ICD 10 CM. Knowledge is powerful. IT is everywhere. Compliance is everything.

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1 Health IT & Compliance in Medical Practice JANE DOE E1Ø Z85.Ø38 W20.8xxA S06.0x1A Y G ICD 10 PCS ICD 10 CM ICD 10 PCS Y93.g3 Presented by: Stephanie Cecchini, CPC, CEMC, CHISP GENERAL OBJECTIVES Knowledge is powerful. IT is everywhere. Compliance is everything. Computer Science concepts Language in Health IT EMR Implementations Rules, Regulations, & Standards in Health IT 2 1

2 IT MEETS COMPLIANCE. EHR use grew from 16% in 2009 to 35% in K hospitals & 41k doctors have received $3.1B in incentives Still growing Health IT jobs is expected to increase 20% by ,000 doctors still operate with paper charts 2012 HIPAA audits with boosted HITECH penalties Up to $1.5 million per calendar year per incident type Reporting is required on any data breach incident Business associates are fully subject to Rules Breaches increased 97% from 2010 to 2011* *Per 2012 report on PHI Breach Analysis from Redspin 3 COMPUTER SCIENCE SKILLS For effective communication between health care providers, administrators, and IT staff. Basic concept #1: Operating Systems Basic concept #2: Computer Networks Basic concept #3: Data Security Basic concept #4: Markup Basic concept #5: Data Query 4 2

3 BASIC CONCEPT #1: OS 5 BASIC CONCEPT #2: NETWORKS Local area networks (LANs) and Wireless Local Network (WLAN) Wireless Personal Area Networks (WPANs) (i.e. Bluetooth) Wide area networks (WANs) The Internet is the world's largest public WAN. Clients and Servers Clients rely on Servers Application Server: runs (business) applications Print Server: Shares and routes print jobs Database Server: Stores/fetches data Mail Server: Manages Web Server: Manages Internet FTP Server: Manages file sharing 6 3

4 NETWORK ARCHITECTURE There are countless ways to architect Packets of data hit the Router Router passes the data to the Firewall Inside the DeMilitarized i Zone (DMZ) Data is delivered to the Proxy Proxy decides to pass to the inside client Other hardware Switches Hubs Bridges Cables Network cards Router Firewall DMZ Internet Firewall Web Server Proxy Server Switch Network 7 NETWORK COMMUNICATION PROTOCOLS TCP/IP (Transmission Control Protocol/Internet Protocol): The standard family of protocols for communicating with Internet devices FTP (File Transfer Protocol): FTP is the simplest way to exchange files between computers on the Internet. FTP is an application i protocol that uses the Internet s TCP/IP protocols. HTTP (HyperText Transfer Protocol): HTTP is the set of rules for exchanging files (text, graphic images, sound, video, and other multimedia files) on the World Wide Web. HTTP is an application protocol that uses the Internet s TCP/IP protocols. POP3 (Post Office Protocol 3): An e mail protocol used to retrieve e mail from a remote server over an Internet tconnection. SMTP (Simple Mail Transport Protocol): The standard protocol used for Internet e mail messages. 8 4

5 BASIC CONCEPT #3: DATA SECURITY (Asymmetric) cryptography: encryption & decryption keys. PPK Hashing: A hash is a # that uniquely identifies text in a message. 2 different messages will not produce the same hash results. Digital signatures: Combines the public key encrypted message, with a hash and a private key, that can only be decrypted by the public key Public Key Infrastructure: storing, managing gand maintaining the public and private keys HUH? 9 PUBLIC AND PRIVATE KEYS 10 5

6 SECURE DATA WITH PPK 11 INTEGRITY & DIGITAL SIGNATURE 12 6

7 BASIC CONCEPT #3: MARKUP Markup: Codes embedded in a document that describe its structure and/or its format. HTML (Hypertext Markup Language): The language of the web HTML defined presentation for content. <B> Makes this content bold </B> XML (extensible Markup Language): User defined structured XML describes content. 13 HTML 14 7

8 XML 15 BASIC CONCEPT #3: DATA QUERY SQL (Structured Query Language) is a standard language with the ANSI (American National Standards Institute) for accessing databases. SQL understands d a set of rules that t are communicated with keywords, punctuation, spaces, mathematical operators, and characters that have meaning when used inside of query statements. SQL statements are written to fetch information from tables that are located in a relational data base. 16 8

9 RDBMS RDBMS (Relational Database Management Systems) are software programs used to maintain data records and indices in tables. RDBMS software rules are similar, but vary by program MS SQL Server, IBM DB2, Oracle, MySQL, Microsoft Access, etc. 17 SQL COMMANDS SELECT tells SQL what column/s to go to get the data and how much detail you are asking for from that column. FROM tells SQL what table/s to go to find the data. SELECT pt_id, pt_name FROM Patients WHERE tells SQL the special conditions you want applied to the data. It is like giving a more detailed map to SQL in order to limit data to the exact data you want. SELECT pt_id FROM Patients WHERE pt_id =

10 MORE SQL COMMANDS GROUP BY is used when an aggregate function is used and more than one column is selected. It tells SQL how you want to group the data. AVG() Returns the average value COUNT() Returns the number of rows FIRST() Returns the first value LAST() Returns the last value MAX() Returns the largest value MIN() Returns the smallest value SUM() Returns the sum ORDER BY tells SQL how to sort the data results. 19 EXAMPLE SQL QUERY 20 10

11 BASIC LANGUAGE OF HEALTH IT Stakeholders HITECH HIE CDS CPOE DICOM/PACS RFID Wireless Concepts 21 STAKEHOLDERS 22 11

12 HITECH The Health Information Technology for Economic and Clinical Health Act, or HITECH Act, is a part of the Recovery Act An incentive payment program to encourage Eligible Professionals and hospitals to use electronic health records (EHR). EPs = OVER 10% outpatient Physicians, Dentists, Podiatrists, Optometrists, Chiropractors Non EP= UNDER 10% outpatient ED physicians, anesthesiologists, and pathologists 23 HITECH MEDICAID PAYMENTS Apply and register with CMS (needs NPI) Up to $64K Does not require MU to be demonstrated before payments begin Payments begin when state is ready to administer the program. 30% Medicaid Pts (or 20% for Pediatricians) No penalty for non participation in HITECH HITECH Caps 85% Max Incentive $25,000 in Year 1 $21,250 $63,750 $10,000 in Years 2 6 $8,500 For Pediatricians under 30% Medicaid Patients $16,667 in Year 1 $14,167 $42,500 $6,667 in Years 2 6 $5,

13 HITECH MEDICARE PAYMENTS Apply and register with CMS (needs NPI) Up to $44K Requires 90 days MU before payments begin Capped at 75% of MFS allowable or lesser of Penalties as follows. 25 HITECH MEDICARE REDUCTIONS For most office based physicians who do not adopt EHR technology by 2015, Medicare payments will be reduced by: From Year Reduction in Medicare Payments % % % 26 13

14 MEANINGFUL USE To qualify for incentive payments an EP must become a meaningful users of technology Don t make Perfect the enemy of Good Stage 1: Implement base EHR technology Stage 2: Expand HIE health information exchange. Stage 3: Pt centered HIE that improves population health. First Payment Year Payment Year Stage 1 Stage 1 Stage 2 Stage 2 Stage Stage 1 Stage 1 Stage 2 Stage Stage 1 Stage 2 Stage Stage 1 Stage Stage 3 27 MU STAGE 1 EP must meet objectives from 4 categories Category 1: Core objectives (15) Category 2: Menu set objectives (5 of 10) Category 3: Core Clinical Quality Measures (3 of 6) Category 4: Menu Set Clinical Quality Measures (3 of 38) 28 14

15 MU 1 - CAT 1: CORE OBJECTIVES 1. Tested ability to exchange data with other EMRs 2. 50% of visits record basic Pt demographic information 3. 80% of visits document a current Pt problem list 4. 80% of visits document current medication lists 5. 80% of visits document allergies 6. 50% of visits document vital signs (ht and wt for children) 7. 50% of visits document smoking status 8. At least one EHR clinical decision support rule and alert % Drug drug, drug allergy, drug formulary checks % e Rx (retail pharmacy) % CPOE (for medication orders) % of visits provide the Pt a clinical summary (w/in 3 days) % of visits ii provide the Pt a chart copy (w/in 3 days) 14. Ability to report on meaningful use CMS quality measures 15. Keep Pt data private & secure HIPAA risk analysis with action plan 29 MU 1 - CAT 2: MENU-SET OBJECTIVES (5 OF 10) 1. Tested ability to transmit immunization information to registries 2. Tested ability to send data to public health agencies 3. 10% of visits provide Pts with education resources 4. 10% of visits provide Pts with lab results within 4 days of report 5. 50% of new visits include Rx Reconciliation current to best choice 6. Implement a drug formulary accuracy check 7. 50% of outbound Pt referrals provide a summary of care record 8. 40% of Pt visits incorporate lab test results into the EHR 9. Ability to generate reports of Pts with a specific defined condition 10. Follow up reminders to 20% of Pts (Internet or phone) 30 15

16 MU 1- CAT 3: CLINICAL QUALITY MEASURES (3 OF 6) Required Core Clinical Quality Measures: 1. NQF 0013: Hypertension: Blood Pressure Measurement 2. NQF 0028: Preventive Care and Screening Measure Pair: a.) Tobacco Use Assessment; b.) Tobacco Cessation Intervention 3. NQF 0421: PQRI 128 Adult Weight Screening and Follow up If the Denominator (all patients that meet the defined properties) is Zero Alternate Core Quality Measures: 1. NQF 0024: Weight Assessmentand Counseling for Children and Adolescents 2. NQF 0041: PQRI 110 Preventive Care and Screening: Influenza Immunization for Pts 50 Years Old 3. NQF 0038: Childhood Immunization Status 31 MU 1 Cat 4: Clinical Quality Measures (3 of 38) 1. NQF 0031/PQRI 112 Breast Cancer Screening. 2. NQF 0027/PQRI 115 Smoking and Tobacco Use Cessation 3. NQF 0055/PQRI 117 Adult Weight Screening Follow Up 4. NQF 0004 Initiation Alcohol Drug Dependence Tx 5. NQF 0018 Controlling High Blood Pressure 6. NQF 0075 Ischemic Vascular Disease (IVD) 7. NQF 0105/PQRI 9 Anti depressant medication manage 8. NQF 0036 Use of Appropriate Medications for Asthma 9. NQF 0002/PQRI 66 Testing for Children with Pharyngitis 10. NQF 0043/PQRI 111 Pneumonia Vac Status Older Adults 11. NQF 0047/PQRI 53 Asthma Pharmacologic Therapy 12. NQF 0001/PQRI 64 Asthma Assessment 13. NQF 0034/PQRI 113 Colorectal Cancer Screening 14. NQF 0012 Prenatal Care 15. NQF 0014 Prenatal Care: Anti D Immune Globulin 16. NQF 0032 Cervical Cancer Screening 17. NQF 0033 Chlamydia Screening for Women. 18. NQF 0081/PQRI 5 Heart Failure (HF) 19. NQF 0070/PQRI 7 Coronary Artery Disease (CAD) 20. NQF 0067/PQRI 6 Coronary Artery Disease (CAD) 21. NQF 0083/PQRI 8 Heart Failure (HF) 22. NQF 0074/PQRI 197 Coronary Artery Disease (CAD) 23. NQF 0084/PQRI 200 Heart Failure (HF) 24. NQF 0068/PQRI 204 Ischemic Vascular Disease (IVD) 25. NQF 0059/PQRI 1 Diabetes 26. NQF 0064/PQRI 2 Diabetes 27. NQF 0061/PQRI 3 Diabetes 28. NQF 0055/PQRI 117 Diabetes 29. NQF 0056/PQRI 163 Diabetes 30. NQF 0073/PQRI 201 Ischemic Vascular Disease (IVD) 31. NQF 0575 Diabetes 32. NQF 0086/PQRI 12 Primary Open Angle Glaucoma 33. NQF 0088/PQRI 18 Diabetic Retinopathy 34. NQF 0089/PQRI 19 Diabetic Retinopathy 35. NQF 0387/PQRI 71 Oncology Breast Cancer 36. NQF 0385/PQRI 72 Oncology Colon Cancer 37. NQF 0389/PQRI 102 Prostate Cancer 38. NQF 0052 Low Back Pain 32 16

17 HEALTH INFORMATION EXCHANGE (HIE) HIE is the process of moving or sharing HIPAA protected health information (PHI) among organizations Exchange of clinical and, potentially, administrative data Exchange of the continuity of care document (CCD) eprescribing Medication history and reconciliation Delivery of lab results Management of a master patient index Record locator services Electronic eligibility and claims transactions Computerized Physician Order Entry (CPOE) Provider portal 33 HEALTH INFORMATION EXCHANGE 34 17

18 Patient Index EMPI BASIC CONCEPT OF AN HIE Pt: ID # EMR Stephanie L. Jones 1014 Leg1 S. Jones Z1245 Pharmacy Steph Jones Leg1 Stephanie Jones Provider S.L. Jones Laboratory 35 CDS Clinical Decision Support (CDS) tools provide health care providers with Pt specific information to help prevent errors and improve healthcare efficiency at the time and location of the medical decision making. It is a real time reference that combines comparative, Pt specific information (such as the Pt s signs and symptoms, allergies, and lab results) with general knowledge: Diseases Diagnoses Medications Treatments Drug Formularies (coverage limitations) Medical/Clinical Guidelines Payer Requirements 36 18

19 E-RX E prescribing electronically transmits a new prescription or renewal authorization to a pharmacy. It can be accomplished as part of an EMR/EHR EMR or via an application service provider (ASP). According to the 2009 National Progress Report on e Prescribing, released by Surescripts 70 percent of physicians who do e prescribe do so through their EHR. 37 CPOE The EMR transmits the order to the appropriate place, department, or individuals so it can be carried out. Medications Laboratory tests and Radiology and imaging tests Blood dbanks Therapies (e.g., physical, occupational, respiratory, rehabilitation) Consultations with specialists Surgical preparation and Recovery room protocols Discharges and Pt transfers and more This can reduce errors related to the interpretation of handwritten orders It provides an opportunity for real time clinical decision support such as dosage and alternative medication i suggestions, duplicate therapy warnings, and drug drug, drug disease, drug lab value, and drug allergy interaction checking

20 DICOM STANDARDS AND PACS EMRS Electronic Picture Archiving and Communication EMRs (PACS) store and receive diagnostic images in a PACS uses files and messages from a data dictionary called DICOM (Digital Imaging and Communications in Medicine) This description is meant for purposes of illustration only. 39 RFID IN HEALTH CARE Radio Frequency Identification (RFID) technology uses radio waves for the remote exchange of data between an RFID reader and a RFID tag, which is attached to a specific object. Blood banking: tagging of blood transfusions from donor to patient t with active tags to provide alerts if blood dhas not been properly refrigerated. Medication administration: tagging of unit of use drugs for proper administration to reduce errors and to improve safety. Medication authentication and restocking: tracking of drug origin and expiration date so that the system can alert the caregiver in case an item is counterfeit, has expired or needs to be refilled. Patient tracking: RFID wristbands and physician laptop readers to automatically identify the patient name, blood type, allergies and medications

21 WIRELESS CONCEPTS IN HEALTH CARE Mobile health (mhealth), also termed wireless healthcare Examples: Remote use of tablets, PDAs, Smartphones, and SMS texting 41 EMR SELECTION & IMPLEMENTATION Types Costs Questions to ask the Vendor 42 21

22 CLOUDY WITH A CHANCE OF SAAS Client Server Model ASP Model Runs on the Internet Storage, processing, security, and bandwidth are run by vendor Usually cheaper Access can be easier and can also be an issue Speed can be an issue Requires ownership of data language in the contract 43 COST - WHAT S A GENERAL IDEA? 44 22

23 AND, THEN WHAT? 45 SAVINGS WHAT S A GENERAL IDEA? Chart, Fax, Paper and Ink: $5 per Pt x 2496 = $12,480 Pharmacy Calls: $.50 per Pt x 2496 = $1,248 A/R: 3% on Collections: $364,800 A/R x.03 = $10,944 Storage/Destruction: $40 x 12 months = $480 Per Year $25,

24 WHAT ABOUT PRODUCTIVITY? Work flow preparation and planning Assume a 30 50% reduction in visits for a period of time Plan to extend hours Reassignment of staff duties 47 QUESTIONS BUYER SHOULD ASK When do I want to do this? How does it affect my workflow? How does it affect my compliance and policies? Have I looked at my choices and narrowed it to 3 5 vendors? How will it interface with my practice management software? What is the structure of the license, and length of agreement? What guarantees are offered for HITECH incentive payments? What are the professional references of the EMR company? What templates can be customized or dictated? What is the total price; what s included (and what s not)? Will I maintain complete data ownership? What is the typical implementation period? Have I negotiated the best price? 48 24

25 INTEROPERABILITY AND STANDARDS 49 INTEROPERABILITY AND STANDARDS Structured Data Concept/names (Hypertension, High Blood Pressure) Name/concepts: I m Im cold cold, I have a cold cold, or COLD (Chronic Obstructive Lung Disease) There are hundreds of vocabularies (i.e., terminologies or nomenclatures) SNOMED CT, CPT, ICD 9, LOINC, RXNorm, etc. EMR historically used proprietary vocabularies 50 25

26 FINAL STANDARDS RULE 45 CFR PART 170 HIT: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology Vocabulary Codes Content Markup Privacy and Security Rules 51 VOCABULARY Problem List ICD 9 CM, Vols. 1 2 or SNOMED CT July 2009 Procedures ICD 9, Vol. 3, CPT, HCPCS Level II Laboratory Test Results Logical Observation Identifiers Names & Codes (LOINC ) version 2.27 Medications Any source vocabulary that is included in RxNorm Immunizations HL7 Standard d Code StCVX Set Vaccines Administered, i d July 30, 2009 Race and Ethnicity OMB Standards Statistical Policy Directive No. 15, October 30,

27 ICD-9-CM, VOLS. 1-2 (VOCABULARY STANDARDS PROBLEM LIST) International Classification of Diseases, Ninth Revision, Clinical Modifications Volumes 1 and 2 are diagnosis codes. ICD 9 CM is made up of alphanumeric codes that represent diseases, conditions, or circumstances that has or could cause a person s illness, injury, or death. Volume 3 contains procedure codes. ICD-9-CM Example ICD-9-CM = Acute myocardial infarction 410, Unspecified site 9, unspecified episode of care 0 This description is meant for purposes of illustration only. 53 SNOMED CT JULY 2009 (VOCABULARY STANDARDS PROBLEM LIST) SNOMED Clinical Terms (SNOMED CT ) International Release July 2009 are codes used for research and for sharing of information about the Pt s diagnosis and treatment. An update of the codes is done every six months. At its simplest, it contains three primary core tables: Concepts, Descriptions, and Relationships. SNOMED CT Example: conceptid= descriptionid= type=fullyspecifiedname name=myocardial infarction descriptionid= type=preferred name=myocardial infarction descriptionid= type=synonym name=cardiac di infarction descriptionid= type=synonym name=heart attack descriptionid= type=synonym name=infarction of heart relationshipid= relationship=is a concept2=disorder of myocardium ( ) relationshipid= relationship=is a concept2=structural disorder of heart ( ) This description is meant for purposes of illustration only

28 CPT (VOCABULARY STANDARDS PROCEDURES) Current Procedural Terminology (CPT ) procedure codes, published by the American Medical Association (AMA), represent procedures performed and billed by physicians. The format for CPT codes is five characters. CPT also may have modifiers up to two digits. For example: xxxxx xx. This description is meant for purposes of illustration only. 55 HCPCS LEVEL II (VOCABULARY STANDARDS PROCEDURES) Healthcare Common Procedure Coding EMR (HCPCS) LevelII codes areused to identify medications, medical supplies, and some medical procedures. The format for HCPCS Level II codes is up to five characters. For example: xxxxx. This description is meant for purposes of illustration only

29 LOGICAL OBSERVATION IDENTIFIERS NAMES AND CODES (LOINC ) (VOCABULARY STANDARDS LABS) LOINC are open source codes used to identify laboratory clinical observations and results. LOINC is updated every six months (LOINC 2.27 was released July 7, 2009). LOINC is available as a Microsoft Access (.mdb) database file and a tab delimited text file (.txt). LOINC Example: CODE<component/analyte>:<kind of property>:<time aspect>:<emr type>:<scale>:<method> <Hepatitis B virus surface Ab>:< ACnc >:< Pt> :< Ser >:< Qn >:< EIA > This description is meant for purposes of illustration only. 57 RXNORM (VOCABULARY STANDARDS MEDS) RxNorm provides unique identifiers for clinical drugs from 11 source vocabularies (including SNOMED CT, FDA, VA, First DataBank Inc., etc.). It is a set of relational tables that organize data by concepts. Drugs that are identical in name, ingredients, strengths, and dose forms are grouped together with the same unique code EXAMPLE: RxCUI = AMOXICILLIN 200 MG ORAL TABLET Amoxicillin 200 MG Oral Tablet Amoxicillin trihydrate 200 mg tablet Amoxicillin trihydrate200 mg tablet (product) This description is meant for purposes of illustration only

30 HL7 CODE SET CVX (VOCABULARY STANDARDS IMMUNIZATIONS) The Center for Disease Control and Prevention s (CDC s) NationalCenter ofimmunization andrespiratory Diseases (NCIRD) maintains the HL7 external code set CVX. The codes in HL7 Version 2.3 table 0292, represent the initial content of the external CVX code, which was added by the CDC in order to remain current with new vaccines. The code set consists of two to three digit code, short description, and full vaccine name. 59 CONTENT MARKUP STANDARDS Pt Summary Record HL7 Clinical Document Architecture, Release 2 (CDA) Continuity of Care Document (CCD) ASTM E2369 Standard Specification for Continuity of Care Record Electronic Prescribing NCPDP SCRIPT Standard, Implementation Guide, Version 8 NCPDP SCRIPT Standard, Implementation Guide, Version

31 CONTENT MARKUP STANDARDS (CONT.) Electronic Submission of Lab Results to Public Agencies HL Electronic Submission to Public Health Agencies HL HL Electronic Submission to Immunization Registries HL HL Quality Reporting The CMS Physician Quality Reporting Initiative (PQRI) 2009 Registry XML Specification 61 CCD AND THE CCR PATIENT SUMMARY RECORD (CONTENT MARKUP) Both are XML based language, which provide a uniform format for the transmission of health related information. HL7 CDA, Release 2 Continuity of Care Document (CCD) ASTM E2369 standard specification for continuity of care record (CCR) 1. Information Source Required 2. Person Information Required 3. Language Spoken Required if known 4. Support Required if known 5. Advance Directive Optional 6. Allergy / Drug Sensitivity Optional 7. Comment Optional 8. Condition/Problem Optional 9. Encounter Optional 10. Health care Provider Optional 11. Immunization Optional 12. Payers Optional 13. Medication Prescription and Non Prescription Optional 14. Plan of Care Optional 15. Pregnancy Optional 16. Procedure Optional 17. Vital Sign Optional 18. Results Optional 62 31

32 NCPDP SCRIPT STANDARD ELECTRONIC PRESCRIBING (CONTENT MARKUP) The National Council for Prescription Drug Programs (NCPDP) governs the SCRIPT HEALTH LEVEL SEVEN (CONTENT MARKUP) Lab Results, Submission to Public Health Agencies, Immunization Registries, and Patient Summary Record Health Level Seven (HL7) is an XML based language, which provides a uniform format for the transmission of health related information. It provides a messaging g standard, which is a set of rules that enable clinical applications to exchange data. These messages are in a human readable format but require some interpretation. HL7 Message Example: MSH ^~\& AccMgr ADT^A P 2.3 EVN A PID ^^^1^MRN^ 1 SMITH^DONALD^D M 1 111^SMITH ST^^FOWL^CA^ ^^M ^^^ AccMgr^VN^ NO PV1 1 I IN1^214^1^1^^^S 3 IN1^214^1 37^JONES^WALT^^^^^^AccMgr^^^^CI ^ JONES^WALT^^^^^^AccMgr^^^^CI ^^^AccMgr^VN 4 63 PHYSICIAN QUALITY AND REPORTING INITIATIVE (PQRI) (CONTENT MARKUP) XML Specification PQRI, first created as a Medicare quality reporting program. PQRI is reported in a CMS approved XML format. The 179 PQRI measures were developed by various organizations. The denominator (total number of Pts in the measured population) defines the condition or aspect of care. Example: PQRI 112 Breast Cancer Screening. Description: Percentage of women years of age who had a mammogram to screen for breast cancer

33 PRIVACY STANDARDS Encryption and Decryption of ephi Any encryption algorithm identified by the National Institute of Standardsand Technology (NIST) as an approved security function in Annex A of the Federal Information Processing Standards (FIPS) Publication Verification Information not Altered in Transit A hashing algorithm with a security strength equal to or greater than SHA 1 (Secure Hash Algorithm (SHA 1) as specified by the National Institute of Standards and Technology (NIST) in FIPS PUB (October, 2008)) must be used to verify that electronic health information has not been altered 65 QUESTIONS 66 33