Chapter 2: Data Flow in HIT Flashcards
ADC
automated dispensing cabinet
CIS
clinical information system
CPOE
computerized physician order entry
eMAR
electronic medication administration record
EDIS
emergency department information system
HIE
health information exchange
HL7
Health Level 7
IS
information system
LIS
lab information system
MPI
master patient index
MRN
medical record number
MAR
medication administration record
RIS
radiology information system
account number
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.
automated dispensing cabinet (ADC)
An electronic cabinet with drawers containing medications that are placed throughout the hospital for convenient access by healthcare providers to quickly administer medicines.
blood bank
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.
clinical information system (CIS)
An information system directly related to the care of patients. Examples are the information systems for radiology, lab, surgery, pharmacy, and order entry.
cold feed
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.
computerized physician order entry (CPOE)
An order entry system designed specifically for doctors’ use.
dashboard
An application’s graphic user interface (GUI) that provides status information at a quick glance and commands to manage the application.
diagnostic lab
A service used for advanced testing for disorders or diseases through laboratory analysis. Most diagnostic labs are remote from the hospital.
dictation
A typed transcript of a recorded healthcare provider’s oral report of patient care as spoken into a voice recorder.
electronic medication administration record (eMAR)
The medication administration record (MAR) recorded electronically using hand-held scanners at several locations from the pharmacy to the patient bedside.
emergency department information system (EDIS)
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.
health information exchange (HIE)
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.
Health Level 7 (HL7)
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.
hospital information system (HIS)
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).
information system (IS)
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.
interface
The connection between two information systems for the purpose of exchanging data.
interface engine
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.
lab information system (LIS)
The information system responsible for orders, charging, and results of laboratory tests.
master patient index (MPI)
The database of all MRNs and account numbers. This centralized database is responsible to prevent duplication of MRNs and account numbers.
medical record number (MRN)
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.
medication administration record (MAR)
The legal record of medication consumption in a hospital. The MAR tracks all medications in the hospital. Sometimes called drug charts.
message
The information sent from one system to another.
operative record
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.
order entry
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.”
pathology lab
A service that focuses on the diagnosis of diseases through laboratory analysis.
perioperative information system
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.
pharmacy information system
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
physician portal
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.
point-to-point connection
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.
radiology information system (RIS)
The information system responsible for orders, charging, and results of medical imaging.
requisitions
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.
solutions
Products or programs offered by vendors to provide an answer to a need.
specimen
Sample of bodily fluids or tissue taken for analysis.
surgical summary report
A brief accounting of the surgical case report for immediate referral during the postoperative phase.
