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Ethical Decision Making -Process that requires striking a balance between science and morality. -Making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong. American Nurses Association- Code of Ethics for Nurses with Interpretive Statements. provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT Bioethical Standards Autonomy, freedom, veracity, privacy, beneficence, and fidelity are maximally appropriate to the health care setting. Autonomy The right to choose for himself or herself; respecting the clients opinions, perspectives, values and beliefs. Freedom The ability of an individual to act independently, without coercion or constraint in ones choice and action veracity Being completely truthful with patients; a patients right to truth. privacy The right to be left alone when you want to be, to have control over your own personal possessions, and not to be observed without your consent Beneficence Actions performed that contribute to the welfare of others; Action of doing good or right by and for the patient. Fidelity Right to what has been promised; keeping to one's promise. Telehealth Use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. Telemedicine Remote clinical health services mHealth (Mobile Health) -The practice of medicine and public health supported by mobile devices such as mobile phones, tablets, personal digital assistants and the wireless infrastructure. -The use of wireless communication to support efficiency in public health and clinical practice. Mobile Medical Applications (Apps) -Accessories to a regulated medical device or are a software that transforms a mobile platform into a regulated medical device. -Facilitates mHealth Medical Devices Any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients. Rationale APP is NOT Considered Medical Devices Apps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. FDA Oversight for Medical Devices -Regulatory body that oversees mobile apps that are medical devices and whose functionality could pose a risk to a patient's safety if the mobile app were to not function as intended. -Also oversee the cybersecurity management of these devices as well as the hospital network security. (POC) Point of Care Testing and diagnosis at the patient's side and can be conducted anywhere the patient is, such as the home, physician office, ambulance, or hospital bedside Privacy Practice of maintaining the security and confidentiality of patient records. Confidentiality The act of holding information in confidence, not to be released to unauthorized individuals. Cybersecurity -Measures taken to protect a computer or computer system against unauthorized access or attack. -FDA is main regulatory agency Computer-aided Translators Language translation in which a human translator uses computer hardware to support and facilitate the translation process. HIPPA (Health Insurance Portability and Accountability Act) Enacted in 1996; federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. ICD-10 Codes -Alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses. -Shorthand for the patient's diagnosis , which are used to provide the payer information on the necessity of the visit or procedure performed CPT Codes (current procedural terminology) official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non-physician providers Evaluation and Management Coding process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing. Necessity for establishing E/M Codes Place of Service; Type of Service; Patient Status Components of Risk Based E/M Coding History; Physical; Medical Decision Making Medical Decision Making (MDM) 1 of 3 components to establishing E/M codes; way of quantifying the complexity of thinking that is required for the visit. 3 key elements to medical decision making risk, data, and diagnosis Reimbursement Coding -Claims and documentation filed by providers using medical diagnosis and procedure codes. -Assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. Clinical Support Tools -Found in EHR software that when applied effectively, can enhance patient care quality and outcomes, improve efficiency, and help to ensure regulatory compliance. -Process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assessments, recommendations, or other forms of guidance for clinicians, patients, and others involved in care delivery.