifying, and accrediting bodies; and to demonstrate performance for reimbursement purposes. This chapter begins with an examination of the licensure, certification, and accreditation of health care facilities and health plans, followed by an overview of key comparative data sets often used by health care organizations in benchmarking performance. The chapter concludes with a description of the national initiatives using performance measures to improve the quality and safety of health care, including those affecting provider reimbursement. In the section titled “Licensure, Certification, and Accreditation,” we define these processes, list the accrediting organizations recognized by CMS, and examine the missions and general functions of the Joint Commission and the National Committee for Quality Assurance (NCQA). These discussions focus on how the licensure, certification, and accreditation processes not only use health information to measure performance but also how they influence the health care information that is collected. “Measuring the Quality of Care” begins with a historical perspective of major milestones in the national agenda for health care quality Chapter 9 Privacy and Security Privacy is an individuals constitutional right to be left alone, to be free from unwarranted publicity, and to conduct his or her life without its being made public. In the healthcare environment, privacy is an individuals right to limit access to his or her health care information. In spite of this constitutional protection and other legislated protections discussed in this chapter, approximately 112 million Americans (a third of the United States population) were affected by breaches of protected health information (PHI) in 2015 (Koch, 2016). Three large insurance-related corporations accounted for nearly one hundred million records being exposed (Koch, 2016). In one well-publicized security breach at Banner Health, where hackers gained entrance through food and beverage computers, approximately 3.7 million individuals information was accessed, much of it health information (Goedert, 2016). Health information privacy and security are key topics for healthcare administrators. In todays ever-increasing electronic world, where the Internet of Things is on the horizon and nearly every health care organization employee and visitor has a smart mobile device that is connected to at least one network, new and more virulent threats are an everyday concern. In this chapter we will examine and define the concepts of privacy, confidentiality, and security as they apply to health information. Major legislative efforts, historic and current, to protect health care information are outlined, with a focus on the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification rules. Different types of threats, intentional and unintentional, to health information will be discussed. Basic requirements for a strong health care organization security program will be outlined, and the chapter will conclude with the cybersecurity challenges in8/16/22, 7:35 PM CMS Crosswalk https://e--dition-jcrinc-com.eu1.proxy.openathens.net/MainContent.aspx 1/1 The Joint Commission July 1, 2022 Requirements Hospital Information Management IM.01.01.03 1. The hospital follows a written plan for managing interruptions to its information processes (paper-based, electronic, or a mix of paper-based and electronic). CMS Medicare Requirements Hospital §482.15 §482.15 Condition of Participation: Emergency Preparedness The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all- hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: §482.15(b) (b) Policies and procedures. The hospital must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following: §482.15(b)(5) TAG: E-0023 (5) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.8/16/22, 7:34 PM CMS Crosswalk https://e--dition-jcrinc-com.eu1.proxy.openathens.net/MainContent.aspx 1/1 The Joint Commission July 1, 2022 Requirements Hospital Information Management IM.01.01.03 2. The hospitals plan for managing interruptions to information processes addresses the following:- Scheduled and unscheduled interruptions of electronic information systems - Training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable- Backup of electronic information systems (See also IM.03.01.01, EP 1) CMS Medicare Requirements Hospital §482.15 §482.15 Condition of Participation: Emergency Preparedness The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all- hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: §482.15(b) (b) Policies and procedures. The hospital must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following: §482.15(b)(5) TAG: E-0023 (5) A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.