Chapter 6 - Computerization in Health Informatics and Information Management Flashcards
health information management (HIM)
an allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions
confluence
a coming or flowing together, meeting, or gathering at one point
chief clinical informatics officer (CCIO)
a person who works with clinical providers, such as physicians and nurses, to lead them in the use of technology to improve quality of care, medical education, and healthcare research
mapping specialist
a person who creates maps between systems such as vocabularies and classification systems; the mapping specialist must be an expert in both systems so that they can correctly create the maps
data integrity analyst
A person responsible for ensuring the quality of the data in HIM information systems. Data integrity analysts must be able to apply data and content standards to data collection and data storage. They must be able to maintain the information systems, ensure compliance with legal and accreditation requirements, and be able to analyze data
clinical informatics coordinator
a person who requires knowledge of clinical information systems; they are experts in the data retrieval needed by healthcare providers conducting patient care
content analysts
People who design the clinical information system that will be implemented. Their work is directed by the needs of the users.
chief technology officer (CTO)
A person who assists in the development of the healthcare organization’s strategic business plan in relation to information systems and technology. Their goal is to ensure the healthcare organization operates effectively and that they are competitive with other healthcare organizations within their community
data quality manager
a person who works with physicians and other healthcare providers to assist them in the achievement of the healthcare organization’s data quality goals as needed for coding and reimbursement as well as general documentation throughout the healthcare organization
chief security officer (CSO)
a company executive responsible for the security of personnel, physical assets, and information in both physical and digital form
disclosure of information system
also called release of information system; the system that is designed to manage the processing of requests for protected health information (PHI) received and processed by the HIM department
HIPAA Disclosure Accounting
also called Accounting of Disclosures (AOD); the action or process of keeping records of disclosures of PHI for purposes other than Treatment, Payment, or Healthcare Operations. You are required by law to provide patients a list of all the disclosures of their PHI that you have made outside of TPO.
TPO
TPO stands for Treatment, Payment, and Operations. (operations being healthcare operations, which are things needed to run the business)
TPO describes the circumstances in which covered entities are allowed by law to disclose patient information without the need to obtain authorization from patients.
backlog
a buildup of work that needs to be completed
encoder
specialty software used by coders to select the appropriate code for the diagnosis(es) and procedure(s) supported by the health record
rules-based encoder
an encoder that requires the user to type in the name or portion of the name of the diagnosis or procedure. This entry into the encoder generates a list of suggestions from which the coder selects. For example, if the coder types in pneu-, the encoder may suggest pneumonia and pneumonitis. From there the coder scrolls down until the proper code is selected.
automated codebook encoder
an encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index located in the ICD-10-CM and CPT manuals
grouper
a computer program that uses specific data elements to assign the diagnostic and procedural codes entered into the encoder into the appropriate Medicare severity diagnosis-related group (MS-DRG) or other diagnosis-related group (DRG)
The grouper uses the appropriate grouping software for the insurer assigned to the patient. The most common groupers are the MS-DRG grouper and ambulatory payment classification (APC) grouper; however, other insurers, including some Medicaid programs, have developed their own groupers for use in determining payment to the healthcare organization.
Medicare Code Editor
a software program used to detect and report errors in coding data while processing inpatient hospital Medicare claims using the International Classification of Diseases, Tenth Edition (ICD-10) codes
National Correct Coding Initiative
a Centers for Medicare & Medicaid Services (CMS) program designed to prevent improper payment of procedures that should not be submitted together.
principal diagnosis
the condition, after study, which caused the admission to the hospital
secondary diagnosis
conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay
principal procedure
a procedure that is performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or a procedure that was necessary to take care of a complication
secondary procedure
a surgical procedure which is performed to ameliorate conditions that are found to exist during the performance of a primary surgery and which is considered an independent procedure that may not be performed as a part of the primary surgery or for the existing condition
