Health Information Management; Principles and Practices, Ch. 1, Key terms

the study of human remains
Data entry of codes and other pertinent information (e.g., patient identification data, admission/discharge dates) utilizing computer software.
Voluntary process that a health care facility undergoes to demonstrate that it as met standards beyond those required by law.
Accreditation Council for Graduate Medical Education (ACGME)
Professional organization responsible for accrediting medical training programs in the United States through a peer review process that is based on established standards and guidelines
Medical staff member who delivers most hospital medical services and performs significant organizational and administrative medical staff duties.
Listing of all items of business to be discussed at a committee meeting.
American Recovery and Reinvestment Act
Legislation that authorized an expenditure of $1.5 billion in grants for construction, renovation, and equipment, and for the acquisition of health information technology systems; Health Information Technology for Economic and Clinical Health Act (HITECH Act) was included in America Recovery and Reinvestment Act of 2009 and amended the Public Health Service Act to establish an Office of National Coordinator for Health Information Technology within HHS to improve health care quality, safety, and efficiency.
Medical staff member whose advancement to active category is being considered.
A identifier that measures a borrower’s unique physical characteristic or behavior and compares it to a stored digital template to authenticate the identity of the borrower, such as fingerprints, hand of face geometry, a retinal scan, or handwritten signature.
Rules that delineate medical staff responsibilities.
case mix
Types and categories of patients treated by a health care facility.
case mix adjustment
Multiple possible payment rates based on patients’ anticipated care needs that allow payment systems to decrease the average differences between the pre-established payment and each patient’s actual cost to the facility.
Centers for Medicare & Medicaid Services (CMS)
DHHS agency that administers Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP); formerly called the Health Care Financing Administration (HCFA).
chief resident
position held by a physician in the final year of residency (e.g., surgery) or in the year after residency has been completed (e.g., pediatrics); plays a significant administrative or teaching role in guiding new residents.
Civil Monetary Penalties Act
Imposes a maximum penalty of up to $10,000 plus a maximum assessment of up to three times the amount claimed by providers who knew that a procedure/service was not rendered as submitted on the claim; violators can also be excluded from participation in government programs.
Standard institutional claim form submitted by hospitals, skilled nursing facilities, and other institutional-based providers to payers to obtain reimbursement for health care services provided to patients, also called UB-04.
Code of Federal Regulations (CFR)
Codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the federal government.
Numeric and alphanumeric characters
Assigning numeric and alphanumeric codes to diagnoses, procedures, and services; this function is usually performed by credentialed individuals (e.g., certified coding specialists).
compliance guidances
Guidelines that identify risk areas and offer concrete suggestions to improve and enhance an organization’s internal controls so that its billing practices and other business arrangements are in compliance with Medicare’s rules and regulations.
consulting medical staff
Highly qualified practitioner who is available as a consultant when needed.
continuum of care
complete range of programs and services, with the type of health care indicating the health care services provided.
contract services
arranging with outside agencies to perform certain functions, such as health information services, housekeeping, medical waste disposal, and clinical services; the purpose of contracting out the services is to improve quality while containing costs.
courtesy medical staff
Medical staff member who admits an occasional patient to the hospital.
critical pathways
Interdisciplinary guidelines developed by hospitals to facilitate management and deliver of quality clinical care in a time of constrained resources,
Current Procedural Terminology (CPT)
Published annually by the American Medical Association; codes are five-digit numbers assigned to ambulatory procedures and services.
deemed status
Hospitals that are accredited by approved accreditation organizations (e.g., The Joint Commission) are determined to have met or exceeded Conditions of Participation to participate in the Medicare and Medicaid programs.
deeming authority
When an accrediting organization’s standards have met or exceeded CMS’s Conditions of Participation for Medicare certification, accrediting facilities are eligible for reimbursement under Medicare and Medicaid, and CMS is less likely to conduct an on-site survey of its own.
Deficit Reduction Act of 2005
Created the Medicaid Integrity Program (MIP), which is fraud and abuse detection program.
digital signature
Type of electronic signature that uses public key cryptography. Created using public key cryptography to authenticate a document or message.
disability insurance
Replaces 40-60% of an individual’s gross income (tax free) if an illness or injury prevents the individual from earning an income (also called disability income insurance).
disaster recovery plan
Ensures an appropriate response to internal and external disasters (e.g., explosion) that may affect hospital staff, patients, visitors, and the community. The plan identifies the responsibilities of individuals and departments during the management of a disaster situation.
do not resuscitate (DNR)
An order documented in the patient’s medical record by the physician, which instructs medical and nursing staff to not try to revive the patient if breathing or heartbeat stops.
electronic data exchange (EDI)
Computer-to-computer transfer of data between provider and payer (or clearinghouse) using data format agreed upon by the sending and receiving parties.
electronic health record (EHR)
Automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient; has the ability to link patient information created at different locations according to a unique patient identifier; provides access to complete and accurate health problems, status, and treatment data; and contains alerts (e.g., drug interaction) and reminders (e.g., prescription renewal notice) for health care providers.
electronic signature
Encompasses all technology options available that can be used to authenticate a document. Generic term that refers to the various methods an electronic document can be authenticated, including name typed at the end of an email message by the sender, digitized image of a handwritten signature that is inserted (or attached) to an electronic document, secret code or PIN (personal identification number) to identify the sender to the recipient, unique biometrics-based identifier, or digital signature.
Emergency Medical Treatment and Labor Act (EMTALA)
Address the problem of hospitals failing to screen, treat, or appropriately transfer patients (patient dumping) by establishing criteria for the discharge and transfer of Medicare and Medicaid patients; also called the anti-dumping statute.
False Claims Act (FCA)
Enacted in 1863 in response to widespread abuses by government contractors during the Civi War and amended in 1986 to strengthen the law and increase monetary awards (e.g., up to $11,000 per false claim, plus three times the amount of damages that the government sustains). Imposes civil liability on those who submit false/fraudulent claims to the government for payment and can exclude violators from participation in government programs.
Federal Register
Legal newspaper published every business day by the National Archives and Records Administration (NARA); available in paper form, on microfiche, and online.
Business in which excess income is distributed to shareholders and owners.
an act that represents a crime against payers or other health care programs, or attempts or conspiracies to commit those crimes.
Genetic Information Nondiscrimination Act of 2008
Prohibits group health plans and health insurance companies from denying coverage to health individual or charging higher premiums based solely on a genetic predisposition to development of a disease in the future; also bars employers from using genetic information from making hiring, firing, job placement, and promotion decisions.
governing board
Membership serves without pay and is represented by professionals from the business community; has ultimate legal authority and responsibility for the hospital’s operation and is responsible for the quality of care administered to patients; also called board of trustees, board of governors, board of directors.
government-supported hospitals
Not-for-profit, supported by local, regional, or federal taxes, and operated by local, state, or federal governments; also called public hospitals.
HCPCS Level II (national) codes
Developed by the Centers for Medicare & Medicaid Services (CMS) and used to classify report procedures and services. Codes are reported to third-party payers (e.g., insurance companies) for reimbursement purposes.
Health Care Procedure Coding System (HCPCS)
Comprised of Level I (CPT) and Level II (National) codes.
health care proxy
Legal document (recognized by New York State) in which the patient chooses another person to make treatment decisions in the even of the patient becomes incapable of making these decisions.
Health Insurance Portability and Accountability Act (HIPAA)
Mandated administrative simplification regulations that govern privacy, security, and electronic transactions standards for health care information; also protects health insurance coverage for workers and their families when they change or lose their jobs.
Health Plan Employer Data and Information Set (HEDIS)
The National Committee for Quality Assurance (NCQA) “tool used by health plans to collect data about the quality of care and service they provide.”
Healthcare Integrity and Protection Data Bank (HIPDB)
Created as part of HIPAA to combat fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioner’s, provider’s, or supplier’s past actions.
Hill-Burton Act
Provided federal grants to modernize hospitals that had become obsolete due to lack of capital investment throughout the period of the Great Depression and World War II (1929-1945); in return for federal funds, facilities agreed to provide free or reduced charge medical services to persons unable to pay.
First physician to consider medicine a science and art separate from the practice of religion.
Hippocratic Oath
Adopted as an expression of early medical ethics and reflected high ideals.
Retired medical staff member who is honored with emeritus status; also includes outstanding practitioners whom the medical staff wish to honor.
hospital administration
Serves as liaison between the medical staff and governing board and is responsible for developing a strategic plan for supporting the mission and goals of the organization.
hospital departments
provide direct patient care as well as ancillary (e.g., clinical laboratory) and support services (e.g., health information department).
house officers
physicians whose only job is to work at the facility treating patients; they are considered employees of the facility.
Human Genome Project
Nationally coordinated effort to characterize all human genetic material by determining the complete sequence of the DNA in the human genome; in 2000, the human genome sequencing was published.
hybrid record
combination of paper reports and digital files.
incomplete record processing
includes the assembly and analysis of discharged patient records.
historical term used to designate physicians in the first year of graduate medical education (GME); since 1975, the Accreditation Council for Graduate Medical Education (ACGME) has referred to individuals in their first year of GME as residents.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures. ICD-9-CM is in use until October 1, 2013, when ICD-10-CM and ICD-10-PCS will be implemented.
Private network that utilizes Internet protocols and technology and allows users to immediately and simultaneously access health care information with complete security and an audit trail, regardless of where users are located.
Obtaining a license to operate
living will
contains the patient’s instructions about the use of life-sustaining treatment.
Medicaid (Title 19)
Joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered for those who qualify for both Medicare and Medicaid.
medical staff
Licensed physicians and other licensed providers as permitted by law (e.g., nurse practitioners and physician assistants) who are granted clinical privileges.
medical transcription
Accurate and timely transcription of dictated reports (e.g., history, physical examination, discharge summary).
Medicare (Title 18)
Health program for people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD, which is permanent kidney failure treated with dialysis or a transplant).
Medicare Prescription Drug Improvement, and Modernization Act of 2003 (MMA)
Provides Medicare recipients with prescription drug savings and additional health care plan choices (other than traditional Medicare); modernizes Medicare by allowing private health plans to compete; and requires the Medicare Trustees to analyze the combined fiscal status of the Medicare Trust Funds and warn Congress and the President when Medicare’s general fund subsidy exceeds 45%.
Medieval medicine
Developed during the Middle Ages (or Dark Ages), its most significant event was the construction of hospitals to care for the sick (e.g., bubonic plague).
Middle Ages
Characterized by a lack of education except among nobility and the most wealthy; also called Dark Ages.
Concise, accurate records of actions taken and decisions made during a meeting.
modern medicine
Characterized by the implementation of standards for sanitation, ventilation, hygiene, and nutrition; in addition, choosing health care as a profession became more acceptable, hospitals were reformed, and training of physicians and nurses improved.
National Practitioner Data Bank (NPDB)
Established by the federal Health Care Quality Improvement Act of 1986. It contains information about practitioner’s credentials, including previous medical malpractice payment and other adverse action history; state licensing boards, hospitals, and other health care facilities access the NPDB to identify and discipline practitioners who engage in unprofessional behavior.
ORYX initiative
Introduced by The Joint Commission to integrate outcomes and other performance measurement data into the accreditation process.
Loose-textured, porous, white paper used as a writing material and made from the papyrus water plant.
Patient Safety and Quality Improvement Act of 2005
Amends Title IX of the Public Health Service Act to provide improved patient safety and reduced incidence of events adversely affecting patient safety.
Patient Self-Determination Act
Requires consumers to be provided with informed consent, information about their right to make advance health care decisions (called advance directives), and information about states laws that impact legal choices in making health care decisions.
physician quality reporting initiative (PQRI)
The Tax Relief and Health Care Act of 2006 (TRHCA) authorized implementation to establish a financial incentive for eligible professionals who participate in a voluntary quality reporting program.
Prehistoric Medicine and Ancient Medicine
Characterized by the belief that illness was caused by the supernatural; an attempt to explain changes in body functions that were not understood (e.g., evil spirits were said to have invaded the body of the sick person).
primary care
Services include preventative and acute care that are referred to as the point of of first contact and are provided by a general practitioner or other health professional (e.g., nurse practitioner) who has first contact with a patient seeking medical treatment, including general dental, ophthalmic, and pharmaceutical services.
proprietary hospitals
For-profit hospitals owned by corporations (e.g., Humana), partnerships (e.g., physicians), or private foundations (e.g., Tarpon Springs Hospital Foundation, Inc., which does business as Helen Ellis Memorial Hospital in Tarpon Springs, Florida).
public key cryptography
Attaches an alphanumeric number to a document that is unique to the document and to the person signing the document. Uses an algorithm of two keys, one for creating the digital signature by transforming data into a seemingly unintelligible form and the other to verify a digital signature and return the message to its original form.
quality improvement organization (QIO)
New name for peer review organizations (PROs); QIOs continue to perform quality control and utilization review of health care furnished to Medicare beneficiaries.
quaternary care
Considered as an extension of “tertiary care” and includes advanced levels of medicine that are highly specialized, not widely used (e.g., experimental medicine), and very costly; it is typically provided by tertiary care centers.
record circulation
Includes the retrieval of patient records for the purpose of inpatient readmission, scheduled and unscheduled outpatient clinic visits, authorized quality management studies, and education and research.
Interpretation of a law; written by a responsible regulatory agency such as Centers for Medicare & Medicaid Services (CMS)
Renaissance medicine
Mostly associated with Europe; was characterized by a renewed interest in the arts, sciences, and philosophy. This was the beginning of modern medicine, based on education instead of spiritual beliefs.
Physician who has completed an internship and is engaged in a program of training designed to increase his or her knowledge of the clinical disciplines of medicine, surgery, or any other special fields that provide advanced training in preparation for the practice of a specialty.
rules and regulations
procedures based on federal and state regulations, and accreditation standards, which clarify medical staff bylaws.
secondary care
Services provided by medical specialists or hospital staff members to a patient whose primary care was provided by a general practitioner who first diagnosed or treated the patient (the primary care provider refers the patient to the specialist).
Shared Visions–New Pathways
Introduced by The Joint Commission in 2003 to radically change the survey process so it focuses on whether the organization is making improvements system-wide. Facilities will adopt a continuous survey process starting in 2004, which means survey preparation will be an ongoing process (instead of the traditional once-every-three-years labor-intensive preparation that proved not to impact on improving patient care.)
smart card
Plastic card that contains a small central processing unit, some memory, and a small rectangular gold-colored contact area that interacts with a smart-card reader.
Measurements developed by an accreditation organization to evaluate a health care organization’s level of performance in specific areas (usually more rigorous than regulations).
State Children’s Health Insurance Programs (SCHIP)
Health insurance programs for infants, children, and teens that covers health care services such as doctor visits, prescription medicines, and hospitalizations; also called Title XXI of the Balanced Budget Act of 1997
Evaluation process conducted off-site and on-site to determine whether the facility complies with standards.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
Established the first Medicare prospective payment system, called Diagnosis Related Groups (DRGs), which was implemented in 1983.
teaching hospitals
Government (not-for-profit), proprietary (for-profit), or voluntary (non-profit) hospitals that are affiliated with a medical school.
tertiary care
Services provided by specialized hospitals equipped with diagnostic and treatment facilities not generally available at hospitals other than primary teaching hospitals or Level I, II, III, or IV trauma centers.
Title XXI of the Balanced Budget Act of 1997
Children’s Health Insurance Program
An organized method of identifying and treating patients according to urgency of care required.
universal chart order
Discharged patient record is organized in the same order as when the patient was on the nursing floor; eliminates the time-consuming assembly task performed by the health information department.
Individuals who have served n the United States military and are eligible to receive care at VA Medical Centers (VAMCs) located throughout the United States.
voluntary hospitals
Not-for-profit hospitals operated by religious or other voluntary groups (e.g., Shriners).
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