Ethical Decision Making
-Process that requires striking a balance between science and morality.
-Making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong.
American Nurses Association- Code of Ethics for Nurses with Interpretive Statements.
provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT
Bioethical Standards
Autonomy, freedom, veracity, privacy, beneficence, and fidelity are maximally appropriate to the health care setting.
Autonomy
The right to choose for himself or herself; respecting the clients opinions, perspectives, values and beliefs.
Freedom
The ability of an individual to act independently, without coercion or constraint in ones choice and action
veracity
Being completely truthful with patients; a patients right to truth.
privacy
The right to be left alone when you want to be, to have control over your own personal possessions, and not to be observed without your consent
Beneficence
Actions performed that contribute to the welfare of others; Action of doing good or right by and for the patient.
Fidelity
Right to what has been promised; keeping to one’s promise.
Telehealth
Use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.
Telemedicine
Remote clinical health services
mHealth (Mobile Health)
-The practice of medicine and public health supported by mobile devices such as mobile phones, tablets, personal digital assistants and the wireless infrastructure.
-The use of wireless communication to support efficiency in public health and clinical practice.
Mobile Medical Applications (Apps)
-Accessories to a regulated medical device or are a software that transforms a mobile platform into a regulated medical device.
-Facilitates mHealth
Medical Devices
Any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients.
Rationale APP is NOT Considered Medical Devices
Apps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease.
FDA Oversight for Medical Devices
-Regulatory body that oversees mobile apps that are medical devices and whose functionality could pose a risk to a patient’s safety if the mobile app were to not function as intended.
-Also oversee the cybersecurity management of these devices as well as the hospital network security.
(POC) Point of Care
Testing and diagnosis at the patient’s side and can be conducted anywhere the patient is, such as the home, physician office, ambulance, or hospital bedside
Privacy
Practice of maintaining the security and confidentiality of patient records.
Confidentiality
The act of holding information in confidence, not to be released to unauthorized individuals.
Cybersecurity
-Measures taken to protect a computer or computer system against unauthorized access or attack.
-FDA is main regulatory agency
Computer-aided Translators
Language translation in which a human translator uses computer hardware to support and facilitate the translation process.
HIPPA (Health Insurance Portability and Accountability Act)
Enacted in 1996; federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
ICD-10 Codes
-Alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses.
-Shorthand for the patient’s diagnosis , which are used to provide the payer information on the necessity of the visit or procedure performed
CPT Codes (current procedural terminology)
official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non-physician providers
Evaluation and Management Coding
process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing.
Necessity for establishing E/M Codes
Place of Service; Type of Service; Patient Status
Components of Risk Based E/M Coding
History; Physical; Medical Decision Making
Medical Decision Making (MDM)
1 of 3 components to establishing E/M codes; way of quantifying the complexity of thinking that is required for the visit.
3 key elements to medical decision making
risk, data, and diagnosis
Reimbursement Coding
-Claims and documentation filed by providers using medical diagnosis and procedure codes.
-Assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders.
Clinical Support Tools
-Found in EHR software that when applied effectively, can enhance patient care quality and outcomes, improve efficiency, and help to ensure regulatory compliance.
-Process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assessments, recommendations, or other forms of guidance for clinicians, patients, and others involved in care delivery.
Alert Fatigue
Main challenge to effective implementation of CDS Tools
Primary Goal of CDS Tools
leverage data and the scientific evidence to help guide appropriate decision making.
Workflow
-Term used to describe the action or execution of a series of tasks in a prescribed sequence.
-The progression of steps (tasks, events, interactions) that constitute a work process, involve two or more persons, and create or add value to the organization’s activities.
-Used interchangeably w/ process or process flows;
Workflow Analysis
-Study of the way work (inputs, activities, and outputs) moves through an organization.
-Observation and documentation of workflow to better understand what is happening in the current environment and how it can be altered
Sequential Workflow
each step depends on the occurrence of the previous step
Parallel workflow
two or more steps in a process can occur concurrently.
Workflow design
A critical aspect of the informatics role in workflow analysis
American Recovery and Reinvestment Act of 2009 (ARRA)
-provided funds to government agencies for improving information-technology systems;
-provisions include the right for every person to receive an electronic copy of their EHR and to have a copy of their EHR transmitted to a party that they designate
Patient Protection and Affordable Care Act (ACA)
Guarantees healthcare for all Americans, expands Medicaid, provides incentives intended to improve care coordination and quality, restructures healthcare payment, and provides additional information to patients so that they can make value-based decisions.
Administrative Data
Include billing information derived from insurance claims, inpatient discharges (or hospital bills), and outpatient visits.
National Prevention Strategy: America’s Plan for Better Health and Wellness
comprehensive plan that sets forth evidence-based and achievable means for improving health for all Americans at every stage of life. These efforts are designed to stop disease before it starts and to create strategies for a healthy and fit nation, recognizing that prevention must be part of daily life.
Fee-for-Service Model
a provider is given a set amount of monetary reimbursement for a specific visit or procedure performed that is adjusted for geographical location
Medical Coding
use of codes to communicate with payers about which procedures were performed and why .
Medical Billing
process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider