Ch. 16 Health Information Management Technology: An Applied Approach – Flashcards
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1. A computer software program designed to prevent unauthorized use of an information resource 2. The process of designing, implementing, and monitoring a system for guarenteeing that only individuals with a legitimate need are allowed to view or amend specific data sets
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Access Control
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An organizationof healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program
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Accountable care organization (ACO)
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A committee of the National Standards Institute that develops and maintains standards for the electronic exchange of business transactions, such as 837-Health Care Claim, 835-Health Care Claim Payment/Advice, and others
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Accreditied Standards Committee X12 (ASC X12)
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Also knon as Patient Protection and Affordable Care Act (PPACA). A federal statue that was signed into law on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the act is the product of the healthcare reform agenda of the Democratic 111th Congress and the Obama administration
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Affordable Care Act (ACA)
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When an excessive number of alerts are used in an information system, users may get tired of looking at the alerts and ignore them
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Alert Fatigue
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The organization that accredits all U.S. standards development organizations to ensure they are following due process in promulgating standards
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American National Standards Institute (ANSI)
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Previously known as the stimulus bill or HR 1. The actions related to health information technology are spread throughout the law; however, the bulk of the items are in Title XIII-Health Information Technology; also called HeLth Information Technology for Economic and Clinical Health Act or HITECH
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American Recovery and Reinvestment Act (ARRA)
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Electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on)
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Ancillary systems
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The configuration, structure, and relationships of hardware (the machinery of the computer including input/output devices, storage devices, and so on) in an information system
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Architecture
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Formerly known as the American Society for Testing and Materials, a system of standards developed primarily for various EHR management processes
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ASTM International
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"A chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) that is used to determine security violations"
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Audit log (Audit Trail)
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1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source
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Authentication
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System that makes drugs available for patient care
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Automated drug dispensing machines
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Systems that identify the right patient and right drug to be given at the right time, in the right dose, and via the right route
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Barcode medication administration record (BC-MAR)
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Information system that generates bill for healthcare services performed
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Billing system
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The end product or goal of knowledge management
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Business intelligence (BI)
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1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prescribed set of requirements
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Certification
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The process of performing an impact analysis and obtaining approval before modifications to the project scope are made
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Change control
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The process of collecting all services, procedures, and supplies provided during patient care
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Charge capture
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An EHR implementation activity in which data from the paper chart are converted into electronic form
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Chart conversion
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A software system designed to allow the HIM department to electronically track and manage documentation omissions from the health record
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Chart deficiency system
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A relatively new position within the information services organizational structure, typically held by a member of the medical staff and responsible for, among other things, leading EMR system implementation, engaging healthcare professionals in the system's development and use, and leading the group designated to serve as the central governance forum for establishing the healthcare organization's clinical IS priorities
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Chief medical informatics officer (CMIO)
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Itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other healthcare provider; submitted with a claim for healthcare services provided
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Claim
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Additional information that is submitted with a claim for healthcare services provided
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Claims attachment
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Information required to be reported on a healthcare claim for service reimbursement
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Claims data
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Claims status inquiry and response
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A computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amonts of shared data
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Client/server architecture
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A central database that focuses on clinical information
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Clinical data repository (CDR)
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A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface; also called a data warehouse
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Clinical data warehouse (CDW)
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The process in which individual data elements are represented un the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts
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Clinical decision support (CDS)
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A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions
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Clinical decision support system (CDSS)
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HL7 electronic exchange model for clinical documents (such as discharge summaries and progress notes)
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Clinical document architecture (CDA)
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The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts
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Clinical documentation system
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A category of a healthcare information system that includes systems that directly support patient care
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Clinical information system (CIS)
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The function of electronically delivering data and automating the workflow around the management of clinical data
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Clinical messaging
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Clinical transformation
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A healthcare provider, including physicians and others who treat patients
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Clinician
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Information systems used to provide patient safety when ordering and administrating medications
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Closed-loop medication management
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Information systems that use the Internet to access data
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Cloud computing
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Information system used to assign code numbers and enter key information from the health record
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Coding and abstracting systems
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Under meaningful use, EHR technology that has been developed to meet, at a minimum, all applicable certification criteria adopted by the Secretary of HHS
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Complete EHR
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Technology that electronically stores documents and distributes them with fax, email, web, and traditional hard copy print process
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Computer output to laser disk (COLD)/enterprise report management (ERM)
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Sytems that allow physicians to enter medication or other orders and recieve clinical advice about drug dosages, contraindications, or other clinical decision support; sometimes called computerized physician order entry
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Computerized provider order entry (CPOE)
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The process of keeping a record of changes made in an EHR system as it is being customized to the organization's specifications
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Configuration management
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A process by which may opt in or opt out of having their data exchanged in the HIE
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Consent directive
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Health information exchange model where there is no centerilized storage of patient data
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Consistent federated model (of HIE)
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The condition of depending on the parts of a written or spoken statement that precede or follow a specified word or phrase and can influence its meaning or effect
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Contextual
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In the exchange of information with other providers and the patient, the CCD combines the content that physicians have agreed should be included in patient referrals with a means to format that data for electronic transmission
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Continuity of care document (CCD)
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Documentation of care delivery from one healthcare experience to another
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Continuity of care record (CCR)
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Medication should not be prescribed due to another medication or condition
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Contraindication
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A predefined set of terms and their meanings that may be used in structured data entry or natural language processing to represent expressions
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Controlled vocbulary
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Standardized performance measure developed to improve the safety and quality of healthcare (for example, core measures are used in the Joint Commission on Accreditation's ORYX initiative)
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Core measures
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The extent to which healthcare data are accessible whenever and wherever they are needed
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Data availability
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Where hardware and software for the electronic information systems are held
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Data center
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The standardization of vocbulary such as that the meaning of a single term is the same each time the term is used in order to produce consistency in information derived from the data
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Data comparability
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The task of moving data from one data structure to another, usually at the time of a new system installation
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Data conversion
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A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology
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Data dictionary
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Protocols that help ensure that data transmitted from one system to another remain comparable
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Data exchange standards
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Data Use and Reciprocal Support Agreement (DURSA)
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An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications
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Database
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Computer software that enables the user to create, modify, delete, and view the data in a database
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Database management system (DBMS)
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The cabinet-level federal agency that oversees all of the health-and human-services-related activities of the federal government and administers federal regulations
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Department of Health and Human Services (HHS)
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Laboratory and other tests performed to help diagnose a patient
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Diagnostic studies
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A process in which vocal sounds are converted to bits and stored on computer for random access
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Digital dictation
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Data provided in a computer-readable format
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Digital images
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A standard that promotes a digital image communications format and picture archive and communications systems for use with digital images
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Digital Imaging and Communications in Medicine (DICOM)
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Discrete reportable transcription (DRT)
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1. A more expansive view of case management in which patients with the highest risk of incurringhigh-cost interventions are targeted for standardizing and managing care throughout intergrated delivery systems 2. A program focused on preventing exacerbation of chronic diseases and on promoting healthier life styles for patients and clients with chronic diseases
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Disease management (DM)
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Information system that allowed a paper document to be scanned and displayed
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Document imaging management system (DIMS)
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A database of information about drugs
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Drug knowledge database
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A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations
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Electronic data interchange (EDI)
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A type of electronic document management system that uses methods such as bar coding on the forms to identify specific content
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Electronic document/content management (ED/CM)
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A storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks
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Electronic document management system (EDMS)
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Process of moving money electronically
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Electronic funds transfer (EFT)
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An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians andstaff across more than one healthcare organization
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Electronic health record (EHR)
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An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization
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Electronic medical record (EMR)
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A system designed to prevent medication errors by checking a patient's medication information against his or her barcoded wristband
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Electronic medication administration record (E-MAR)
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Systems that capture data from print files and other report-formatted digital documents, such as email, efax, instant messages, web pages, digital dictation, and speech recognition and store them for subsequent viewing
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Electronic (or enterprise) report management (ERM)
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A system that requires the author of a document to sign onto a patient record using a user ID and password, reviews the document to be signed, and indicates approval
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Electronic signature authentication (ESA)
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Confirmation of insurance status
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Eligibility verification
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Converted into code
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Encoded
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Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
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Encoder
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The process of transforming text into an unitelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination
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Encryption
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Enables prescriptions to be checked for drug contraindications and sent directly to retail pharmacy of the patient's choosing
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e-Prescribing (e-RX)
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Healthcare services based on clinical methods that have been throughly tested through controlled, peer-reviewed biomedical studies
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Evidence-based medicine
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Non-face-to-face interaction between patient and provider
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e-visits
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Model of heath information exchange where there is not a centralized database of patient information
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Federated model (of HIE)
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Early form of database where data is stored in plain text file
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Flat file
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A plan in which information is shared among providers
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Health information exchange (HIE)
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An organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards
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Health information exchange organization (HIEO)
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The technical aspects of processing health data and records, including classification and coding, abstracting, registry development, storage, and so on
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Health information technology (HIT)
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Part of the American Recovery and Reinvestment Act of 2009, the HITECH Act includes requirements for standards development and for investment in health information technology infrastructure and strengthens federal privacy and security law; meant to increase the momentum of developing and implementing the EHR by 2014
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Health Information Technology for Economic and Clinical Health (HITECH)
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The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee yhe security and privacy of heslth information. The act limits exclusion for preexisting medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarentees renewability of insurance to all employees regardless of size of employer. Public Law 104-191, also known as the Kassenbaum-Kennedy Law
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Health Insurance Portability and Accountability act of 1996 (HIPAA)
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A standards development organization accredited by the American National Standards Institute that addresses issues at the seventh, or appication, level of heslthcare systems interconnections
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Health Level Seven (HL7)
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Type of database that allows duplicate data
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Hierarchial database
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The comprehensive database containing all the clinical, adminstrative, finacial, and democratic information about each patient served by a hospital
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Hospital information system (HIS)
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Hospitalist
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Human-computer interface
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Hybrid record
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Identity management
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Identity matching algorithm
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Institute of Medicine (IOM)
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Interface
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International Classification of Diseases, Ninth revision, Clincial Modification (ICD-9-CM)
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International Classification of Diseases, Tenth revision, Clinical Modification (ICD-10-CM)
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International Health Terminology Standards Development Organization
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Interoperability
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Issues Management
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Kiosk
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Laboratory information system (LIS)
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Logical Observations, Identifiers, Names and Codes (LOINC)
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Meaningful use
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Medical devices
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Medication five rights
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Medication reconciliation
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Message format status
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Metadata
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Migration path
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Modular EHR
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Multi-dimensional database
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National Alliance for Health Information Technology (NAHIT)
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National Committee for Quality Assurance (NCQA)
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National Council for Prescription Drug Programs ( NCPDP)
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National Drug Codes (NDC)
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National Health Information Infrastructure (NHII)
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Nationwide health information network (NHIN)
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National Library of Medicine (NLM)
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National Language Processing (NLP)
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Nursing information system (NIS)
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Office of the National Coordinator (ONC) for Health Information Technology
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ONC authorized testing and certifying body (ONC-ATCB)
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Online Analytical Processing (OLAP)
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Online Transaction Processing (OLTP)
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Operating Rules
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Opt-in/Opt-out
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Order communication
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Patient acuity staffing
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Patient-Centered Medical Home (PCMH)
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Patient financial system (PFS)
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Patient portal
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Patient safety
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Personal health record (PHR)
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Pharmacy benefits manager (PBM)
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Pharmacy information system
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Physician champion
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Physician Quality Reporting System (PQRS)
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Picture archiving and communications system (PACS)
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Point of care (POC)
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Point-of-Care charting
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Portals
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Practice Guidelines
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Practice Management System (PMS)
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Primary care physician (PCP)
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Print file
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Prior authorization
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Process involvement
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Proprietary vocabulary
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Protocol
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Provider
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Radio-frequency identification (RFID)
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Radiology information system (RIS)
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Record locator service (RLS)
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Redundant arrays of independent (or inexpensive) disks (RAID)
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Registration-Admission, Discharge, Transfer (R-ADT)
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Registry
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Relational database
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Release of information system
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Remittance advice
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Remote patient monitoring device
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Report cards
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Results management
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Results retrieval
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Retention schedule
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Revenue cycle management (RCM)
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RxNorm
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Server failover
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Server redundancy
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Source systems
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Speech dictation
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Speech recognition
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Standard vocabulary
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Storage area network (SAN)
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Storage management
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Storage management software
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Structured data
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System
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Systemized Nomenclature of Medicine-Clinical Terms (SNOM-CT)
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Telehealth
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Template
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Textual
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Thick client
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Thin client
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Transaction
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Transactional database
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Unintended consequence
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Uninterruptable power supply (UPS)
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Unstructured data
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Value
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Vocabulary standards
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Voluntary Universal Health Identifier (VUHID)
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Web services architecture (WSA)
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Wireless on wheels (WOWs)
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Workflow
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Workflow and process management
