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No part of the student manual can be reproduced in any form without prior wrien permission from MedPro.
Stu
Course Developer MedPro
A Division of ECPI University
Development Team Marie Twigg, BS, A+, Network+, Security+,
Project+, Linux+, Server+, CTT+, HIT, i-Net,
CDIA+, MCT
Ryan Sco Williams, BS, MCSE, MCT, VCP,
EMCPP, HIT
Randal Beard, M.Ed, CPA, RMA
Eding Team Larry Hill, BS, RMA, AHI
Trudy Gaba, BA English
Joseph Price, A+, Network+, MOUS
Chrise Adams, MOUS
Layout and Graphics Soa Bergin, Master of Fine Arts,
Graphic Design and Communicaons
ALL RIGHTS RESERVEDNo part of this work may be reproduced, transcribed, or used in any form or by any
means; graphic, electronic, or mechanical, including photocopying, recording, taping,
web distribuon or informaon storage and retrieval systems without wrien permis-
sion from MedPro.
All MedPro manuals are supplied on the basis of a single copy of a course per student.
LIMITATION OF LIABILITYEvery eort has been made to ensure complete and accurate informaon. Neither
MedPro, the developers or publisher can be held legally responsible for any mistakes
in prinng or for faulty instrucons contained within this course. MedPro reserves the
right to revise this manual and make changes from me to me in its content without
noce.
The contents of this material were created for the CompTIA Healthcare IT Professional
Cercaon exam (HIT-001) covering the CompTIA cercate objecves that are current
as of 01/12.
For addional manuals, and/or volume purchase programs, contact:
[email protected] or call 757-419-3700.
Acknowledgement
Introducon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
T he Heal th ca re Ch al leng e for I T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
About this manual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14ICON GUIDE: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Module 1HEALTHCARE FUNDAMENTALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Module 1 UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Organizaonal structures and dierent methods of operaon.. . . . . . . . . . . . . . . . . . . . 16
Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Private Pracce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Assi sted Livi ng Faci lity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Home Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Ambulator y Surgery C ente rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Module 1 UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Medical Departments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Module 1 UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Code of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Adapng procedural behavior to dierent situaons and environments . . .29
Adapng social behavior based on sensivity of the environment. . . . . . . .30
The need to follow medical precauonary guidelines. . . . . . . . . . . . . . . . . . 31
Hand Cle ani ng Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Module 1 UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Basic Clinical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Module 1 UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Medical Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Table of Contents
Table of Contents
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Module 1 UNIT 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Medical Interfaces Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Module 1 LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Module 1 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Module 2COMPUTERS AND PERIPHERALS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Module 2 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Types of Computers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Module 2 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Peripheral Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Module 2 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Medical Applicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Module 2 UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Peripheral Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Keyboard Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . 62
Mouse Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Monitor and Display Device Maintenance and Troubleshoong . . . . . . . . . . 63
3D video . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
Troubleshoong and Maintaining Printers . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Ports and Connecvity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Module 2 - UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Computer Troubleshoong and Maintenance Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Maintaining and Troubleshoong the Computer Operang System . . . . . . .71
Prevenve Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . 73
Motherboard Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . 74
Power On Self Test (POST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Power Supply Unit (PSU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Basic Input/ Output System (BIOS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77
Complimentary Metal Oxide Semiconductor (CMOS). . . . . . . . . . . . . . . . . . . 78
Unied Extensible Firmware Interface (UEFI) . . . . . . . . . . . . . . . . . . . . . . . . . 78
CPU Maintenance and Troubleshoong. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
RAM (Random Access Memory) Maintenance and Troubleshoong . . . . . .80
Expansion Card Maintenance and Troubleshoong . . . . . . . . . . . . . . . . . . . . 80
Table of Contents
I mp or ta nt Thing s to Keep in Mind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Module 2 - UNIT 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Technical Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Module 2 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Module 2 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Module 3NETWORK FOUNDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Module 3 UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93OSI Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
OSI Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Router Setup and Conguraon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Setup and Conguring Port Forwarding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
The Physical Network. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
Network Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
Internet Modem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
Mobile Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Tablets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Portable Media Players . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Clinical Vendor Applicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Module 3 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Network Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
The TCP/IP Suite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Installing and Conguring DHCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Module 3 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119Foundaons of the Intranet and the Internet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Intranet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
Extranet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Peer-to-Peer Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
Client-Server Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Mainframe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Terminal Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
Virtualizaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
API (Applicaon Program Interface). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
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Student Manual Stu
Ethernet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
Computer Applicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Applicaon Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Applicaon Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Module 3 - UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Wireless Connecvity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Methods of Wireless Connecvity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Wire less Ac cess Point S ec ur ity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133Bluetooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Wireless Access Point Conguraons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Guest Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Module 3 - UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Network and Business Communicaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Email . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Instant Messaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
Short Message Service (SMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Telecom / Voice Over IP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Electronic Medical Records (EMR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Facsimile (Fax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Secure FTP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
Database Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Data Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Types of Databases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
Database Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Applicaon Servers and Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Network Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Layered Network Troubleshoong Essenals . . . . . . . . . . . . . . . . . . . . . . . . 147
The L ogical N etwork. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Troubleshoong Common Network Issues . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Module 3 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Module 3 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Module 4HEALTHCARE ENVIRONMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Module 4 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Table of Contents Table of Contents
Medical Devices in the Medical Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Interface Problems with Hea lthcare Devices. . . . . . . . . . . . . . . . . . . . . . . . . 164
Module 4 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167Clinical Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Clinical Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Module 4 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Healthcare Soware Modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Module 4 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Module 4 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Module 5MEDICAL INTERFACES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Module 5 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177Medical Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179
Module 5 - UNIT 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
ePrescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Control led Substances and ePrescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Module 5 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
EMR/EHR Outbound Communicaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Types of Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186
B il ling C lear ing hous e I nterfac e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Module 5 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Module 5 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Module 6CLINICAL SOFTWARE AND CHANGE CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Module 6 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195Clinical Soware and Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
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Compability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Daily Business Expectaons and Upgrades . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Soware Modules and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Support and Troubleshoong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Module 6 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200Change Control Best Pracces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Module 6 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Module 6 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Module 7DOCUMENT STORAGE AND MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Module 7 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207Storage Opons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Storage Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207
Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
File Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213
Module 7 UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222Document Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Step 1: Document Preparaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Installing and Conguring Imaging Devices . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Module Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234
Module 7 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Module 7 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Module 8SECURITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Module 8 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240Authencaon Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Module 8 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Physical Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Locaon for Hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
Module 8 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253Access Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Roles and Responsibilies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Passwords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254
Directory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Module 8 - UNIT 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258Cryptography and PKI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Hash Funcons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Symmetric Encrypon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Asymmetric Cryptography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260
Other Uses of Asymmetric Cryptography.. . . . . . . . . . . . . . . . . . . . . . . . . . . 261
PKI (Public Key Infrastructure) and SSL (Secure Socket Layer) . . . . . . . . . . . 261
PGP (Prey Good Privacy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Module 8 - UNIT 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264Securing Communicaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Module 8 - UNIT 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267Securing Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Module 8 - UNIT 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269Remote Access and Firewalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Te chnologi es and Hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Types of F irewalls and Apply ing Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Remote Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
HTTPS and FTPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Terminal Emulaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
SSH (Secured Shell) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
RDC (Remote Desktop Connecon)/Remote Control Applicaons . . . . . . .272
Tunneling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273
Module 8 - UNIT 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275Wireless Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Physical Implementaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Secure Conguraon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Other Security Consideraons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Security Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277
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Module 8 - UNIT 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278Business Connuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Business Connuance (BC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Disaster Recovery (DR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Disaster Recovery Pracces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Backup Conguraons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Backup Storage | Courier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283
BRITTANIA HEALTH SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285Informaon Technology Business Connuance and Disaster Recovery Plan . . . . . . . .285
Execuve Summary:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Disaster Recovery Summary:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Soluon Design: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
RTO LEVEL I Funconal Priority: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
RTO LEVEL II Funconal Priority: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Module 8 - UNIT 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291Healthcare IT Aack Venues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Security Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Module 8 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Module 8 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Module 9REGULATORY REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Module 9 - UNIT 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Module 9 - UNIT 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308HIPAA Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Data Compliance / HIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
HIPAA Violaons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Module 9 - UNIT 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312Best Pracces and Documentaon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Legal Best Pracces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Business Associate Agreements (BAA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Module 9 - LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Module 9 - Exam Objecves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
ANSWERS TO LABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320Module 1 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Module 2 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Module 3 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329
Module 4 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Module 5 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .338
Module 6 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340Module 7 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .342
Module 8 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Module 9 - LAB Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Briania Health Systems Hands-on Virtual Labs . . . . . . . . . . . . . . . . . . . . 356
GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
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Student Manual StuIntroducon Introducon
IntroduconThe Healthcare Challenge for IT
Health informaon technology (HIT) provides the framework to demonstrate the com-
prehensive management of health informaon across automated systems and its secure
exchange between consumers, providers, government enes, and insurers. HIT is
viewed as the most promising tool for improving the overall quality, safety and eciency
of the health delivery system.
Expansive and consistent ulizaon of HIT will:
Reduce health care costs
Prevent medical errors
Improve health care quality
Increase eciencies
Reduce paperwork
Increase access to aordable care
The Informaon Technology profession is generally in the pracce of meeng the needs
of common professional business and enterprise vercals that may relate to Defense,
Legal, and Financial Instuons. The Healthcare industry is one of the most challenging
vercal markets for Informaon Technology today with regulatory requirements and dy-
namic laws that must be met. Healthcare IT connues to grow, as demand has increased
due to Government regulaons, Healthcare Reform, the American Recovery and theReinvestment Act. More than 88.5 billion was spent by providers in 2010 on developing
and implemenng Electronic Health Records (EHRs), health informaon exchanges, and
other Health Informaon Technology (HIT) iniaves. According to the study conducted
by the University of San Diego, HealthCare IT tops the list of hot careers and is ex-
pected to grow by 20% thru 2018. Healthcare connues to be a highly challenging and
rewarding career choice in the eld of IT.
The processes that are governed within a given healthcare organizaon rely heavily
upon the applicaons, systems, and networks that support the processes and which
processes are directly related to paent care and accessing life-saving data. Comput -
ers have become the crical tool of choice for paent care. Condenal and crical
informaon must be eciently stored, gathered, reported, and diagnosed by healthcare
professionals and specialists.
An IT professional in Healthcare needs to understand how essenal their role is within
an organizaon, being cognizant to perform with high security, opmal eciency and
under the most stressful circumstances. Medical professionals need to understand how
to use and opmize the automated tools available to provide comprehensive paent
care. Creang a centralized understanding between the IT professional and Healthcare
professional creates a powerful infrastructure to support the evolving medical industry.
CompTIAs Healthcare IT Technician is a vendor neutral Professional Cercaon. The
CompTIA Healthcare IT TechnicianProfessional Cercaon is designed to validate IT
professionals have the operaonal, regulatory, and security knowledge necessary to
provide hardware and soware support in medical environments where electronic
health record systems are being deployed and/or maintained. Addionally, the Profes-
sional Cercaon illuminates a commitment to work with, as well as, empathize with
the needs of Healthcare professionals by understanding the organizaonal behaviors
and pracces of a licensed Healthcare Organizaon.
This course provides an individual with the knowledge and skills required to implement,
deploy and support Health IT systems in various clinical sengs. Upon compleon of
the course, candidates will understand regulatory requirements, healthcare terminol-
ogy and hold an understanding of praccal workow while adhering to code of conduct
policies and securit y best pracces. The course prepares students for CompTIAs HIT-
001 Professional Cercaon exam.
About the HIT-001 Exam:
Exam Duraon: 60 minutes
Number of Quesons: 60
Passing Score: 650 on a scale of 100-900
The below table displays the domain areas measured during the examinaon, along
with the approximate degree to which they are represented in the examinaon as per
CompTIAs objecve guidelines.
Domain % of Examinaon
1.0 Regulatory Requirements 13%
2.0 Organizaonal Behavior 15%
3.0 IT Operaons 26%
4.0 Medical Business Operaons 25%
5.0 Security 21%
TOTAL 100%
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Student Manual StuAbout this manual About this manual
About this manual
This manual was designed to provide parcipants with an eecve roadmap to suc-
cessfully understand the Healthcare IT industry and to adequately prepare individu-
als for the Healthcare IT Cercate Exam (HIT-001). The course has been wrien by
a team of professionals with concentraons ranging from HealthCare Management,
Healthcare IT to IT Support Technicians. All individuals parcipang in the develop-
ment of the training materials hold both praccal experience in the industry, in addi-
on to a combined 45 years of instruconal experience. The course has been devisedto support the most eecve learning methods and it is our hope that you nd the
course a valuable learning tool. Your feedback is extremely important to us. All com-
ments and recommendaons will be taken into consideraon as future updates are
released. Feedback can be sent to: [email protected]
The manual consists of 9 modules to enable easy break points and support reten -
on. It begins by providing parcipants knowledge of the medical infrastructure,
then follows presenng parcipants an understanding of IT terms and tools. Holding a
foundaon in both the medical and the IT infrastructure allows for a natural bridge
between the two industry pracces, ulmately providing a centralized understanding
for the nal modules. In the nal modules, the best pracces to support regulatory
requirements, security requirements, and means to opmize resources for the health -
care organizaon are clearly outlined.
Aer each module, parcipants will have acvity labs to validate material retenon
and prepare for the HIT-001 cercate exam. At the end of the manual, parcipants
will nd virtual labs. The virtual l abs provide the opportunity for parcipants to experi-
ence hands-on understanding. As parcipants go through the labs, they will encounter
realisc situaons within a model health care organizaon, Britannia Hospital, where
they can take appropriate acons that parallel the content of each module.
Lastly, the manual is laid out with ICONS to help the parcipant easily transion be-
tween modules and to later use the manual as a reference guide.
ICON GUIDE:
MODULE INTRO
Introducon to the Module.
NOTE-TAKING
Throughout the module, parcipants
will noce ample area on each pagefor note taking.
WARNING
A note of warning!
MORE INFO
More Informaon on this topic can be
found in the Module/Unit referenced.
REVIEW Q
Review quesons to help test what the
parcipant has learned.
HANDS-ON LAB
A hands-on lab for parcipants to
pracce skills learned during this
module.
SLIDE
A slide accompanies the material.
OBJECTIVES
A lisng of objecves that support the
Cercate Exam.
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Student Manual StuModule 1 UNIT 1 Module 1 UNIT 1
Module 1HEALTHCARE FUNDAMENTALS
Working in a healthcare seng can be dierent from other industries. Its impor-
tant that a clear understanding of the industry, challenges and requirements of this
market be understood to properly support the unique necessies of the healthcare
eld. This module will provide you an overview of a healthcare organizaon as
concepts of the dierent types of healthcare structures, dierent departments,
dierent roles and responsibilies, dierent communicaon behavior require-
ments, clinical terms and medical interfaces are presented. Upon conclusion of this
module, you will have an overview of the healthcare terminology and environment
that is needed for an IT Healthcare Technician.
Module 1 UNIT 1Organizaonal structures and dierent methods of
operaon.
There are many types of medical facilies which exist to ll parcular needs of
paents. Whether the facility lls a specialized paent need or a general need,
paents need to be seen promptly and conveniently.
Hospitals
Most people think of a general hospital when they hear the word hospital. A
general hospital is set up to deal with many kinds of diseases and injuries, and
may have an emergency department to deal with immediate and urgent threats to
health. They oen have acute services such as an emergency department, burn
unit, surgery, or urgent care. The acute services may include more specialized units
such as cardiology or coronary care units, intensive care units, neurology, cancer
center, and obstetrics and gynecology departments. Support units in a hospital
usually include a pharmacy department, pathology department, and radiology
department. On the non-medical side, there oen are Medical Records Depart-ments, Informaon Management Departments, Maintenance Departments, Dining
Services, and Security Departments.
There are other types of hospitals that include:
Trauma centers
Rehabilitaon hospitals
Childrens hospitals
Geriatric hospitals
Psychiatric hospitals
Hospice centers
Private Pracce
Private pracce or clinics may include a single physician, mulple physicians, or a
physician pracce with a Physician Assistant (PA) or Nurse Praconer (NP). This
type of pracce may be general or specialized. A general or family pracce will
see most ages of paents and refer paents to a specialist if needed. With most
health maintenance organizaons (HMOs) insurances, these providers are the pri -
mary care physician (PCP). The PCP is the gatekeeper the paent must see before
going to a specialist.
Examples of specialty clinics would include:
Dermatology
Ear, Nose and Throat
Neurology Psychiatry
Pediatric
Womens clinic (OB\GYN)
Ambulatory (same day) Surgery
Ophthalmology
Gastroenterology
Nursing Homes
A nursing home or skilled nursing facility is a place for people who dont need to
be in a hospital but can not be cared for at home. Most of these facilies have
nursing aides and skilled nurses on hand 24 hours a day. The physician is not
always at the facility but the paents personal doctor or a sta doctor is available
by phone. The doctors examine paents and review the nursing notes periodi -
cally. The sta provides medical care, as well as physical, speech and occupaonal
therapy. Some nursing homes have special care units for people with serious neu-
rological problems such as Alzheimers disease and other forms of demena.
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Student Manual StuModule 1 UNIT 1 Module 1 UNIT 1
Assisted Living Facility
Assisted living facilies (ALFs) provide supervision or assistance with acvies of
daily living (ADLs); coordinaon of services by outside health care providers; and
monitoring of resident acvies to help to ensure their health, safety, and well-
being. Assistance may include the administraon or supervision of medicaon,
or personal care services provided by trained sta personnel. ALFs are normally
populated by seniors, for whom independent living is no longer appropriate, but
who do not need the 24-hour medical care provided by a nursing home. Assisted
living is a philosophy of care and services promong independence and dignity. As-
sisted living facilies can range in size from a small residenal house for one resi-
dent up to very large facilies providing services to hundreds of residents. There is
no special medical monitoring equipment that you would nd i n a nursing home,
and nursing sta may not be available 24 hours. However, trained sta is usually
on-site around the clock to provide other needed services. Registered Nurses and
License Praccal Nurses are available by phone or on-call during o-hours to en-
sure proper aenon is provided to all residents.
Home Healthcare
Home health care is a wide range of health care services that can be given at
home. The goal of home health care is to treat an ill ness or injury without the pa-
ent traveling to a medical treatment facility. Home health care allows the paentto maintain their independence, and become self-sucient as soon as possible.
Home health care includes part-me or intermient skilled nursing care, and
other skilled care services like physical therapy, occupaonal therapy, and speech-
language pathology (therapy) services. Services may also include medical social
services or assistance from a home health aide.
Examples of skilled home health services include:
Wound care for pressure sores or a surgical wound
Physical and occupaonal therapy
Speech-language therapy
Paent and caregiver educaon
Intravenous or nutrion therapy
Injecons
Monitoring serious illness and unstable health status
Examples of other home health aide services that may be available include:
Help with basic daily acvies like geng in and out of bed, dressing,
bathing, eang, and other maers of personal hygiene
Help with light housekeeping, laundry, shopping, and cooking for
the paent
Hospice
The goal of hospice care is providing comforng care by relieving symptoms and
supporng paents with a life expectancy of up to six months or less. Hospice in-
volves a team approach with the medical personnel and family to provide medical
care, pain management and emoonal, as well as spiritual support. The emphasisis on comfort, not curing. Hospice may be provided in the paents home or in a
free standing hospice facility.
Ambulatory Surgery Centers
Ambulatory Surgery Centers (ASCs) are medical facilies that specialize in elecve
same-day or outpaent surgical procedures. Paents treated in these surgical cen-
ters do not require admission to a hospital and are well enough to go home aer
the procedure. Ambulatory surgery centers are stand alone facilies. Paents seen
at an ASC have to be referred by their PCP. These facilies also must also have at
least one room that is used only for operaons.
Examples of ASCs are:
cosmec and facial surgery centers
endoscopy centers
ophthalmology pracces
laser eye surgery centers
centers for oral and maxillofacial surgery
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Student Manual StuModule 1 UNIT 1 Module 1 UNIT 2
orthopedic surgery centers
plasc surgery centers
mul-specialty surgery centers
Module 1 UNIT 2Medical Departments
Healthcare organizaons are large and can be made up of many medical depart -
ments. Departments are typically recognized by an area of specializaon. In
many cases, the departments can be represented with both inpaent and out -
paent available care. Oen, one may hear the terms outpaent or inpaent
used when referring to a type of diagnosc or therapeuc procedure. Inpaent
means that the procedure requires the paent to be admied to the hospital, pri -
marily so that he or she can be closely monitored during the procedure and aer-wards, during recovery. Outpaent means that the procedure does not require
hospital admission and may also be performed outside the premises of a hospital.
Here you will nd a list of the medical departments and notaons of whether the
department is typically seen as inpaent, outpaent or both.
DEPARTMENT DEFINITION INPATIENT/OUTPATIENT
Obstetrician/Gynecology
(OB/GYN)
This branch of medicine
includes providing care forall phases of pregnancies,
as well as, a wide variety
of genital tract diseases in
women.
INPATIENT
OUTPATIENT
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Student Manual StuModule 1 UNIT 2 Module 1 UNIT 2
ONCOLOGY This eld covers the study
of tumors, both benign, or
noncancerous, and malig-
nant, or cancerous. Oncolo-
gists are specialized physi-
cians who diagnose, treat,
and provide informaon
on prevenve measures
against tumors. Cancer
registrars, who also work
in the Oncology eld, are
specialists in cancer data
management.
INPATIENT
OUTPATIENT
PEDIATRICS This is the medical specialty
that deals with the care and
development of children
from birth to usually age
18, as well as, the diagnosis
and treatment of all child-
hood diseases.
OUTPATIENT
INPATIENT
Family Birthing Center
(FBC)
Labor and Delivery (L&D)
Stork
Neonatal Intensive Care
Unit (NICU)
FBC, or Family Birthing Cen-
ter, as well as L & D (Labor
and Delivery), are special-
ized units in an inpaent
hospital seng that deals
with the care of newborns.
In Family Birthing Centers,
every aempt is made toaccommodate the expect-
ant mother and a select
number of family members,
to experience and share in
the birthing process. These
centers aempt to simulate
a more domesc, home-like
seng, while sll providing
quality care for the mother
and newborn. The NICU is
the Neonatal (newborn)
Intensive Care Unit, which
provides life-sustaining care
for newborns who face seri-
ous medical condions aer
delivery.
INPATIENT
Intensive Care Unit (ICU)
Cardiac Care Unit (CCU)
These specialized units in
an inpaent seng provide
highly specialized care for
crical paents. The ICU
is the Intensive Care Unit
whose paents are closely
monitored aer they have
been stabilized either
from a traumac accident,
chronic medical condion,
or aer major surgery. The
CCU, or Cardiac Care Unit,
specializes in the care of
cardiac paents.
INPATIENT
Primary Care Unit (PCU)
Transional Care Unit (TCU)
The PCU, or Primary Care
Unit, provides compre-
hensive acute and chronic
medical care in the same
environment, with main-
tenance in connuity of
care and physician-paent
relaonships.
A TCU, or Transional Care
Unit, is an environment
that bridges the gap be-
tween acute care (imme-
diately aer surgery) andpaent self-reliance such as
going home.
INPATIENT
MED/SURG This unit, in an inpaent
hospital seng, provides
care for post-surgical
paents without serious
complicaons, and for those
paents who have been
diagnosed with an acute or
chronic medical condion
that requires hospitaliza-
on.
INPATIENT
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Student Manual StuModule 1 UNIT 2 Module 1 UNIT 2
PSYCHIATRY/BEHAVIORAL
HEALTH
This specialty can be either
in a hospital seng, or in
an out-paent clinic. This
branch of medicine deals
with paents that are suf-
fering from mental and
emoonal issues that could
stem from a wide variety
of reasons and causes. The
treatment of these paents
may result in long-term
therapy.
INPATIENT
Post Anesthesia Care Unit
(PACU)
The Post- Anesthesia Care
Unit, or more commonly
called the Recovery Room,
is a unit close in locaon
to the suite of Operang
Rooms where paents
that have just undergone
surgery are sent to be moni-
tored. The objecve of this
unit is to ensure the paent
remains stable before they
are admied to the proper
ward or unit within the
hospital.
INPATIENT
Operang Room (OR) Operang Rooms are usu-
ally in a suite- type sengwhere rooms are typically
designed in pods close to
each other. They are ulized
for major surgical proce-
dures that usually involve
unconscious sedaon and
anesthesia. ORs are all
sterile environments and
access is limited.
INPATIENT
Emergency Room (ER)
Urgency Room (UR)
Emergency Rooms or
Trauma Centers provide
for the emergent care and
treatment of paents with
life-threatening injuries or
crical medical condions
that are unstable. Many
also have a special secon,
somemes called Fast-
Track. Fast-Track provides
care for minor acute illnessand injuries. The paents
who are placed here for
treatment usually could not
get a same-day appoint-
ment with their Primary
Care Provider, or they do
not have medical insurance.
A UR is considered a step
below the ER and handles
cases on an unscheduled
walk-in basis. These facili-
es treat paents that may
require immediate care but
the maer is not serious
enough to warrant a visit to
an ER.
INPATIENT
Plasc Surgery This specialty provides a
variety of care either in a
hospital seng or in an
outpaent clinic. Some of
the services provided are
reconstrucve surgery,
liposucon, face-lis, breast
augmentaons and post-
burn paent skin graing to
name a few.
OUTPATIENT
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Student Manual StuModule 1 UNIT 2 Module 1 UNIT 2
Ear Nose Throat (ENT) Paents are treated for
either surgical or medical
condions involving the
upper respiratory system.
These specialists are called
Otolaryngologists. They
provide a variety of ser-
vices from outpaent minor
chronic condions up to
and including surgery.
OUTPATIENT
RESPIRATORY THERAPY/PULMONOLOGY
This area of medicineincludes the care, diagno-
sis and treatment for all
diseases and condions
concerning the lungs. These
specialists primarily serve
in a hospital seng, but
some Respiratory Therapy
Specialists and Technicians
can also provide treatments
in a home-care seng, or in
skilled nursing facilies.
OUTPATIENT
PHYSICAL/
OCCUPATIONAL THERAPY
These two speciales are
interlinked to a certain
degree. Both Physical and
Occupaonal Therapistsprovide rehabilitave care
for paents who have suf-
fered from strokes, spinal
cord injuries, traum ac am-
putaons, or injuries that
do not allow these patents
full use of their extremies,
or loss of vision, hearing or
speech. The main goal in
this specialty is to return
as much funcon back to
the paent as possible. This
usually includes long-term
therapy in an outpaent
seng.
OUTPATIENT
AMBULATORY/SAME DAY
SURGERY
These outpaent clinics
provide minor surgical
procedures that do not
require general anesthesia.
As the name implies, these
paents are treated and
released within the same
day. Uncomplicated follow-
ups occur on an outpaent
basis as well.
OUTPATIENT
RADIOLOGY This supporve area ofmedicine provides imagin-
ing studies which aid the
physician in the diagnosis
of illness and disease.
These tests include X-
rays, Magnec Resonance
Imaging (MRIs), Computer
Tomography (CT) Scans and
Positron-Emission Tomogra-
phy (PETs) to name a few.
These tests can be com-
pleted in both inpaent and
outpaent environments.
OUTPATIENT
LABORATORY This supporve clinic
provides for the collec-on, analysis, and results
of a multude of urine,
blood and other body uids
test that are ordered by a
physician. Laboratory ser-
vices can be provided in a
hospital, emergency room,
or stand alone outpaent
clinics. These tests also aid
the physician in properly
diagnosing diseases.
OUTPATIENT
OPTHALMOLOGY This branch of medicine
deals with condions,
injuries and diseases of the
eye. Opthalmologists can
prescribe medicaon and
perform surgical procedures
on the eye, as well as, con-
duct various types of visual
screenings.
OUTPATIENT
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Student Manual StuModule 1 UNIT 2 Module 1 UNIT 3
DERMATOLOGY This medical specialty
provides diagnosis and
treatment of condions
pertaining to the skin and
accessory organs, which
include the hair and nails.
Dermatologists usually work
in an outpaent seng.
OUTPATIENT
NUCLEAR MEDICINE Typically found within a
hospital seng, this spe-
cialty involves the injeconof radioacve isotopes into
a paent as part of an imag-
ing study, or to ascertain
structural funcon of an or-
gan. Strict guidelines must
be followed when dealing
with radioacve material .
OUTPATIENT
CARDIOVASCULAR Cardiovascular services that
are frequently oered as
an outpaent can be quite
varied. They may include
monitoring and control of
hypertension, most oen
through medicaon, pace-
maker monitoring, and lipidcontrol through medicaon.
This may also involve ongo-
ing rehabilitave services
aer a cardiac and Vascular
Tesng, EKGs, Echocardio-
grams, Event Monitor, Holt-
er Monitor, Stress tesng
(Includes Stress Echo and
Exercise Tolerance Tests),
and Vascular Ultrasound.
OUTPATIENT
Module 1 UNIT 3Code of Conduct
Communicang in the medical eld can be dicult, if you are not prepared. Al-
though the average American reads and speaks on an 8th or 10th grade level, the
medical professional has had 14-20 years of educaon. They oen speak using
medical jargon, which allows them to be concise and precise as they communi-
cate. Though extremely educated in their eld of experse, you may be working
with non-IT professionals. Time is crical i n this eld and concise, professionalcommunicaon is essenal.
Every profession has its own jargon and we oen forget to change our vocabulary
as we talk with those outside of our eld of experse. It is a team eort to com-
municate, as the speaker must ensure that they are not only heard, but under-
stood. However, it is also the listeners responsibility to indicate what theyheard
and did not understand. Learning some of the basic medical terminology and the
roles of the dierent medical professionals will make working within the medical
eld easier and you more ecient.
Adapng procedural behavior to dierent situaons
and environments
There are a large variety of medical environments, oen within the same facility.
Some have relaxed standards enabling you to work with lile change. While others
may have strict standards which will restrict your movements and require Personal
Protecve Equipment (PPE) as you work
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Student Manual StuModule 1 UNIT 3 Module 1 UNIT 3
Examples of such environments:
Imaging rooms - if the units are acve you may be exposed to radiaon
from x-rays or computer tomography (CT) scans. In contrast, a magnec
resonance imaging (MRI) uses a strong magnec eld, which will not
only aract metallic items, but deacvate any cards that use data strips
such as credit cards, or security badges.
Procedural room - a variety of procedures may take place such as,
sterile dressings, suture removal, minor surgical procedures (removal
of cysts, drainage of abscesses, or scar revision), gynecological proce-
dures, catheterizaons or applicaons of plaster casts.
Recovery room - paents arrive just out of surgery, and although not
in a sterile environment, the patents are sll in a precarious condion.
They are being monitored constantly for signs of danger.
Examinaon room - general room to talk with paents and to perform
non-invasive procedures.
Float room also referred to as a prep room, temp room, or hold -
ing bay this room consists of an area that is used to temporarily house
paents in transion between their paent room and another locaon.
One example is aer tests or surgeries.
Emergency room - The emergency medical department (EMD) is at
mes almost a whole hospital environment in itself. There may be x-rays, minor surgical procedures, cardiac procedures, laboratory proce-
dures, and general exams being conducted at the same me. Paents
are oen in pain and may be dying. The sta will be hurried using quick
precise movements to get as many paents seen and treated as soon
as possible.
Adapng social behavior based on sensivity of the
environment.
Entering the medical environment you may have to adapt your behavior to those
around you. Paents not only show up to receive general or emergency medical
care, but they may also be afraid for themselves or their family. Their future may
seem empty, without hope. In the Emergency Medical Departments (EMD) you
may be exposed to those who have just experienced extreme violence, such as
trauma, rape or child/spouse abuse. Your prejudices must be le at the door, as
you must always present yourself in a professional manner.
The need to follow medical precauonary guidelines.
The medical environment has many dangers not only for the paents, who may be
suscepble to disease, but also for those who may be exposed to their diseases.
You must look and ask about precauons as you enter an area.
Some of the precauons may include:
Universal Precauons, precauons designed to prevent the transmis-
sion of blood-borne diseases. Universal Precauons include specic
recommendaons for use of gloves, gowns, masks, and protecveeyewear when possible contact with blood or body secreons contain-
ing blood is ancipated.
Airborne precauons are used when a paent has a lung or throat in -
fecon or virus, such as chicken pox or tuberculosis that can be spread
via ny droplets in the air. The precauon that may be taken is called
airborne isolaon. This means the room will have negave air pres-
sure. When the door to the hospital room is open, air ows into room
but wont ow out into the hall. There will be a sign on the room door
alerng individuals to the situaon. You will need to clean your hands
when entering and exing the paents room. You should also conrm
that you have been vaccinated or have had the paents disease that
would have helped you to develop immunity.
Contact precauons are used when harmful germs can spread through
paent touch or the paent environment. There will be a sign on the
room door to alert individuals and advise of any required acons. You
will need to clean your hands when entering and exing the paents
room. Avoid contact with dressings, tubes, bed sheets and other items
the paent may touch.
Droplet precauons are used when the paent may have germs in
their lungs or throat, such as those caused by the u that can spread
by droplets from the mouth or nose when they speak, sneeze or cough.
These germ droplets can also infect people who touch the surfaces
around the paent. There will be a sign on the room door to alert
individuals. You will need to clean your hands when entering and exit-
ing the paents room, and perhaps wear a mask and eye protecon
before entering the room.
In any medical environment you have to connually wash your hands to avoid thespread of disease.
The following steps should be adhered:
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Student Manual StuModule 1 UNIT 3 Module 1 UNIT 4
Hand Cleaning Standards
When cleaning hands with soap and water:
Wet hands with warm water.
Dispense one measure of soap into palm.
Lather by rubbing hands together for 15 seconds,
covering all surfaces of hands and ngers.
Rinse hands thoroughly.
Dry hands with paper towel.
Use a paper towel to turn o faucet.
Discard the paper towel in the trash container.
When cleaning hands with alcohol gel:
Dispense one measure of gel into palm of one dry hand.
Rub hands together covering all surfaces of hands and ngers unl dry,
about 15 to 20 seconds.
Conform to requirements set forth by the project manager:
You should always conform to all specied requirements as you begin a project.
You may be tasked to work in an environment that requires precauons, or to
work around scheduled mes when specic areas are not in use by paents or sta.
Module 1 UNIT 4Basic Clinical Terms
During your me in the medical facility you may hear various medical terms.
Although you may not be directly aected, it may require the aenon of the sta
around you.
Some common medical terms may be:
Medical imaging Images of body parts, ssues, or organs, which are used to
make clinical diagnosis. Imaging i ncludes not only x-rays, magnec resonance
imaging (MRI), positron-emission tomography (PET), and ultrasound, but other
studies as well.
Primary Care Physician (PCP) - A Physician, Physician Assistant, or Nurse Praco-
ner is usually the rst contact for a person with an undiagnosed health problem.
Typically, the PCP has specialized in family or general pracce medicine. They are
the gatekeeper for admission to the insurance companys system. HMO paents
must see their PCP and get a referral prior to going to a medical specialist.
STAT - Comes from the Lan word stam which means immediately. In the medi -
cal world it is said and wrien when something is urgent and needs to be done in
a rush.
Acuity - Sharpness or clarity of vision or of percepon.
Code Blue/Rapid Response - A slang term used by medical sta to refer to a pa -
ent in cardiopulmonary arrest. A team of trained providers (called a code team)
rush to a specic locaon with specialized medical drugs and equipment and ini-
ate immediate resuscitave eorts. They are also called a rapid response team.
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Student Manual StuModule 1 UNIT 4 Module 1 UNIT 4
Some facilies may use other terms to avoid alerng paents, such as Dr. Blue.
Hospital Trauma Level - Hospitals have designated trauma levels based on the
emergency services they provide:
Level I - A Level I Trauma Center provides the highest level of surgical
care to trauma paents. It has a full range of specialists and equipment
available 24 hours a day. The Level I center will also have programs of
research and educaon.
Level II - A Level II trauma center works in collaboraon with a Level I
center. It provides comprehensive trauma care and supplements the
clinical experse of a Level I instuon. It provides 24-hour availability
of all essenal speciales, personnel, and equipment.
Level III - A Level III trauma center does not have the full availability of
specialists, but does have resources for emergency resuscitaon,
surgery, and intensive care of most trauma paents.
Level IV - A Level IV provides inial evaluaon, stabilizaon, diagnosc
capabilies, and transfer to a higher level of care.
Level V - Provides inial evaluaon, stabilizaon, diagnosc capabili-
es, and transfer to a higher level of care. It may not be open 24 hours
daily, but it will have an aer-hours trauma-response protocol.
Other schedules or levels used in healthcare involve the levels of controlledsubstances. There are several drugs that are not accepted for medical use and are
unsafe. By comparison, there are drugs used for medical treatment with certain
restricons that may be abused like drugs with no medical use. Drugs with a po -
tenal for abuse are controlled by healthcare facilies including pharmacies. The
use of e-prescribing ensures correct controlled substance regimens are correctly
followed. Best pracces for eMAR (Electronic Medicaon Administraon Records)
may include the pharmacy being able to track inventory of controlled substances
through the use of wristband vericaon. This may include data input into an Elec-
tronic Health record (EHR) via a scanned barcode on a paents wristband.
Controlled Substance Levels- Drugs and other substances that are considered
controlled substances under the Controlled Substance Act are divided into ve
schedules.
Schedule I Controlled Substances - Substances in this schedule have
a high potenal for abuse, have no currently accepted medical use in
treatment in the United States, and there is a lack of accepted safety
for use of the drug or other substance under medical supervision.
Schedule II Controlled Substances - Substances in this schedule have
a high potenal for abuse which may lead to severe psychological or
physical dependence.
Schedule III Controlled Substances - Substances in this schedule have
a potenal for abuse less than substances in schedules I or II and abuse
may lead to moderate or low physical dependence or high psychologi-
cal dependence.
Schedule IV Controlled Substances - Substances in this schedule have a
low potenal for abuse relave to substances in schedule III.
Schedule V Controlled Substances - Substances in this schedule have a
low potenal for abuse relave to substances listed in schedule IV and
consist primarily of preparaons containing limited quanes of certain
narcocs.
EMR (Electronic Medical Record)/EHR (Electronic Health Record) - The EMR is an
electronic record of health-related informaon on a paent that is created by asingle medical organizaon by providers who are involved in the i ndividuals health
and care. This is usually iniated by a specialty clinic that is not responsible for the
total care of the paent. T he EHR is an electronic record of health-related infor-
maon on a paent that is created and gathered from more than one health care
organizaon and is managed and consulted by a physician/sta involved in the
paents overall health and care.
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Student Manual StuModule 1 UNIT 5 Module 1 UNIT 5
Module 1 UNIT 5Medical Roles
Healthcare instuons are responsible for maintaining paent records in a safe
and secure manner.
Today, paperless, digital and computerized systems for maintaining paent data
are available and have made the medical industry more ecient. As menoned
in the prior unit, the automated system is called Electronic Medical Record (EMR)
system. Pung an EMR system into operaon is a complex, expensive investment
that has created a demand for Healthcare IT professionals and accounts for a
growing segment of the healthcare workforce.
Implemenng an Electronic Health Record (EHR) or Electronic Medical Record
(EMR) system inherently changes the way in which informaon is managed. This
includes, but is not limited to, the pracces for managing the security of EHR data.
Access roles and responsibilies are assigned to support the Health Insurance Por-
tability and Accountability Act (HIPPA) regulaons. When implemenng an EHR or
EMR system a team should be formed to evaluate a facilitys data security needs,
determine the best soluons and set security requirements. EHR and EMR systems
frequently have Role Based Access Control (RBAC) with predened proles that
can be assigned. RBACs are designed by the level of access that role needs to be
able to appropriately perform their dues.
Here is a typical series of paent encounters that involve an EMR system and the
necessity for access roles.
The paent checks in at the front desk by an administrator at Britannia Hospital
who has access only to appointment and demographic informaon.
When the paent is moved to the examinaon room, the nurse has
security access to record the paents vital health i nformaon (weight,
blood pressure and temperature) and to conrm his medicaon list.
The aending Physician, then meets with the paent diagnosing the
medical problem and issuing orders to the lab.
The EMR system allows for each paent encounter to be recorded and to pro-
vide each medical provider the access he/she needs to perform their role, while
protecng the condenali ty of the paent. In the example above, the three
individuals providing a service to this paent all have the appropriate access level
of authencaon that parallels their role of service.
Medical facilies should evaluate how a paents informaon is stored within their
system and determine which sta members have access to paent data and how
much data they should be allowed to handle. Access levels should be assigned to
allow sta to work eciently and producvely, while maintaining the highest level
of security.
For example, Clinical roles in an environment include:
Medical Doctor (MD)
Registered Nurse (RN)
Physicians Assistant (PA)
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Student Manual StuModule 1 UNIT 5 Module 1 UNIT 6
Dental Assistant (DA)
Paent Care Technician (PCT)
Medical Assistant (MA)
Licensed Praccal Nurse (LPN)
While the above clinical roles need access to paent medical data, medical oce
sta, consultants and business clients would have a more restricted access to the
EHR or EMR data, which would be dependent upon their specic role.
Medical Oce Sta roles would include:
Nursing Unit Clerk (NUC)
Unit Administrator (UA)
Project Manager (PM)
Oce Manager
Sta
If healthcare facilies take the appropriate steps to safeguard EHR and EMRs,
the threat of security breaches and resulng HIPPA penales can be minimized
while providing paents a level of trust. It is imperave that appropriate access
roles and responsibilies be established. Most EMR systems provide a record of
accountabil ity. Should any suspicious acvity be detected, a detailed record of
data access and modicaon to paent records can be viewed. The accountability
reports play a vital role in ongoing security management.
Module 1 UNIT 6Medical Interfaces Fundamentals
Regular and advanced devices are used within the healthcare seng to provide
analysis and measurements during an encounter. Informaon from these devices
ows from the local device to a workstaon. This device may be ed back to a
module that accesses and updates an EHR within an EMR system. Troubleshoong
experse of interfaces, devices, advanced devices, and the general understand -
ing of a workow such as an encounter is the key to a successful outcome for the
Healthcare IT Technician. The most common interfaces are listed as follows:
HL7 | Health Level 7 | Most common Applicaon Interface
ePrescribing
CCD
CCR
ICD10
CPT
SNOWMED
NDCID
PACS
E/M Codes
In review of the 10 most common applicaon interfaces,
HL7 - Health Level Seven Internaonal (HL7) is the global authority on standards
for interoperability of health informaon technology with members in over 55
countries. Hospitals and other healthcare provider organizaons typically have
many dierent computer systems used for everything from billing records to
paent tracking. All of these systems should communicate with each other (or
interface) when they receive new informaon, but not all do so. HL7 species
a number of exible standards, guidelines, and methodologies by which various
healthcare systems can communicate with each other. Such guidelines or data
standards are a set of rules that allow informaon to be shared and processed in a
uniform and consistent manner. These data standards are meant to allow health-
care organizaons to easily share clinical informaon. HL7 is derived from the OSI
model Layer 7 (described in Module 3, Unit 1), where applicaons communicate
and communicate across the enterprise.
E-Prescribing denes a new feature for the prescribers ability to electronically
send an accurate prescripon to a pharmacy from a physician. This allows for ane-prescribing plaorm in enhancing paent safety. E-prescribing is one of the key
iniaves to expedite the adopon of electronic medical records and build a na-
onal electronic health informaon infrastructure in the United States.
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Student Manual StuModule 1 UNIT 6 Module 1 UNIT 6
For example, most electronic medical record systems include e-prescribing fea-
tures. The workow may be as follows:
1. Prescriber Two-Factor Authencaon
-Something you know, and something you have, as described in Module 8,
Unit 1
2. Paent Lookup
3. Drug and Regimen selecon
4. Allergy and drug reacons noted
5. Selecon of alternave drugs
6. Pharmacy Selecon
7. Electronic transfer
8. Paent goes to get lled prescripon
CCD - Connuity of Care Document is the preferred interface standard for com -
municaon between EMR soware systems and paent portal systems. This is
because the CCD standard oers greater scalability in comparison to the CCR stan-
dard, as it can grow and wil l accommodate greater amounts of work. Medical Web
Experts has outstanding experience with this technology. The CCD is a joint eortof HL7 and ASTM to foster interoperability of clinical data to allow physicians to
send electronic medical informaon to other providers. The CCD is a CDA imple-
mentaon of ASTMs Connuity of Care Record (CCR). It is intended as an alternate
implementaon to the HL7 Clinical Document Architecture. The CCD represents
a complete implementaon of CCR, combining the best of HL7 technologies with
the richness of CCRs clinical data representaon, and does not disrupt the exisng
data ows in payer, provider, or pharmacy organizaons. The CCD is an XML-based
standard that species the structure and encoding of a paent summary clinical
document. It provides a snapshot in me, constraining a summary of the per -
nent clinical, demographic, and administrave data for a specic paent.
CCR - The Connuity of Care Record, or CCR, is a standard developed by ASTM
Internaonal - a gl obal leader in the creaon of consensus standards. Because a
CCR document is slightly limited in its ability to become a highly-scalable soluon
for interfacing two systems, the Connuity of Care Document (or CCD) was invent -
ed to link ASTMs CCR with the HL7s Clinical Documentaon Architecture.
ICD-10 - The Internaonal Stascal Classicaon of Diseases and Related Health
Problems, 10th Revision is a medical classicaon list for the coding of diseases,
signs and symptoms, abnormal ndings, complaints, social circumstances, and
external causes of injury or diseases. It is maintained by the World Health Organi-
zaon (WHO).
CPT - (Current Procedural Terminology) codes are numbers assigned to every task
and service a medical praconer may provide to a paent including medical,
surgical and diagnosc services. They are then used by insurers to determine the
amount of reimbursement that a praconer will receive by an insurer. Since ev -
eryone uses the same codes to mean the same thing, they ensure uniformity. CPT
codes are developed, maintained and copyrighted by the AMA (American Medical
Associaon.) As the pracce of health care changes, new codes are developed for
new services, current codes may be revised, and old, unused codes are discarded.
Thousands of codes are in use, and they are updated annually.
SNOMED CT - (Systemazed Nomenclature of Medicine), is a systemacally
organized computerized collecon of medical terminology covering most areas
of clinical informaon such as diseases, ndings, procedures, microorganisms,
substances, etc. allowing a consistent way to index, store, retrieve, and aggregate
clinical data across speciales and sites of care. It also helps organizing the content
of medical records, reducing the variability in the way data is captured, encoded
and used for clinical care of paents and research. It is a structured collecon of
medical terms that are used internaonally for recording clinical informaon and
are coded in order to be computer processed. It covers areas such as diseases,
symptoms, operaons, treatments, devices and drugs. SNOMED CT is considered
by some to be the most comprehensive, mullingual clinical healthcare terminol-
ogy in the world. It provides for consistent informaon interchange and is funda-
mental to an interoperable electronic health record. It can be used to record the
clinical details of i ndividuals in electronic paent records and support applicaonfunconality such as informed decision making, linkage to c linical care pathways
and knowledge resources, shared care plans and as such support long term paent
care. It was originally created by the College of American Pathologists (CAP) and,
as of April 2007, owned, m