Health Care Information System Terms
This paper explains the following Health Care Information System terms and how they are used in health care: Health Insurance Portability and Accountability Act (HIPAA), Electronic medical record (EMR), Electronic health record (HER), Personal health record (PHR), Computerized provider order entry system (CPOES), Unique patient identifier (UPI), Protected health information (PHI), Centers for Medicare & Medicaid Services (CMS), Covered entities, Health information exchange (HIE).Health Care Information System Terms
Key words: Health Care Information System.
Health Care Information System Terms
Health Insurance Portability and Accountability Act (HIPAA) protects patient health information from unauthorized use and ensures patient privacy. HIPAA guarantees that all information that is discussed or written in a medical facility is protected for the patient, and all employees must follow rules and instructions by HIPAA regulations (in order to avoid legal regulations and fines).
Electronic medical record (EMR) defined as “electronic medical information about individuals that are held within one health care organization, which can be gathered, managed or consulted by health care professionals” (Wager, Lee, Glaser, 2009). EMR systems are mostly used by providers for diagnosis, treatment, tests, and medications.
Electronic health record (EHR) is “a digital version of individual’s paper chart”, which contains the medical and treatment histories, diagnosis, medications, laboratory and test results of the patients that makes information available instantly and securely to authorized users. EHR is used to share information with other health care organizations (specialists, laboratories, emergency facilities, pharmacies, and medical facilities).
Personal health record (PHR) makes it available to manage and gather individual’s medical information in accessible to anytime and secure location, in other words, it is a collection of information about individual’s health. PHR includes doctor’s name, medications, allergies, chronic health problems, and family history. PHRs allow their patients to access and print their records at any time.Health Care Information System Terms
Computerized provider order entry system (CPOES) is an application that allows health care providers to enter medical orders electronically excluding traditional methods (telephone, fax, papers). CPOES is used to directly enter medical orders (as well as laboratory, admission and procedure orders) through a computer application, to improve medication safety and quality of health care. Unique patient identifier (UPI) contains information which identifies the patient and includes a set of individual characters by which that person can be recognized. This system uses data such as an individual’s birth date and security number to create a unique code instead of a name. UPI is used to easily identify individuals, facilitate accurate and comprehensive care, and guarantee the privacy, security and safety of patient information.
Protected health information (PHI) generally refers to medical history, laboratory results, test results, insurance information, and other information that healthcare professional gather to identify a patient and determine effective care. PHI is used to provide professional healthcare service, diagnosis and treatment.
Centers for Medicare & Medicaid Services (CMS) is an agency within the US Department of Health & Human Services responsible for administration of Medicare program, Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards. CMS is used to provide administrative simplification standards from the HIPAA, quality standards in long-term care facilities through certification process, clinical laboratory standards, etc.Health Care Information System Terms
Covered entities are defined as health plans, health care clearing houses, and health care providers who electronically transmit health information in connection with transactions concerning billing and payment for services or insurance coverage (HIPAA). Covered entities are used to handle protected health information.
Health information exchange (HIE) allows medical staff and health care providers to access and share an individual’s medical information electronically. HIE is used to facilitate access to, and retrieval of, clinical data to provide safe, timely, efficient, effective, equitable and patient-centered care (Healthcare Information and Management Systems Society, 2016).
References:
Healthcare Information and Management Systems Society (2016). Health Information Exchange. Retrieved from http://www.himss.org/library/health-information-exchange?navItemNumber=16135
Wager, K., Lee, F. W., Glaser, J. P. & Burns, L. R. (2009). Health Care Information Systems. A Practical Approach for Health Care Management (2 ed.). Health Care Information System Terms