Chapter 11: Vocabulary Flashcards
To assist you in learning the vocabulary found throughout your text, the exam, and the industry.
Accredited Standards Committee X12 (ASC X12)
A committee accredited by ANSI responsible for the development and maintenance of EDI standards for many industries. The ASC “X12N” is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms
Adoption
Reflects the fact that the organization has implemented all of the major components of technology, although there may be some available technology that is more specialized, costly, or time-consuming to implement that has not yet been implemented
Alert fatigue
When an excessive number of alerts are used in an information system, users get tired of looking at the alerts and may ignore them
American Recovery and Reinvestment Act (ARRA)
The purposes of this act include the following: (1) To preserve and create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases
Analytics
Refers to statistical processing of data to reveal new information
Ancillary systems
Systems that serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR
Application service provider (ASP)
A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing
Auto-analyzer
Device that analyzes the specimen
Automoated drug dispensing machines
System that makes drugs available for patient care
Barcode medication administration record (BC-MAR)
System that uses barcoding technology for positive patient identification and drug information
Best of breed
A vendor strategy used when purchasing an EHR that refers to system applications that are considered the best in their class
Best of fit
A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vendor
Big data
Very large volume of data that offers greater reliability and validity
Billing system
Information system that generates a bill for healthcare services performed
Biometrics
The physical characteristics of users (such as fingerprints, voiceprints, retinal scans, iris traits) that systems store and use to authenticate identity before allowing the user access to a system
Business intelligence (BI)
The end product or goal of knowledge management
Certificate authority
An organization that verifies a person’s credentials and can revoke the certificate if the credentials are revoked
Certification
- The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program
Change control program
Assures that there is documented approval for the change to be made and evidence that all elements of implementation, testing, rollout, training, and such are performed
Charge capture
The process of collecting all services, procedures, and supplies provided during patient care
Chart tracking
A process that identifies the current location of a paper record or information
Cheif medical informatics officer (CMIO)
A salaried physician (most often part time so that he or she retains credibility with other practicing physicians) who is heavily involved in policy development, workflow and process improvement, and ongoing maintenance of CDS and other systems requiring significant physician input
Claim
A request for payment for services, benefits, or costs by a hospital, physician or other provider that is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider
Claim attachment
Any of a variety of hardcopy or electronic forms needed to process a claim in addition to the claim itself, such as a copy of the emergency department note
Claims data
Information required to be reported on a healthcare claim for service reimbursement
Claims status inquiry and response
Used to determine if a health plan has ended a claim for additional information or is processing the claim
Client/server system
System in which the healthcare organization has commercial software installed on servers housed and maintained within the organization itself, housed within the organization and managed by an outsourced company, or housed and maintained by a contractor for the healthcare organization
Clinical data repository (CDR)
A central database that focuses on clinical information
Clinical data warehouse (CDW)
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface
Clinical decision support (CDS)
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
Clinical decision support system (CDSS)
CDS that requires the combination of data from more than one sources and the ability to deliver the alert back to the appropriate system or systems
Clinical Document Architecture (CDA)
An HL7 XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes). The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from HL7, Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for Stage I Meaningful Use, and HITECH final rule. It is commonly referred to as Consolidate CDA or C-CDA
Clinical documentation system
System that supplies templates to the user to be completed primarily via point-and-click, drop-down, type-ahead, and other data-entry tools
Clinical transformation
A fundamental change in how medicine is practiced using health IT systems to aid in diagnosis and treatment
Closed-loop medication management
Information systems used to provide patient safety when ordering and administering medications
Cloud computing
A practice that uses a vendor to archive data, and in some cases also provide application software, including an EHR, on multiple, disparate servers
Computerized provider order entry (CPOE)
Electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically. These systems usually contain error prevention software that provides the user with prompts that warn against the possibility of drug interaction, allergy, or overdose and other relevant information
CONNECT
Open-source software that implements health exchange specifications; it enables discovery of where there may be information as well as directly retrieving it from the source
Consolidated Clinical Document Architecture (C-CDA)
HL7-created document templates
Continuity of care document (CCD)
The result of ASTM’s Continuity of Care Record standard content being represented and mapped into the HL7’s Clinical Document Architecture specifications to enable transmission of referral information between providers; also frequently adopted for personal health records
Continuity of care record (CCR)
Is a core data set of the most relevant administrative, demographic, and clinical information about a patient’s healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care
Contraindication
Medication should not be prescribed due to another medication or condition
Data
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions
data conversion
The task of moving data from one data structure to another, usually at the time of a new system installation
Data dictionary
A descriptive list of the names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use
Data model
- A picture or abstraction of real conditions used to describe the definitions of fields and records and their relationships in a database 2. A conceptual model of the information needed to support a business function or process
Data quality
The reliability and effectiveness of data for its intended uses in operations, decision making, and planning
Data Use and Reciprocal Support Agreement (DURSA)
A trust agreement entered into when exchanging information with other organizations using an agreed upon set of national standards, services and policies developed in coordination with the Office of the National Coordinator for Health Information Technology
Digital Imaging anf Communications in Medicine (DICOM)
An ISO standard that promotes a digital image communications format and picture archive and communications systems for use with digital images
Discrete reportable transcription (DRT)
Transcription system that combines speech dictation with natural language processing
Document imaging
- The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed; 2. The process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end-user
Drug knowledge database
A subscription service that provides current information about drugs and is accessible to users and CDS
Due diligence
An individual covered by both Medicare and Medicaid
eHealth Exchange
A group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. Participating organizations mutually agree to support a common set of standards and specifications that enable the establishment of a secure, trusted, and interoperable connection among all participating Exchange organizations for the standardized flow of information
Electronic health record (EHR)
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 and staff across more than one healthcare organization
Eligibility verification
Verification that determines if a patient’s health plan will provide reimbursement for services to be performed, and sometimes prior-authorization management systems where a health plan requires review and approval of a procedure (or referral) prior to performing the service
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
End User
Persons who will use the system for their daily processes
e-Prescribing (e-Rx)
When a prescription is written from the personal digital assistant and an electronic fax or an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy’s information system
Evidence-based medicines
Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies
Federal Health IT Strategic Plan 2015-2020
Issued by the Office of the National Coordinator for Health Information Technology (ONC), this plan describes a vision of high-quality care, lower costs, healthy population, and engaged people and mission to improve the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most