Healthcare Informatics

Healthcare Informatics Skill

Clinical terminology, healthcare compliance (HIPAA/HITECH), patient safety, and health data management.

Core Principle

Healthcare information systems exist to improve patient outcomes. Every data decision balances access (clinicians need information) against privacy (patients deserve protection). When in doubt, protect the patient.

HIPAA Compliance

Protected Health Information (PHI)

PHI is any individually identifiable health information. The 18 HIPAA identifiers:

De-identification Methods

Minimum Necessary Standard

• Use or disclose only the minimum PHI necessary for the purpose
• Role-based access controls in EHR systems
• Audit logs for every PHI access

HITECH Act Extensions

FHIR Patient Resource Example

{
  "resourceType": "Patient",
  "id": "example",
  "identifier": [
    {
      "system": "http://hospital.org/mrn",
      "value": "12345"
    }
  ],
  "name": [
    {
      "use": "official",
      "family": "Doe",
      "given": ["John"]
    }
  ],
  "gender": "male",
  "birthDate": "1985-06-15",
  "address": [
    {
      "use": "home",
      "city": "Springfield",
      "state": "IL",
      "postalCode": "62704"
    }
  ]
}

Clinical Terminology Standards

Key Coding Systems

Interoperability Standards

Electronic Health Records (EHR)

Core EHR Functions

1. Clinical Documentation — Progress notes, assessments, plans
2. CPOE — Computerized Provider Order Entry (meds, labs, imaging)
3. CDS — Clinical Decision Support (alerts, reminders, pathways)
4. Results Management — Lab values, imaging reports
5. Medication Management — e-Prescribing, interaction checks, reconciliation

Patient Safety Checks

Healthcare Data Analytics

Quality Measures

Risk Adjustment

• HCC (Hierarchical Condition Categories) for Medicare risk scoring
• Comorbidity indices (Charlson, Elixhauser) for severity adjustment
• Social Determinants of Health (SDOH) as contextual factors

Research & Clinical Trials

IRB Requirements

Clinical Trial Phases

AI in Healthcare — Guardrails

Critical: AI-generated medical information must never be presented as clinical advice.

• Always include disclaimer: "This is informational only. Consult a healthcare professional."
• Never diagnose or recommend treatment
• Flag when confidence is low or data is ambiguous
• Cite clinical guidelines (USPSTF, ACC/AHA, IDSA) when referencing evidence-based practices
• Document provenance of any clinical data used in analysis