Chapter 1 · Healthcare Environment · Lesson 1 of 9

Health, the Four Pillars and the Environment You Work In

Big picture

Walkthrough

How the source defines health

• The World Health Organization defines health as a state of complete physical, mental and social well-being.
• The definition adds that health is not merely the absence of disease or infirmity.
• The WHO has not amended this definition since 1948.
• Care sought only at an advanced stage of disease costs more and produces less desirable outcomes.
• Healthcare practice is increasingly focused on the activities with the greatest impact on the health of communities and patient populations.
• A state of health is no longer limited to office visits and hospital admissions; it extends to wellness encounters with nonphysician providers, virtual encounters through telehealth or mobile health technologies, and safety and preventive care outreach programs.

The definition is doing two jobs at once. It states what health is, and it rejects a narrower definition in the same sentence. That built-in rejection is why the phrase about absence of disease shows up so often as a wrong answer.

The four pillars and the stakeholders pressing on them

• The four pillars are quality, access, cost and value.
• The pillars require dynamic trade-offs; professionals are pressured to deliver the highest quality to the greatest portion of the supported population within tight cost constraints.
• Health IT carries the added burden of demonstrating the value of the technology itself.
• The source pictures the pillars as a four-legged stool onto which stakeholder demands are placed.
• Named stakeholders: governments, consumer groups, professional associations, regulatory organizations, payers and insurers, and suppliers.

The stool image matters because it states the relationship between the pillars. Loading more weight on one leg does not remove weight from the others; it changes what the other three have to carry.

Comparing national systems with OECD indicators

• The Organisation for Economic Cooperation and Development provides key indicators on health system performance across countries.
• Those indicators give a basis for comparing international approaches to organizing and resourcing national healthcare.
• The comparison shows substantial variance in spending by country.
• It also shows variance in the proportion of public to private contribution to national health expenditures.
• Investment has produced large reductions in cardiovascular and infant mortality rates.
• Lifestyle and risk factors remain: more than 18 percent of adults smoke daily, and almost one-third of children aged 5 to 9 are overweight.
• The overweight rate in that age group rose from 20.5 percent to 31.4 percent between 1990 and 2016.

Spending level and funding mix are two different axes. A country can spend heavily and still be mostly publicly funded, or spend less with a large private share, which is why the source reports both.

Memory tips

Key concepts

Practice questions

1 item mapped to this lesson: 1 from the diagnostic rebuild. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: WHO definition of health and its 1948 currency · the cost and outcome argument for earlier engagement · extension of health encounters beyond office and hospital · the four pillars and their trade-offs · the four-legged stool and its stakeholder load · named stakeholder groups · OECD as the basis for international comparison · spending and public-private variance · mortality gains and lifestyle risk factors.

Chapter 1 · Healthcare Environment · Lesson 2 of 9

Hospitals and How They Are Classified

Big picture

Walkthrough

How the source organizes healthcare organizations

• The number and types of organizations providing, supporting and paying for care is large, complex and constantly evolving.
• The simplest way to categorize them is through the eyes of the patient.
• Hospital-based care is referred to as inpatient care.
• Care from doctors' offices is referred to as outpatient or ambulatory care.
• Providers of ancillary services are included because of the diagnostic services and pharmaceuticals the care process requires.
• Regulators and payers of care complete the picture.
• Structures vary by country and often by geographic location within a country.

This patient's-eye ordering is also the order the chapter follows, so a question about what comes next in the source is usually answered by walking this list.

Classification by ownership

• A single hospital may be classified in more than one way at the same time; for example private, not-for-profit and specialty.
• Ownership splits into public, meaning government-managed, versus private.
• In public hospitals, governments at national, provincial, state or other level own the facility and are responsible for operations.
• Providers in public hospitals are generally private practitioners, although in some countries they may also be government employees.
• The National Health Service of the United Kingdom and the U.S. Veterans Health Administration are the source's examples of government-employed providers.
• Private hospitals span a broad spectrum of private practitioners or groups of providers, and in some countries are further classified as for profit versus nonprofit.
• For-profit private hospitals are also called investor-owned and often sit within a multihospital system, with varying degrees of interrelationship among the system's hospitals.
• Nonprofit private hospitals are not investor owned; they organize under national and state laws as nonprofit corporations, generally avoiding federal and property taxes.
• Canada's hospitals are almost exclusively private nonprofit organizations, although publicly financed through provincial and territorial governments.
• Just more than half of hospitals in the United States operate as private, nonprofit organizations.

The Canadian example is the load-bearing one. Public financing does not make a hospital public, because ownership and funding are independent axes.

Classification by service, teaching status and geography

• Types of service provided: most hospitals are general hospitals supporting common medical and surgical needs.
• Psychiatric hospitals focus on mental healthcare.
• Rehabilitation hospitals generally focus on restoring neurological and musculoskeletal function following treatment in an acute care facility.
• Children's hospitals focus on the care and treatment of children.
• Teaching status: teaching hospitals train future physicians and other providers in addition to delivering inpatient clinical services.
• Teaching hospitals are often associated with academic institutions and may be further classified as academic medical centers or university hospitals.
• Many teaching institutions also contribute substantially to medical research and publish knowledge that advances medical science.
• Geographic location: urban hospitals sit in large cities, rural hospitals substantially distant from major urban areas with greater resources.
• Operating challenges differ enough between urban and rural settings to require programs of specialization.
• Meeting government standards for urban or rural classification may give hospitals access to special government funding programs.

Specialty hospitals are defined by the function they restore or the population they serve, not by acuity. Rehabilitation follows acute treatment rather than replacing it.

Memory tips

Key concepts

Practice questions

12 items mapped to this lesson: 8 from the diagnostic rebuild and 4 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: patient's-eye categorization of organizations · inpatient and outpatient constructs · multiple simultaneous classification · ownership: public versus private, provider staffing in each · NHS and VHA as government-employer examples · for-profit and investor-owned synonymy · nonprofit tax treatment · Canada's private nonprofit hospitals · U.S. nonprofit share · service classification and the three named specialty types · teaching status and its subclassifications · research and publication role · urban and rural classification and funding access.

Chapter 1 · Healthcare Environment · Lesson 3 of 9

Ambulatory Care, Community Health Organizations and Ancillary Services

Big picture

Walkthrough

The shift to outpatient and ambulatory care

• Care that does not require the intensive management of a hospital setting is generally received in an outpatient or ambulatory setting, most frequently a doctor's office.
• Most primary care, delivered by primary care providers or general practitioners, is provided in the ambulatory setting.
• Most referrals from those providers to clinical specialists for evaluation are also completed in the ambulatory setting.
• The past decade has seen a dramatic shift from acute care to less expensive, more patient-friendly settings.
• Less complicated surgical procedures that once required an overnight stay have moved to the outpatient setting.
• Even major surgeries such as total joint replacement are now routinely performed in an ambulatory surgery center with same-day discharge.
• Urgent care and injury clinics are opening at a tremendous rate in response to demand for flexible hours.
• Nontraditional settings are emerging, including drugstore minute clinics and other walk-in options.
• Patients accustomed to an always-on, always-available experience now demand the same from healthcare.
• Direct appointment booking and virtual visits using video calling apps are proliferating.
• Patients are no longer content to call an office and wait for a callback or wait weeks for a specialist.
• Practices responsive to this model are the ones that will thrive.

The source names three models of outpatient care: single independent provider offices, larger multi-provider group practices with a broader range of specialists, and hospital emergency departments, which it flags as not a preferred approach from an expense perspective.

Community health organizations

• A community generally refers to the specific geographic location in which healthcare is delivered.
• Organizations serving local populations are broadly referred to as community health organizations.
• Community-centered hospitals and clinics provide most of the care available to local populations in most nations.
• Some nations give formal designations that impose both legally constrained definitions and operational characteristics.
• In Canada, a community health center is a key provider of local health services, aspiring to support access and comprehensive care, including health promotion and illness prevention, through a publicly administered process.
• In the United States, community health centers are generally associated with medically underserved areas as defined by the Health Resources and Services Administration.
• U.S. centers strive to provide comprehensive, culturally competent, quality primary healthcare to medically underserved communities and vulnerable populations.
• Small community hospitals in rural areas of the United States may apply for designation as critical access hospitals, which allows higher reimbursement rates.

Two designations, two different tests. The community health center designation turns on serving a medically underserved area; critical access status turns on being a small rural hospital and pays off in reimbursement.

Diagnostic and pharmaceutical services

• Diagnostic services and pharmaceutical treatments are commonly referred to as ancillary services.
• Larger hospitals generally have these capabilities in house.
• Smaller hospitals and outpatient care centers usually rely on external providers of these services.
• Key services in this area are laboratory and anatomic pathology services, diagnostic imaging or radiology services, and pharmacies.
• Close associations with these providers are formed with provider offices and hospitals to ensure effective and comprehensive care delivery.

The reliance on external ancillary providers is what makes results delivery and prescription routing the highest-volume interfaces in an ambulatory practice.

Memory tips

Key concepts

Practice questions

10 items mapped to this lesson: 6 from the diagnostic rebuild and 4 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: definition of the ambulatory setting · primary care and referral location · the decade-long shift from acute to ambulatory · ASC and same-day joint replacement · urgent care growth and nontraditional settings · always-on patient expectations, virtual visits and direct booking · three models of outpatient care including the ED expense caveat · definition of community · Canadian CHC characteristics · U.S. CHC and HRSA underserved-area association · critical access hospital designation and reimbursement · ancillary services and the three named service lines · external reliance by smaller organizations.

Chapter 1 · Healthcare Environment · Lesson 4 of 9

Healthcare Payers

Big picture

Walkthrough

The three sources of payment

• From the delivery organization's perspective, payments come from three types of entities.
• Government-financed and managed programs.
• Insurance programs administered by private entities.
• Personal funds.

The framing is deliberate. These are not three kinds of insurance; they are three kinds of payer, and personal funds is a payer type in its own right.

Government-financed and managed programs

• These programs are generally funded through countries' general taxes.
• Some pay for the healthcare system directly, as in the single-payer NHS of the United Kingdom, which finances hospitals and the salaries of most NHS providers.
• Others fund a national health insurance program, as in Canada, administered through provincial health plans.
• Canadian plans fund hospitals through community trusts and pay providers through the government's insurance program.
• Multipayer systems such as that of the United States are more complex to administer.
• Medicare is federally managed and provides for most healthcare needs of citizens 65 years of age and older.
• Medicaid is a shared-cost federal and state program supporting care for low-income families.
• The Children's Health Insurance Program is another federal and state program covering children of uninsured families that do not qualify for Medicaid.
• Several other programs serve smaller special populations.
• Medicare, Medicaid and CHIP together cover roughly one-third of the U.S. population.

Direct financing and insurance financing are different mechanisms. The NHS pays the providers; Canada insures the patients and pays through plans, which is why the administrative structures differ so much.

Privately administered insurance

• Private insurance programs are generally funded by employers, by citizens themselves, or by a combination of both.
• Germany mandates shared contributions from employers and employees.
• Those German funds are administered by about 1,100 private, nonprofit sickness funds.
• The sickness funds cover more than 90 percent of the German population by paying hospitals and providers.
• In the United States, roughly 55 percent of citizens have employer-based insurance and an additional 11 percent purchase insurance directly.
• Even in many countries with universal programs, people who can afford private insurance are usually allowed to purchase it.
• Private purchase generally allows services not covered under a national benefit structure and may improve access to care.
• When organizations treat privately insured patients, they bill the private entity rather than a government organization.

Germany is the source's example of a mandate that is publicly required but privately administered, which is why it does not belong in the government-program category.

Personal funds and the financial risk of care

• Services are often personally funded by individuals who have government or employer-supported plans, as well as by the uninsured.
• Patient co-payments were not required by many universal coverage programs in the past, but an increasing number of countries are adding them to offset growing costs.
• In the United States, co-payments are required under most programs, whether government or privately managed.
• Persons with higher incomes may choose to avoid insurance constraints and, being able to tolerate the financial risk, pay cash.
• Those who fail to qualify for programs such as Medicaid but cannot afford insurance face premium, nonnegotiated rates.
• A 2019 study found that 66.5 percent of all U.S. bankruptcies from 2013 to 2016 were tied to medical issues.
• 58.5 percent were caused specifically by medical bills; the remainder met medical bankruptcy criteria through income loss related to illness.
• The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, intended to reduce financial risk and make care more affordable and accessible.
• Despite gains in coverage and access, findings suggest the ACA did not change the proportion of bankruptcies with medical causes.

The cash payer and the uninsured patient look alike in a billing system and are opposites in the source's framing. One chooses to carry the risk; the other cannot escape it.

Memory tips

Key concepts

Practice questions

14 items mapped to this lesson: 11 from the diagnostic rebuild and 3 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: the three payer types from the delivery organization's perspective · general tax funding · NHS direct financing · Canadian provincial administration and community trusts · U.S. multipayer complexity · Medicare, Medicaid and CHIP definitions and the one-third coverage figure · private funding sources · German mandate, sickness funds and coverage share · U.S. employer and direct-purchase percentages · supplemental private purchase in universal systems · billing the private entity · personal funding and co-payments · cash payers · nonnegotiated rates for the unqualified uninsured · 2019 bankruptcy findings · ACA date, intent and measured effect.

Chapter 1 · Healthcare Environment · Lesson 5 of 9

Interrelations Within and Across Healthcare Organizations

Big picture

Walkthrough

Why interrelationships exist

• Enabling comprehensive care.
• Assuring effective transfers of care.
• Ensuring the general portability of information in support of care.
• Reporting public and population health information.
• Obtaining appropriate reimbursement for care.
• Supporting particular organizational models of care.

This is a named list of six purposes, and the chapter expands only the first three. The last three are still examinable as members of the set.

Enabling access to comprehensive care services

• Organizations rely on partners inside or outside the organization to deliver comprehensive care.
• Outpatient providers often rely on external laboratory and radiology services for accurate diagnoses.
• They also rely on pharmacy availability to complete the care plan with prescribed medications.
• Without effective communication, increasingly electronic, the care process breaks down and outcomes can suffer.
• This is the area where technology is having the greatest impact.
• Public and private initiatives are in place to facilitate seamless, transparent interchange of patient clinical data.
• Interoperability is the keyword: transferred data must be consumable by the receiving system.
• Consumable data eliminates duplicate data entry and makes information instantly available to the treating provider.

The source sets a specific bar for interoperability. Delivery is not enough; the receiving system has to be able to use what arrives without rekeying it.

Assuring effective transfers of care

• A transfer of care happens when a provider determines the scope of care required is outside his or her capability.
• Communicating health information during the transfer is exceptionally important to patient welfare.
• A complete information set covers the history of the present illness, subjective and objective findings including diagnostic test results, and medications prescribed and administered.
• With that set, the receiving organization advances treatment substantially more efficiently and effectively.
• Without it, time is lost while information is recreated through repetitive evaluation and repeat diagnostic testing, sometimes invasive.
• A U.S. initiative encourages use of Health Level Seven International's Consolidated-Clinical Document Architecture, a standard for electronically transmitting continuity of care information.
• Lost time in an acute patient and repeated invasive tests both carry adverse consequences.
• Not knowing which pharmaceuticals a patient is taking or has been given can be life threatening.
• That risk has led some countries to require that medication reconciliation take place.

Medication reconciliation

• In the United States it is defined as the process of identifying the most accurate list of all medications the patient is taking.
• The list includes name, dosage, frequency and route.
• The process compares the medical record to an external list obtained from the patient, hospital or other provider.

The definition is built on a comparison, so a description that only collects a list without comparing it against the record does not meet the source's definition.

Ensuring the general portability of care

• Patients enrolled with a specific organization still need care elsewhere, including when they travel away from their routine places of care.
• A patient who falls ill or is injured hundreds of miles from home is the scenario the source uses.
• Having correct health information available can powerfully influence outcomes from the clinical intervention.
• The most common example of failure is a new provider who does not know a patient's medication allergies.
• Some nations are implementing national health information exchanges to provide virtual, real-time access to patients' health information.
• Canada Health Infoway is a nonprofit organization made up of the 14 federal, provincial and territorial deputy ministers of health.
• Infoway's vision is healthier Canadians through innovative digital health solutions.
• In the United States, work continues on standards for sharing through state-level HIEs and nationally via the Nationwide Health Information Network and the Nationwide Interoperability Roadmap.
• The United Kingdom has invested heavily in NHS Digital, formerly the Health and Social Care Information Centre, which connects England's healthcare organizations.
• NHS Digital facilitates availability of clinical information shared to support continuity of care and patient safety.

Portability differs from transfer of care in who initiates it. Transfer is a decision by a provider; portability is a patient turning up somewhere no one planned for.

Memory tips

Key concepts

Practice questions

19 items mapped to this lesson: 11 from the diagnostic rebuild and 8 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: the six named purposes of interrelationships · reliance on internal and external partners · lab, radiology and pharmacy dependence · interoperability definition and its two outcomes · trigger and definition of transfer of care · complete transfer information set · consequences of missing information · HL7 C-CDA · medication safety risk · medication reconciliation definition and its four attributes · portability scenario and the allergy example · national HIE purpose · Canada Health Infoway composition and vision · NHIN and Nationwide Interoperability Roadmap · NHS Digital and its former name.

Chapter 1 · Healthcare Environment · Lesson 6 of 9

Roles and Responsibilities of Health Information and Management Systems Professionals

Big picture

Walkthrough

How department size shapes the role

• The number of position titles in the HIM and health IT space is quite large.
• In a single-provider office, one person may perform the broad range of HIM and IT tasks, work less than full-time, or double as the office manager.
• In a large academic medical center or integrated delivery system, the IT department could include more than 100 personnel.
• The top IT position in healthcare organizations is usually the chief information officer.
• The CIO is generally accountable for a broad range of IT activities, including many not directly related to healthcare.
• Those activities include organizational computing rooms, individual desktop computers, telephone communications including mobile, bring your own device and Internet of Things equipment, secure Internet access, local and wide area networks, and the organization's website.

Size is the variable that drives specialization. The same set of tasks exists in both settings; only the number of people it is divided among changes.

Specialized executive roles

• The chief security officer secures computing and communications assets against intentional or unintentional breaches from inside or outside the organization.
• Lead IT security personnel may hold the Certified Information Systems Security Professional credential from ISC2.
• The privacy officer ensures that personally identifiable data, including protected health information, is accessed exclusively by those authorized under law.
• In the United States those laws include the Privacy Act and the Health Insurance Portability and Accountability Act, among others.
• A credential supporting the privacy role is Certified in Healthcare Privacy and Security.
• The chief technology officer is generally responsible for the technical architecture of the IT systems supporting the organization.
• The CTO also watches the developing HIM and IT market to keep the organization competitive technologically, across mobile platforms, cloud-based computing and state-of-the-art clinical applications.

Security protects the asset; privacy governs who may see the data. A stem that names breaches and assets points to the CSO, while a stem that names authorized access and identifiable data points to the privacy officer.

Health information management and clinical informatics roles

• Health information managers have held roles in medical records departments for decades.
• Before electronic health records were commonly available there was not a strong relationship between HIM and IT departments.
• As medical records functions became automated, culminating in advanced EHRs, HIM departments find themselves at the center of IT activities.
• U.S. HIM credentials named are Registered Health Information Administrator and Registered Health Information Technologist.
• The Canadian credential named is Certification in Health Information Management.
• Organizations may rely on the Certified Professional in Healthcare Information and Management Systems credential to confirm a broad base of knowledge and experience.
• The role of clinical informatics professionals is expanding as medicine is increasingly supported by EHRs and other health information systems; Chapter 3 covers it in depth.
• The American Medical Informatics Association advocates advanced training for clinicians to develop a clinical informatics subspecialty in the practice of medicine.
• A frequently used title for such staff is chief medical information officer.
• Popular variants are chief medical informatics officer and chief health information officer.
• In nursing, the equivalent title is chief nursing informatics officer.
• Effective integration of clinical insight into systems solutions grows in importance as IT use in care processes increases.

The automation of medical records is what pulled HIM toward IT. The two departments are described as converging because of the EHR, not because of a reporting-line change.

How an IT organization is structured

Structure varies with organization size, geographical distribution and line of business. The source gives one sample structure a CIO may oversee and one list of common positions, and both are complete named sets.

Functions in a sample CIO organization

• Application development and support.
• Data center operations.
• Database administration.
• Desktop support.
• Information security.
• Network operations.

Common position types

• Desktop support technician.
• Database administrator.
• Programmer or application developer.
• Web developer.
• Network engineer or analyst.
• Systems analyst or administrator.
• Project manager.
• Security analyst.

• Roles may be filled by staff, consultants or contractors.
• The specific roles an organization fills vary with the functions it supports.
• Great variation in the size and structure of IT departments drives the number and specialization of jobs within it.

Memory tips

Key concepts

Practice questions

16 items mapped to this lesson: 9 from the diagnostic rebuild and 7 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: breadth of HIM and IT titles · single-office versus large-organization staffing · CIO scope including non-healthcare activities · CSO role and CISSP · privacy officer role, governing laws and CHPS · CTO architecture and market role · HIM history and convergence with IT · RHIA, RHIT, CHIM and CPHIMS · clinical informatics expansion and the Chapter 3 pointer · AMIA subspecialty advocacy · CMIO and its variants including CNIO · the six sample CIO functions · the eight common position types · staff, consultant or contractor sourcing · drivers of structural variation.

Chapter 1 · Healthcare Environment · Lesson 7 of 9

Government and Healthcare Regulators

Big picture

Walkthrough

Why government is so heavily involved

• Healthcare affects quality of life, longevity and survival after life-threatening disease or accident.
• Delivering high-quality care to very large populations is enormously expensive.
• Those two facts make extensive government oversight and a large number of regulatory bodies unsurprising.
• Most countries continue to see healthcare consume a growing proportion of gross domestic product.
• Governments fear these trends will weaken national economies if not slowed, stopped or reversed.
• Stopping the growth requires exceptionally difficult decisions, because citizens have grown accustomed to existing health benefit programs.

The political difficulty is part of the source's argument, not an aside. Cost control is framed as a problem of withdrawing benefits people already expect.

The spending trend the source cites

• The Peterson Kaiser Health System tracker is the source of the spending comparison.
• Over the past four decades the gap between U.S. health spending as a share of the economy and that of comparable OECD countries has widened.
• In 1970 the United States spent about 6 percent of GDP on health, similar to several comparable countries, whose average was 5 percent.
• The United States was relatively on pace with other countries until the 1980s.
• From the 1980s its health spending grew significantly faster relative to GDP.
• In 2017 the United States spent 17 percent of GDP on health consumption.
• The next highest comparable country, Switzerland, devoted 12 percent.
• The source concludes that healthcare is consuming national economies at an unsustainable rate, making government engagement essential.

Four numbers and one turning point carry this topic. The decade of divergence matters as much as the percentages, because it dates the problem the later reforms respond to.

Government responses to cost growth

• Australia: enhancements to the primary care delivery system to manage chronic diseases more effectively.
• Canada: experimentation with privatization.
• Germany: global budgeting and competition among sickness funds.
• Japan: requiring long-term care residents to pay for room and board.
• United Kingdom: consideration of pro-market reforms.
• United States: encouragement of accountable care organizations with a goal of better health outcomes at lower cost.
• Such trends will continue as nations balance quality, access, cost and safety for the greatest proportion of their populations.

Healthcare regulators

• Regulatory agencies generally implement the provisions of a nation's health laws through a more explicit system of regulations.
• In the United Kingdom, the Health and Care Professions Council is the statutory regulator for 15 professions covering nearly 290,000 health and care professionals.
• The HCPC maintains standards of proficiency and conduct for the professions it regulates.
• In the United States, the dominating regulatory entity is CMS.
• CMS drafts rules and finalizes regulations for multiple federally subsidized healthcare programs through a complex rulemaking process involving public engagement.
• The Food and Drug Administration evaluates and approves medical devices and new drugs used in treatment.
• In Canada, medical devices are regulated by Health Canada's Therapeutic Products Directorate.
• It is a common belief that regulatory organizations are always government entities, but private-sector organizations, commissions and associations may also act in a regulatory capacity.

The last bullet is the one the exam leans on. Any option asserting that regulators are exclusively governmental contradicts the source directly.

Memory tips

Key concepts

Practice questions

7 items mapped to this lesson: 4 from the diagnostic rebuild and 3 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: rationale for government oversight · GDP growth concern and its political difficulty · Peterson Kaiser figures for 1970, the 1980s divergence and 2017, with the Switzerland comparison · unsustainability conclusion · six national cost responses by country · ACO goal · definition of regulatory agency function · HCPC scope and numbers · CMS rulemaking · FDA and Therapeutic Products Directorate · correction of the belief that regulators are always government entities.

Chapter 1 · Healthcare Environment · Lesson 8 of 9

Professional Associations and Accreditation Organizations

Big picture

Walkthrough

What a profession and an association are

• Merriam-Webster defines a profession as a calling requiring specialized knowledge and often long and intensive academic preparation.
• Professional associations in healthcare have proliferated greatly, many serving in a semi-regulatory role.
• The College of Kinesiologists of Ontario provides the description the source uses.
• The primary role of an association is to advocate on behalf of its members and promote the profession.

What associations may do

• Advocate with policy makers in the interest of members.
• Market and promote the profession.
• Provide continuing professional development opportunities.
• Represent members' interests by monitoring developments that may affect scope of practice and employment opportunities, and by enhancing relationships with related professionals.

What regulatory bodies may do

• Set requirements for entry to the profession.
• Maintain a list of individuals eligible to practice.
• Develop standards of practice.
• Receive and investigate complaints about professional practice and administer appropriate disciplinary action when necessary.
• Require professionals to participate in continuing professional development.

The two lists share activities that sound alike, so the deciding question is who is served. An association serves its members; a regulatory body exists to protect the public by regulating the profession.

Table 1.1: associations related to healthcare and healthcare IT

The source splits the table into clinical associations and administrative or IT associations. Six appear in each column, and the exam tests the acronym-to-name pairing more than the column itself.

Accreditation organizations and deemed compliance

• Accreditation organizations have substantial interactions with healthcare organizations.
• They generally play a semi-regulatory role, often serving on behalf of federal organizations to ensure specific standards or conditions of participation are met.
• The Joint Commission and Joint Commission International are perhaps the most recognized accreditors for certification of hospitals in the United States and internationally.
• Joint Commission International currently operates in more than 100 countries.
• In the United States, the accreditation organizations under CMS are very visible examples.
• CMS accreditors determine compliance with Medicare conditions of participation.
• When an organization is certified by a CMS accreditor for compliance, it is deemed to have met the requirements.
• A deemed organization may then bill CMS for covered services.
• A number of other organizations are authorized to act as accreditors for participation in Medicare programs.

The phrase serving on behalf of federal organizations is what makes the role semi-regulatory, and it is also the mechanism behind deemed status. A private body's survey substitutes for a federal one.

Table 1.2: CMS-approved accreditation organizations

• The Joint Commission covers the broadest range of program types in the table.
• Several accreditors are single-program, including CIHQ, IMQ, NDAC and TCT.
• The interrelationships among government agencies, regulators, professional associations and accreditors can be surprisingly complex.
• The source illustrates that complexity with the organizations involved in a physician assistant's path from training into practice.

Memory tips

Key concepts

Practice questions

17 items mapped to this lesson: 11 from the diagnostic rebuild and 6 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: definition of a profession · proliferation and semi-regulatory role of associations · the four association activities · the five regulatory body activities and the public protection purpose · Table 1.1 clinical and administrative or IT associations · accreditor interactions and semi-regulatory basis · Joint Commission and JCI recognition and JCI's country reach · CMS accreditors and conditions of participation · deemed compliance and billing consequence · Table 1.2 organizations and program types · complexity of interrelationships illustrated by the physician assistant pathway.

Chapter 1 · Healthcare Environment · Lesson 9 of 9

Technology Trends and Patient Outcomes

Big picture

Walkthrough

The move from encounters to population impact

• Healthcare practice is increasingly focused on activities with the greatest impact on the overall health of communities and patient populations.
• A state of health is not best achieved by limiting engagement to office visits and hospital admissions.
• Engagement extends to wellness encounters with nonphysician healthcare providers.
• It extends to virtual encounters through telehealth or mobile health technologies.
• It extends to safety and preventive care outreach programs.
• Reporting public and population health information is one of the named purposes of interrelationships among organizations.
• The strain of healthcare costs on national economies forces continual reevaluation of the delivery paradigm to optimize outcomes at an affordable cost.

Population-level work is defined by who is being managed rather than by the technology used. The unit of attention moves from the visit to the group, and prevention and outreach become the work.

Consumer expectations and virtual access

• Patients are accustomed to an always-on, always-available experience and demand it from healthcare.
• That expectation is credited with the proliferation of direct appointment booking and virtual visits using video calling apps.
• Patients are no longer content to call an office and wait for a callback, or to wait weeks to see a specialist.
• Urgent care and injury clinics are opening rapidly in response to demand for flexible hours.
• Nontraditional settings such as drugstore minute clinics and walk-in options are emerging.
• Practices responsive to this new model are the ones that will thrive.

The driver named here is patient expectation, not payer mandate or regulation. Options that attribute virtual care growth to reimbursement rules or accreditation standards are substituting a plausible cause for the stated one.

Demonstrating the value of health IT

• Health IT carries the burden of demonstrating the value of the technology, alongside the quality, access and cost pressures everyone faces.
• Value is shown through measured effect on outcomes, access and cost rather than through acquisition of new technology.
• Improving one pillar requires trade-offs against the others, so a gain has to be assessed across all four.
• Advances in automation, including inexpensive data storage, increasing network capacities and simplified software programming tools, will let professionals simplify work for those who deliver care.
• The mechanism is transferring much of the information processing requirement to automated tools.

The summary's claim is specific about how technology helps. It reduces the information handling burden carried by clinicians rather than adding capability for its own sake.

Memory tips

Key concepts

Practice questions

11 items mapped to this lesson: 4 from the diagnostic rebuild and 7 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: focus on community and population impact · extension of encounters to wellness, virtual and outreach settings · public and population health reporting as an interrelationship purpose · cost pressure driving reevaluation of the delivery paradigm · always-on patient expectations and their effect on booking and virtual visits · growth of urgent care and nontraditional settings · the value pillar obligation on health IT · trade-offs among pillars · summary claims on automation advances and transfer of information processing.

Chapter 2 · Technology Environment · Lesson 1 of 9

The Three Components of the Technology Environment

Big picture

Walkthrough

Where healthcare IT stands today

• Healthcare adopted information technology more slowly than other industries.
• The electronic health record is now an essential part of every facility that provides patient care, from population health to the intensive care unit.
• Most hospitals and outpatient sites run one wireless network for staff and a separate network for family and visitors.
• Patients update social media, review care plans from the hospital bed and check in for outpatient visits from smartphones.
• Institutions that once banned staff social network use now employ staff to monitor and update social media sites.
• Many patients keep personal health records online and also have portal access through the facility's EHR.

Understanding the attributes of healthcare IT, and the applications and hardware needed to use them, is presented as essential to improving care and its safety.

The three components

• Applications: the software used by administrative, clinical and support staff to process and store data, manage patients' records, and provide information and knowledge.
• Hardware: the actual servers, whether virtual, cloud or physical, plus network connections and the devices used to access and generate information.
• Networks: the wired or wireless connections that link the infrastructure together and enable accessibility of the applications and patient data.
• A healthcare facility requires all three components to function.
• The sections of these components change frequently with rapid technology change and software improvement.
• Decreased access time and increased processor and hard drive speed return processed data to the requesting clinician more quickly.
• Technology changes both support and change the applications and their functions.

The source flags its own lists as overviews rather than complete inventories, which matters when a question asks what the guide names rather than what exists in the market.

Memory tips

Key concepts

Practice questions

2 items mapped to this lesson: 1 from the diagnostic rebuild and 1 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: slower healthcare IT adoption · the EHR as essential across settings · separate staff and visitor networks · patient use of devices and portals · the three components and their definitions · all three required to function · effect of speed improvements on clinician response · the guide's lists as overviews rather than complete listings.

Chapter 2 · Technology Environment · Lesson 2 of 9

Clinical Applications

Big picture

Walkthrough

EMR, EHR and PHR

• The EMR is the continuous, longitudinal electronic record in one specific setting, such as a provider's office, a hospital or a home healthcare service.
• The EHR is a longitudinal record covering multiple settings over time.
• The PHR is a medical record often created, edited, maintained and controlled by the patient.
• A PHR may include importation of clinical data from other sources.
• PHRs are often created online and are accessible to providers when the patient invites them to review information using secure access.

The three terms are described as seeming interchangeable while carrying different meanings, which is exactly why they appear as competing options.

What the EHR does and what it connects to

• Clinical applications support patient care wherever it is delivered, and the most apparent one is the EHR.
• In some institutions the EHR is a one-vendor application; in others it is best of breed, with many different vendor applications performing different functions.
• Clinicians use the EHR to document care from medication administration to order entry, and to retrieve lab and radiology data.
• Provider offices can send electronic prescriptions to the pharmacy and import or export data from inpatient stays or outpatient testing through a health information exchange.
• EHR systems can execute algorithms that stratify clinical and operational activities.
• Data points driving those prediction models range from vital signs and lab results to the number of no shows for outpatient visits.
• Enterprise EHRs may include population health capabilities, clinical specialty modules and integration with outside regulatory and public health systems.

Best of breed is a configuration choice, not a defect. It buys departmental fit and pays for it in the number of interfaces the organization has to maintain.

Specialty systems, PACS and the case for interoperability

• The EHR interfaces with specialized systems in different departments.
• In the United States, radiology and pathology formatting and data display are governed by accrediting agencies including Clinical Laboratory Improvement Amendments, the College of American Pathologists and the American College of Radiology.
• In Europe, the European Cooperation for Accreditation covers laboratory certifications.
• Dietitians, case managers and social workers have specific software functionality needs, often dictated by professional or regulatory standards.
• Areas with specialized documentation and information needs include the perinatal areas of labor and delivery, nursery, neonatal intensive care and postpartum.
• They also include the perioperative areas of preoperative unit, operating rooms and post anesthesia care unit, plus critical care units, outpatient primary care centers and special functions such as renal dialysis.
• The picture archiving and communication system stores and displays images from ultrasound to computed tomography and magnetic resonance imaging.
• PACS requires fine-resolution monitors, large storage drives, good bandwidth and large amounts of random access memory for image display.
• Some major EHR vendors support all specialty areas; others require purchase and interface of a niche system for each specialty.
• The goal of all these systems is to communicate and exchange patient health information, known as interoperability.
• Data should not be entered into systems more than one time.
• Images available in the EHR save clinician time and institutional money, since no films are created, stored or retrieved.
• Perinatal systems archive fetal monitor strips electronically, saving thousands of dollars in paper strip storage charges.

Memory tips

Key concepts

Practice questions

7 items mapped to this lesson: 4 from the diagnostic rebuild and 3 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: EMR, EHR and PHR definitions and their confusability · single-vendor versus best of breed · EHR documentation and retrieval uses · e-prescribing and HIE import and export · stratification algorithms and their data points · enterprise EHR capabilities · accrediting agencies governing lab and imaging display · other disciplines' functionality needs · named perinatal, perioperative and other specialized areas · PACS function and hardware demands · niche system interfacing · interoperability goal and the single-entry rule · savings from images in the EHR and electronic fetal strip archiving.

Chapter 2 · Technology Environment · Lesson 3 of 9

Administrative and Financial Applications

Big picture

Walkthrough

Administrative applications

• Administrative applications support clinicians as well as administrative staff.
• They run from electronic time cards, intranet, payroll, staff competency record keeping and educational applications to scheduling.
• Scheduling covers both staff for work shifts and patients for procedures and office visits.
• Bed management systems include housekeeping and patient transportation staff as well as clinicians, and help get patients into a room as soon as possible.
• Equipment-tracking applications using radio frequency identification save staff time otherwise spent hunting for equipment.
• Web-based applications that let staff bid for understaffed shifts reduce overtime labor costs and increase staff satisfaction, as do self-scheduling systems.

Financial applications and practice management

• Financial applications cover all the features of any organization's financial needs, with more variables than most businesses.
• Multiple regulations govern how billing is done, how bills are submitted and what details must accompany a bill, such as diagnosis codes and providers' licenses and billing numbers.
• Systems must handle charge posting through both orders and manual charge entry, payment posting and billing based on the providers.
• Insurance, coinsurance and deductibles enter the calculations, as do revenue codes, supplies, tests and medications.
• Items requiring a provider's order that cannot be billed without one must be distinguished from items that do not require an order.
• Statements go to patients and claims go to insurance companies.
• These billing systems are commonly referred to as practice management systems.

The order requirement distinction is a billing rule enforced in software. If the system cannot tell the two item types apart, the organization bills for something it may not bill for.

General ledger, payroll and supply chain

• A general ledger must accurately track charges, bills and payments.
• Payroll must accept data from the electronic time card system and convert it to salary costs.
• It must correctly match regular and overtime hours worked and calculate overtime pay, holiday bonuses, shift differentials and additional wages earned from professional certifications.
• Payroll also tracks earnings for paid time off, usually based on hours worked.
• Accounts payable must stay in sync with all other systems, and financial systems have to communicate in real time.
• The supply chain function must include all methods of supply purchasing and invoice payment, correctly linked.

Memory tips

Key concepts

Practice questions

6 items mapped to this lesson: 3 from the diagnostic rebuild and 3 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: scope of administrative applications · scheduling of staff and patients · bed management participants · RFID equipment tracking · shift bidding and self-scheduling effects · regulatory complexity of billing · charge and payment posting mechanics · order-required versus non-order billing distinction · statements and claims · practice management naming · general ledger duties · payroll calculation elements · accounts payable synchronization and real-time communication · supply chain purchasing and invoice linkage.

Chapter 2 · Technology Environment · Lesson 4 of 9

Consumer Applications

Big picture

Walkthrough

Portals and patient ownership of the record

• Consumers are increasingly involved in electronic records and their own health information.
• Patients not infrequently request electronic versions of their charts from providers.
• The question of who owns the medical record appears to have been decided in the patient's favor.
• Most EHRs have a patient portal that lets patients view test results and clinical notes, request prescription refills, send secure e-mail to the provider or office staff and schedule appointments.
• Some portals permit patients to add comments or request amendments to their EHR.

Personal health records

• Some PHRs are standalone and not connected with an institution's EHR.
• They may be web based, installed on the user's computer, or a mobile app.
• CMS encourages PHR use and links to Blue Button, a PHR initiative that originated through the Veteran's Administration and is now offered through other organizations' patient portals.
• The National Committee on Vital and Health Statistics provides detailed information on PHR advantages.
• Web-based PHRs give the patient full control of the record's contents and often allow import of prescription medication history from national drug store chains or results from laboratories.
• Some healthcare organizations have partnered with web-based PHR vendors and uploaded records into patients' PHR applications.
• Some healthcare insurers allow PHR creation from their websites.
• A California Health Care Foundation national survey provides evidence that PHRs support patients in improving their own health.
• Caregivers in that survey noted PHRs were almost a necessity for maintaining knowledge and continuity of care for family members with multiple chronic conditions.
• Most patients want to use PHRs that their physician or insurer provides.
• The survey identified security as the major stumbling block to PHR adoption, with patients looking for evidence that entered information is completely secure.
• Most sites explain how privacy and security are maintained and let patients decide who may view information, often through a secure URL or a separate login and password for the provider.
• Patients who established a PHR through an insurer or third party have found information could not be easily transferred to a different PHR, forcing reentry of data.
• PHR use has increased with medical home and accountable care platforms, which incentivize keeping patients healthy.
• In-home health monitoring systems and wearable devices have intensified the need for PHRs.

The NHS Summary Care Record

• The SCR is an electronic summary of key clinical information including medicines, allergies and adverse reactions, sourced from the general practitioner record.
• Authorized healthcare professionals use it with the patient's consent to support care and treatment.
• Registration with a GP practice in England creates an SCR automatically unless the patient has opted out, and 98 percent of practices now use the system.
• The SCR is uploaded to the Spine, a set of national services used by the NHS Care Record Service.
• The Personal Demographics Service stores demographic information and the NHS number, and patients cannot opt out of it.
• The Secondary Uses Service uses record data to provide anonymized and pseudonymised business reports and statistics for research, planning and public health delivery.

Secure messaging and record access

• Patients are very interested in communicating electronically with their providers.
• Doctors are described as far behind the rest of the world in using electronic communication.
• Patient portals or secure messaging applications can provide the needed security.
• Most patient issues can be addressed by office staff in e-mail, leaving only a few for the physician or nurse practitioner.
• Both sides of the communication have to be secure, and web-based and application-driven tools can supply security and convenience where providers lack the skill to build it.
• Providing human-readable medical records in electronic format is new to healthcare.
• In the past, patients went to health information management, completed paperwork and often paid a per-page fee for a paper copy.
• Stage 1 of CMS Meaningful Use requires a copy of the medical record be available to the patient within 24 hours of request.
• Delivery may be by flash drive or pushed through an existing patient portal.
• Regardless of regulation, informed patients want copies of their records.

Memory tips

Key concepts

Practice questions

4 items mapped to this lesson: 3 from the diagnostic rebuild and 1 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: consumer involvement and chart requests · record ownership decided in the patient's favor · portal functions including amendment requests · standalone PHR forms · CMS encouragement and Blue Button origin · NCVHS information · web PHR control and data import · organization and insurer PHR partnerships · CHCF survey evidence, caregiver finding, preference and the security barrier · viewing controls · PHR portability difficulty · medical home and ACO effect · monitoring and wearable drivers · SCR content, consent, opt out and 98 percent figure · Spine, PDS and SUS · secure messaging volume and security requirement · human-readable access and the Meaningful Use 24-hour rule.

Chapter 2 · Technology Environment · Lesson 5 of 9

Clinical Business Intelligence and Analytics

Big picture

Walkthrough

The HIMSS CBI definition and its uses

• The HIMSS Clinical and Business Intelligence Committee defines CBI as technologies, applications and practices for the collection, integration, analysis and presentation of clinical information.
• The stated purpose of CBI is better clinical decision-making.
• Quality in healthcare is described as being shaped by evidence-based medicine and proper utilization of data.
• CBI tools support clinicians in improving patient safety and patient care.
• They also analyze operating room use and staff overtime patterns.
• Collecting and reporting data meaningfully supports direct patient care and all aspects of healthcare, including predictive analytics.
• Hospitals and providers both want to show they deliver high-quality, low-cost care, and data analysis is the only key to showing it.
• Organizations implement CBI through specific applications or by constructing data warehouses.
• They use it to document care delivered, show trends in patient conditions and document improvements in patient status and population health outcomes.

Memory tips

Key concepts

Practice questions

1 item mapped to this lesson: 1 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: the HIMSS CBI definition and its purpose clause · evidence-based medicine and data utilization shaping quality · clinical and operational uses of CBI tools · predictive analytics · the demonstration of high-quality, low-cost care · implementation through applications or data warehouses · documentation of trends, patient status and population health outcomes.

Chapter 2 · Technology Environment · Lesson 6 of 9

Hardware: Infrastructure, Servers, Storage and Devices

Big picture

Walkthrough

Technology infrastructure and servers

• Hardware systems store data, run applications and connect applications and tools together.
• Physical routers, switches and virtual and physical servers connect clinicians, administrators, providers and patients to clinical systems, information and support.
• Firewalls, both physical and software based, along with virus scanning systems, protect the network from unauthorized access and maintain information security.
• Most healthcare IT departments run virtual, physical and cloud servers.
• Which type of server an application is installed on is determined by the vendor's recommendations and by the organization's capability to support the technology.
• Servers are among the most expensive equipment in a healthcare IT shop and must be managed well.
• Cloud computing offers cost-effective options for organizations lacking the space, resources or desire to house and maintain data in-house.

Data storage and retention

• Regulations set how long patient data must be maintained, depending on the type of patient.
• Many healthcare organizations are resigned to keeping charts forever.
• With paper records, permanent retention means large sums spent storing paper that will probably never be read again.
• Organizations historically stored paper charts off-site and ordered them when needed, adding transportation costs.
• Some health systems scan paper charts and then appropriately dispose of the paper.
• EHRs have reduced or eliminated the need for paper chart storage.
• Current practice for storing, backing up and archiving data is changing, often to the cloud.
• The cloud can provide room for storage even when needs double every few years.

Mobile devices and BYOD

• Hardware must be designed to support clinical workflow, which increasingly means portable devices and wireless connectivity.
• Institutions use workstations on wheels with wireless access as well as smaller handheld devices.
• Workstations can be configured with drawers for storage, holders for barcode medication scanners and locked drawers for medication security.
• Other workstations are designed for outpatient clinics with no need for drawers or scanners, and some carry mounted medical devices.
• Standardization may be a goal, but one documentation device will likely not meet every area or end user need.
• Smartphone popularity and functionality prompt end users to ask for similar devices in healthcare units.
• Most EHR vendors have updated their applications for handheld devices.
• Touchscreen devices are being configured for healthcare with attention to infection control when equipment is touched by gloved hands.
• Devices such as MRI scanners use touchscreens to program examinations and review images.
• Security is a major concern with any handheld device connecting to the institution's network, especially when users bring their own.
• Before permitting personal device use in clinical areas, establish a policy ensuring protected health information is safe, that the institution can wipe a compromised device and that passwords are required.
• Permitting data storage on a personal device must depend on maintaining the data's security.

Medical devices and their regulation

• Physiologic devices such as cardiac monitors, ventilators, some IV fluid pumps, medication pumps and vital sign monitors can send out the data they obtain, often in HL7 format.
• Integration with the EHR decreases data entry and transcription errors and saves time.
• Data may go directly to preconfigured fields, or a third-party device may translate it into EHR-acceptable format.
• Clinician validation of the information is required before data is permanently stored in the EHR.
• Laboratory devices conduct tests and export information to the EHR.
• Radiologic images are typically stored in a PACS and viewed through a link from the EHR to the image in PACS or the enterprise imaging system.
• In the United States the Food and Drug Administration regulates medical devices, so IT must know the FDA laws and regulations applying to IT-supported hardware and software.
• FDA coverage includes displays of physiologic data such as heart rhythms, fetal monitor tracings, ventilator or heart waveforms, and implantable devices such as automatic cardiac defibrillators.
• The FDA also regulates mobile medical apps, such as those displaying fetal heart tracings or cardiac waveforms on physicians' cell phones.
• The biomedical engineering department must work closely with IT to maintain these systems.
• In Europe, the Parliament and the Council of the European Union have developed directives for medical devices and in vitro diagnostics.
• Canada and Japan have medical device regulations, and in Russia the Ministry of Public Health and Social Development controls medical devices.
• The WHO reports that 65 percent of 145 countries have an authority responsible for implementing and enforcing medical device specific product information.

Validation before permanent storage is the clinical safeguard on device integration. Automated capture removes transcription error, not the need for a human to confirm the value belongs to this patient at this time.

Memory tips

Key concepts

Practice questions

4 items mapped to this lesson: 2 from the diagnostic rebuild and 2 from the canonical pool. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.

Source fidelity

Covered from the source: hardware's role and the named infrastructure components · firewalls and virus scanning · three server types and placement criteria · server cost and cloud alternatives · retention regulation and permanent chart keeping · off-site paper storage, scanning and EHR effect · cloud-based storage growth · workflow-driven mobile hardware · WOW configurations and area differences · handheld and touchscreen adoption and infection control · BYOD risk and the three policy elements · physiologic device data in HL7 and the validation requirement · lab device export and PACS viewing · FDA scope including mobile medical apps · biomedical engineering partnership · EU, Canadian, Japanese and Russian regulation · the WHO 65 percent figure.

Chapter 2 · Technology Environment · Lesson 7 of 9

Networks and Communications

Big picture

Walkthrough

Network infrastructure

• The network remains dependent on cables while increasingly connected using wireless access points.
• Putting information at the point of care requires wireless access points rather than physical wires.
• Clinicians do not accept walking from the patient's room back to the nurse's station to log in and retrieve results.
• Providers can take the electronic chart into the room and review lab results, x-ray reports and other tests with the patient.
• Virtual private networks and voice over Internet protocol use fiber-optic and coaxial cables and supporting protocols governing router and switch connections.
• Local area networks use Ethernet and token ring; wide area networks use multiprotocol label switching or asynchronous transfer mode.
• VPN technology is a safer, more secure method of providing remote access to an organization's network and servers.
• VPNs use tunneling protocols and encryption and require authentication to block unauthorized users.
• Regulatory bodies, professional organizations and standards require documentation about patients, the care given and procedures performed.
• A major EHR requirement is supporting the documentation, order entry and lab results reporting that regulations, professional standards and patient need demand.
• Care documented when and where it is provided reduces errors.
• Cabled access to the intranet and Internet is more reliable and faster.
• Many institutions already have cable installed from before wireless met their price and speed requirements.
• Clinical, administrative and support departments usually have hardwired desktop computers, and some outpatient settings install a fixed device in each exam room.
• Radiology examination rooms need larger, high-resolution monitors and high-speed graphic cards supporting detailed images.
• Hardware in patient care areas has to be cleaned with appropriate cleansing agents.

Communications

• Healthcare IT uses many data communication protocols and media, from standard telephone landlines with conferencing and video capability to devices using VoIP and broadband access.
• Data communication protocols allow information to transmit from one point or medium to another, the telephone being the most common example.
• Some devices look like ordinary cell phones, while others are clip-on, hands-free phones worn by staff.
• Infection control is a major concern, so device materials need to be antibacterial and cleanable.
• Some devices send and receive text messages, but there are concerns about the security of text messages for patient orders, and not all providers want to use them for orders.
• Bifurcated workflows of that kind can result in missed patient care.
• Other communication protocol examples include broadband access, Ethernet and Wi-Fi for transmitting data across networks or accessing the Internet.

The warning about bifurcated workflow is the point worth carrying. A second, informal channel for orders means the record no longer holds the whole story.

Memory tips

Key concepts

Practice questions

4 items mapped to this lesson: 4 from the diagnostic rebuild. Answer, then check. The trap family in the feedback is the thing to log, not the miss itself.