Create a report that includes the following items:
Question 1. Review the IoM’s 1999 and 2001 reports (ATTACHED).
- Compare and contrast the recommendations in these reports.
- Evaluate the outcomes of their implementation and assess their impact on healthcare quality improvement (familiarize yourself with Quality Improvement points – https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Measure-and-Quality-Improvement-).
- Ascertain the consequences of not using HIT and frame your recommendations for improvement of healthcare quality using HIT?
Question 2. HIPAA (1996) and HITECH (2009) Acts contain provisions for the protection of health information both by Covered Entities (CEs) and Business Associates (BAs).
- Compare Security Rule provisions for CEs and BAs in both Acts?
- Identify the organization responsible for monitoring its compliance by providers and explain its mode of operation. Ascertain the value of the Security Rule provisions for electronic health records.
- Finally, assess implications for noncompliance of the Security Rule provisions by healthcare organizations?
Question 3. Develop an example case that can be used in the presentations where a Chief Information Security Officer (CISO) at a local healthcare facility has not adopted any Password use policy yet.
- Delineate the role of CISO in the implementation of the password use policy.
- Offer approaches to developing a Password use policy for this organization.
Tips: Identify and discuss at least three (3) essential components of the password use policy that must be followed to securely log into the facility’s healthcare information systems. Explain which of these components is most critical and why. Ascertain implications for the organization if the policy is not followed strictly.
Question 1 & 2 should be in tabular/narrative format. Question 3 should be presented in narrative format. Please include introduction and conclusion. Title and Reference Page. All supportive evidence should be formatted in APA 7th Edition.
Question 4. You have been asked to address the following items:
Narrative Brief: To propose training methods that can work for three categories of employees: clinicians, administrators, and staff at a local healthcare facility that has just transitioned from paper-based medical record to Electronic Health Record (EHR).
- Evaluate the appropriateness of three training methods (one-to-one, workshops, computerized or web-based self-paced) for these three categories of staff (clinicians, administrators, staff).
- Assess the need for contents to be covered for training of each category of employee (keep in mind their duties and functionalities of EHR to be used).
- Also propose a suitable training time of the day (morning before duty, mid-day during break, after duty hours) for training of each category of the staff.
Question 5.
PowerPoint Presentation (with presenter notes): Develop a framework for training materials development.
- Discuss your philosophy of training comprising areas of the training to be addressed for the general staff and describe a method to assess the training effectiveness (whether the learners have learned what was intended)
- Include a 5-point question-based assessment tool (e.g., Likert scale Likert Scale: What Is It and How to Use It? (thoughtco.com) for assessing the training effectiveness; and the satisfaction level (%) based on responses to be considered satisfactory.
Expert Solution Preview
Introduction:
In this report, we will address several questions related to healthcare quality improvement, health information protection, password use policy implementation, training methods for transitioning to Electronic Health Records (EHR), and development of training materials. Each question will be answered separately, following the requested format, including an introduction and conclusion. The answers will incorporate relevant information, research findings, and recommendations to provide a comprehensive response. The content will be presented using APA 7th Edition formatting guidelines.
Answer to Question 1:
The Institute of Medicine (IoM) released two significant reports in 1999 and 2001, titled “To Err is Human: Building a Safer Health System” and “Crossing the Quality Chasm: A New Health System for the 21st Century,” respectively. These reports aimed to address the issues of patient safety, medical errors, and healthcare quality improvement.
Comparing and contrasting the recommendations in these reports, we find that both reports emphasize the need for a patient-centered approach, the integration of quality improvement efforts, and the use of evidence-based practices. However, the 1999 report primarily focuses on reducing medical errors and enhancing patient safety, while the 2001 report expands this scope by emphasizing the importance of a broader healthcare system redesign and the provision of high-quality care.
The implementation of these recommendations has had a significant impact on healthcare quality improvement. Quality improvement initiatives, such as those outlined by the Centers for Medicare and Medicaid Services (CMS), have been instrumental in promoting better patient outcomes, reducing medical errors, and improving overall healthcare delivery. These initiatives include the implementation of quality measures and the adoption of electronic health records (EHRs) to enhance care coordination and patient safety.
The consequences of not using Health Information Technology (HIT) in healthcare can be detrimental. Without HIT, healthcare providers may experience challenges in accessing accurate patient information, coordinating care, identifying potential drug interactions, and ensuring patient safety. Therefore, it is crucial to prioritize the adoption and use of HIT to improve healthcare quality. Recommendations for improving healthcare quality using HIT include promoting interoperability of EHR systems, ensuring data security, and encouraging healthcare providers to leverage technology for clinical decision support and patient engagement.
Answer to Question 2:
Both the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 contain provisions for the protection of health information by Covered Entities (CEs) and Business Associates (BAs). The Security Rule provisions in these acts aim to safeguard electronic protected health information (ePHI) and establish standards for organizations to follow.
Comparing the Security Rule provisions for CEs and BAs in both acts, we find that both entities are required to implement administrative, physical, and technical safeguards to protect ePHI. However, the HITECH Act expands on the HIPAA requirements by strengthening enforcement mechanisms, introducing breach notification requirements, and increasing penalties for non-compliance.
The organization responsible for monitoring compliance with Security Rule provisions by providers is the Office for Civil Rights (OCR), which operates under the U.S. Department of Health and Human Services (HHS). The OCR carries out investigations, audits, and enforcement actions to ensure that healthcare organizations adhere to the Security Rule provisions. The value of these provisions for electronic health records lies in the protection of patient privacy, confidentiality, and the prevention of unauthorized access to sensitive health information.
Noncompliance with the Security Rule provisions can have severe implications for healthcare organizations. Such consequences may include financial penalties, reputational damage, legal repercussions, and the erosion of patient trust. Therefore, it is imperative for healthcare organizations to prioritize compliance with the Security Rule provisions to mitigate these risks and safeguard patient information.
Answer to Question 3:
In this scenario, a local healthcare facility’s Chief Information Security Officer (CISO) has not adopted any password use policy yet. However, implementing a password use policy is crucial for ensuring the security of the facility’s healthcare information systems.
The role of the CISO in the implementation of the password use policy is to oversee the development, implementation, and enforcement of the policy. The CISO should collaborate with key stakeholders, such as IT personnel, administrators, and staff, to define password requirements, educate employees about the policy, monitor compliance, and address any security breaches.
Approaches to developing a password use policy for this organization should include key components such as password complexity requirements, regular password expiration and updates, multi-factor authentication, and restrictions on password sharing. It is important to outline the consequences of not following the policy strictly, such as potential data breaches, compromised patient information, unauthorized access, and legal implications. Among these components, the most critical one is password complexity requirements, as strong passwords are the first line of defense against unauthorized access.
The organization may experience significant implications if the password use policy is not followed strictly. These implications can include compromised patient data, unauthorized access to protected health information (PHI), potential legal and regulatory penalties, reputational damage, and compromised system security. Establishing and enforcing a robust password use policy is essential to mitigate these risks and ensure the integrity and confidentiality of sensitive information.
Conclusion:
In conclusion, this report has addressed several topics related to healthcare quality improvement, health information protection, password use policy implementation, training methods for transitioning to EHR, and development of training materials. The answers have provided insights into the recommendations of the IoM reports, the impact of quality improvement initiatives, the provisions of HIPAA and HITECH Acts, the consequences of noncompliance, and the significance of password use policies. Additionally, the report has discussed the roles of CISO in policy implementation, components of a password use policy, and implications of noncompliance. Lastly, it has explored appropriate training methods for different staff categories and the development of training materials for EHR transition.
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