Chapter 2: Data Flow in HIT

Question 1

ADC

Answer 1

automated dispensing cabinet

Question 2

CIS

Answer 2

clinical information system

Question 3

CPOE

Answer 3

computerized physician order entry

Question 4

eMAR

Answer 4

electronic medication administration record

Question 5

EDIS

Answer 5

emergency department information system

Question 6

HIE

Answer 6

health information exchange

Question 7

HL7

Answer 7

Health Level 7

Question 8

IS

Answer 8

information system

Question 9

LIS

Answer 9

lab information system

Question 10

MPI

Answer 10

master patient index

Question 11

MRN

Answer 11

medical record number

Question 12

MAR

Answer 12

medication administration record

Question 13

RIS

Answer 13

radiology information system

Question 14

account number

Answer 14

The number assigned to a patient to reference the care of that patient for the current visit. The account number is sometimes referred to as an encounter number, accession number, or registration number in different information systems.

Question 15

automated dispensing cabinet (ADC)

Answer 15

An electronic cabinet with drawers containing medications that are placed throughout the hospital for convenient access by healthcare providers to quickly administer medicines.

Question 16

blood bank

Answer 16

A reserve of donated blood used to replenish blood supply of patients who experience extreme blood loss. Testing is performed on the blood to reduce risk of problems during blood transfusions.

Question 17

clinical information system (CIS)

Answer 17

An information system directly related to the care of patients. Examples are the information systems for radiology, lab, surgery, pharmacy, and order entry.

Question 18

cold feed

Answer 18

The real-time transfer of data from a source IS to a destination IS that does not receive acknowledgment of receipt of data. The data transfer is not guaranteed in a cold feed. Other data transfers require a receipt of data acknowledgment, called an ACK message, that guarantees the data was received.

Question 19

computerized physician order entry (CPOE)

Answer 19

An order entry system designed specifically for doctors’ use.

Question 20

dashboard

Answer 20

An application’s graphic user interface (GUI) that provides status information at a quick glance and commands to manage the application.

Question 21

diagnostic lab

Answer 21

A service used for advanced testing for disorders or diseases through laboratory analysis. Most diagnostic labs are remote from the hospital.

Question 22

dictation

Answer 22

A typed transcript of a recorded healthcare provider’s oral report of patient care as spoken into a voice recorder.

Question 23

electronic medication administration record (eMAR)

Answer 23

The medication administration record (MAR) recorded electronically using hand-held scanners at several locations from the pharmacy to the patient bedside.

Question 24

emergency department information system (EDIS)

Answer 24

The information system that manages patient flow, orders, patient history, record healthcare providers’ notes on the patient’s visit, and more in the ED. The stage of a patient’s visit to the ED, who is caring for the patient, and other information are displayed on the tracking board from the EDIS for convenient reference to a healthcare provider’s current caseload.

Question 25

health information exchange (HIE)

Answer 25

Sharing of patient information among multiple providers. These providers do not need to work in the same hospital to have access to patient information. Currently, this is typically done for hospitals in close geographic locations, but the goal is to make HIE nationwide.

Question 26

Health Level 7 (HL7)

Answer 26

The standard protocol of formatting a message for healthcare interfacing. HL7 is ANSI certified. HL7 operates at the seventh or application layer of the OSI communication model.

Question 27

hospital information system (HIS)

Answer 27

The primary information system used to manage data flow and maintain databases in a hospital. An HIS usually manages patient administration and order entry. HIS is sometimes called a healthcare information system (HIS).

Question 28

information system (IS)

Answer 28

A computerized system used to facilitate the functions of an organization. An IS is a group of components that collect, process, store, and communicate information.

Question 29

interface

Answer 29

The connection between two information systems for the purpose of exchanging data.

Question 30

interface engine

Answer 30

An application that serves as a communications hub and offers services to the messages as they travel through a network. These services include but are not limited to forwarding, filtering, translation, and queue management.

Question 31

lab information system (LIS)

Answer 31

The information system responsible for orders, charging, and results of laboratory tests.

Question 32

master patient index (MPI)

Answer 32

The database of all MRNs and account numbers. This centralized database is responsible to prevent duplication of MRNs and account numbers.

Question 33

medical record number (MRN)

Answer 33

The number assigned to a patient to reference the care of that patient for all visits at one particular hospital. An MRN is unique to a patient within a hospital’s network.

Question 34

medication administration record (MAR)

Answer 34

The legal record of medication consumption in a hospital. The MAR tracks all medications in the hospital. Sometimes called drug charts.

Question 35

message

Answer 35

The information sent from one system to another.

Question 36

operative record

Answer 36

A complete and detailed accounting of the surgical case happenings from preoperative through postoperative phases. This document is written to be used for legal reference if ever needed.

Question 37

order entry

Answer 37

A component of an HIS where healthcare providers enter orders for patient care. Orders can be for procedures, imaging, or maybe tests. Order entry is sometimes written as OE but still read as “order entry.”

Question 38

pathology lab

Answer 38

A service that focuses on the diagnosis of diseases through laboratory analysis.

Question 39

perioperative information system

Answer 39

The information system that manages patients in surgery. The perioperative IS starts with scheduling for surgery through discharge or transfer out of surgery. The perioperative IS works largely independent from other information systems because there is rarely a need for interaction with the other clinical departments.

Question 40

pharmacy information system

Answer 40

The information system used by the pharmacy. The pharmacy IS supports but is not limited to order entry, management, dispensing of medications, monitoring, reporting, and charging

Question 41

physician portal

Answer 41

A user interface that accesses the HIS or EHR/EMR. The physician portal is where doctors go to view patient records, add notes, and electronically sign off on charts.

Question 42

point-to-point connection

Answer 42

A one-to-one interface between two information systems. Point-to-point connections require the IS at each end of the connection to guarantee the delivery and interpretation of the data.

Question 43

radiology information system (RIS)

Answer 43

The information system responsible for orders, charging, and results of medical imaging.

Question 44

requisitions

Answer 44

The list of requests sent to the nursing staff for collection of specimens from patients. The timing of the collection is sometimes critical for accuracy of tests.

Question 45

solutions

Answer 45

Products or programs offered by vendors to provide an answer to a need.

Question 46

specimen

Answer 46

Sample of bodily fluids or tissue taken for analysis.

Question 47

surgical summary report

Answer 47

A brief accounting of the surgical case report for immediate referral during the postoperative phase.