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rivacy can be distinguished as an individual’s right to be free from observation and to limit access to their personal health care information. Confidentiality in terms of healthcare is the presumption that one’s personal information will not be used in any other format other than to aid in treatment for its intended purpose and not disclosed otherwise. Security is the system in place to ensure the confidential and private information of patients remains safe and undistributed to outside entities (Wager et al., p. 288, 2017). HIPAA has impacted health care information systems immensely in the sense that prior to HIPAA, there were no federal regulations from one program that enforced privacy and security for patient information. Starting in 1996, legislation required health care systems to follow a set of rules designed to protect personal health information.
There is an increased need to identify and discuss resources that are available to improve cybersecurity in health organizations because outside threats such as human tampering, environmental disasters, and technological malfunctions can damage, steal or tamper with important patient health information that is private ( Bhartiya et al., 2013). Outside human tampering can steal patient information through the form of malware and hacking. These forms of tampering can ruin technological infrastructure and compromise the security of patients. Now more than ever, data has become extremely valuable and health data can be sold for a lot of money making PHI very sought after. In addition to human tampering, information can be damaged by flooding, hurricanes, and fires. When EHR hard drives are permanently damaged by these factors, PHI is at risk of being lost or damaged. Lastly, there are technological malfunctions that may cause damage to hard drives or loss of data. This can be seen during internet outages, failure for successful backups, and improper storing and retrieval of data.
Licensure, certification, and accreditation in relation to health care are the processes in place to ensure that healthcare organizations are up to standards. Specifically, these processes are needed to operate, file with Medicare and Medicaid services, and demonstrate quality performance. Licensure maintains that an organization is able to legally operate. State governments regulate the licensure process for facilities and are dependent on the state’s specific rules and regulations. These rules and regulations set up minimum standards for physical infrastructure, personal, and equipment quality. Licensure of an organization is required before a healthcare organization opens its doors to patients. Certification is the process that an organization goes through to be enrolled in federal Medicare and Medicaid programs. Medicare and Medicaid set the standard for health care organizations nationally and in order to be reimbursed by their programs, it requires facilities to follow conditions of participation (CoPs). Lastly, there is accreditation which is a voluntary process where organizations pay for an accrediting agency to recognize that the organization is meeting performance standards (Accreditation of Medicare Certified Providers and Suppliers, 2020). An example of this agency is the National Committee for Quality Assurance or NCQA. This accreditation organization has been determined to identify standards of an accredited program to a standard that CMS agrees upon and therefore exempts accredited programs from surveys by the state agencies.
As an administrator, it is important to ensure the quality of care in your organization. I would personally measure quality based on how safe, efficient, patient-centered, timely, efficient and equitable the organization is (Wager et al., p. 335). In order to measure these factors, I would analyze data from my organization to evaluate the quality in each area. This information would come from qualitative data, health records, public health registries, and administrative data. While there are many programs that define standards for quality of care, I feel that it is important to have a holistic plan of how to promote high-quality care and take many factors into curating a standard for excellence.
Three important and related concepts are often used interchangeably in discussing the protection of health information within the U.S. healthcare system: confidentiality, privacy, and security. Yet, each of these concepts has a different fundamental meaning and unique role. (“Patient Confidentiality and Privacy in Healthcare I UIC Online”, 2021). Privacy protects a person’s right to control the information that the organization collects, maintains, and shares with others. Confidentiality controls prevent the unauthorized use of information already held by an organization and security refers to protection against the unauthorized access of data. Health professionals have a moral obligation to protect the confidentiality of their patients. A healthcare system with strong privacy systems will increase public confidence in healthcare service. HIPAA ensures that all information shared, created, transmitted, or sorted by providers and health plans is subject to strict security controls. Patients can also control who gets their information and to whom. Cyber security is important because it protects all categories of data from theft and damage and all categories of data from theft and damage. To ensure cyber security, a healthcare organization must: Use strong passwords, use security tools like malware bytes, Upgrade programs and systems regularly and Use security software, etc. (“Why is Cybersecurity Important? | UpGuard”, 2021)
Certification, accreditation, and licensure are all professional development opportunities for students and health care workers who want to improve their knowledge and skills in the health care industry. Licensure is provided by government authority and usually includes an academic component. Accreditation is how facilities show their level of quality and commitment to being the best in their field. Licensure and accreditation will act as a lever for ensuring that practicing health professionals meet specific criteria and continue to maintain competence in a specific content area. The primary responsibility of the health care manager/administrator is to foster an environment that can provide necessary and quality healthcare at maximum profit. To ensure the quality of healthcare, the healthcare manager: Set goals and commit to ongoing evaluation, College data and analyze patient’s outcomes, focus on patient’s engagement, and ensure quality services, etc.