Which data elements of the patient record are considered protected health information (PHI) and which record types across the EHR system are considered PHI? Provide reasoning and examples.
Protected Health Information (PHI) and EHR
Protected Health Information (PHI) is also known as personal health information. Some of the data elements that are considered PHI include demographic information, mental health conditions, insurance information, lab results among data that is collected by healthcare professionals for identification of an individual and come up with the required care (Baumann, Baker, Elshaug, 2018). Health Insurance Portability and Accountability act of 1996 is the principal law that helps in overseeing the use, access to disclosure of PHI in the US. It defines data that relates to the past, present future health information of a patient. It also outlines the provision and payment of healthcare to a patient.
Healthcare entails dealing with some of the sensitive information about a patient such as the date of birth, medical conditions as well as insurance claims. Regardless of whether the information about a patient is stored on paper or in an electronic health record (EHR), PHI will always explain the medical history of a patient. This may include ailments, treatment methods, and the resultant outcome (Akhu-Zaheya, Al-Maaitah, Hani, 2018).
EHR consolidate patients’ medical chart into digital documents. They are updated and can be accessed in real-time by authorized users in a digital way. HER contains information about the medical history of patients, the type of medications patients have received, allergies, radiology images, and information about treatment plans required for patients (Snowden, Kolb, 2017). HER also provides physicians as well as care providers with tools necessary to help them in coming up with decisions about the care of patients. This, therefore, implies that the HER systems that are considered PHI are protected health information that is in digital form.
Baumann, L.A.; Baker, J.; Elshaug, A.G. (2018). The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy 2018, 122, 827–836
Akhu-Zaheya, L.; Al-Maaitah, R.; Hani, S.B. (2018). Quality of nursing documentation: Paper-based health records versus electronic-based health records. J. Clin. Nurs. 2018, 27, e578–e589
Snowden, A.; Kolb, H. (2017). Two years of unintended consequences: Introducing an electronic health record system in a hospice in Scotland. J. Clin. Nurs. 2017, 26, 1414–1427