Chapter 9 Key Terms

Question 1

unstructured data

Answer 1

also called narrative data, can be entered in a free text format by the user

Question 2

template-based entry

Answer 2

blending of both free text and structured data entry

Question 3

structured data

Answer 3

generally found in checkboxes, drop-down boxes, and other data entry means whereby the user chooses from options already built into the system

Question 4

source systems

Answer 4

information systems that capture and feed data into the EHR

Question 5

reminders

Answer 5

usually notify physician of lab test results and preventive measures

Question 6

radiofrequency identification devices

Answer 6

RFIDs: microchip implanted in an item to allow tracking of that item

Question 7

population health

Answer 7

cohesive, integrated, and comprehensive approach to health considering the distribution of health outcomes in a population

Question 8

personal health record

Answer 8

PHR; an electronic or paper health record maintained and updated by the patient

Question 9

patient-provider portal

Answer 9

secure method of communication between healthcare provider and the patient, providers, or the patient and provider

Question 10

order entry and results reporting

Answer 10

software application in which healthcare professionals can enter patient care orders and then see the test results

Question 11

ONC-ACBs

Answer 11

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

Question 12

ONC-AA

Answer 12

entity designated by the ONC to accredit and oversee the certification bodies

Question 13

Office of the National Coordinator for Health Information Technology

Answer 13

ONC; lead federal agency spearheading the national effort to improve patient safety and health outcomes

Question 14

National Voluntary Laboratory Accreditation Program

Answer 14

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

Question 15

Longitudinal health record

Answer 15

permanent record of significant information listed in chronological order and maintained across time, ideally from birth to death

Question 16

interoperability

Answer 16

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

Question 17

hybrid record

Answer 17

mixture of paper and electronic health records

Question 18

health level seven international

Answer 18

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)

Question 19

health information technology

Answer 19

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

Question 20

health information blocking

Answer 20

persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information

Question 21

electronic signature

Answer 21

requires at least a password but can use a two-factor authentication method

Question 22

electronic medication administration record

Answer 22

EMAR; software that automates many of the medication administration processes in a healthcare facility

Question 23

electronic medical record

Answer 23

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

Question 24

document management system

Answer 24

DMS; electronic method of capturing and managing documents

Question 25

digitized signature

Answer 25

a scanned image of an individuals signature

Question 26

digital signature

Answer 26

similar to electronic signature except that it uses encryption to provide non repudiation to prove authenticator’s identity, which makes it most secure

Question 27

core data set

Answer 27

a data set that contains the most relevant admin, demographic, and clinical info about a patient’s healthcare

Question 28

continuity of care record

Answer 28

CCR; core data set which is most relevant admin, demographic, and clinical information about a patient’s healthcare, covering one or more healthcare encounters

Question 29

computerized provider order entry

Answer 29

CPOE; preprogrammed clinical decision support designed to assist the user through making an entry appropriately

Question 30

clinical messaging

Answer 30

a tool that connects the medical staff and hospital by providing access to information systems such as order entry and results reporting and DMS

Question 31

clinical decision support systems

Answer 31

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

Question 32

Certified EHR technology

Answer 32

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

Question 33

Barcode medication administration record

Answer 33

BC-MAR; software that automates many of the medication adminstration processes in a healthcare facility.

Question 34

Audit Log

Answer 34

or audit trail, an electronic footprint