Chapter 6 - Computerization in Health Informatics and Information Management

Question 1

health information management (HIM)

Answer 1

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

Question 2

confluence

Answer 2

a coming or flowing together, meeting, or gathering at one point

Question 3

chief clinical informatics officer (CCIO)

Answer 3

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

Question 4

mapping specialist

Answer 4

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

Question 5

data integrity analyst

Answer 5

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

Question 6

clinical informatics coordinator

Answer 6

a person who requires knowledge of clinical information systems; they are experts in the data retrieval needed by healthcare providers conducting patient care

Question 7

content analysts

Answer 7

People who design the clinical information system that will be implemented. Their work is directed by the needs of the users.

Question 8

chief technology officer (CTO)

Answer 8

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

Question 9

data quality manager

Answer 9

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

Question 10

chief security officer (CSO)

Answer 10

a company executive responsible for the security of personnel, physical assets, and information in both physical and digital form

Question 11

disclosure of information system

Answer 11

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

Question 12

HIPAA Disclosure Accounting

Answer 12

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.

Question 13

TPO

Answer 13

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.

Question 14

backlog

Answer 14

a buildup of work that needs to be completed

Question 15

encoder

Answer 15

specialty software used by coders to select the appropriate code for the diagnosis(es) and procedure(s) supported by the health record

Question 16

rules-based encoder

Answer 16

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.

Question 17

automated codebook encoder

Answer 17

an encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index located in the ICD-10-CM and CPT manuals

Question 18

grouper

Answer 18

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.

Question 19

Medicare Code Editor

Answer 19

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

Question 20

National Correct Coding Initiative

Answer 20

a Centers for Medicare & Medicaid Services (CMS) program designed to prevent improper payment of procedures that should not be submitted together.

Question 21

principal diagnosis

Answer 21

the condition, after study, which caused the admission to the hospital

Question 22

secondary diagnosis

Answer 22

conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay

Question 23

principal procedure

Answer 23

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

Question 24

secondary procedure

Answer 24

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

Question 25

admitting diagnosis

Answer 25

the initial working diagnosis documented by the patient’s admitting or attending physician who determined that inpatient care was necessary

Question 26

discharge disposition

Answer 26

the person’s anticipated location or status following the patient leaving the hospital (e.g. death, transfer to home/hospice)

Question 27

chart locator system

Answer 27

also called chart tracking system; it is a system designed to identify the current location of the paper health record

Question 28

dictation system

Answer 28

used by physicians to dictate various medical reports, such as history and physical examinations, discharge summaries, radiology reports, autopsy reports, catheterization reports, and other designated reports into the dictation system. The HIM department uses the dictation system to manage the dictated reports and to monitor the amount of transcription that is pending

Question 29

expander

Answer 29

also called macros; they are tools that allow a medical transcriptionist to use acronyms such as “CHF” and the full phrase “congestive heart failure” will automatically be spelled out, thus saving keystrokes and time

Question 30

macro

Answer 30

a single instruction that expands automatically into a set of instructions to perform a particular task

Question 31

healthcare quality indicator system

Answer 31

An abstracting system that records information about the patient, the care provided to the patient, and the healthcare practitioner(s) involved in the care delivered. Abstracting is the process of extracting information from a document or data elements from a database to create a brief summary of a patient’s illness, treatment, and outcome and entering the summary into an automated system. A quality indicator is a standard against which actual care may be measured to identify a level of performance for that standard.

Question 32

nosocomial

Answer 32

(of a disease) originating in a hospital