CHIMA Flashcards
a brief summary of the major aims, hypotheses, results and methodology of a research paper; specific demographic, administrative and clinical data that are extracted from a source document, coded and submitted to health databases for use in planning, management, funding or research
Abstract
the process by which data that has been extracted from documentation is prepared and submitted for use
Abstracting
a voluntary process of institutional or organizational review in which an accrediting body evaluates the quality of the performance against pre-established criteria; a determination by an accrediting body that an organization complies with applicable standards
Accreditation
the degree to which a measurement or value represents the true value of the attribute being measured
Accuracy
care of limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or short-term illness; includes rehabilitative care provided to persons who are in the immediate recovery phase following an illness or accident
Acute care
service-specific data that are used to document a person’s encounter with the health care system; may also contain limited clinical information, such as codes for diagnoses and interventions
Administrative data
a system that documents demographic information obtained when a person registers for service at a health care institution or facility. Information in the ADT system may include name, sex, date of birth, next of kin, health insurance details, and dates of admission and discharge from the facility
Admission, discharge, and transfer information systems (ADT)
individual episodes or incidents of harm or potential harm to patients, t public or staff. An individual episode of harm may result from a breach of duty by staff, from faulty equipment or from poorly written policies
Adverse patient occurrence/incidents
an example of a quality improvement (QI) tool that organizes and sorts information into related groups, condensing large amounts of information into smaller more manageable groups
Affinity diagram
data that have been collected or combined from many different sources or records to form anonymized or de-identified information about groups of patients; data can be compiled into meaningful categories to facilitate comparison and analysis
Aggregate data
provides an alternate approach to funding physician services other than fee-for-service. The scope of services, deliverables, decision making, reporting requirements and accountability structure are defined in an AFP agreement between government (ministry of health), health facility or academic health research centre, medical association, or other partners within available funding
Alternative funding plans (AFP)
health treatment provided during an episode of care that does not require an overnight stay in a medical facility
Ambulatory care
a character encoding based on the English alphabet that represents text in computers, communications equipment, and other devices that work with text; provides definitions for 128 characters, including the 26 letters of the alphabet, 10 numbers (0-9) and additional graphics and control characters
American Standard Code for Information Interchange (ASCII)
support data analysis and decision making; example is a data warehouse
Analysis-oriented database systems
a severity of disease scoring system for seriously ill or injured patients, used to predict mortality, monitor outcomes, and facilitate decisions regarding treatment options
APACHE (Acute Physiology, Age, Chronic Health Evaluation)
a criteria-based review tool that assesses the appropriateness of hospitalization upon the patient’s admission to hospital
Appropriateness evaluation protocol (AEP)
the study and design of intelligent agents or technology that can be programmed to assume some capabilities normally thought to be like human intelligence (i.e. reasoning, knowledge, planning, learning, communication, perception, ability to move and manipulate objects)
Artificial intelligence (AI)
a qualitative characteristic of an individual or item (i.e age, sex, genetic, biochemical or physiological characteristics, economic status, occupation, residence) in a health study; of data in a file, a column of a table in a relational database
Attribute
documentary evidence of monitoring each activity of individuals on an information network, used to track unauthorized access by authorized users, to determine if a security breach occurred and what, if anything, was lost during the breach; a review process conducted by health care facilities to identify variations from established guidelines
Audit
to attest that something, such as a medical record, is genuine; confirm by signing
Authenticate
showing authorship and assigning responsibility for an act, event, condition, opinion, or diagnosis; might involve confirming the identity of a person or the origins of an artifact, or ensuring that a computer program is a trusted one
Authentication
the granting of permission to disclose confidential information; in computer security, allowing access to resources only to those permitted to use them
Authorization
one of the dimensions of a graph (i.e. the horizontal or x axis, the vertical or y axis); in a classification system, the conceptual framework of a classification system into which items are divided (i.e. topography, etiology, morphology, anatomic site)
Axis
a strategic planning and management tool that aligns activities related to the vision and strategy of the organization; that improves internal and external communications; that monitors organization performance against strategic goals
Balanced scorecard (BSC)
form of technology in which identification data are coded into a series of bars that can be scanned and recognized electronically
Bar code
the process of comparing one’s health care practice/performance to that of the finest in the business or to the best practices in that sector; improves the quality of care or services by observing the practices of the most efficient comparable organization, and adopting or incorporating them
Benchmarking
deviation of results from the truth or processes that lead to such deviations (i.e. sampling bias, recall bias, selection bias); within a research study, procedures are followed to attempt to reduce the introduction of bias into the study design (i.e. randomization reduces sampling bias, blinding reduces observer bias)
Bias
the multidisciplinary field, which includes mathematical modelling, the design, implementation and application of algorithms and computer technology to resolve important questions in biology
Bioinformatics
the broad discipline concerned with the study and application of computer science, information science, informatics, cognitive science and human-computer interaction in the practice of biological research, biomedical science, medicine and health care
Biomedical informatics
all living things, from cells to organisms, deliver signals of biological origin can be electric (i.e. depolarization of a nerve cell or heart muscle), mechanical (i.e. sound generated by heart valves) or chemical (i.e. PC02 in the blood) and are of interest for diagnosis, patient monitoring, and biomedical research may be captured electronically
Biosignal
a study in which the subjects and/or observer are ignorant of the group to which the subjects are assigned; most common is single blind, in which the subject is kept unaware of the group assigned; most desired is double blind, when both observer and subject are unaware of groupings (control of intervention/treated)
Blind study
a group problem-solving technique that involves the spontaneous contribution of ideas from all members of the group
Brainstorming
narrative descriptions of a policy, procedure or principle within an organization
Business rule
national standard for classifying diagnostic, therapeutic and other associated health care interventions, the companion classification system to ICD-10-CA that provides the diagnosis codes
Canadian Classification of Health Interventions (CCI)
a guide issued by CIHI for instruction in the use of the current coding classification systems for abstracting data elements from health records. The standards are a compilation of international rules of coding as established by the WHO
Canadian Coding Standards (CCS)
Standards developed to denote case complexity for application in Canadian facilities. The manual contributes to data quality by providing case study examples and directive statements, exceptions and examples to help direct coders to the application of the correct ICD-10-CA and CCI codes
Diagnosis Typing
a patient management process that involves a nurse or physician following a patient from admission to post-discharge
Case management
categorizes patients into statistically and clinically homogeneous groups based on the collection of clinical and administrative data; groups acute care patients with similar clinical and resource utilization characteristics (based on most responsible diagnosis, comorbidities, age and selected interventions that have been determined to affect resource utilization). This methodology was introduced April 1, 2007
Case Mix Group (CMG+)
in the broadest sense, reasoning that draws from a library of similar cases to assist in decision making and problem solving rather than using a set of rules; a powerful method of computer reasoning using a four-step process: retrieve past cases, reuse and map to current problem, test and revise solution, retrain the result
Case-based reasoning (CBR)
number of inpatients present in a health care facility at a specified time point (i.e. daily patient census taken every night at midnight); on a broad scale, the process of acquiring information on every member of a given population (i.e. population census performed every five years on Canadian household residents)
Census
worksheet designed as a table to collect information; a qualitative management tool
Check sheet
the senior manager appointed by a governing board to direct an organization’s overall long-term strategic management
Chief executive officer (CEO)
the senior manager responsible for the fiscal management of an organization
Chief financial officer (CFO)
a senior physician who manages the medical staff and medical activities of a health facility; may also be referred to as Chief of Staff
Chief medical officer (CMO)
responsible for managing day-to-day activities of an organization
Chief operating officer (COO)
individuals and activities related to the direct care and treatment of a particular patient for a particular episode of care; includes the health care providers who deliver care and services for the primary therapeutic benefit of the patient as well as related activities, such as laboratory work and professional or case consultation with other health care providers
Circle of care
an arrangement of the elements of a subject into groups or categories according to established criteria
Classification system
the process of using particular “subjects” of interest (i.e. user, patient, clinical encounter, charge item) to “virtually” link disparate applications so that the end-user sees them operate in a unified, cohesive way; allows a user to gain a unified view of a specific focus, a person or encounter across multiple clinical applications at a single point of use
Clinical context management
a standard for single sign-on and clinical context management. Single sign-on allows a clinical user to access multiple applications on his or her computer via a single username and password, permitting browsing or searching of a person’s details across these applications. The standard has been adopted in the United States and Canada by many commercial vendors who now supply their compliant clinical information systems
Clinical context object workgroup (CCOW)
a real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient; data disclosed by a patient, as well as observations and findings generated by the members of a health care team (i.e. history and physical exam, laboratory test results, digital radiology images, biopsy and pathology reports, hospital admission/discharge/transfer dates, discharge summaries, progress notes) that assist in arriving at a diagnosis and determining a treatment plan
Clinical data repository (CDR)
the HL7 version of this is an XML-based document markup standard that specifies the structure and semantics of clinical documents (i.e. discharge summaries, progress notes) for the purpose of electronic exchange
Clinical document architecture (CDA)
sequence of key events in the process of patient care designed to increase the appropriateness, effectiveness, efficiency and predictability for persons who have a given clinical condition
Clinical path
a detailed statement or summary of knowledge based on best evidence to assist health care providers in making decisions for appropriate health care for specific clinical circumstances. For example, the Canadian Medical Association Infobase is a public database that includes more than 1,200 evidence-based CPGs developed or endorsed by an authoritative medical or health organization in Canada
Clinical practice guidelines
the process of assigning an alphanumeric code to diagnostic and intervention data retrieved from a source document; assignment of diagnosis codes (i.e. ICD-10-CA classification system, SNOMED-CT nomenclature) or intervention codes (i.e. CCI classification)
Coding
an epidemiological study in which subsets of a define population can be identified who are or have been (retrospective) or who may be, in the future (prospective), exposed or not exposed to a factor that is thought to influence the occurrence of a given disease or outcome; this generally implies observations of large numbers of people over a long period of time with comparisons of incidence rates between the exposed and not-exposed groups
Cohort study
law originating from court decisions, jurisprudence or case law, rather than originating from statutes or legislation
Common law
grouping methodology for ambulatory care patients, such as those in emergency departments, clinics and same-day surgery. Patients are grouped according to principle procedure, main diagnosis and visit disposition data collected via NACRS
Comprehensive ambulatory classification system (CACS)
a computer program that allows providers to order tests, medications and procedures electronically instead of manually
Computerized provider order entry (CPOE)
used to outline possible courses of action and identify relationships between objects, concepts and terms
Conceptual framework
obligation upon an organization or person to provide information that has been entrusted in its care for a specific purpose, and to ensure that the information is accessible only to those authorized
Confidentiality
organizational or professional duties with respect to limiting disclosure or improper use of information without authorization
confidentiality
refers to the individual’s right to determine how their information is handled
privacy
a situation in which someone in a position of trust (i.e. medical research scientist, physician) has competing professional or personal interest; any situation in which an individual is in a position to exploit a professional or official capacity in some way for their personal or corporate benefit, making it difficult to fulfill their duties impartially
Conflict of interest
variable that can cause or prevent the outcome being studied and is associated with the factor under study. Unless it is possible to adjust for a confounding variable, its effects cannot be distinguished from the factor being studied
Confounding variable
informed voluntary agreement with what is being done or proprosed, given explicitly, either orally or in writing. Express consent is unequivocal and does not require any inference on the part of the organization seeking consent; implied consent arises where consent may reasonably be inferred from the action or inaction of the individual
Consent
close conformity between the findings in different samples or populations at different times or in different circumstances, or in studies conducted by different methods or different investigators; with regard to data quality, data consistency summarizes the validity, accuracy, usability and integrity of related data between applications and across information systems
Consistency
a tabular cross-classification of data such that subcategories of one characteristic are indicated horizontally in rows and subcategories of another classification are indicated vertically in columns. The simple version of this is the fourfold or 2x2 table in which exposure (present or absent) is represented along the rows and disease or outcome vertically in the columns (present or absent); tests of association between the characteristics (i.e. relative risk) can be readily applied
Contingency table
a component of total quality management (TQM) that emphasizes the importance of knowing and meeting customer expectations, reducing variation with processes, and relying on data to build knowledge for improvement; a continuous cycle of planning, measuring and monitoring performance
Continuous quality improvement (CQI)
the full range of health care services provided to patients from routine to intensive care, including primary care, acute care, long-term care, home care and public health; the seamless communication and documentation taking place allowing the patient to move between health care providers and levels of care
Continuum of care
schemes that mandate the use of pre-defined, authorized terms, which have been pre-selected by the designer of the controlled vocabulary (i.e. medical subject headings [MeSH] issued by the National Library of Medicine in indexing the medical literature)
Controlled vocabulary
a management function involving the establishment and implementation of mechanisms to ensure that objectives are met
Controlling
a measure of association that indicates the degree to which two variables have a linear relationship this coefficient, r, can vary between +1, where there is a perfect positive relationship (one variable varies directly with the other) and -1, in which there is a negative or inverse linear relationship between the variables
Correlation coefficient
examines the relationship between diseases (or other health-related outcome or characteristic) and other variables of interest as they exist in a defined population at one particular time
Cross-sectional study
clinical vocabulary system developed and maintained by the American Medical Association (AMA); used as the preferred system of coding medical, surgical and diagnostic services in the United States
Current procedural terminology (CPT)
the study of human control functions and of mechanical and electronic systems designed to replace them
Cybernetics
collection of elements on a given subject; the raw facts and figures expressed in text, numbers, symbols and images, which have no inherent meaning on their own
Data
responsible for managing the entire data resource and the technical aspects of data related to data quality and security
Data administrator
serves as the central repository for all information about the database and functions as a catalogue for identifying the nature of all the data in a system; provides the central resources for ensuring that standard definitions for data elements and data structures are used throughout the system
Data dictionary
an individual fact or measurement that is the smallest unique component of a database
Data element
transmission of data over communication channels or across separate information or computer systems
Data exchange
procedures that keep data from being modified or otherwise corrupted, to ensure the accuracy and completeness of data; refers to the data in the database, as well as to the organizational processes, users and activities involved in maintaining the integrity
Data integrity
process to enhance the linkage of data from different data sets to improve integration and accessibility
Data linkage
processes that focus on the proper generation, storage, retrieval and use of data
Data management
the process of extracting useful information from large data sets and then quantifying and filtering discrete, structured data
Data mining
a picture or abstraction of real conditions used to organize the fields and records, and to determine their relationship in a database
Data model
the process of determining user’s information needs and identifying relationships among the data
Data modelling
the extent to which health care data are complete, accurate, consistent and timely
Data quality
brings together information from all or some of an organization’s applications and databases; data from diverse sources are stored so that an integrated, multidisciplinary view of the data can be achieved
Data repository
the technical, physical and procedural methods by which access to confidential information is controlled and managed
Data security
a list of recommended data elements with uniform definitions, and that are relevant for a particular use
Data set
person responsible for managing the data in an organization in terms of integrated, consistent definitions, structures, calculations, derivations, etc.
Data steward
the management of the organization’s data assets in order to improve their reusability, accessibility, and quality; in health care the HIM professional may be responsible for the collection, storage, transmission, analysis and reporting of health data according to ethical and legal standards
Data stewardship
a centrally managed and easily accessible copy of data (often anonymized or de-identified) collection from transaction-based information systems; access to data from multiple databases with the ability to combine the results into a single query and reporting interface
Data warehouse
an organized collection of data in a standardized format, organized in fields and records; typically stored in a computer system for use by multiple applications
Database
the individual responsible for the technical aspects of designing and managing databases
Database administrator (DBA)
traces the history of a database within an information system; consists of six phases: initial study, design, implementation and loading, testing and evaluation, operation, and maintenance and evolution
Database life cycle (DBLC)
computer software that enables the user to create, modify delete and view the data in a database
Database management system (DBMS)
classification system for ambulatory hospital patients that focuses on the area of day surgery to which individuals are assigned; categorizes according to the principal procedure or intervention; assignment to the same category represents a homogeneous group with similar clinical episodes and resource utilization
Day procedure groups (DPG)
the shift of decision-making authority and responsibility to other levels of the organization; the registration of individuals and/or filing of individual records in an area separate or located distally from a central registration area or filing system
Decentralization
a subcategory of clinical information system designed to help health care providers make knowledge-based administrative or clinical decisions
Decision support system (DSS)
data that have been stripped of elements that may readily identify a person
De-identified data
personal data elements sufficient to identify an individual (i.e. name, address, date of birth)
Demographic data
a variable, the value of which is dependent on the effect of other variable(s) (i.e. the independent variable) in the relationship under study; the dependent variable can be predicted by a regression equation
Dependent variable
data that have been derived from other data elements using a mathematical, logical or other type of transformation
Derived data
a study that describes the existing distribution of variables without regard to causal or other hypotheses (i.e. a case report, case series, community health survey)
Descriptive study
published by the American Psychiatric Association; covers all mental health disorders and the criteria for diagnosing them, for both children and adults. DSM-IV-TR, published in 2000, is the current version in use
Diagnostic and statistical manual of mental disorders (DSM)
a global technology standard that addresses the format and exchange of digital images and related information; a joint standard effort between users and industry encompassing CT, MRI, nuclear medicine, ultrasound, etc.
Digital Imaging and Communications in Medical (DICOM)
national CIHI database containing standard clinical, demographic and administrative data pertaining to each patient hospital discharge and some day surgery events
Discharge Abstract Database (DAD)
the process of coordinating the activities related to the release of a patient when inpatient hospital care is no longer needed
Discharge planning
the act of making information known; making personal health information available or releasing it to another health information custodian or to another person outside the organization
Disclosure
a procedure of blind assignment to treated and control groups in a clinical trial in which both the subjects and the observer are unaware of group assignment
Double blind study
a measure of the extent to which a specific intervention, treatment or service does what it is intended to do for a specific population
Effectiveness
a measure of the extent to which a specific intervention treatment or service produces a beneficial result under ideal circumstances
Efficacy
the effects or end results achieved in relation to the effort expended in terms of money, resources and time; the extent to which the resources used to provide a specific intervention, treatment or service of known efficacy are minimized
Efficiency
the emerging field at the intersection of health informatics, public health and business that involves health services and information delivered or enhanced through the Internet and related technologies (i.e. electronic health record, telehealth, e-commerce)
e-Health
electronic health information management; the application of technology to managing health information, including migration of the paper record to an electronic record information infrastructure; best practices in the management of electronic health information (institutional and within the personal health record), and improved costs and quality of health care as a result of improved information management. The term has been trademarked by AHIMA to reflect one of its areas of strategic focus
e-HIM
method of establish authorship or validity of a statement, order, document, report or record by electronic means (i.e. electronic or digital signature, public key infrastructure); replaces the handwritten signature
Electronic authentication
a storage solution based on digital scanning technology, in which source documents are scanned to create digital images of the documents that can be store electronically
Electronic Document Management Systems (EDMS)
computer-based clinical data for an individual across multiple locations. This longitudinal health record includes data from a number of different interoperable EMRs and EPRs and is shared across multiple jurisdictions
Electronic Health Record (EHR)
computer-based clinical data from an individual that are kept by a single physician office or practice, or community health centre
Electronic Medical Record (EMR)
computer-based clinical data for an individual that are kept by a single health care organization (i.e. hospital, acute care facility, regional health authority)
Electronic Patient Record (EPR)
the process of transforming text into codified data through logical pathways for the purpose of consistency and comparison
Encoding
a health care contact who is responsible for diagnosing and treating the patient
Encounter
a process that protects transmitted information by changing readable text into a set of different characters and numbers on the basis of a mathematical algorithm
Encryption
an individual person, group or organization; a noun (person, place, thing, or event) about which data are to be stored
Entity
a specific type of data modelling that uses graphical representations to depict the database components and their relationships
Entity relationship diagram (ERD)
the health science that deals with the distribution and incidence of diseases in human populations; identifies etiologic factors in the pathogenesis of diseases, and prepares data for planning, implementation, and assessment of measures for the prevention, suppression and treatment of diseases
Epidemiology
includes all health care treatment and expenditures surrounding a single admission within an acute care institution or day surgery unit
Episode of care
the branch of philosophy that deals with distinctions between right and wrong and the moral consequences of human actions; ethical issues that arise in research include informed consent, confidentiality, respect for human rights and scientific integrity (i.e. conflict of interest); HIM professionals adhere to a code of ethics within the conduct of their duties
Ethics
information that a fact-finder may use to decide an issue; information that makes a factor issue before a court or tribunal more or less probable
Evidence
health care services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies
Evidence-based medicine (EBM)
the total number of days that a patient is anticipated to remain in hospital and receive treatment for a given condition, considering factors such as age and complexity level of the case
Expected length of stay (ELOS)
a study in which conditions are under the control of the researcher. For example, in a randomized control trial, a population is selected for a planned trial of treatment, the effects of which are measured by comparing the outcomes in an experimental group (which receives the intervention) with the outcomes in a control group (which receives an inactive placebo)
Experimental study
a subset of artificial intelligence that attempts to reproduce the performance of a human expert, commonly in a specific domain or problem, in a software system by creating a knowledge base that has captured the subject matter expert’s knowledge in a formal way; the purpose is to support the work of professionals in the development or evaluation of complex activities that require high-level knowledge
Expert systems (ES)
a standardized computer markup language that allows the user to specify data elements and that facilitates the sharing and interchange of data as a structured text across different information systems
Extended markup language (XML)
a method of payment for physicians based on a fee schedule that itemizes each service and provides a fee for each service rendered
Fee-for-service
the designated place on an abstract or within a database where specific data are entered. A field has a specified length, format and character limitations
Field
a graphic tool that uses standard symbols to visually display detailed information of the sequential flow of work of an individual or a product as it progresses through a process
Flow chart
a small convenience sample of a group brought together to discuss a topic or issue to ascertain and record the range of views; often used to appraise perceptions of health problems, assess acceptability of a field study or refine the questions to be used in a field of study
Focus group
a performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced
Force field analysis
a key attribute in a database table whose values must match the primary key in another table or whose values must be null; used to link one entity or table to another
Foreign key
the total market values of all final goods and services produced within a country in a given period of time
Gross domestic product (GDP)
a way of relating the types of individuals a health care facility treats to the resources utilized by the health care facility; designed as a quality improvement tool
Grouping methodology
a situation of cause of harm or damage that has caused or may cause an adverse effect
Hazard
field of study; the interdisciplinary domain of theory and practice situated at the intersection of biomedicine, computing and the study of human behaviour
Health informatics (HI)
an interface specification that constitutes the integration layer between all point of service (PoS) applications (i.e. pharmacy system, physician’s office, radiology information system, hospital electronic patient record) and the EHR infostructure; defines service components, service roles, information models and messaging standard required for the exchange of EHR data and execution of interoperability profiles between EHR services
Health information access layer (HIAL)
a person or organization who has custody or control of personal health information as a result of or in connection with performing the person’s or organization’s powers or duties; also known as custodian or trustee
Health information custodian
discipline that focuses on health care data and the management of health care information, regardless of the medium and format. Research and practice in HIM address that nature, structure and translation of data into usable forms of information for the advancement of health and health care of individuals and populations
Health information management (HIM)
the legal and business record for the health care professional or facility; contains all data on an individual’s health status including birth, immunization and death records, and the records of all services received, illnesses and treatments performed in any health care setting
Health record
testimony that is given by a witness who relates not what he or she knows personally but what others have said. The testimony is therefore dependent on the credibility of someone other than the witness
Hearsay
captures data from various types of organizations that are responsible for providing publicly funded home care services and combines the information within a single reporting framework
Home care reporting system (HCRS)
database that captures administrative, clinical and demographic information on hospital inpatient events; provides national discharge statistics from Canadian health care facilities by diagnoses and procedures
Hospital morbidity database (HMDB)
a health record that includes both paper and electronic components
Hybrid record
terms used to refer to all types of crime in which someone wrongfully obtains and uses another person’s personal data in some way that involves fraud or deception (i.e. using their personal information to take money out of a bank account, obtain a credit card or social insurance number)
Identity fraud/theft
the rate at which new events or cases of disease occur in a population. The numerator is the number of new events or cases that occur in a defined period and the denominator is the population at risk of experiencing the event during this period
Incidence rate
factual documenting of an adverse event or incident in a health facility at the time the event occurred by the person(s) most familiar with the event(s)
Incident report
the characteristic being observed or measured that is hypothesized to influence another event (the dependent variable) within a study
Independent variable
an organized list of specific data that serves to guide, indicate or otherwise facilitate reference to the data
Index
a set of statistical techniques that allows researchers to make generalizations about a population’s characteristics on the basis of a sample’s characteristics
Inferential statistics
the study of information and ways to process and handle information, especially by means of information technology
Informatics
data that have been organized and process into meaningful form to make it valuable to the user
Information
the health information custodian’s policies regarding when, how and the purposes for which the organization collects, uses, modifies, discloses, retains and disposes of personal health information (PHI). It also includes the administrative, technical and physical safeguards and practices that are in place
Information practices
the system of persons, data records and activities that process the data and information in a given department or organization
Information system
computer technology (hardware and software) combined with telecommunications technology (data, image and voice networks); may also be referred to as information and communication technology(ies)
Information technology (IT)
a legal term referring to a patient’s right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed; an individual’s voluntary agreement to participate in research or to undergo a diagnostic, therapeutic or preventative medical procedure
Informed consent
the development and adoption of modern systems of information and communication technologies (ICTs), for instance in the Canadian health care system. An infostructure is similar to “infrastructure,” except is doesn’t refer to anything physical; is the layout of information in a manner such that it can be easily navigated and used
Infostructure
represents the basic underlying physical framework of a system or structure
Infrastructure
a patient who is provided with room, board and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight
Inpatient
the zone between different computer systems across which users want to pass information; the aggregate of means by which people interact with a machine, device, computer program or other complex tool
Interface
published by the International Council of Nurses (ICN); provides standardized terminology used in clinical nursing practice, helps facilitate the integration of nursing into computerized information systems and can be used as a tool for clinical decision making related to the discipline of nursing
International classification for nursing practice (ICNPR)
standardization method to identify mortality and to facilitate the collection and tabulation of vital statistics. ICD-10-CA is the Canadian modification of ICD-10, produced for use in Canada by CIHI under a license agreement from the WHO for classifying mortality and morbidity data
International Classification of Diseases (ICD)
developed by the WHO, primarily used in tumour or cancer registries for coding the topography and morphology of neoplasms obtained from a pathology report. ICD-O-3 is the current version in use
International Classification of Diseases for Oncology (ICD-O)
classifies patient data and clinical activity in the primary care setting. Created in 1987, it is in its second edition
International Classification of Primary Care (ICPC)
classification of health and health-related domains that describe body functions and structures, activities and participation
International Classification on Functioning, Disability and Health (ICF)
the ability, generally by adoption of standards, of systems to work together and exchange information or services directly among users; with respect to software, used to describe the capability of different programs to exchange data via a common set of exchange formats, to read and write the same file formats, and to use the same protocols
Interoperability
a clinical manipulation, treatment or therapy; a generic term used by researchers to mean an act of some kind
Intervention
the power and authority of a court to hear and decide specific types of cases; a generic term referencing the singular or collective provinces and territories of Canada; the extent of authority or control
Jurisdiction
an organized body of information, or the comprehension and understanding consequent on having acquired and organized a body of facts; derived from information once it has been organized, analyzed and synthesized
Knowledge
a software application that is programmed to imitate human problem-solving by means of artificial intelligence; reference to a database of expert knowledge on a particular problem
Knowledge-based systems
the range of practices used by organizations to identify, create, represent and distribute knowledge; a management philosophy that promotes an integrated approach to the process and use of information
Knowledge management
a class of software that receives, processes and stores information generated by medical laboratory processes
Laboratory Information System (LIS)
the management function of influencing employees to work toward achieving the set objectives; involves good leadership
Leading
the set of skills and competencies that students are expected to have upon graduation from CHIMA-recognized health information management programs. The most recent version of this document was revised in 2006 and published in 2007
Learning Outcomes for Health Information Management (LOHIM)
older mainframe computers or computer software applications that have been in use for a long period of time and that contain many years of an institution’s or facility’s data
Legacy systems
developed in 1994 by Regenstrief Institute to facilitate the exchange and pooling of laboratory results (i.e. blood hemoglobin) or vital signs for the purposes of clinical care and research
Logical Observation Identifier Names and Codes (LOINC)
health care services provided in a non-acute care setting to chronically ill, aged, disabled or mentally handicapped individuals
Long-term care
in the ____ system, methodology cases are grouped into 19 categories, or major Ambulatory Clusters, based on the main problem code assigned to each case
CACS (Comprehensive Ambulatory Classification System)
19 categories of methodology cases or Ambulatory Clusters
Major ambulatory cluster (MAC)
in determining case mix grouping (for CMG+), assignment of each case begins with organization into one of 21 categories, based on the most responsible diagnosis (i.e. diseases and disorders of the nervous system, diseases and disorders of the cardiovascular system, pregnancy and childbirth, newborns and neonates)
Major clinical categories (MCC)
the general term for an information system that supports operations, management, analysis and decision-making functions within an organization; involves the use of computer hardware and software, data and databases, and decision making
Management information systems (MIS)
framework for the collection of financial and statistical data related to staffing, costs, workload and department activities, which are submitted to provincial ministries of health and then to CIHI. CIHI develops and publishes standards which outline a standardized framework for the collection and reporting on the day-to-day financial and statistical data on the operations of health service organizations across the continuum of care; these are updated on a regular basis
Management information systems standards (MIS)
a database relationship where multiple instances of an entity may be associated with multiple instances of another entity
Many-to-many relationship (M:N)
a list or database created and maintained by a health care facility to record the name and unique identification number of every patient who has ever been admitted or treated in a facility; also known as Central Person Index; Enterprise Master Person Index (across multiple facilities)
Master person index (MPI)
the average value of the data in a distribution; mathematically, the sum of the values divided by the total number of samples; a measure of central tendency
Mean
a controlled vocabulary of terms that have been developed by the National Library of Medicine to index the world medical literature
Medical Subject Headings (MeSH)
Canada’s national health care program where Canadians receive hospital and physician services financed by the provinces through funding provided from the federal government
Medicare
systems that assist organizations in prescribing, dispensing and administering medications
Medication administration systems
protocols that allow for the elctronic exchange of data between computer systems for example HL7 messaging standard, or DICOM (Digital Imaging and Communications in Medicine) data transmission standard for medical images
Messaging standard
descriptive data that characterize other data to create a clearer understanding of their meaning, characteristics and usage and to achieve greater reliability and quality of information; the metadata required for effective data management vary with the type of data and context of use; in the context of an information system, where the data form the content of the computer files, metadata about an individual data item would typically include the name of the field and its length
Metadata
a photographic process that saves the image of an original paper document in a smaller size on a film in order to preserve a copy and to save storage space
Microfilming
the representation of a theory in a visual format, on a smaller scale, or with objects
Mode
the incidence or prevalence of a disease or of all disease in a population
Morbidity
the outward appearance (shape, structure, colour, pattern) of an organism or organ (in pathology, gross morphology describes the overall shape, colour or makings); forms one of the axes within the SNOMED-CT terminology
Morphology
the number of deaths in a given population, usually expressed as a rate
Mortality
the diagnosis or condition that can be described as being the one most responsible for the patient’s stay in hospital; if there is more than one such condition, the one held most responsible is the one requiring the greatest portion of stay or greatest use of resources
Most responsible diagnosis (MRDx)
having multiple categories or axes (i.e. the CCI is a multiaxial classification system that categorizes interventions on the basis of type of procedure, the area of the body or organ system, the generic type of intervention, the approach used)
Multiaxial
data acquisition and reporting standards related to hospital and community-based private and public ambulatory care activity that occurs in clinics, emergency departments and some day surgical units
National Ambulatory Care Reporting System (NACRS)
the field of artificial intelligence and computational linguistics that studies the problems of automated generation and understanding of natural human languages. Natural-language natural human languages. Natural-language generation systems convert information from computer databases into normal-sounding human language, while natural-language understanding systems convert samples of human language into more formal representations that are easier for computer programs to manipulate
Natural language processing (NLP)
a series of activities conducted to identify gaps between current and desired organizational, group of individual performances. Following this analysis, activities are developed to address the gaps
Needs analysis/assessment
a set or system of names or terms used to name things. more specifically, in a nomenclature, codes are assigned to medical concepts, and medical concepts can be combined according to specific rules to form more complex concepts (i.e. SNOMED-CT)
Nomenclature
example of a consensus-building tool that enables ranking and prioritizing of options in order to come to agreement on the best solution of the most pressing problem
Nominal group technique (NGT)
statistically, an assumption about population distribution and population mean that is tested against alternative hypotheses. The null hypothesis states that there is no difference between the populations being studied
Null hypothesis
the field of information science concerned with the management of data and information used to support that practice and delivery of nursing care through computers and technology
Nursing informatics
an entity-relationship model is based on a perception of the world as consisting of a collection of basic objects (entities) and relationships among these objects; is based on a collection of objects
Object-oriented model
a study in which the researcher simply observes or records the changes in one characteristic being studied in relation to changes in other characteristics (i.e. case control or cohort study); does ont involve an intervention
Observational study
a risk management technique in which the risk manager reviews the health records of current and discharged hospital inpatients with the events
Occurrence/generic screening
a database relationship that exists when an instance of an entity is associated with multiple instances of another entity
One-to-many relationship (1:M)
a database relationship that exists when an instance of an entity is associated with only one instance of another entity, and vice versa
One-to-one relationship (1:1)
a data access architecture that allows that user to retrieve specific information from a large volume of data
Online analytical processing (OLAP)
the real-time processing of day-to-day business transactions from a concepts
Online transaction processing
a formal representation of a set of concepts within a domain and the relationships between those concepts
Ontology
the reference model is a description of the seven-layer data communications networking standards model and the services performed at each level. A layer is a collection of related functions; each one provinces services to the layer above it and receives service from the layer below it. From top to bottom, model consists of these seven layers: Application, presentation, session, transport, network, data link and physical
Open systems interconnections (OSI)
the management function related to designing and developing a system to ensure that the appropriate resources can be allocated to implement the organization’s objectives
Organizing
a health professional, other than a physician or nurse, who is involved with the delivery of services pertaining to the identification, evaluation and prevention or treatment of diseases and disorders (i.e. dietary and nutrition services, rehabilitation, health systems management). Examples include: dental hygienists, optometrists, dieticians, medical technologists, occupational therapists, physical therapists, radiology technician, respiratory therapists, and speech language pathologists. Titles and roles, as well as requirements for recognition and/or certification and scope of practice, may vary from province to province
Other health professionals
the process of systematically tracking a patient’s clinical treatment and the responses to that treatment, including measures of morbidity and functional status, for the purpose of determining outcomes of and improving care
Outcomes management
measuring the results of an intervention and the impact it will have on the quality of life. A widely used model of outcomes management, measures performance by examining the structures, process and outcomes of health care delivery
Outcomes measurement
a patient admitted to a hospital, clinic or other health care facility for treatment that does not require an overnight stay
Outpatient
a bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems or solutions
Pareto chart
the principle that 20% of the sources of the problem are responsible for 80% of the actual problems
Pareto principle
a qualitative research method in which the researcher or observer is (or pretends to be) a member of the group being studied
Participant observation
process of review of research proposals/grants, manuscripts for publication, conference abstracts for scientific and technical merit by other researchers/scientists in the same field
Peer review
the continuous study and adaptation of a health care organization’s functions and processes to increase the likelihood of achieving desired outcomes
Performance improvement
a key measure designed to assess an aspect of qualitative or quantitative performance; useful for establishing standards, assessing whether a standard is being met, monitoring whether a standard is being met, monitoring performance and comparing performance to industry norms; usually expressed as a number or percentage
Performance indicators
the process of comparing the outcomes of an organization against pre-established performance plans and standards
Performance measurement
identifying information (verbal or documented) about an individual’s physical or mental health or about the provision of health services to the individual. Individuals can be living or deceased
Personal health information
an individual’s longitudinal health record, maintained by the individual, encompassing a complete record of their health (i.e. immunizations, allergies, health encounters, lifestyle choices); may contain links to health information held by a health care provider or health care facility. The concept continues to evolve as more health information is available electronically and it is possible to provide linkage via the Internet
Personal health record (PHR)
a system used for storage and management of clinical image data, primarily digital radiology images; can provide timely access of data to physicians both within the institution and at remote sites
Picture archiving and communications system (PACS)
an inert medication or procedure (i.e. it has no effect) that is intended to make subjects feel as though they are receiving treatment
Placebo
an examination of the future and subsequent preparation of action plans to attain goals; one of four traditional management functions
Planning
the location where a health care service is provided (i.e. patient’s bedside or home)
Point of care
a written plan of action to guide decisions and achieve outcomes; either the department or organization determines how to handle a specific situation
Policy
all the inhabitants of a given country or area; in sampling, the samel is intended to yield results that are representative of the whole population
Population
an approach to health that aims to improve the health of the entire population; an understanding of the factors that underlie health and health risks
Population health
an incident that has caused harm and may lead to professional, facility or general liability claims, which may result in financial loss to the health care facility (through compensation claimed by the injured party)
Potentially compensable event
the quality of being sharply defined or stated; does not imply accuracy. Examples of measures of precision include the number of significant digits in the measurement; the standard error of the measurement; and the standard deviation of a series of replicate determinations
Precision
the number of events or instances of a diseases or condition in a given population at a specified time. Point prevalence is the number of persons known to have had the disease at any point during a specified period of time
Prevalence
the first or primary source of assistance for problems with health; usually the family physician or general practitioner, but may be another health professional
Primary health care
an attribute that is a unique identifier of each record/row in a database table
Primary key
the right of an individual to control who has access to his or her personal information and under what circumstances; the right to determine what information is shared, when, how and with whom
Privacy
the specified action or series of actions, acts or operations that have to be executed in the same manner in order to obtain the same results in the same circumstances (i.e. emergency procedures); can indicate a sequence of activities, tasks, steps, decisions, calculations and processes, that when undertaken in the sequence laid down, produces the described result, product or outcome; a surgical or medical procedure
Procedures
a temporary undertaking to create a unique product or service; has defined start and end points and specific objectives that, when attained, signify completion
Project
a document issued by senior management that gives the project manager authority to apply organizational resources to project activities and formally recognizes that existence of the project; includes a description of the business need that the project addresses, and a description of the product or service to be delivered by the project
Project charter
the application of knowledge, skills, tools and techniques to project activities to meet or exceed stakeholders’ needs and expectations
Project management
a type of ratio in which the numerator is included in the denominator and therefor the value is dimensionless
Proportion
a study that follows subjects forward in time
Prospective study
intended to reduce the complexity of care processes by imposing pre-defined structures on them (i.e. clinical algorithms, protocols, guidelines, care pathways, practice parameters)
Protocol-based system
a system of digital certificates and other registration authorities that verify and authenticate the validity of each party involved in a secure transaction
Public key infrastructure (PKI)
a review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
Qualitative analysis
a research record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
Qualitative research record
a research record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care
Qualitative research record
a research methodology that employes non-numeric information to explore individual or group characteristics (i.e. case reports, ethnography or participant observation, methods use surveys, questionnaires, interviews, focus groups, narrative text)
Qualitative research
a set of activities designed to measure the quality of service, product, or process with remedial action, as needed, to maintain a desired standard
Quality assurance (QA)
a set of activities that measure the quality of a service or product through systems or process evaluation and then implements revised processes that result in better health care outcomes for patients, based on standards of care
Quality improvement (QI)
evaluation of the quality of health care services and delivery using standards and guidelines developed by various entities, including the government and accreditation organizations; includes quality improvement, utilization management and risk management
Quality management (QM)
a review of the health record to determine completeness and accuracy
Quantitative analysis
a research methodology that uses numerical measures to explore group characteristics or behaviour (i.e. case-control or cohort studies, randomized control trials)
Quantitative research
an instrument consisting of a predetermined set of questions used to collect data; may be self-completed (by the study subject) or administered (by the researcher)
Questionnaire
used radiology departments to store, manipulate and distribute patient radiological data and imagery
Radiology information systems (RIS)
a selected subset of a population that is arrived at by selecting units such that each possible unit has an equal chance of being selected
Random sample
an experiment in which subjects in a population are randomly allocated to groups (usually treatment and control groups) and either receive or don’t receive an experimental preventive or therapeutic procedure, manoeuvre or intervention. Results are assessed by comparison of rates of disease, death, recovery or other outcome; are generally considered the most scientifically rigorous method of hypothesis testing in research studies
Randomized control trial (RCT)
the difference between the largest and smallest values in a distribution
Range
a measure of the frequency of an occurrence of a phenomenon; an expression of the frequency with which an event occurs in a defined population in a specified time period
Rate
the value obtained by dividing one quantity by another; a general term in which rate, proportion and percentage are subsets. A ratio is an expression of the relationship between a numerator and denominator where the two are usually separate and distinct quantities. This differs from a proportion, where the numerator (a subset of the population being studied) is included in the denominator (the whole population being studied)
Ratio
the process by which records are retained in a secure fashion until they are no longer required
Records hold
HL7 information model that expresses data content needed in a specific administrative or clinical context and uses explicit representation of meaningful vocabulary in the message fields to increase precision of communication and decrease implementation costs
Reference information model (RIM)
provision of long-term care services to patients recovering from chronic illness or debilitating injuries where the stay often lasts several months
Rehabilitative care
a database that represents data as a collection of tables in which all data relationships are represented by common values in related tables
Relational database
the disclosure of documents containing personal health information to a third party
Release of information
the degree to which the results obtained by a measurement or procedure can be replicated
Reliability
a formal document organizations use to gather information from vendors or suppliers about products or services that the organization is interested in acquiring or using
Request for information (RFI)
a formal document that publicly announces an organization’s intention to acquire and implement new products or services, and that sets out the required specifications. Interested vendors or suppliers that respond must demonstrate that they meet the specifications and provide an associated cost. Usually the company that meets all the specifications and that has submitted the lowest bid wins the contract
Request for proposal (RFP)
an essential practice that evidence and consultation have determined an organization must have in place to enhance patient/client safety and to minimize risk
Required organizational practices (ROPs)
the architecture of a study: its structure, details of the studied population, time frame, methods and procedures; includes ethical considerations that are clearly explained in the research protocol
Research design
the process whereby inactive health records are stored and made available for future use in compliance with local, provincial or federal requirements; the ability to keep valuable employees from seeking employment elsewhere
Retention
research design used to test hypotheses about etiology in which inferences about exposure to the hypothesized causal factor(s) are derived from data relating to characteristics of the persons under study or the events or experiences in the past. For example, in the case control, some of the persons under study have the disease or other outcome of interest (cases) and their characteristics and past experiences or exposures are compared with those of unaffected persons (controls)
Retrospective study
a probability, likelihood, occurrence or course of action that involves an adverse or unwanted event, and the severity or degree of the consequences of that event; the probability that an event will occur, i.e. that an individual will become ill or die within a stated period of time
Risk
an assessment of possible security threats to the organization’s data; the qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specific health hazards or from the absence of beneficial influences
Risk analysis/assessment
the exchange of information and opinions on risk and risk-related factors among risk managers and assessors, staff, health care professionals, patients, the public and other interested stakeholders in order to achieve a better understanding of risk, risk management, risk-related issues and decisions. Factors include the existence, nature, form, severity or acceptability of risk and how they should be managed
Risk communication
actions taken to prevent, eliminate or avoid risk from the facility’s perspective
Risk control
a process undertaken to evaluate the risk management program itself, as well as the actual or potential risks to assess whether the program is effective
Risk evaluation
a process undertaken to identify potential agents, persons, policies or scenarios capable of causing, or known to cause, adverse effects or events
Risk identification
the processes undertaken to identify, control and minimize the impact of uncertain events, with the objective of reducing risk
Risk management
a selected subset of a population. In a random sample, all individuals have an equal chance of selection and are selected at random from a random number table until the desired sample size is obtained; in a cluster sample, each unit selected is a group of persons rather than an individual (i.e. members of a family, all residents in a city block)
Sample
systematic error due to study of a non-random sample of a population
Sampling bias
the amount of effort, materials and resources needed to produce project deliverables
Scope
the growth of the scope of a project while it is in progress, virtually guaranteeing that it will be over budget and behind schedule
Scope creep
care provided by a specialist. Patients are usually referred to a secondary health provider by the primary health provider
Secondary health care
the administrative, physical and technological safeguards a health care agency/facility uses to prevent accidental or intentional disclosure by inappropriate access or by unauthorized individuals; includes existing mechanisms in place to protect the information from alteration, destruction or loss
Security
error due to systematic differences in characteristics of those who take part in a study and those who don’t. Examples include subjects in a survey or study limited to volunteers; subjects in a survey who are present in a particular place at a particular time, such as a phone survey conducted during the day; hospital cases under the care of a physician
Selection bias
communication between systems with the objective of processing meaning in the receiving system accurately enough to produce useful results, as defined by the end users of both systems
Semantic interoperability
an unexpected occurrence usually resulting in death or serious injury
Sentinel event
statistical methods allow an estimate of the probability of an observed association between independent and dependent variables under the null hypothesis. From this estimate, for a sample of a given size, the statistical significance of a result can be stated, usually by the “p” value (i.e. p=.05)
Statistical significance
a doctrine of evidence that provides that a negative inference may be made against a defendant to a lawsuit for the intentional destruction of information that is considered evidence in the lawsuit
Spoliation
a scientifically based statement of expected behaviour against which structures, processes and outcomes can be measured. A technical standard is an established requirement, usually issued in a formal document that specifies uniform engineering or technical criteria, methods, processes and practices
Standard
a measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement, the square root of variance
Standard deviation
a procedure used to decide whether a hypothesis about the distribution of one or more populations or variables should be accepted or rejected. A t-test and ANOVA are two parametric tests for normally distributed sample populations
Statistical test
a communication tool that visually tells the story when you need to explain an idea or process
Story boarding
a broad organization-wide plan by which the facility accomplishes its strategic goals; involves the production of the fundamental decisions that shape and guide what an organization does and why it does it
Strategic plan
the separation of a sample into several sub-samples according to specified criteria (i.e. age, sex, socio-economic status). Confounding variables may be controlled by identifying these factors and assigning subjects randomly into these strata
Stratified randomization
data entry that is based on selection of pre-defined medical concepts; results in uniformity of data, and facilitates reporting, decision support, quality assessment and clinical research
Structured data entry (SDE)
a database computer and programming language designed for the retrieval and management of data in relational database management systems. The core is a command language that allows the retrieval, insertion, updating and deletion of data and the performance of management and administrative functions on the database
Structured query language (SQL)
a person who is authorized under privacy legislation to consent on behalf of an incapable individual to the collection, use or disclosure of personal health information about the incapable individual
Substitute decision maker
an investigation in which information is systematically collected among a studied population by various methods, such as face-to-face inquiry or interview, self-completed questionnaire or telephone survey
Survey
a strategic planning tool used to evaluate the strengths, weaknesses, opportunities and threats involved in a project or in a business venture; involves specifying the objective of the business venture or project and identifying the internal and external factors that are favourable and unfavourable to achieving that objective
SWOT analysis
a set of related and highly interdependent components that are operating for a particular purpose
System
a process and approach used when reviewing the literature to limit bias in the assembly, critical analysis and synthesis of all relevant studies on a specific topic
Systematic review
comprehensive clinical health care terminology; provides a formal representation of concepts, terms and relations between concepts in the medical domain
Systematized Nomenclature of Medicine (SNOMED)
the most comprehensive, multilingual clinical health care terminology in the world; provides the core general terminology for the electronic health record and contains more than 357,000 concepts with unique meanings and formal logic-based definitions organized into hierarchies
Systematized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)
the person responsible for maintenance and operation of a computer system and/or network. Duties can be wide ranging and vary from institution to institution but generally include installing, supporting and maintaining servers or other computer systems, and planning for and responding to service outages and other problems
Systems administrator
traces the history (life cycle) of an information system; the traditional methodology used to develop, maintain and replace information systems
Systems development life cycle (SDLC)
a telecommunications system that links health care organizations and patients from diverse geographic locations and transmits information for consultation and treatment
Telehealth
a system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement
Terminal digit
terms belonging to a specialized subject; nomenclature, specific and consists of a single unique name of each entity
Terminology
complex care that is provided by a number of specialists and health providers within a hospital, usually after referral by the primary or secondary care provider
Tertiary health care
a process used by organizations when implementing new technologies to ensure systems work together as they should
Test end-to-end
the study or description of an anatomical region or part, its physical or natural features (i.e. within SNOMED-CT, nomenclature refers to the axist that describes the anatomic region)
Topography
a management philosophy that includes all activities in which the needs of the customer and the organization are satisfied in the most efficient manner by using employee potentials and continuous improvement
Total quality management (TQM)
a database that processes data or records in real-time
Trasaction-oriented/transactional database
the exchange of data between a person and a program, or a program and a program, when the sender and receiver are at a distance from one another
Transmission
all kinds of non-hierarchical relationships that can exist between two concepts
Transverse relationships
a study in which the subjects, observers and analysts are blinded as to which subjects receive which interventions
Triple blind study
a clinical vocabulary system developed by the US-based National Library of Medicine (NLM); facilitates the integration and understanding of information from different computer systems.
Unified medical language system (UMLS)
One of the major components of UMLS a very large, multi-purpose and multilingual vocabulary database that contains information about biomedical and health-related concepts, their various names, and the relationships among them; built from the electronic versions of many different thesauri, classifications, code sets, and lists of controlled terms used in patient care, health services billing, public health statistics, indexing and cataloging biomedical literature, and/or basic, clinical, and health services research
Metathesaurus
general-purpose modelling language that includes a graphical notation used to create an abstract model of a system
Unified modelling language (UML)
any identifier that is guaranteed to be unique among all identifiers used for a specific set of objects and for a specific purpose and that refers to only one individual or organization; may be a numeric or alphabetic representation
Unique identifier
the process of evaluating the necessity, appropriateness and efficiency of health care services to ensure quality of patient care
Utilization management (UM)
the evaluation of medical necessity and efficiency or quality of health care services, prospectively, concurrently or retrospectively; limited to the physician’s diagnosis, treatment and billing amount to identify areas where improvement can be made to achieve optimum use
Utilization review (UR)
the degree to which a measurement actually measures what it purports to measure; internal validity - the differences observed in dependent variables under study in the control and treated/experimental/exposed group are attributable only to the hypothesized effect under study; external validity - the extent to which the study findings can be generalized to a population beyond the subjects in the study
Validity
any attribute, phenomenon or event that can have different values; any quantity that varies; dependent variable - value is dependent on the effect of another variable (independent variable)
Variable
voice recognition, or more correctly speech recognition systems, convert spoken word into machine-readable input. Speech recognition applications include simple data entry, preparation of structured documents from dictation (i.e. radiology or pathology reports) or direct speech-to-text processing, or voice dialing
Voice recognition system
the intelligence that gives individuals the empowerment and courage to act; the trait of utilizing knowledge and experience with common sense and insight
Wisdom
a hierarchical structure that decomposes project activities into levels of detail; organizes and defines the total scope of the project in terms of the project components (products or tasks)
Work breakdown structure (WBS)
