Chapter 9 Key Terms Flashcards
unstructured data
also called narrative data, can be entered in a free text format by the user
template-based entry
blending of both free text and structured data entry
structured data
generally found in checkboxes, drop-down boxes, and other data entry means whereby the user chooses from options already built into the system
source systems
information systems that capture and feed data into the EHR
reminders
usually notify physician of lab test results and preventive measures
radiofrequency identification devices
RFIDs: microchip implanted in an item to allow tracking of that item
population health
cohesive, integrated, and comprehensive approach to health considering the distribution of health outcomes in a population
personal health record
PHR; an electronic or paper health record maintained and updated by the patient
patient-provider portal
secure method of communication between healthcare provider and the patient, providers, or the patient and provider
order entry and results reporting
software application in which healthcare professionals can enter patient care orders and then see the test results
ONC-ACBs
under HITECH, an organization or group of organizations that has applied to and been authorized by the ONC to perform the certification of complete EHRs, EHR modules, or other types of HIT under the ONC HIT Certification Program
ONC-AA
entity designated by the ONC to accredit and oversee the certification bodies
Office of the National Coordinator for Health Information Technology
ONC; lead federal agency spearheading the national effort to improve patient safety and health outcomes
National Voluntary Laboratory Accreditation Program
NVLAP; program that maintains the HIT Testing Laboratory Accreditation Program and accredits organizations contracted to perform Health IT conformance testing in the ONC Health IT Certification Program
Longitudinal health record
permanent record of significant information listed in chronological order and maintained across time, ideally from birth to death
interoperability
the ability of different IS and software apps to communicate; to exchange data accurately, effectively, and consistently; and to use the information that has been exchanged
hybrid record
mixture of paper and electronic health records
health level seven international
HL7; not-for-profit ANSI accredited SDO dedecitated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services (interoperability)
health information technology
includes the hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by healthcare entities or patients for the electronic creation, maintenance, access, or exchange of health information
health information blocking
persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information
electronic signature
requires at least a password but can use a two-factor authentication method
electronic medication administration record
EMAR; software that automates many of the medication administration processes in a healthcare facility
electronic medical record
EMR; an electronic collection of all the patient’s health information and clinical care that is store, manged, and referred to by authorized members of one healthcare entity
document management system
DMS; electronic method of capturing and managing documents
digitized signature
a scanned image of an individuals signature
digital signature
similar to electronic signature except that it uses encryption to provide non repudiation to prove authenticator’s identity, which makes it most secure
core data set
a data set that contains the most relevant admin, demographic, and clinical info about a patient’s healthcare
continuity of care record
CCR; core data set which is most relevant admin, demographic, and clinical information about a patient’s healthcare, covering one or more healthcare encounters
computerized provider order entry
CPOE; preprogrammed clinical decision support designed to assist the user through making an entry appropriately
clinical messaging
a tool that connects the medical staff and hospital by providing access to information systems such as order entry and results reporting and DMS
clinical decision support systems
CDS; process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts
Certified EHR technology
CEHRT; an EHR that has been evaluated by a member of ONC-ACBs and verified that it meets the criteria set by the Meaningful Use incentive programs
Barcode medication administration record
BC-MAR; software that automates many of the medication adminstration processes in a healthcare facility.
Audit Log
or audit trail, an electronic footprint
