Chapter 9 - Electronic Health Record Flashcards
longitudinal health record
a permanent health record of significant information listed in chronological order and maintained across time, ideally from birth to death
codification
the process of collecting and restating the law of a jurisdiction in certain areas, usually by subject, forming a legal code, i.e. a codex (book) of law
source system
information systems that capture and feed data into the electronic health record
Health Level Seven International (HL7)
a non-profit ANSI-accredited standards development organization dedicated to providing standards and solutions that empower global health data interoperability
health information blocking
a thing that occurs when “persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information”. Blocking stems from healthcare providers or HIT vendors protecting their own proprietary and business interests above the interests of the patient and healthcare improvement.
proprietary (adjective)
(1) of, relating to, or characteristic of an owner or title holder
(2) used, made, or marketed by one having the exclusive legal right
(3) privately owned and managed and run as a profit-making organization
certified EHR
an EHR that’s demonstrated the technological capability, functionality, and security requirements required by the Secretary of Health and Human Services and has received certification by the Office of the National Coordinator (ONC)
order entry and results reporting software
software in which healthcare professionals can enter patient care orders and then see the test results
chronic obstructive pulmonary disease (COPD)
A chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. It’s typically caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke. People with COPD are at increased risk of developing heart disease, lung cancer and a variety of other conditions.
radiofrequency identification devices (RFIDs)
a microchip implanted in an item to allow tracking of that item
MAR vs eMAR
A Medication Administration Record (MAR) is a tangible (paper) medication chart, whereas the electronic version is known as eMAR. eMAR software helps facilitate the process of distributing, tracking and ordering medications and treatments safely and efficiently.
eMARs are sometimes called “barcode medication administration record (BC-MAR)”
eight rights of medication administration
the right patient right medication right time right dose right route right reason for giving the patient medication right documentation the right of the patient to refuse medication
digitized signature
a scanned image of an individual’s actual signature
digital signature
a type of electronic signature with encrypted information that helps verify the authenticity of messages and documents
sentinel event
any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient’s illness
audit log
also called an audit trail, it is an electronic footprint of the actions that occurred in a particular file in an information system or that were performed by a specific individual
de-identification
the process used to prevent someone’s personal identity from being revealed
General Equivalence Mappings (GEMs)
a process used to convert older codes into newer codes and vice versa; for example, it was used to convert ICD-9-CM codes to ICD-10-CM or ICD-10-PCS codes or the reverse
Radio Frequency Identification (RFID)
A wireless system comprised of two components: tags and readers. The reader is a device that has one or more antennas that emit radio waves and receive signals back from the RFID tag. Tags, which use radio waves to communicate their identity and other information to nearby readers, can be passive or active. Passive RFID tags are powered by the reader and do not have a battery. Active RFID tags are powered by batteries.
RFID tags can store a range of information from one serial number to several pages of data. Readers can be mobile so that they can be carried by hand, or they can be mounted on a post or overhead. Reader systems can also be built into the architecture of a cabinet, room, or building.
extract, transform, load (ETL)
a data integration process that combines data from multiple data sources into a single, consistent data store that is loaded into a data warehouse or other target system
Extract is the process of reading data from a database. In this stage, the data is collected, often from multiple and different types of sources.
Transform is the process of converting the extracted data from its previous form into the form it needs to be in so that it can be placed into another database. Transformation occurs by using rules or lookup tables or by combining the data with other data.
Load is the process of writing the data into the target database.
denial management
the process of systematically investigating each denial, performing root cause analysis of why each claim was denied, analyzing denial trends to uncover a trend by one or more insurance carriers, and redesigning or re-engineering the process to prevent or reduce the risk of future claim denials
