Chapter 16 Health Information Technology: An Applied Approach

access control
a computer software program designed to prevent unauthorized use of an information resource. 2. the process of designing, implementing, and monitoring a system for guaranteeing that only individuals with a legitimate need are allowed to veiw or amend specific data sets
accountable care organizations (ACO)
an organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enroleld in the traditional fee for service program
accreditated standards committee X12 (ASC X12)
…a committee of the national standards institute that develops and maintains standards for the electronic exchange of business transactions,
affordable care act (ACA)
…also known as patient protection and affordable care act. a federal statute that was signed into law on March 23, 2010. along with the health care and education reconciliation act of 2010, the act is the product of thehealthcare reform agenda of the demoncratic 111th congress and teh obama administration
alert fatigue
…when an excessive number of alerts are used in an information system, users may get tired of looking at the alerts and ignore them
american national standards institute (ANSI)
…the organziation that accredits all US standards deveopment organizations to ensure that they are following due process in promulgating standards
american recovery and reinvestment act (ARRA)
…previously known as the stimulus bill or HR1. the actions related to health information technology are spread throughout the law
ancillary systems
…electronic sytems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on
architecture
…the configuration, structure, and relationhships of hardware ( the machinery of the computer including input/output devices, storage devices, and so) inan information system
ASTM international
…formerly known as the american society for testing and materials, a system of standards developed primarily for various EHR management processes
audit log
…a chronological set of computerized records that provides evidence of information system activity tha is used to determine security violations
authentication
…the process of identifying the sourcer of heatlh recrod entries by attaching a handwritten signature, the authro’s initials, or an electronic signature
automated drug dispensing machines
…system that makes drugs available for patient care
barcode medication administration record (BC-MAR)
…systems that identify the right patient and the right drug to be given at the right tiem, in the right dose, and via the right route
billing system
…information system that generates bill for healthcare services performed
business intelligence (BI)
…the end product or goal of knowledge management
certification
…the process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements
change control
…the process of performing an impact of analysis and obtaining approval before modifications to the project scope are made
charge capture
…the process of collecting all services, procedures, and supplies provided during patient care
chart conversion
…an EHR implementation activity in which data from the paper chart are converted into electronic form
chart deficiency system
…a software system designed to allow the HIM departemtn to electronically track and manage documentation omissions from the health record
cheif medical informatics officer (CMIO)
…a relativelly 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
claim
…itemized statement of healthcare services and their costs provided by a hospital, physician’s office, or other healthcare provider, submitted for reimbursement to the health care insurance plan by either the insured party or by the provider
claim attachment
…additional information that is submitted with a claim for healthcare services provided
claims data
…information required to be reported on a healthcare claim for servcie reimbursement
client/server architecture
…a computer architecture in which multiple computers are connected to other computers that store and distributre large amounts of shared data
clinial data repository (CDR)
…a central database that focuses on clinical information
clinical data warehouse (CDW)
…a database that makes it possibel to access data from multiple databases and combine the results into a singel query and reoprting interface
clincial decision support (CDS)
…the process in which individual data elements are represented in the computer by a special coee to be used in making comparisons, trending results, and supplying clinical reminders and alerts
clinical decision support system (CDSS)
…a special subcategory of clinical information systems that is designed to help helathcare providers make knowledge based clinical decisions
clinical document architecture
…HL7 electronic exchange model for clinical documents
clinical documentation system
…the porcess in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying that directly support patientcare
clinical information system (CIS)
…a category of a healthcare informaitn system that includes systems that directly support patient care
clinical messaging
…the function of electronically delivering data and automating the workflow around the management of clinical data
clinician
..a healthcare provider, including physicians and others who treat patients.
closed loop medication management
…information systems used to provide patient safety when ordering and administering medications
cloud computing
…information systems that use the Internet to access data
coding and abstracting systems
…information system used to assign code numbers and enter key information from the health record
complete EHR
…under meaningful use, EHR technology that has beendeveloped to meet, at a minimum, all applicabel certification criteria adopted by the Secretary of HHS
computer output to laser disk (COLD)/enterprise report management (ERM)
…technology that electronically stores documents and distributes tehm with fax, e-mail, web, and traditioanl hard-copy print processes
computerized provider order entry (CPOE)
…systems that allow physicinas to enter medication or other orders and receive clinical advice about drug doseages, contraindications, or other clinical decision support;
configuration management
…the process of keeping a record of changes made in an EHR system as it is being customized to the organization’s specifications
consent directive
…a process by which patients may opt in or opt out of having their data exchanged in the HIE
consistent federated mode (of HIE)
…health information exchange model where there is no centerilized storage of patient data
contextual
…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
continuity of care document (CCD)
…in the exchange of information with other providers and the patient, it combines the content that physicians have agreed should be included in patient referrals with a means to format that data fro electrnoic transmission
continuity of care record (CCR)
…documentation of care delivery from one healthcare experience of another
contraindication
…medication should not be prescribed due to another medication or condition
controlled vocabulary
…a predefined set of terms and their meanings that may be used in structured data entry or natural language processing to represent expressions
core measures
…standardized performance measure developed to improve the safety and quality of healthcare
data availability
…the extent to which healthcare data are obtainable
data center
…where the hardware and software for the electronic information systems are held
data comparability
…the standardization of vocabulary such that the meaning of a single term is the same time the term is used in order to produce consistency in information derived from the data
data conversion
…the task of movign dtaa from one data structure to another, usually at the time of a new system installation
data dictionary
…a descriptive list of the data elements to be collected in an information system or databsae whose purpose is to ensure consistency of terminology
data exchange standards
…protocols that help ensure that data transmitted form one system to another remain comparable
database
…an organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications
database management system (DBMS)
…computer software that enables the user to create, modify, delete, and view the data in a database
department of health and human services (HHS)
…the cabinet level federal agency that oversees all of the health and human servcies related activiteis of the federal government and administers federal regulations
diagnostic studies
…laboratory and other tests performed to help diagnose a patient
digital dictation
…a process in which vocal sounds are converted to bits and stored on computer for random access
digital images
…data provided in a computer readable format
digital imaging and communications in medicine (DICOM)
…a standard that promotes a digital image communications format and picture archive and communciations systes for use with digital images
disease management
…a more expansive view of case management in which patients with the highest risk of incurring high cost interventions are targeted for standardizing and managing care throughout integrated delivery systems
document imaging management system (DIMS)
…information system that allowed a paper document to be scanned and displayed
drug knowledge database
…a databaseof information about drugs
electronic date interchange (EDI)
…a standard transmission format using strings of data for business information communicated among teh computer systems of independent organizations
electronic document/content management (ED/CM)
…a type of electronic document management system that uses methods such as bar coding on the forms to identify specific content
electronic document management system (EDMS)
…a storage solution based on digital scanning technolgoy in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks
electronic funds transfer (EFT)
…process of moving money electronically
electronic health record (EHR)
…an electronic record of health related information on an individual tha conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
electronic medical record (EMR)
…an electronic record of health related information on an iindividual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization
electronic medication administration record (E-MAR)
…a system desinged to prevent medication errors by checkning a patient’s medication information against his or her barcoded wristband
electroinic signature authentication (ESA)
…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
eligibility verification
…confirmation of insurance status
encoded
…converted into code
encoder
…specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules fo teh coding system
encryption
…the process of transforming text into an unintelligible string of characters that can be transmitted via communications media wtih a high degree of security and then decrypted when it reaches a secure destination
e-prescribing (eRx)
…enables prescriptions to be checked for drug contraindications and sent directly to a retail pharmacy of the patient’s choosing
evidence based medicine
…healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies
e-visits
…non face to face interaction between patient and provider
federated model (of HIE)
…model of health information exchange where there is not a centralized database of patient information
flat file
…early form of database where data is stored ni plain text file
health information exchange (HIE)
…a plan in which healht information is shared among providers
health information technology (HIT)
…the technical aspects of processing health data and records, includign classification and coding, abstracting, registry development, storage, and so on
health information technology for economic and clinical Health (HITECH)
…part of the American Recovery and Reinvestment Act of 2009, this act includes requiremetns for standards debvelopmetn and for investment in health information technology infrastructure and strengthens federal privacy and security law; mant to increase themomentum of developing an dimplementing the EHR by 2014
health insurance portability and accoutnability Act of 1996 HIPAA
…the federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the securiyt and privacy of health informaiton.the act limits exclusion for preexisting medical conditions, prohibits discriminiation against employees an ddependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size of employer.
health level seven (HL7)
…a standard development organization accredited by the american national standards institute that addresses issues at the seventh, or application, level of healthcare systems interconnections
hierarchical database
…type of database that allows duplicate data
hospital informatin system (HIS)
…the comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital
hospitalist
…physician emploeyd by teaching hospitals to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs
human computer interface
…the device used by humans to access and enter data into a computer system, such as a keyboard on a PC, personal digital assistant, voice recognition system, and so on.
hybrid record
…a health record that inlcudfes both paper and electronic elements
i
identity matching algorithm
…process used to idenify any patient for whom data are to be exchanged
institute of medicine (IOM)
…a branch of the national academyu of sciences whoe goal is to advance and distribute scientific knowledge with the mission of improving human health
interface
…the zone between different computer systems across which users want to pass information
internatinal classification of diseases, ninth revision, clinical modification (ICD-9-CM)
…a classfication system used in the United States to report morbidity and mortality information
international classification of diseases, tenth revision, clinical modification (ICD-10-CM)
…the planned replacement for ICD-9-CM, volumes 1 and 2, developed to contain more codes and allow greater specificity
international health terminology standards development organization
…a company based in Denmark that is responible for maintining SNOMED International, a method for encoding data variables when physicans enter data into a history and physical exam template
interoperability
…the ability, generally by adoption of standards, of systems to work together
issues management
…the process of resolving unexpected occurrences
laboratory information system (LIS)
…an inforamtion system that collects, stores, and manages laboratory tests and their respective resutls. It can speed up acess to test results through improved efficiency from various locations, including anywhere in the hospital, the physician’s office, or even the clinician’s home..
logical observations, identifiers, names and codes (LOINC)
…a databse protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research
meaningful use
…tern used in the ARRA/HITECH legislation for providers to qualify for incentives for using EHR
medical devices
…instruments that collect or supply health information
medication five rights
…the right drug, in the right dose, through the right route, at the right time,and to the right patient
medication reconciliation
…process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to intensive care unit
message format standards
…protocols that help ensure that data transmitted from one system to another remain comparable
metadata
…descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information
migration path
…a series of steps required to mvoe from one situation to another
modular EHR
…EHR product meets only one or more but not all of the requirements of certified EHR
multi-dimensional database
…a database specifically designed to handle data organzi3ed into a data structure with numerous dimensions
national alliance for health information technolgoy (NAHIT)
…a partnership of government and private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, and operating performance
national committee for quality assurance (NCQA)
…a private not for profit accreditation organization whose mission is to evaluate and report on the quality of managed care organizations in the United States
national council for prescription drug programs (NCPDP)
…an organization that develops standards for exchanging prescription and payment information
national drug codes (NDC)
…codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected over the counter products
national health information infrastructure (NHII)
…an infrastructure proposed by the national committee on vital and health statistics in 2002 that would be a set of technologies, standards, applications, systems, values, and laws that support all facets of provider healthcare, individual health, and public health
nationwide health information network (HNIN)
…provides the technoogy to support the national health information infrastructure
national library of medicine (NLM)
…the world’s largest medical library and a branch of the national institutes of health
natural language processing (NLP)
…a field of ocmputer science and linguistics concerned with the interactions between computers and human (natural) languages that converts informatin from computer database into readable human language
nursing information system (NLP)
…information system that assists in the planing and monitoring of overall patient care and documents the nursing care provided to a patient
office of the National Coordinator (ONC) for health information technology
…office that provides leadership for the development and implementation of an interoperable health information technology infrastructer nationwide to improve healthcare equality and delivery
online analytical processing (OLAP)
…a data access architecture that allows the user to retrieve specific information from a large volume of data
online transaction processing (OLTP)
…related to clinical data repository (CDR) with transactions relating tro patient care to include access lab results, enterorder, post viatl signs, and record meds administered and is often included in ambulatroy EHR separate component for acute care
operating rules
…rules that futher explain the standards so their use is consistent across health plans
opt in/opt out
…patients’ choices for having their data exchanged in the HIE
patient acuity staffing
…the number of nurses and other care provides is based on how sick the patient is
patient centered medical home (PCMH)
…a program to provide comprehensive primary care that partners physicians with the patient and their famly to allow better access to healthcare and improved outcomes
patient financial system (PFS)
…information system that manages patient accounts
patient portal
…information system that allows patietn to login to obtain information, register and perform other functions
patient safety
…the condition of a patient being safe from harm or injury
personal health record (PHR)
…an electronic record of health related information on an individual that confroms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual
pharmacy benefits manager (PBM)
…the vendor selected by teh Bureau of Workers’ Compensation to process outpatient medication bills submitted electronically
pharmacy information system
…system that assists care providers in ordering, allocating, and administering medication; focuses on patient safety isseus, especially medication errors and providing optimal patient care
physician champion
…an individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes
physician quality reporting system (PQRS)
…an incentive payment system for eligible professionals who satisfactorily report data on quality measures for covered profeessional services furnished to Medicare beneficiaries
picture archiving and communications system (PACS)
…an integrated computer system that obtains, stores, retrieves, and displays digital images
point of care (POC)
…the place or location where the physician administers services to the patient
point of care charting
…a system whereby information is entered into the health record at the time and location of service
portals
…special web pages that offer secure access and entry of data upon authorization of the owner of the page
practice guidelines
…protocols of care that guide the clinical care process
practice management system (PM)
…software designed to help medical practices run more smoothly and efficiently
primary care physician (PCP)
…the physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan.
print file
…output from a computer system that generates a file containing an image of information that can be printed
prior authorization
…process of obtaining approval from a healthcare insurance company before receiving healthcare services
process improvement
…a series of actions taken to identify, analyze, and improve existing processes
proprietary vocabulary
…a controlled vocabulary that is formally approved by an organization such a a vendor that developed the vocabulary
protocol
…in healthcare, a detailed plan of care for a specific medical condition based on investigatve studies; in medical research, a rule or procedure to be followed in a clinical trial in a computer network it is used to address and ensur edelivery of data
provider
…physician, clinic, hospital, nursing home, or other healthcare entity that delivers heatlhcare services
radio frequency identification (RFID)
…an automatic recognition technology that uses a device attached to an object to transmuit data to a receiver an ddoes not require direct contact
radiology information system (RIS)
…a system that collects, stores, and provides information on radiological tests such as ultrasound, magentic resonance imaging, and positron emission tomograpy