Chapter 8 - Clinical Information Systems

Question 1

annotation

Answer 1

(1) a note added by way of comment or explanation

(2) the ability to add to an image in some way

Question 2

backscanning

Answer 2

the process of scanning past health records into the DMS (document management system) so there is an existing database of patient information, making the DMS valuable to the user from the first day of implementation

Question 3

cloud computing

Answer 3

the delivery of on-demand computing services – from applications to storage and processing power – typically over the internet

Question 4

interdisciplinary charting system

Answer 4

a system that can be used by any healthcare professional to collect and store patient assessments, progress notes, and care plans

Question 5

telehealth

Answer 5

(1) Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site
(2) A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment

Question 6

telemedicine

Answer 6

a subset of telehealth that focuses on the provision of care whereas telehealth includes administrative uses and education

Question 7

teleradiology

Answer 7

The ability to view radiology images from any location by the radiologist and other users.

Question 8

telesurgery

Answer 8

surgery performed by a doctor considerably distant from the patient, using medical robotics and multimedia image communication

Question 9

symbiology

Answer 9

1: the art of expression by symbols
2: the study or interpretation of symbols
3: a system of symbols
4: a system of encoding data (e.g. barcode and scanner)

Question 10

smart card

Answer 10

a plastic card with a built-in microprocessor, used typically for electronic processes such as financial transactions and personal identification

Question 11

picture archival communication system (PACS)

Answer 11

A PACS is an integrated information system that obtains, stores, retrieves, and displays digital images. In a PACS, x-ray films, MRIs, mammograms, and other radiological examinations (such as cardiac catheterization films and ultrasounds) are stored digitally, thus eliminating the need to store and manage the physical film.

Question 12

clinical information system (CIS)

Answer 12

a system that collects and stores medical, nursing, clinical ancillary areas (such as radiology and laboratory), and therapy department information related to patient care

Question 13

purpose for clinical decision support software

Answer 13

To provide:

• the right information* (evidence-based guidance, response to clinical need)
• to the right people* (entire care team – including the patient)
• through the right channels* (e.g., EHR, mobile device, patient portal)
• in the right intervention formats* (e.g., order sets, flow-sheets, dashboards, patient lists)
• at the right points in workflow* (for decision making or action)

Question 14

clinical order sets

Answer 14

a pre-defined template that provides support in making clinical decisions for a specific condition or medical procedure

Question 15

optical character recognition (OCR)

Answer 15

the electronic or mechanical conversion of images of typed, handwritten or printed text into machine-encoded text

Question 16

flatbed scanner

Answer 16

A scanner that provides a flat, glass surface to hold a sheet of paper, book or other object for scanning. The scan head is moved under the glass. Flatbed scanners often come with sheet feeders for scanning multiple sheets of paper rather than one at a time. Contrast with “sheet-fed scanner,” which accepts only paper, and contrast with handheld scanner and drum scanner.

Question 17

drum scanner

Answer 17

A type of scanner used to capture the highest resolution from an image. Photographs and transparencies are taped, clamped or fitted into a clear cylinder (drum) that is spun at speeds exceeding 1,000 RPM during the scanning operation. A light source that focuses on one pixel is beamed onto the drum and moves down the drum a line at a time.

Question 18

Logical Observation Identifiers, Names and Codes (LOINC)

Answer 18

A clinical terminology with more than 93,000 terms for laboratory and clinical functions. It provides electronic exchange standards for lab results. As with many terminologies and standards, LOINC programming and codes provide standardized communication between entities when transmitting results

Question 19

clinical documentation

Answer 19

any manual or electronic notation or recording made by a physician or other healthcare clinician related to a patient’s medical condition or treatment

Question 20

emergency department system (EDS)

Answer 20

a system designed to meet the unique needs of the emergency department, including tracking patients from triage to discharge

Question 21

triage

Answer 21

A practice invoked when acute care cannot be provided for lack of resources. The process rations care towards those who are most in need of immediate care, and who benefit most from it. More generally it refers to prioritization of medical care as a whole.

Question 22

cardiac pacemaker

Answer 22

An electronic device that is implanted in the body to monitor heart rate and rhythm. It gives the heart electrical stimulation when it does not beat normally.

Question 23

insulin pump

Answer 23

Also called continuous subcutaneous insulin therapy.
An insulin pump is an insulin-delivering device that’s used by some people with diabetes. A small battery-operated device that can be worn on a belt or put in a pocket, it’s connected to a narrow plastic tube that’s inserted just under the skin and taped in place. People who use the pump program it to deliver insulin continuously throughout the day and to release extra doses of insulin to handle rises in blood sugar (after eating, for example).

Question 24

patient-generated health data (PGHD)

Answer 24

health-related data created, recorded, or gathered by or from patients (or family members or other caregivers) to help address a health concern

Question 25

chargemaster

Answer 25

also known as charge master or charge description master (CDM)
it is a comprehensive listing of items billable to a hospital patient or a patient’s health insurance provider. In practice, it usually contains highly inflated prices at several times that of actual costs to the hospital. The chargemaster typically serves as the starting point for negotiations with patients and health insurance providers of what amount of money will actually be paid to the hospital. It is described as “the central mechanism of the revenue cycle” of a hospital.