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Since the early 2000s, Chinese government has sought to encourage the growth of private health insurance (PHI) while simultaneously expanding the breadth of coverage in its social health insurance (SHI) system. This paper examines how the prevalence of PHI has changed during this period and the extent to which PHI contributed to the growth of horizontal and geographical inequities with a focus on healthcare utilization. National data from China Health and Nutrition Survey between 2000 and 2015 were analysed using a multilevel modelling approach. The analysis investigated the impact of SHI membership as related to PHI uptake, PHI enrolees’ utilization of health services and out-of-pocket (OOP) expenses. This study found being covered by an SHI scheme reduced the uptake of PHI between 2004 and 2015. Having PHI caused an increase in utilizing outpatient care but did not affect OOP expenses. Coverage prevalence of PHI in a residential community was positively associated with the average level of healthcare utilization. Coverage prevalence of PHI and its effects on healthcare utilization varied geographically. The findings suggest that expanding the role of PHI was not effective without clear support from government policy. Furthermore, the expansion of PHI may cause an increase in horizontal and geographical inequities in healthcare utilization.

All it takes is one. One person, one email, one click, to grant cybercriminals access to your confidential files, your applications, and your patients’ protected health information. But the damage ...

In response to a case of an undocumented patient who was reported to immigration authorities, this commentary considers whether a patient's immigration status should be deemed protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. A legal argument, supported by clinical data, is offered that immigration status should be regarded as PHI not subject to valid exception for release without patient authorization. This argument concludes that covered entities (eg, hospitals and health care professionals) are legally precluded under the HIPAA Privacy Rule from disclosing a patient's immigration status.

Background Automated de-identification methods for removing protected health information (PHI) from the source notes of the electronic health record (EHR) rely on building systems to recognize mentions of PHI in text, but they remain inadequate at ensuring perfect PHI removal. As an alternative to relying on de-identification systems, we propose the following solutions: (1) Mapping the corpus of documents to standardized medical vocabulary (concept unique identifier [CUI] codes mapped from the Unified Medical Language System) thus eliminating PHI as inputs to a machine learning model; and (2) training character-based machine learning models that obviate the need for a dictionary containing input words/n-grams. We aim to test the performance of models with and without PHI in a use-case for an opioid misuse classifier. Methods An observational cohort sampled from adult hospital inpatient encounters at a health system between 2007 and 2017. A case-control stratified sampling (n = 1000) was performed to build an annotated dataset for a reference standard of cases and non-cases of opioid misuse. Models for training and testing included CUI codes, character-based, and n-gram features. Models applied were machine learning with neural network and logistic regression as well as expert consensus with a rule-based model for opioid misuse. The area under the receiver operating characteristic curves (AUROC) were compared between models for discrimination. The Hosmer-Lemeshow test and visual plots measured model fit and calibration. Results Machine learning models with CUI codes performed similarly to n-gram models with PHI. The top performing models with AUROCs > 0.90 included CUI codes as inputs to a convolutional neural network, max pooling network, and logistic regression model. The top calibrated models with the best model fit were the CUI-based convolutional neural network and max pooling network. The top weighted CUI codes in logistic regression has the related terms ‘Heroin’ and ‘Victim of abuse’. Conclusions We demonstrate good test characteristics for an opioid misuse computable phenotype that is void of any PHI and performs similarly to models that use PHI. Herein we share a PHI-free, trained opioid misuse classifier for other researchers and health systems to use and benchmark to overcome privacy and security concerns.

Background De-identification is a critical technology to facilitate the use of unstructured clinical text while protecting patient privacy and confidentiality. The clinical natural language processing (NLP) community has invested great efforts in developing methods and corpora for de-identification of clinical notes. These annotated corpora are valuable resources for developing automated systems to de-identify clinical text at local hospitals. However, existing studies often utilized training and test data collected from the same institution. There are few studies to explore automated de-identification under cross-institute settings. The goal of this study is to examine deep learning-based de-identification methods at a cross-institute setting, identify the bottlenecks, and provide potential solutions. Methods We created a de-identification corpus using a total 500 clinical notes from the University of Florida (UF) Health, developed deep learning-based de-identification models using 2014 i2b2/UTHealth corpus, and evaluated the performance using UF corpus. We compared five different word embeddings trained from the general English text, clinical text, and biomedical literature, explored lexical and linguistic features, and compared two strategies to customize the deep learning models using UF notes and resources. Results Pre-trained word embeddings using a general English corpus achieved better performance than embeddings from de-identified clinical text and biomedical literature. The performance of deep learning models trained using only i2b2 corpus significantly dropped (strict and relax F1 scores dropped from 0.9547 and 0.9646 to 0.8568 and 0.8958) when applied to another corpus annotated at UF Health. Linguistic features could further improve the performance of de-identification in cross-institute settings. After customizing the models using UF notes and resource, the best model achieved the strict and relaxed F1 scores of 0.9288 and 0.9584, respectively. Conclusions It is necessary to customize de-identification models using local clinical text and other resources when applied in cross-institute settings. Fine-tuning is a potential solution to re-use pre-trained parameters and reduce the training time to customize deep learning-based de-identification models trained using clinical corpus from a different institution.

Policy Points: Historically, in addition to economic and technical hurdles, state and federal health information privacy laws have been cited as a significant obstacle to expanding electronic health information exchange (HIE) in the United States. Our review finds that over the past decade, several helpful developments have ameliorated the legal barriers to HIE, although variation in states' patient consent requirements remains a challenge. Today, health care providers' complaints about legal obstacles to HIE may be better understood as reflecting concerns about the economic and competitive risks of information sharing. Context Although the clinical benefits of exchanging patients' health information electronically across providers have long been recognized, participation in health information exchange (HIE) has lagged behind adoption of electronic health records. Barriers erected by federal and state health information privacy law have been cited as a leading reason for the slow progress. A comprehensive assessment of these issues has not been undertaken for nearly a decade, despite a number of salient legal developments. Methods Analysis of federal and state health information privacy statutes and regulations and secondary materials. Findings Although some legal barriers to HIE persist, many have been ameliorated-in some cases, simply through improved understanding of what the law actually requires. It is now clear that the Health Insurance Portability and Accountability Act presents no obstacles to electronically sharing protected health information for treatment purposes and does not hold providers who properly disclose information liable for privacy breaches by recipients. The failure of federal efforts to establish a unique patient identifier number does slow HIE by inhibiting optimal matching of patient records, but other action to facilitate matching will be taken under the 21st Century Cures Act. The Cures Act also creates the legal architecture to begin to combat "information blocking." Varying patient consent requirements under federal and state law are the most important remaining legal barrier to HIE progress. However, federal rules relating to disclosure of substance-abuse treatment information were recently liberalized, and development of a technical standard, Data Segmentation for Privacy, or DS4P, now permits sensitive data requiring special handling to be segmented within a patient's record. Even with these developments, state-law requirements for patient consent remain daunting to navigate. Conclusions Although patient consent requirements make HIE challenging, providers' expressed worries about legal barriers to participating in HIE likely primarily reflect concerns that are economically motivated. Lowering the cost of HIE or increasing financial incentives may boost provider participation more than further reducing legal barriers.

Objective In 2018, California legislators passed the California Consumer Privacy Act (CCPA), a digital privacy regulation conferring consumers more control over their online personal information. CCPA is a significant regulation overseeing technology companies’ data collection and usage practices in the United States. This article analyzes CCPA and its implications on healthcare organizations. We elaborate on the compliance challenges that have emerged due to the interplay of the CCPA with the Health Insurance Portability and Accountability Act (HIPAA) from legal and technical/operational perspectives. Methods Qualitative methods comprising semi-structured expert interviews, qualitative data coding, and analysis were used to explore the perceptions of the practitioners on various dimensions of the policy and to obtain insights from the field. Results Our findings indicated that California's healthcare organizations faced several legal and technological challenges in complying with CCPA. A lack of regulatory clarity and a low likelihood of enforcement emerged as two major themes of legal concern. Poor data discovery and inventory processes, lack of sophisticated digital infrastructure, the interaction between technology and privacy professionals, and the high cost of compliance emerged as significant technological hurdles to CCPA compliance. Conclusions Despite considerable ambiguity around the scope and jurisdiction of CCPA in the healthcare sector, healthcare organizations may be subject to CCPA, primarily when they collect personally identifiable information that is not protected health information. Such organizations may need to comply with both regulations. Furthermore, it is in their best interest to develop compliance plans proactively rather than being caught in the quandary of last-minute implementation or expensive litigation.

Correctional populations are disproportionately affected by conditions that affect cognition, such as psychiatric illness and head trauma. Honoring bioethical principles in the care of such patients can be particularly difficult in the correctional setting. However, the approach should not change markedly because a patient is incarcerated. That is, the same standards of respecting patient autonomy and confidentiality should be maintained, and the fact that correctional populations are already marginalized makes it all the more important for clinicians to honor these principles. Physicians should act in the best interest of their patients; in jails this might include disclosing information to and consulting with a patient's legal defense. However, this step should only be taken with a patient's consent or, in cases in which the patient does not have decision-making capacity, when it seems consistent with a patient's wishes.

In early 2015, Sylvia Burwell, Secretary of the Department of Health and Human Services, described the federal administration's goals for delivery of health care in the United States. Prominently featured was a conversion from volume to value through the incorporation of Alternative Payment Models. The Department of Health and Human Services laid the framework, but recognized significant knowledge gaps in how providers and institutions would develop Alternative Payment Models. To that end, the Health Care Payment Learning and Action Network was conceived. On March 25, 2015, the Health Care Payment Learning and Action Network held its first meeting, which included a broad swath of industry participants. This collaboration was considered mission critical to achieving success in the goals of advancing Alternative Payment Models. This article highlights the Health Care Payment Learning and Action Network and the framework it is proposing for Alternative Payment Models that would have meaningful implications for radiologists.

IntroductionIt is a remarkable feature of the last decades that our world is becoming more integrated, both with respect to economic activities and in a more general sense. While there are many other observations to corroborate this statement, one indicator is that people increasingly tend to move from one country to another, e.g., as commuters or as tourists. It is important to note that this potentially has implications for health care: First, a need for health care may arise while being in a foreign country, either suddenly due to some developing illness or because of a persistent health problem. Second, people may also wish to go abroad in order to obtain health care. Hence, cross-border health care may be a by-product of people working or temporarily staying in another country while its availability may also constitute the prime reason for crossing national boundaries.Basically, cross-border health care will enhance individual choice sets, by providing another option to obtain health care which may either exhibit a better quality or be available at a lower cost in comparison with a purely national provision. From an economic point of view, it would be desirable to have cross-border health care whenever it could reasonably be expected to generate a net benefit to society, i.e., to the countries involved. However, with individual countries relying on their own system of health insurance, a number of barriers may exist which prevent mutually beneficial transactions. In particular, this is true for social health insurance which, due to restrictions on the benefit package and specific ways of financing, naturally involves a focus on care provided within the country for which it has been designed.Turning to the European Union (EU), health policy has not been on the agenda for many years because the founding treaties contain no specific article explicitly referring to it. Moreover, as the Treaty on the Functioning of the European Union acknowledges, every EU Member State is first and foremost responsible for organizing its own health care system. However, the implementation of the European Single Market, one of the EU cornerstones today, has affected the health care sector of the Member States by means of the "four fundamental freedoms": These imply free movement of goods (e.g., medicinal products and medical devices), freedom of movement for workers (e.g., mobility of health care professionals), the right of establishment and freedom to provide services (e.g., social and private health insurances), and free movement of capital (e.g., investment in health infrastructure), respectively. In addition, the EU is engaged in the coordination of social security systems, and it also assumes a strong role in improving health in areas such as the environment and the workplace (Greer et al., 2014).For a long time, cross-border health care in the EU for individuals with social health insurance has been based on a Social Security Regulation which took effect in 1971. However, this Regulation has been applied in a rather restrictive manner. As a consequence, the number of patients going abroad in order to receive planned health care remained fairly small. The main reason was that prior authorization had to be obtained from domestic authorities who often refused to grant it on the grounds that the requested health care was also available at home. Over time, several EU citizens have challenged this position, either by complaining about long waiting times at home or by arguing more generally that prior authorization would interfere with their right to choose health care in other Member States.In ruling on these cases, the European Court of Justice with its judgements created case law which has, in effect, enhanced patients' rights considerably with respect to crossborder health care (Palm et al., 2011). In turn, this led to a major revision of the Social Security Regulations which took effect in 2010. While maintaining prior authorization of cross-border health care, the new Regulations contain provisions that limit its use such that a refusal will most likely involve no harm to the health of the patient. …

Against a backdrop of non-ideal political and legal conditions, this article examines the health capability paradigm and how its principles can help determine what aspects of health care might legitimately constitute positive health care rights-and if indeed human rights are even the best approach to equitable health care provision. This article addresses the long American preoccupation with negative rights rather than positive rights in health care. Positive health care rights are an exception to the overall moral range and general thrust of U.S. legal doctrine. Some positive rights to health care have arisen from U.S. Constitutional Eighth Amendment cases and federal and state laws like Medicare, Medicaid, the State Children's Health Insurance Program, the Emergency Medical Treatment and Active Labor Act, and the Patient Protection and Affordable Care Act. Finally, this article discusses some of the difficulties inherent in implementing a positive right to health care in the U.S.

Purpose: Survivorship care plans (SCPs) are recommended for all cancer survivors. Myriad barriers to implementation exist. This study was performed to evaluate the feasibility of interface development between an SCP and an electronic medical record (EMR). Methods: An information technology application was developed to extract data from the EMR in use at our center (Epic). Data were transferred to autopopulate an Internet-based tool for creation of SCPs (LIVESTRONG Care Plan) that had been previously used for the creation of more than 35,000 plans. Results: Data (demographic characteristics, surgeries, chemotherapy drugs, radiation site) were extracted from the EMR and transferred to the care plan platform, without transfer of protected health information. Care plans were created and transferred back to the EMR. During clinical testing, SCPs were created by nurse practitioners during scheduled clinic visits for 146 sequential, eligible patients (67% breast cancer, 33% colorectal cancer). All patients received completed care for a single cancer diagnosis at our institution. All data points that were automatically populated were reviewed by practitioners, and missing/blank data fields were populated manually when necessary. Data entered into generated care plans were accurate in 97% of audited cases, and the process of care plan generation could be completed in < 1 minute. Conclusion: This is a feasible solution for the autopopulation of SCPs from the EMR. It represents a future methodology through which widespread implementation of SCPs may be undertaken. Future directions include further clinical testing, assessment of provider-perceived usefulness, and integration into routine clinical care.

Amendments to the Common Rule and Health Insurance Portability and Accountability Act (HIPAA) raise questions about broad consent and sale of health data.

Healthcare's movement to value-based care is causing health systems across the country to consider whether owning or partnering with a health plan could benefit their organizations. Although organizations have different reasons for wanting to enter the insurance business, potential benefits include improving care quality, lowering costs, managing population health, expanding geographic reach, and diversifying the organization's revenue stream. However, the challenges and risks of owning a health plan are formidable: Assuming 100 percent financial risk for a patient population requires considerable financial resources, as well as competencies that are wholly different from those needed to run a hospital or physician group. For Spectrum Health, an integrated, not-for-profit health system based in Grand Rapids, Michigan, owning a health plan has been vital to fulfilling its mission of improving the health of the communities it serves, as well as its value proposition of providing highquality care at lower costs. This article weighs the pros and cons of operating a health plan; explores key business factors and required competencies that organizations need to consider when deciding whether to buy, build, or partner; examines the current environment for provider-sponsored health plans; and shares some of the lessons Spectrum Health has learned over three decades of running its health plan, Priority Health.

Sensitive data from health research surveys need to be protected from loss, damage or unwanted release, especially when data include personally identifying information, protected health information or other private material. Researchers and practitioners must ensure privacy and confidentiality in the architecture of data systems and in access to the data. Internal and external risks may be deliberate or accidental, involving unintended loss, modification or exposure. To prevent risk while allowing access requires balancing concerns against providing an environment that does not impede work. The authors' purpose in this paper is to draw attention to basic data security needs for health survey data from the perspective of both the health researcher/practitioner and infrastructure/programming staff to ensure that data are securely and adequately protected. We describe risk classifications and how they affect system architecture, drawing on recent experience with systems for storage of and access to electronic health survey data.

Background De-identification is the first step to use these records for data processing or further medical investigations in electronic medical records. Consequently, a reliable automated de-identification system would be of high value. Methods In this paper, a method of combining text skeleton and recurrent neural network is proposed to solve the problem of de-identification. Text skeleton is the general structure of a medical record, which can help neural networks to learn better. Results We evaluated our method on three datasets involving two English datasets from i2b2 de-identification challenge and a Chinese dataset we annotated. Empirical results show that the text skeleton based method we proposed can help the network to recognize protected health information. Conclusions The comparison between our method and state-of-the-art frameworks indicates that our method achieves high performance on the problem of medical record de-identification.

Promoting the use of online consumer health information is critical to achieving the democratic right to know and cannot be separated from facilitating the process of finding and understanding this information. In addition, being informed and being able to share information with a clinician are fundamental principles enabling patient engagement in health care and shared decision making. Online consumer health information may contribute to positive patient outcomes such as improved knowledge, and even better health, while in some situations it also leads to increased worry. This type of negative outcome represents a common experience. Our health is important and therefore anything that touches our health can increase anxiety. In our view, worrying is not a disorder; only occasionally it is an incapacitating cyberchondria. Since 2005, our research has been exploring health information outcomes from the consumers’ viewpoint. We are particularly interested in information outcomes such as the types of informat...

For decades, health information has been collected and shared for health care delivery and public health purposes. While the “primary use” of patient data for providing direct health care services is the cornerstone of health care practice, health departments rely on data sharing for research and analysis to support disease prevention and health promotion in the population.1 As the U.S. health system undergoes a digital revolution, health information that was previously captured in paper form now can be captured electronically. Electronic health information (EHI) has transformed the efficiency, capacity, and functions of the U.S. health system.2 For this reason, there is increased attention to the “secondary use” of electronic patient data for public health uses,3 including disease reporting and investigation, syndromic surveillance, and patient-specific or population-level communications about health conditions and their associated risk factors. Secondary uses may also encompass clinical research, licensure, and payment for services. Laws play an instrumental role in facilitating the recording and sharing of health information and granting protections to patients and providers. However, the transition from paper to electronic health information systems pose challenges to the legal environment surrounding health data.4 Laws governing access to and disclosure of EHI for secondary uses describe the type of information that can be shared and whether it identifies individual patients, the types of entities sharing the information, and the reasons for which the information is shared.5 As the implications and challenges of EHI are understood, states are updating laws that once supported paper health records to include electronic health records (EHRs) and the secondary use of data. This article provides an overview of laws supporting secondary use of EHI data for public health purposes, the state law landscape surrounding the transition from paper to EHI systems, and legal tools available for public health uses of EHI.

The recent confluence of: (1) changing state and national insurance-related policies, and (2) the rapid growth in electronic health record (EHR) use, yields an unprecedented opportunity for patient-centered medical homes (PCMHs) and other primary care practices or care settings to use health information technology (HIT) and health information exchange (HIE) in novel ways to impact patient health. We propose that HIT is an untapped resource for supporting clinic-based efforts to help eligible patients obtain and maintain insurance coverage. This commentary presents a conceptual model and guiding principles for this idea. Additionally, it describes insurance support tools that could be used to conduct 'inreach' and 'outreach' with patients around health insurance, similar to how HIT is used to manage chronic disease and panels of patients, and to improve population health outcomes.

1. Hellen Ransom, DHCE* 2. John M. Olsson, MD, CPE† 1. *Department of Bioethics and Interdisciplinary Studies, 2. †Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC * Abbreviations: CT: : computed tomography MCO: : managed care organization MRI: : magnetic resonance imaging Pediatricians engage in making decisions on allocation of health care resources on a daily basis. However, they may not be aware of the ethical principles underlying those decisions and how to apply those principles in the process of allocating health care resources. After completing this article, readers should be able to: 1. Identify the ethical principles that should be considered when making decisions on allocating health care resources. 2. Apply ethical principles in clinical settings with limited health care resources. 3. Discuss the role of the institutional ethics committee in assisting clinicians in making point-of-care health care allocation decisions. Health care resources are defined as all materials, personnel, facilities, funds, and anything else that can be used for providing health care services. Health care has long been a limited resource for which there has been an unlimited demand; everyone needs health care. Until the 20th century, US health care was allocated by the ability to pay or barter, with small numbers of individuals consuming the bulk of the resources, leaving few resources available to others. During the past 100 years, increased interest in good personal and public health resulted in the development of various forms of health insurance. Health insurance became available through employer-sponsored insurance plans and, in the 1960s, entitlement programs—including Medicare and Medicaid. In spite of the presence of these forms of payment, demands for all aspects of health care continue to exceed its available resources. Millions of people in the United States, including children, continue to lack health insurance or avenues to access health care resources. Likewise, the costs associated with health care have increased dramatically as technology has advanced, …

The HIPAA Rules continue to support and bolster the importance of protecting the privacy and security of patients' protected health information. The HIPAA training requirements are at the cornerstone of meaningful implementation and provide a ripe opportunity for critical education.

The editors selected the articles for inclusion in this two-volume collection through a combination of crowd-sourcing and editorial judgment. The crowd-sourcing component involved emails to roughly 20 scholars working in health economics, health law or bioethics, asking for suggestions. The authors consolidated all of the suggestions they received, added some of their own and then held several marathon meetings to identify the articles best suited for inclusion in this collection. We hope readers will find them as interesting and provocative as we did. Volume I Part I: Access to Health Care, Mortality and Other Clinical Outcomes Individuals living without health insurance may face not only increased health risks but also elevated health care costs when inevitable medical treatment is required. Access to health care - the subject of Part I of Volume I - can have a profound impact on both the health and financial security of individuals. Yet, before the enactment of the Affordable Care Act, better known as ObamaCare, some 40 million Americans were without coverage. The exact impact of the lack of health insurance on mortality and health status as well as the health care marketplace is frequently disputed. Part I contains research discussing possible health advantages to insurance coverage and medical care access as well as the financial difficulties experienced by the uninsured.

Rapid advancements in diagnostic technologies coupled with growth in testing options and choices mandate the development of evidence-based testing algorithms linked to the care paths of the major chronic diseases and health challenges encountered most frequently. As care paths are evaluated, patient/consumers become partners in healthcare delivery. Clinical laboratory scientists find themselves firmly embedded in both quality improvement and clinical research with an urgent need to translate clinical laboratory information into knowledge required by practitioners and patient/consumers alike. To implement this patient-centered care approach in clinical laboratory science, practitioners must understand their roles in (1) protecting patient/consumer autonomy in the healthcare informed consent process and (2) assuring patient/consumer privacy and confidentiality while blending quality improvement study findings with protected health information. A literature review, describing the current ethical environment, supports a consultative role for clinical laboratory scientists in the clinical decision-making process and suggests guidance for policy and practice regarding the principle of autonomy and its associated operational characteristics: informed consent and privacy.

Holding local boards of health accountable presents challenges related to governance and funding arrangements. These challenges result in (a) multiple accountability pressures, (b) population health outcomes whose change is measureable only over long time periods and (c) board of health activity that is often not the key immediate direct contributor to achieving desired outcomes. We examined how well these challenges are addressed in Ontario, Canada at early stages of implementation of a new accountability policy. Findings reveal that senior and middle management are open to being held accountable to the Ministry of Health and Long-Term Care (MOHLTC), but are more oriented to local boards of health and local/regional councils. These managers perceive the MOHLTC system as compliance oriented, and find internal accountability systems most helpful for performance improvement. Like health-care system accountability metrics, performance indicators are largely focused on structures and processes owing to the challenges of attributing population health outcomes to public health unit (PHU) activities. MOHLTC is in the process of responding to these challenges.

Pagers, though reliable and familiar technology, can be suboptimal for facilitating healthcare team communication.1,2 Most paging systems utilize single-function pagers and only allow one-way communication, requiring recipients to disrupt workflow to respond to pages. Paging transmissions can also be intercepted, and the information presented on pager displays can be viewed by anyone in possession of the pager. Smartphones allow for instantaneous two-way and group communication through advanced technological features. Their use is widespread; over 81% of American physicians owned a smartphone in 2011.3 Previous studies demonstrate that healthcare providers rate smartphone-based email positively, and that team smartphones can facilitate communication between nurses and physicians.4,5 However, these studies specifically examined the utility of smartphone-based email and voice calls, and did not include text messaging. Limitations of traditional smartphone-based text messaging include Health Insurance Portability and Accountability Act (HIPAA) noncompliance and dependence on in-hospital cellular reception, which can be unreliable. HIPAA is a 1996 US federal law that established a set of privacy and security rules governing not only what is considered protected health information (PHI), but also minimum standards for the protection of such information. HIPAA compliance is defined as meeting these minimum standards for physical, network, and process security.6,7 Though PHI is often transmitted via paging systems and commercial carrier-based text messaging, these modalities are not secure and are thus not HIPAA-compliant. Text messaging applications that address these security and reliability issues have the potential to greatly enhance in-hospital communication. We hypothesized that a smartphone-based HIPAA-compliant group messaging application could improve in-hospital communication on the inpatient medicine service. To our knowledge, our study is the first to examine a HIPAA-compliant text messaging system, and also the first to compare a combination paging/HIPAA-compliant group messaging (HCGM) system with a paging-only system in assessing healthcare provider perception of communication efficiency.

Electronic health records and electronic health information exchange are essential to improving quality of care, reducing medical errors and health disparities, and advancing the delivery of patient-centered medical care. In the US correctional setting, these goals are critical because of the high numbers of Americans affected, yet the use of health information technology is quite limited. In this article, I describe the legal environment surrounding health information sharing in corrections by focusing on 2 key federal privacy laws: the Health Insurance Portability and Accountability Act of 1996 and the federal Confidentiality of Alcohol and Drug Abuse Patient Records laws. In addition, I review stakeholder concerns and describe possible ways forward that enable electronic exchange while ensuring protection of inmate information and legal compliance.

Health care in the United States is highly regulated, yet compliance with regulations is variable. For example, compliance with two rules for securing electronic health information in the 1996 Health Insurance Portability and Accountability Act took longer than expected and was highly uneven across U.S. hospitals. We analyzed 3,321 medium and large hospitals using data from the 2003 Health Information and Management Systems Society Analytics Database. We find that organizational strategies and institutional environments influence hospital compliance, and further that institutional logics moderate the effect of some strategies, indicating the interplay of regulation, institutions, and organizations that contribute to the extensive variation that characterizes the U.S. health care system. Understanding whether and how health care organizations like hospitals respond to new regulation has important implications both for creating desired health care reform and for medical sociologists interested in the changing organizational structure of health care.

The main objective of this work is the understanding of the health system structure of two major world powers China and India, the members of the BRIKS states, as their economies in recent decades represent the paradigm of rapid development. The research is primarily focused on the similarities and differences that characterize the two health systems, and treats the problems they are confronting and the environment in which they are operating. If they are observed together, the economies of India and China act as powerful engine which pulls forward the world's economy. This paper is only a modest attempt to determinate the uniform mantra by using the available conceived material according to which the two very different health care systems in the future could effectively operate. Among the present academic authorities there is no consensus that in the near future these two systems will be developing in the same direction, with the same dynamics and success. However, this possibility should not be neglected. The paper will be composed in a way to explain a paradox that, despite the full economic momentum of India and China, their health systems are having increasingly difficulties to cope with financial issues, inaccessible and poor quality health care, the continual growth of health care spending, growing needs of the population and dissatisfied health care workers, especially these working in the rural areas. India and China are both struggling for decades with frustrated doctors, because they could not, and do not want, to accept so much differences between the rich poor and urban rural counterparts. Health care workers (especially doctors) have started to ignore the work in rural health facilities, or to modify it for the better paid jobs in traffic, services, agriculture or construction.

Accountable models of care delivery demand that health care provider organizations be able to exchange clinical data about the patient. The “Meaningful Use” program is helping to advance health information exchange by requiring physicians and hospitals to exchange clinical data about patients in order to qualify for incentive payments for electronic health records. Early studies demonstrate that the ability to exchange clinical data among provider organizations has the potential to improve clinical care. However, as with any technology, there is a risk of unintended consequences from health information exchange. This manuscript outlines seven aspects of health information exchange that, if not managed properly, may lead to unintended consequences. These categories are: (1) the desire for complete, accurate and timely data for decision making, (2) data management and presentation, (3) assuring routine use of health information exchange, (4) consideration of patient perceptions and concerns, (5) reputational and financial concerns, (6) technical issues and (7) administrative aspects of health information exchange. Education about the capabilities and limitations of health information exchange, along with checklists to support proper implementation and assure that systems are being used as planned, can mitigate risks and help to realize the promise of this powerful technology.

Text messaging is a powerful communication tool for public health purposes, particularly because of the potential to customize messages to meet individuals’ needs. However, using text messaging to send personal health information requires analysis of laws addressing the protection of electronic health information. The Health Insurance Portability and Accountability Act (HIPAA) Security Rule is written with flexibility to account for changing technologies. In practice, however, the rule leads to uncertainty about how to make text messaging policy decisions. Text messaging to send health information can be implemented in a public health setting through 2 possible approaches: restructuring text messages to remove personal health information and retaining limited personal health information in the message but conducting a risk analysis and satisfying other requirements to meet the HIPAA Security Rule.

Most health care settings have focused on becoming more interconnected using technology. The same trend is occurring in occupational health settings. Using technology to enhance communications, facilitate workers' health, and measure the quality of occupational health services is advantageous to employers. The privacy and security of health information is as much the company's responsibility as protecting financial and personal data. As the health privacy agent for the employer, the occupational health nurse must have knowledge of legal regulations and professional standards that govern the security and privacy of health care information, especially when that information is collected, stored, and potentially transmitted within and outside country boundaries.

Mark A. Rothstein On January 25, 2013, the Federal Register published the Department of Health and Human Services (HHS) omnibus amendments to the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, Enforcement, and Breach Notification Rules.1 These modifications also include the final versions of the HIPAA regulation amendments mandated by the Health Information Technology for Economic and Clinical Health Act (HITECH Act)2 and the Genetic Information Nondiscrimination Act (GINA).3 Although the amended rules were effective on March 26, 2013, covered entities and their business associates (which now have direct liability for violations of the regulations) have a compliance date of September 23, 2013.4 It has been 10 years since the April 14, 2003 compliance date for the original HIPAA Privacy Rule.5 Despite HHS’ clarification of some issues by posting answers to frequently asked questions (FAQs),6 there have been no significant amendments to the Privacy Rule since 2003. It has been the view of many covered entities, regulators, and analysts that several provisions of the original Privacy Rule were unworkable or caused unintended consequences. Therefore, the recent rulemaking provided an opportunity to correct some longidentified problems and to integrate congressional directives under the HITECH Act and GINA into the Privacy, Security, Enforcement, and Breach Notification Rules. The amendments and the regulatory explanations are long, technical, and arcane. This article focuses on two important areas of the Privacy Rule with significant changes: research and genetic information. It indicates how a number of the revisions have failed to resolve or have exacerbated problems under the Privacy Rule. Research Sale of Protected Health Information (PHI) Based on language in the HITECH Act, the revised Privacy Rule prohibits the sale of protected health information (PHI) without an authorization.7 One important exception permits payment for research disclosures where the payment is “a reasonable cost-based fee to cover the cost to prepare and transmit the protected health information.”8 This means that the covered entity may be compensated by a sponsor for performing research; only the disclosure of PHI associated with the research is subject to this limitation.

Health information, both professional as well as consumer oriented, is an important component of the health care service. Professionals constantly need information for academics, research, preventive care, treatment and also to stay updated and to create and update health policies. Consumers need health information to stay healthy and to manage diseases and conditions. Generic search engines like Google and Yahoo answers are utilized extensively for getting health information (Akerkar & Bichile, 2004). However while utilizing these engines information seekers most often have to sift through volumes of data that often includes questionable sources of information. Health professionals face lacunae in receiving training about information resources and databases, and structured approach to searching these. Both consumers and health professionals spend far too much time searching for information, time that could be utilized much better in the actual health care delivery process. This article describes a medical librarian’s journey from being a health information consumer to a health information provider both to health professionals and consumers.

The constant growth of medical knowledge and the increases in specialization in clinical practice have created a significant need to share and access patient information with speed and efficiency. However, current technology is centered on processing data, rather than gathering information. To realize the potential of modern technology in improving patient health, merely collecting and storing data are insufficient: one must convert these data into information and knowledge. In this article, I present an overview of 2 recent advances in technology and their assimilation into the practice of medicine, in the attempt to make clinical data meaningful and then to learn from aggregated clinical data. We address the emergence of clinical data warehouses (CDWs) and health information exchanges (HIEs), as features of the Health Information Technology for Economic and Clinical Health (HITECH) Act. This act, enacted in the United States as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. * Abbreviations : CDWs : clinical data warehouses HIEs : health information exchanges HITECH : Health Information Technology for Economic and Clinical Health EHRs : electronic health records SQL : Structured Query Language IOM : Institute of Medicine NHIN : Nationwide Health Information Network RHIOs : regional health information organizations IHIE : Indiana Health Information Exchange HIEO : Health Information Exchange Organization

IntroductionHealthcare is a very important and, at the same time, difficult element of each state's policy. For many countries, the issue of financing the healthcare system is a delicate matter and one of the basic economic and social issues. Nevertheless, decisions concerning the sources and principles of healthcare financing influence the quality of the entire system (Hady and Lesniowska, 2013, p. 1).The development of medical technologies, as well as the introduction of new generations of drugs, cause that currently there are opportunities of effectively treating cases which until recently were beyond doctors' reach. Another problem which is connected with the functioning of systems of health care is ageing population observed practically in all developed countries as well as new challenges connected with it. These circumstances cause that maintaining domestic systems of health services is generating higher and higher costs (Kujawska, 2015, p. 113).Every health system is aimed at satisfying the specific health needs of the population.Health systems can be described using models of service delivery, financing, and economic policy. Much of the literature depicts health delivery systems in terms of a national health system, social insurance or private insurance model. Within each model, there are various forms of financing including general taxation, specific taxation, and private financing (Kulesher, Forrestal, 2014, p. 127).The cost of delivering health care imposes a large, and often growing, burden in nearly all countries. Increasingly, health care decision-makers are being asked to improve performance by containing expenditures while maintaining steady improvements in access and quality (Anell and Willis, 2000, p. 770).This article presents a comparative analysis of the health system financing in Poland and selected countries: The Netherlands, Germany, United Kingdom, USA. Analysis will cover the period from 2011 to 2013. Data deriving from the OECD Health Data database were used.1.Characteristics of Foreign Health SystemsTraditional models of health systems are treated as benchmarks describing the desired and ideal shape of the system. They represent a collection of potentially possible solutions from which one can choose those best suited in specific conditions. There are three health systems defined in literature:- model of national health service, also known as the Beveridge model,- social insurance system, the so-called Bismarck model,- the system of non-regulated insurance market, the so-called residual model.Britain's National Helath Service (NHS) came into existence on 5 July 1948. It was the first health system in any western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone (Fincham, 2011, p. 27).The Bismarck model of health care structure, financing, and delivery is named in honor of Prussian Chancellor Otto von Bismarck, who unified Germany in the 19th century the system incorporates "sickness funds" which are jointly financed by employers and employees via payroll deductions. In this instance, the Bismarc model represent what is available to employees via employer-sponsored health insurance coverage. The major difference in the German system is that the "sickness funds" companies are not profit-generating entities. These "sickness fund" companies do not make o profit (Fincham, 2011, p. 29).A model of private health insurance in which access to benefits is conditioned on having a private insurance policy. Monies allotted to financing the benefits derive from private insurance premiums, health service manufacturers are private entities (Lyszczarz, 2014, p. 92).The European Union Member States and the United States built their health systems on the basis of these models. …

Background As health care becomes more complex, it becomes more important for clinicians and patients to share information. Electronic health information exchange can help address this need. To this end, all provinces and territories (PTs) in Canada have created interoperable electronic health records (iEHRs). These secure systems offer authorized users an integrated view of a person’s healthcare history across the continuum of care. They include information such as lab results, medications, diagnostic images, clinical reports and immunization profiles. This study explores user experiences and perceived outcomes of iEHR use. Methods Surveys conducted between 2006 and 2014 asked iEHR users in six Canadian PTs about system, information and service quality; iEHR use and user satisfaction; and net quality and productivity benefits. The surveys had a core set of questions that used Likert-type scales. Results were synthesized across surveys for each evaluative dimension. Consensus among researchers and subject matter experts on whether to classify the outcomes as positive, mixed/neutral, or negative was established using a modified Delphi technique. Results A total of 2316 iEHR users responded to the six surveys. Information quality was the most studied area. Results varied across PTs, but positive outcomes were more common than mixed/neutral or negative outcomes by a 19:1:1 ratio across this dimension. The next most frequently studied aspects were user satisfaction, the impact of iEHR use on quality of care, and the impact on productivity. In all three areas, there were more positive than mixed/neutral or /negative results (ratios of 13:1:1, 14:3:1, and 15:2:1respectively). Conclusions Overall, users of iEHRs that provide secure access to patient information collated from across the health system tend to report positive outcomes, including quality of care and productivity. This study is an important first step in understanding user perspectives on iEHRs and health information exchange more broadly.

The chorus in favor of integrating behavioral and physical health services is strong and diverse, both at the federal level and in New Jersey. Providers, payers, regulators, patients, and academics are uniting behind the strong clinical behavioral health literature highlighting integration’s positive effects on access and clinical outcomes. But integration requires providers to share health information so they may coordinate care. Health care providers often report experiencing barriers to the exchange of health information with other providers. As care has been siloed, so too have many patient records, and it is not always clear who has the legal authority to access them. The Center for Health & Pharmaceutical Law & Policy at Seton Hall University School of Law (the Center) was asked to conduct a legal analysis, as part of New Jersey’s State Innovation Model Grant, of the barriers related to the sharing of patient health information in connection with the integration of physical and behavioral health care. To inform the legal analysis, the Center conducted a number of interviews with providers, regulators, health information exchanges (HIEs), health information organizations (HIOs), trade and professional associations, consultants, privacy attorneys, advocates, and researchers, to learn more about the specific problems providers face and the questions that need answering. This Report has three main goals: 1. To summarize the Center’s legal analysis of federal and New Jersey laws regarding the sharing of patient health information among treatment providers; 2. To identify challenges to health information sharing among treatment providers that relate to these legal requirements; and 3. To suggest opportunities for the State to support provider exchange of treatment information for integration.

The penetration of social media into modern society has become a worldwide cultural phenomenon. Social media use widely accessible Web-based and mobile technologies to facilitate the creation and sharing of user-generated content in a collaborative and social manner. The uptake of social media in medicine provides new opportunities for health care professionals and institutions to interact with patients and other professionals. Oncologists may use social media as a platform for patient education and authoritative health messaging, for professional development and knowledge sharing, and for direct patient interaction, although this may be fraught with important legal and privacy concerns. In this article, a working group of the ASCO Integrated Media and Technology Committee explores how oncologists might responsibly use social media in their professional lives. Existing social media policies from hospitals, health systems, and pharmaceutical industries are examined to identify common concepts informing the development of future guidelines. Key principles identified include establishing institutional ownership of social media activities and safeguarding protected health information. Furthermore, oncologists must not confuse the roles of provider of information and provider of care, must understand regulations related to state licensure and medical records, and must recognize the importance of transparency and disclosure of potential conflicts of interest. social media may be particularly useful for raising the awareness of and recruitment to clinical trials, but compliance with federal and state regulations and areas under the purview of a local institutional review board must also be ensured. Examples of constructive use of social media in oncology with Facebook, Twitter, and YouTube are provided.

Electronic health information exchange addresses a critical need in the US health care system to have information follow patients to support patient care. Today little information is shared electronically, leaving doctors without the information they need to provide the best care. With payment reforms providing a strong business driver, the demand for health information exchange is poised to grow. The Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, has led the process of establishing the essential building blocks that will support health information exchange. Over the coming year, this office will develop additional policies and standards that will make information exchange easier and cheaper and facilitate its use on a broader scale.

The duty to maintain a patient's health records dates back to the 4th century BC. Within the health care system, privacy and confidentiality are a part of the provider's requirements for quality health care. The Health Insurance Portability and Accountability Act of 1996 addresses the privacy and security of health care records. Title I ensures insurance portability, while Title II requires the use of national guidelines for electronic health communication. The American Recovery and Reinvestment Act of 2009 has provisions to address health information technology for economic and clinical health. Nurse practitioners must understand both laws.

The Information Prescription or Information Rx project has been of interest to health care professionals and librarians for almost a decade. It began with the simple idea of linking patients to high-quality, reliable online health information written in plain language so that the patient could make better decisions affecting his or her own health. This task is accomplished by having the health care provider write an “information prescription” that leads the patient to an authoritative online resource for additional information about a disease, condition, or surgical procedure. This project has been most popular in the United States and the United Kingdom with varied success. One impediment to the success of this concept has been physicians' reluctance to add this task to their already heavy work load. The project could have an even greater impact if there were better promotion, increased training, and increased Internet access along with online searching assistance for patients seeking health information.

Mining electronic medical records for data without patients' consent might be viewed as less harmful than performing other types of human subjects research without consent, but to do so is a violation of privacy and, as such, of patients' autonomy. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Health care consumers today are information seekers with a plethora of knowledge available at their fingertips. Individuals who have health care decisions will frequently present the health care professional with health information found on the Internet, written health literature, or anecdotes of well-meaning family friends. Yet this health information may be inaccurate or come from unreliable sources. How the health professional responds to information presented by the health care consumer may dramatically affect the relationship with the health professional. If the reaction is interpreted negatively, the health consumer may seek health care somewhere else. By increasing awareness of credible health information sources and steering the health care consumer to appropriate and reliable information, the health professional can have a positive impact on the health care outcome. Patient education must be viewed as part of the continuum of health care and accurate health information the foundation.

As part of a larger e-health strategy, Canadian governments have invested millions in online health information services for the lay public. These services are intended to reduce demands on the primary health care system by encouraging greater individual responsibility for health and are often promoted using the language of personal empowerment. In this paper, we describe how lay searchers generally look for online health information and discuss the disempowering challenges they are likely to face in (a) locating Canadian government-sponsored health information sites and (b) finding useful information on these sites to address everyday health concerns. We conclude with several recommendations for policy changes.

Objective To elicit patients’ views on whether they could contribute to improvements in their care by carrying their own health information to clinician encounters; and to consider the implications for the development of a patient-held health file (PHF). Background Increasing rates of chronic disease lead to health care being delivered by multiple care providers often at distributed geographic locations. As a way of increasing the availability of patient information to care providers our project will trial a PHF. Patients carry these files to doctors’ appointments where clinicians record data for other doctors or the patient. Increasing the availability of patient information is anticipated to enhance the safety and quality of care delivery and improve health outcomes. Study design Qualitative semi-structured interviews were conducted with 10 patients. Participants were evenly distributed in terms of gender, aged 60 years or greater and visited at least two specialists and one general practitioner. Findings In this exploratory study, patients who were currently active in decision making about their own health already recorded some health information. They were receptive to carrying their information and thought they should take some responsibility for their health. Patients who were more passive in making decisions about their health did not perceive a need to carry their own information and felt that their doctors communicated adequately. Conclusion Patient-held health files provide an opportunity for patients to access their health information. Such files have the potential to improve health outcomes for patients who adopt both active and passive roles in relation to their own health and engaging with their health information.

For many years the introduction of Electronic Health Records (EHRs) in medical practice has been considered the best way to provide efficient document sharing among different organizational settings. The actual results of these technologies, though, do not seem to have matched expectations. The issue of document sharing has been lately readdressed by proposing the creation of patient-controlled information and communication technologies, Personal Health Records (PHRs), providing laypeople the tools to access, manage and share their health information electronically by connecting to the existing EHRs and other institutional information systems. In this scenario, patients are called to play a major role in coordinating healthcare professionals by providing them the information they need. From a CSCW perspective the PHR offers an interesting case to reflect on cooperative work that requires new infrastructures that intersect organizational settings and extend into domestic environments. So far though, there has not been enough research to shed light on the self-care activities carried out in the households and how these integrate with the organizational practices of doctors and institutions. Our analyses show that health record keeping is an articulation work necessary for meetings with doctors to proceed smoothly. To do so, people integrate the information contained in medical documents by working on them with annotations, underlinings and integrations. Moreover, we show that health record keeping is a spatialized activity that is inextricably interwoven with the everyday routine and objects. Finally, we provide a tentative classification of three different strategies laypeople use to sort out health records: minimum effort, adaptive, networking.

The revolution in health information technology has enabled the compilation and use of large data sets of health records for genomic and other research. Extensive collections of health records, esp...

The health care reform agenda of restraining costs, improving quality, and enhancing population health will require data to guide decision making. The most useful data for health services research are microdata—collected on individuals or households; only microdata allow the estimation of the impact of different policies or clinical protocols on individuals with relatively rare conditions, specific demographic profiles, or who are subject to a unique delivery system. The dramatic increase in the types of microdata—from biological to geospatial—holds great promise for health services research. And there are new ways of combining data from different sources: information scientists have better technical ways of protecting data; statisticians have better statistical techniques; and social scientists have created virtual collaboratories to promote safe, secure access (Lane 2007). However, legislative efforts to protect individual privacy have reduced the flow of health care data for research purposes and increased costs and delays, affecting the quality of analysis. The Privacy Rule in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) both created new procedural requirements for the use of protected health information (PHI) and defined PHI more broadly than had been done in the past (American Statistical Association 2009). The American Recovery and Reinvestment Act of 2009 directs the new National Coordinator for Health Information Technology to pay attention to both data access and data confidentiality. This paper provides an overview of the challenges raised by concerns about data confidentiality in the context of health services research, the current methodologies used to ensure data security, and a description of one successful approach to balancing access and privacy.

Despite of an insignificant track record of quasi-market models in Sweden, new models of this kind have recently been introduced in health care; commonly referred to as “choice of care”. This time citizens act as purchasers; choosing the primary care centre or family physician they want to be treated by, which, in turn, generates a capitation payment to the chosen unit. Policy makers believe that such systems will be self-remedial, that is, as a result of competition the strong providers survive while unprofitable ones will be eliminated. Because of negative consequences of the fragmented health care delivery, policy makers at the same time also promote different forms of integrated health care arrangements. One example is “local health care”, which could be described as an upgraded community-oriented primary care, supported by adaptable hospital services, fitting the needs of a local population. This article reviews if it is possible to combine this kind of integrated care system with a competition driven model of governance, or if they are incompatible. The findings indicate that some choice of care schemes could hamper the development of integration in local health care. However, geographical monopolies like local health care, enclosed in a non-competitive context, lack the stimulus of competition that possibly improves performance. Thus, it could be argued that if choice of care and local health care should be combined, patients ought to choose between integrated health care arrangements and not among individual health professionals.