CHIMA

Question 1

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

Answer 1

Abstract

Question 2

the process by which data that has been extracted from documentation is prepared and submitted for use

Answer 2

Abstracting

Question 3

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

Answer 3

Accreditation

Question 4

the degree to which a measurement or value represents the true value of the attribute being measured

Answer 4

Accuracy

Question 5

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

Answer 5

Acute care

Question 6

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

Answer 6

Administrative data

Question 7

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

Answer 7

Admission, discharge, and transfer information systems (ADT)

Question 8

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

Answer 8

Adverse patient occurrence/incidents

Question 9

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

Answer 9

Affinity diagram

Question 10

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

Answer 10

Aggregate data

Question 11

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

Answer 11

Alternative funding plans (AFP)

Question 12

health treatment provided during an episode of care that does not require an overnight stay in a medical facility

Answer 12

Ambulatory care

Question 13

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

Answer 13

American Standard Code for Information Interchange (ASCII)

Question 14

support data analysis and decision making; example is a data warehouse

Answer 14

Analysis-oriented database systems

Question 15

a severity of disease scoring system for seriously ill or injured patients, used to predict mortality, monitor outcomes, and facilitate decisions regarding treatment options

Answer 15

APACHE (Acute Physiology, Age, Chronic Health Evaluation)

Question 16

a criteria-based review tool that assesses the appropriateness of hospitalization upon the patient’s admission to hospital

Answer 16

Appropriateness evaluation protocol (AEP)

Question 17

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)

Answer 17

Artificial intelligence (AI)

Question 18

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

Answer 18

Attribute

Question 19

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

Answer 19

Audit

Question 20

to attest that something, such as a medical record, is genuine; confirm by signing

Answer 20

Authenticate

Question 21

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

Answer 21

Authentication

Question 22

the granting of permission to disclose confidential information; in computer security, allowing access to resources only to those permitted to use them

Answer 22

Authorization

Question 23

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)

Answer 23

Axis

Question 24

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

Answer 24

Balanced scorecard (BSC)

Question 25

form of technology in which identification data are coded into a series of bars that can be scanned and recognized electronically

Answer 25

Bar code

Question 26

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

Answer 26

Benchmarking

Question 27

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)

Answer 27

Bias

Question 28

the multidisciplinary field, which includes mathematical modelling, the design, implementation and application of algorithms and computer technology to resolve important questions in biology

Answer 28

Bioinformatics

Question 29

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

Answer 29

Biomedical informatics

Question 30

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

Answer 30

Biosignal

Question 31

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)

Answer 31

Blind study

Question 32

a group problem-solving technique that involves the spontaneous contribution of ideas from all members of the group

Answer 32

Brainstorming

Question 33

narrative descriptions of a policy, procedure or principle within an organization

Answer 33

Business rule

Question 34

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

Answer 34

Canadian Classification of Health Interventions (CCI)

Question 35

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

Answer 35

Canadian Coding Standards (CCS)

Question 36

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

Answer 36

Diagnosis Typing

Question 37

a patient management process that involves a nurse or physician following a patient from admission to post-discharge

Answer 37

Case management

Question 38

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

Answer 38

Case Mix Group (CMG+)

Question 39

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

Answer 39

Case-based reasoning (CBR)

Question 40

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)

Answer 40

Census

Question 41

worksheet designed as a table to collect information; a qualitative management tool

Answer 41

Check sheet

Question 42

the senior manager appointed by a governing board to direct an organization’s overall long-term strategic management

Answer 42

Chief executive officer (CEO)

Question 43

the senior manager responsible for the fiscal management of an organization

Answer 43

Chief financial officer (CFO)

Question 44

a senior physician who manages the medical staff and medical activities of a health facility; may also be referred to as Chief of Staff

Answer 44

Chief medical officer (CMO)

Question 45

responsible for managing day-to-day activities of an organization

Answer 45

Chief operating officer (COO)

Question 46

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

Answer 46

Circle of care

Question 47

an arrangement of the elements of a subject into groups or categories according to established criteria

Answer 47

Classification system

Question 48

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

Answer 48

Clinical context management

Question 49

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

Answer 49

Clinical context object workgroup (CCOW)

Question 50

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

Answer 50

Clinical data repository (CDR)

Question 51

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

Answer 51

Clinical document architecture (CDA)

Question 52

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

Answer 52

Clinical path

Question 53

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

Answer 53

Clinical practice guidelines

Question 54

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)

Answer 54

Coding

Question 55

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

Answer 55

Cohort study

Question 56

law originating from court decisions, jurisprudence or case law, rather than originating from statutes or legislation

Answer 56

Common law

Question 57

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

Answer 57

Comprehensive ambulatory classification system (CACS)

Question 58

a computer program that allows providers to order tests, medications and procedures electronically instead of manually

Answer 58

Computerized provider order entry (CPOE)

Question 59

used to outline possible courses of action and identify relationships between objects, concepts and terms

Answer 59

Conceptual framework

Question 60

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

Answer 60

Confidentiality

Question 61

organizational or professional duties with respect to limiting disclosure or improper use of information without authorization

Answer 61

confidentiality

Question 62

refers to the individual’s right to determine how their information is handled

Answer 62

privacy

Question 63

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

Answer 63

Conflict of interest

Question 64

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

Answer 64

Confounding variable

Question 65

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

Answer 65

Consent

Question 66

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

Answer 66

Consistency

Question 67

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

Answer 67

Contingency table

Question 68

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

Answer 68

Continuous quality improvement (CQI)

Question 69

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

Answer 69

Continuum of care

Question 70

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)

Answer 70

Controlled vocabulary

Question 71

a management function involving the establishment and implementation of mechanisms to ensure that objectives are met

Answer 71

Controlling

Question 72

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

Answer 72

Correlation coefficient

Question 73

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

Answer 73

Cross-sectional study

Question 74

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

Answer 74

Current procedural terminology (CPT)

Question 75

the study of human control functions and of mechanical and electronic systems designed to replace them

Answer 75

Cybernetics

Question 76

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

Answer 76

Data

Question 77

responsible for managing the entire data resource and the technical aspects of data related to data quality and security

Answer 77

Data administrator

Question 78

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

Answer 78

Data dictionary

Question 79

an individual fact or measurement that is the smallest unique component of a database

Answer 79

Data element

Question 80

transmission of data over communication channels or across separate information or computer systems

Answer 80

Data exchange

Question 81

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

Answer 81

Data integrity

Question 82

process to enhance the linkage of data from different data sets to improve integration and accessibility

Answer 82

Data linkage

Question 83

processes that focus on the proper generation, storage, retrieval and use of data

Answer 83

Data management

Question 84

the process of extracting useful information from large data sets and then quantifying and filtering discrete, structured data

Answer 84

Data mining

Question 85

a picture or abstraction of real conditions used to organize the fields and records, and to determine their relationship in a database

Answer 85

Data model

Question 86

the process of determining user’s information needs and identifying relationships among the data

Answer 86

Data modelling

Question 87

the extent to which health care data are complete, accurate, consistent and timely

Answer 87

Data quality

Question 88

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

Answer 88

Data repository

Question 89

the technical, physical and procedural methods by which access to confidential information is controlled and managed

Answer 89

Data security

Question 90

a list of recommended data elements with uniform definitions, and that are relevant for a particular use

Answer 90

Data set

Question 91

person responsible for managing the data in an organization in terms of integrated, consistent definitions, structures, calculations, derivations, etc.

Answer 91

Data steward

Question 92

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

Answer 92

Data stewardship

Question 93

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

Answer 93

Data warehouse

Question 94

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

Answer 94

Database

Question 95

the individual responsible for the technical aspects of designing and managing databases

Answer 95

Database administrator (DBA)

Question 96

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

Answer 96

Database life cycle (DBLC)

Question 97

computer software that enables the user to create, modify delete and view the data in a database

Answer 97

Database management system (DBMS)

Question 98

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

Answer 98

Day procedure groups (DPG)

Question 99

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

Answer 99

Decentralization

Question 100

a subcategory of clinical information system designed to help health care providers make knowledge-based administrative or clinical decisions

Answer 100

Decision support system (DSS)

Question 101

data that have been stripped of elements that may readily identify a person

Answer 101

De-identified data

Question 102

personal data elements sufficient to identify an individual (i.e. name, address, date of birth)

Answer 102

Demographic data

Question 103

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

Answer 103

Dependent variable

Question 104

data that have been derived from other data elements using a mathematical, logical or other type of transformation

Answer 104

Derived data

Question 105

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)

Answer 105

Descriptive study

Question 106

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

Answer 106

Diagnostic and statistical manual of mental disorders (DSM)

Question 107

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.

Answer 107

Digital Imaging and Communications in Medical (DICOM)

Question 108

national CIHI database containing standard clinical, demographic and administrative data pertaining to each patient hospital discharge and some day surgery events

Answer 108

Discharge Abstract Database (DAD)

Question 109

the process of coordinating the activities related to the release of a patient when inpatient hospital care is no longer needed

Answer 109

Discharge planning

Question 110

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

Answer 110

Disclosure

Question 111

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

Answer 111

Double blind study

Question 112

a measure of the extent to which a specific intervention, treatment or service does what it is intended to do for a specific population

Answer 112

Effectiveness

Question 113

a measure of the extent to which a specific intervention treatment or service produces a beneficial result under ideal circumstances

Answer 113

Efficacy

Question 114

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

Answer 114

Efficiency

Question 115

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)

Answer 115

e-Health

Question 116

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

Answer 116

e-HIM

Question 117

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

Answer 117

Electronic authentication

Question 118

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

Answer 118

Electronic Document Management Systems (EDMS)

Question 119

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

Answer 119

Electronic Health Record (EHR)

Question 120

computer-based clinical data from an individual that are kept by a single physician office or practice, or community health centre

Answer 120

Electronic Medical Record (EMR)

Question 121

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)

Answer 121

Electronic Patient Record (EPR)

Question 122

the process of transforming text into codified data through logical pathways for the purpose of consistency and comparison

Answer 122

Encoding

Question 123

a health care contact who is responsible for diagnosing and treating the patient

Answer 123

Encounter

Question 124

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

Answer 124

Encryption

Question 125

an individual person, group or organization; a noun (person, place, thing, or event) about which data are to be stored

Answer 125

Entity

Question 126

a specific type of data modelling that uses graphical representations to depict the database components and their relationships

Answer 126

Entity relationship diagram (ERD)

Question 127

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

Answer 127

Epidemiology

Question 128

includes all health care treatment and expenditures surrounding a single admission within an acute care institution or day surgery unit

Answer 128

Episode of care

Question 129

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

Answer 129

Ethics

Question 130

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

Answer 130

Evidence

Question 131

health care services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies

Answer 131

Evidence-based medicine (EBM)

Question 132

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

Answer 132

Expected length of stay (ELOS)

Question 133

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)

Answer 133

Experimental study

Question 134

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

Answer 134

Expert systems (ES)

Question 135

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

Answer 135

Extended markup language (XML)

Question 136

a method of payment for physicians based on a fee schedule that itemizes each service and provides a fee for each service rendered

Answer 136

Fee-for-service

Question 137

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

Answer 137

Field

Question 138

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

Answer 138

Flow chart

Question 139

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

Answer 139

Focus group

Question 140

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

Answer 140

Force field analysis

Question 141

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

Answer 141

Foreign key

Question 142

the total market values of all final goods and services produced within a country in a given period of time

Answer 142

Gross domestic product (GDP)

Question 143

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

Answer 143

Grouping methodology

Question 144

a situation of cause of harm or damage that has caused or may cause an adverse effect

Answer 144

Hazard

Question 145

field of study; the interdisciplinary domain of theory and practice situated at the intersection of biomedicine, computing and the study of human behaviour

Answer 145

Health informatics (HI)

Question 146

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

Answer 146

Health information access layer (HIAL)

Question 147

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

Answer 147

Health information custodian

Question 148

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

Answer 148

Health information management (HIM)

Question 149

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

Answer 149

Health record

Question 150

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

Answer 150

Hearsay

Question 151

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

Answer 151

Home care reporting system (HCRS)

Question 152

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

Answer 152

Hospital morbidity database (HMDB)

Question 153

a health record that includes both paper and electronic components

Answer 153

Hybrid record

Question 154

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)

Answer 154

Identity fraud/theft

Question 155

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

Answer 155

Incidence rate

Question 156

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)

Answer 156

Incident report

Question 157

the characteristic being observed or measured that is hypothesized to influence another event (the dependent variable) within a study

Answer 157

Independent variable

Question 158

an organized list of specific data that serves to guide, indicate or otherwise facilitate reference to the data

Answer 158

Index

Question 159

a set of statistical techniques that allows researchers to make generalizations about a population’s characteristics on the basis of a sample’s characteristics

Answer 159

Inferential statistics

Question 160

the study of information and ways to process and handle information, especially by means of information technology

Answer 160

Informatics

Question 161

data that have been organized and process into meaningful form to make it valuable to the user

Answer 161

Information

Question 162

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

Answer 162

Information practices

Question 163

the system of persons, data records and activities that process the data and information in a given department or organization

Answer 163

Information system

Question 164

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)

Answer 164

Information technology (IT)

Question 165

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

Answer 165

Informed consent

Question 166

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

Answer 166

Infostructure

Question 167

represents the basic underlying physical framework of a system or structure

Answer 167

Infrastructure

Question 168

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

Answer 168

Inpatient

Question 169

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

Answer 169

Interface

Question 170

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

Answer 170

International classification for nursing practice (ICNPR)

Question 171

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

Answer 171

International Classification of Diseases (ICD)

Question 172

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

Answer 172

International Classification of Diseases for Oncology (ICD-O)

Question 173

classifies patient data and clinical activity in the primary care setting. Created in 1987, it is in its second edition

Answer 173

International Classification of Primary Care (ICPC)

Question 174

classification of health and health-related domains that describe body functions and structures, activities and participation

Answer 174

International Classification on Functioning, Disability and Health (ICF)

Question 175

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

Answer 175

Interoperability

Question 176

a clinical manipulation, treatment or therapy; a generic term used by researchers to mean an act of some kind

Answer 176

Intervention

Question 177

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

Answer 177

Jurisdiction

Question 178

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

Answer 178

Knowledge

Question 179

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

Answer 179

Knowledge-based systems

Question 180

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

Answer 180

Knowledge management

Question 181

a class of software that receives, processes and stores information generated by medical laboratory processes

Answer 181

Laboratory Information System (LIS)

Question 182

the management function of influencing employees to work toward achieving the set objectives; involves good leadership

Answer 182

Leading

Question 183

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

Answer 183

Learning Outcomes for Health Information Management (LOHIM)

Question 184

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

Answer 184

Legacy systems

Question 185

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

Answer 185

Logical Observation Identifier Names and Codes (LOINC)

Question 186

health care services provided in a non-acute care setting to chronically ill, aged, disabled or mentally handicapped individuals

Answer 186

Long-term care

Question 187

in the ____ system, methodology cases are grouped into 19 categories, or major Ambulatory Clusters, based on the main problem code assigned to each case

Answer 187

CACS (Comprehensive Ambulatory Classification System)

Question 188

19 categories of methodology cases or Ambulatory Clusters

Answer 188

Major ambulatory cluster (MAC)

Question 189

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)

Answer 189

Major clinical categories (MCC)

Question 190

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

Answer 190

Management information systems (MIS)

Question 191

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

Answer 191

Management information systems standards (MIS)

Question 192

a database relationship where multiple instances of an entity may be associated with multiple instances of another entity

Answer 192

Many-to-many relationship (M:N)

Question 193

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)

Answer 193

Master person index (MPI)

Question 194

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

Answer 194

Mean

Question 195

a controlled vocabulary of terms that have been developed by the National Library of Medicine to index the world medical literature

Answer 195

Medical Subject Headings (MeSH)

Question 196

Canada’s national health care program where Canadians receive hospital and physician services financed by the provinces through funding provided from the federal government

Answer 196

Medicare

Question 197

systems that assist organizations in prescribing, dispensing and administering medications

Answer 197

Medication administration systems

Question 198

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

Answer 198

Messaging standard

Question 199

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

Answer 199

Metadata

Question 200

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

Answer 200

Microfilming

Question 201

the representation of a theory in a visual format, on a smaller scale, or with objects

Answer 201

Mode

Question 202

the incidence or prevalence of a disease or of all disease in a population

Answer 202

Morbidity

Question 203

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

Answer 203

Morphology

Question 204

the number of deaths in a given population, usually expressed as a rate

Answer 204

Mortality

Question 205

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

Answer 205

Most responsible diagnosis (MRDx)

Question 206

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)

Answer 206

Multiaxial

Question 207

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

Answer 207

National Ambulatory Care Reporting System (NACRS)

Question 208

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

Answer 208

Natural language processing (NLP)

Question 209

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

Answer 209

Needs analysis/assessment

Question 210

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)

Answer 210

Nomenclature

Question 211

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

Answer 211

Nominal group technique (NGT)

Question 212

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

Answer 212

Null hypothesis

Question 213

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

Answer 213

Nursing informatics

Question 214

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

Answer 214

Object-oriented model

Question 215

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

Answer 215

Observational study

Question 216

a risk management technique in which the risk manager reviews the health records of current and discharged hospital inpatients with the events

Answer 216

Occurrence/generic screening

Question 217

a database relationship that exists when an instance of an entity is associated with multiple instances of another entity

Answer 217

One-to-many relationship (1:M)

Question 218

a database relationship that exists when an instance of an entity is associated with only one instance of another entity, and vice versa

Answer 218

One-to-one relationship (1:1)

Question 219

a data access architecture that allows that user to retrieve specific information from a large volume of data

Answer 219

Online analytical processing (OLAP)

Question 220

the real-time processing of day-to-day business transactions from a concepts

Answer 220

Online transaction processing

Question 221

a formal representation of a set of concepts within a domain and the relationships between those concepts

Answer 221

Ontology

Question 222

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

Answer 222

Open systems interconnections (OSI)

Question 223

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

Answer 223

Organizing

Question 224

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

Answer 224

Other health professionals

Question 225

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

Answer 225

Outcomes management

Question 226

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

Answer 226

Outcomes measurement

Question 227

a patient admitted to a hospital, clinic or other health care facility for treatment that does not require an overnight stay

Answer 227

Outpatient

Question 228

a bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems or solutions

Answer 228

Pareto chart

Question 229

the principle that 20% of the sources of the problem are responsible for 80% of the actual problems

Answer 229

Pareto principle

Question 230

a qualitative research method in which the researcher or observer is (or pretends to be) a member of the group being studied

Answer 230

Participant observation

Question 231

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

Answer 231

Peer review

Question 232

the continuous study and adaptation of a health care organization’s functions and processes to increase the likelihood of achieving desired outcomes

Answer 232

Performance improvement

Question 233

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

Answer 233

Performance indicators

Question 234

the process of comparing the outcomes of an organization against pre-established performance plans and standards

Answer 234

Performance measurement

Question 235

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

Answer 235

Personal health information

Question 236

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

Answer 236

Personal health record (PHR)

Question 237

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

Answer 237

Picture archiving and communications system (PACS)

Question 238

an inert medication or procedure (i.e. it has no effect) that is intended to make subjects feel as though they are receiving treatment

Answer 238

Placebo

Question 239

an examination of the future and subsequent preparation of action plans to attain goals; one of four traditional management functions

Answer 239

Planning

Question 240

the location where a health care service is provided (i.e. patient’s bedside or home)

Answer 240

Point of care

Question 241

a written plan of action to guide decisions and achieve outcomes; either the department or organization determines how to handle a specific situation

Answer 241

Policy

Question 242

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

Answer 242

Population

Question 243

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

Answer 243

Population health

Question 244

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)

Answer 244

Potentially compensable event

Question 245

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

Answer 245

Precision

Question 246

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

Answer 246

Prevalence

Question 247

the first or primary source of assistance for problems with health; usually the family physician or general practitioner, but may be another health professional

Answer 247

Primary health care

Question 248

an attribute that is a unique identifier of each record/row in a database table

Answer 248

Primary key

Question 249

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

Answer 249

Privacy

Question 250

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

Answer 250

Procedures

Question 251

a temporary undertaking to create a unique product or service; has defined start and end points and specific objectives that, when attained, signify completion

Answer 251

Project

Question 252

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

Answer 252

Project charter

Question 253

the application of knowledge, skills, tools and techniques to project activities to meet or exceed stakeholders’ needs and expectations

Answer 253

Project management

Question 254

a type of ratio in which the numerator is included in the denominator and therefor the value is dimensionless

Answer 254

Proportion

Question 255

a study that follows subjects forward in time

Answer 255

Prospective study

Question 256

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)

Answer 256

Protocol-based system

Question 257

a system of digital certificates and other registration authorities that verify and authenticate the validity of each party involved in a secure transaction

Answer 257

Public key infrastructure (PKI)

Question 258

a review of the health record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care

Answer 258

Qualitative analysis

Question 259

a research record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care

Answer 259

Qualitative research record

Question 260

a research record to ensure that standards are met and to determine the adequacy of entries documenting the quality of care

Answer 260

Qualitative research record

Question 261

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)

Answer 261

Qualitative research

Question 262

a set of activities designed to measure the quality of service, product, or process with remedial action, as needed, to maintain a desired standard

Answer 262

Quality assurance (QA)

Question 263

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

Answer 263

Quality improvement (QI)

Question 264

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

Answer 264

Quality management (QM)

Question 265

a review of the health record to determine completeness and accuracy

Answer 265

Quantitative analysis

Question 266

a research methodology that uses numerical measures to explore group characteristics or behaviour (i.e. case-control or cohort studies, randomized control trials)

Answer 266

Quantitative research

Question 267

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)

Answer 267

Questionnaire

Question 268

used radiology departments to store, manipulate and distribute patient radiological data and imagery

Answer 268

Radiology information systems (RIS)

Question 269

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

Answer 269

Random sample

Question 270

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

Answer 270

Randomized control trial (RCT)

Question 271

the difference between the largest and smallest values in a distribution

Answer 271

Range

Question 272

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

Answer 272

Rate

Question 273

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)

Answer 273

Ratio

Question 274

the process by which records are retained in a secure fashion until they are no longer required

Answer 274

Records hold

Question 275

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

Answer 275

Reference information model (RIM)

Question 276

provision of long-term care services to patients recovering from chronic illness or debilitating injuries where the stay often lasts several months

Answer 276

Rehabilitative care

Question 277

a database that represents data as a collection of tables in which all data relationships are represented by common values in related tables

Answer 277

Relational database

Question 278

the disclosure of documents containing personal health information to a third party

Answer 278

Release of information

Question 279

the degree to which the results obtained by a measurement or procedure can be replicated

Answer 279

Reliability

Question 280

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

Answer 280

Request for information (RFI)

Question 281

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

Answer 281

Request for proposal (RFP)

Question 282

an essential practice that evidence and consultation have determined an organization must have in place to enhance patient/client safety and to minimize risk

Answer 282

Required organizational practices (ROPs)

Question 283

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

Answer 283

Research design

Question 284

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

Answer 284

Retention

Question 285

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)

Answer 285

Retrospective study

Question 286

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

Answer 286

Risk

Question 287

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

Answer 287

Risk analysis/assessment

Question 288

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

Answer 288

Risk communication

Question 289

actions taken to prevent, eliminate or avoid risk from the facility’s perspective

Answer 289

Risk control

Question 290

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

Answer 290

Risk evaluation

Question 291

a process undertaken to identify potential agents, persons, policies or scenarios capable of causing, or known to cause, adverse effects or events

Answer 291

Risk identification

Question 292

the processes undertaken to identify, control and minimize the impact of uncertain events, with the objective of reducing risk

Answer 292

Risk management

Question 293

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)

Answer 293

Sample

Question 294

systematic error due to study of a non-random sample of a population

Answer 294

Sampling bias

Question 295

the amount of effort, materials and resources needed to produce project deliverables

Answer 295

Scope

Question 296

the growth of the scope of a project while it is in progress, virtually guaranteeing that it will be over budget and behind schedule

Answer 296

Scope creep

Question 297

care provided by a specialist. Patients are usually referred to a secondary health provider by the primary health provider

Answer 297

Secondary health care

Question 298

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

Answer 298

Security

Question 299

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

Answer 299

Selection bias

Question 300

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

Answer 300

Semantic interoperability

Question 301

an unexpected occurrence usually resulting in death or serious injury

Answer 301

Sentinel event

Question 302

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)

Answer 302

Statistical significance

Question 303

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

Answer 303

Spoliation

Question 304

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

Answer 304

Standard

Question 305

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

Answer 305

Standard deviation

Question 306

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

Answer 306

Statistical test

Question 307

a communication tool that visually tells the story when you need to explain an idea or process

Answer 307

Story boarding

Question 308

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

Answer 308

Strategic plan

Question 309

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

Answer 309

Stratified randomization

Question 310

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

Answer 310

Structured data entry (SDE)

Question 311

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

Answer 311

Structured query language (SQL)

Question 312

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

Answer 312

Substitute decision maker

Question 313

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

Answer 313

Survey

Question 314

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

Answer 314

SWOT analysis

Question 315

a set of related and highly interdependent components that are operating for a particular purpose

Answer 315

System

Question 316

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

Answer 316

Systematic review

Question 317

comprehensive clinical health care terminology; provides a formal representation of concepts, terms and relations between concepts in the medical domain

Answer 317

Systematized Nomenclature of Medicine (SNOMED)

Question 318

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

Answer 318

Systematized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)

Question 319

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

Answer 319

Systems administrator

Question 320

traces the history (life cycle) of an information system; the traditional methodology used to develop, maintain and replace information systems

Answer 320

Systems development life cycle (SDLC)

Question 321

a telecommunications system that links health care organizations and patients from diverse geographic locations and transmits information for consultation and treatment

Answer 321

Telehealth

Question 322

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

Answer 322

Terminal digit

Question 323

terms belonging to a specialized subject; nomenclature, specific and consists of a single unique name of each entity

Answer 323

Terminology

Question 324

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

Answer 324

Tertiary health care

Question 325

a process used by organizations when implementing new technologies to ensure systems work together as they should

Answer 325

Test end-to-end

Question 326

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)

Answer 326

Topography

Question 327

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

Answer 327

Total quality management (TQM)

Question 328

a database that processes data or records in real-time

Answer 328

Trasaction-oriented/transactional database

Question 329

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

Answer 329

Transmission

Question 330

all kinds of non-hierarchical relationships that can exist between two concepts

Answer 330

Transverse relationships

Question 331

a study in which the subjects, observers and analysts are blinded as to which subjects receive which interventions

Answer 331

Triple blind study

Question 332

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.

Answer 332

Unified medical language system (UMLS)

Question 333

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

Answer 333

Metathesaurus

Question 334

general-purpose modelling language that includes a graphical notation used to create an abstract model of a system

Answer 334

Unified modelling language (UML)

Question 335

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

Answer 335

Unique identifier

Question 336

the process of evaluating the necessity, appropriateness and efficiency of health care services to ensure quality of patient care

Answer 336

Utilization management (UM)

Question 337

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

Answer 337

Utilization review (UR)

Question 338

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

Answer 338

Validity

Question 339

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)

Answer 339

Variable

Question 340

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

Answer 340

Voice recognition system

Question 341

the intelligence that gives individuals the empowerment and courage to act; the trait of utilizing knowledge and experience with common sense and insight

Answer 341

Wisdom

Question 342

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)

Answer 342

Work breakdown structure (WBS)