DPRC Vocabulary Flashcards
Formulary
Subset of drugs physicians can order that organization decides
EDI
Electronic data interchange (EDI)
-capability to send transactions to clearing houses, which send them on to payers
Document Imaging
4
PACS
Picture archiving and communication system
-stores x-ray, CAT scan, ultrasound, and other types of medical images
-allows clinicians to view the images on a computer screen
High-end computer screens associated with PACS systems allow for diagnostic-quality images to be interpreted by qualified personnel, thus eliminating the need for film in most cases
RIS
Radiology information system
- divisions include patient scheduling, result reporting, and image tracking
- Stores, organizes, and distributes patient radiological data, such as a report of the interpretation by radiologist of an x-ray
Materials Management
- supports the procurement of capital equipment (CAT scans, hospital beds, and dialysis machines) and operational supplies (bandages, linen, and office supplies) and inventory functions associated with supplies
- automates parts of the purchasing, ordering, shipping, and storage processes
General Ledger
- generates income and statement and balance sheets
- what money is coming in and going out
- every business must have one
LIS
Laboratory information system
- divisions include chemistry, hematology, microbiology, and toxicology
- process orders for clinical laboratory services or tests
- connects with laboratory machines so measurements of patients specimens are automatically transferred to LIS and on to the HIS where they are made available to clinicians
Utilization Review
8
HIS
Health information system
- a computer based system that holds and updates patient-related information and records
- has a 2 folded purpose
- ——-1. support direct clinical care
- ——-2. support the management and administration related to such care
HIT
Healthcare information technology
ADT
Admission,discharge, and transfer (ADT)
- called the hotel function of healthcare information systems
(admit) –allows staff to admit patients to a healthcare facility and a specific unit or bed within the facility
(transfer) –move the patient within the facility or across facilities within the enterprise
(discharge) —-discharge the patient from the facility - -has census capability
- –listing of patients in a clinical unit
- –used to “select” a patient record
- has notification and Interface capability
EBM
Evidence-Based Medicine
….Use of Standard and Best Practice
-ensures that diagnostiic and therapeutic services represent “best practice”
-reduces variation and error
—examples
—-using order sets to ensure medication standard is used for stroke treatment in ED
—-Use of surgery check-lists
——prevent wrong patient and wrong site events
——ensure antibiotics given prior to surgery
—-Use of alerts and reminders for
—–preventative services for chronic diseases
—–pediatric vaccinations
AR
Accounts Receivable
—collections management
BCMA
Bar-code medication administration
-also known as barcode point of care (BPOC) and electronic medication administration record (eMAR)
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Centralized HIS
one vendor provides most or all of the divisions or modules of the healthcare information system
Best of Breed
- one HIS provides several of the administrative functions and possibly clinical or financial functions, but with a significant number of additional modules from different vendors.
- requires interfacing between vendor products to enable smooth functioning of the system as a whole
E-Prescribing
an extension of CPOE for medications generally used in outpatient settings
- -physicians or other prescribers use the EHR to “write” a prescription
- -safety checks are made by the EHR at the time of writing
- -the module can print out the prescription and educational material
- -the prescription is usually sent immediately and electronically to the patient’s pharmacy of choice
- -the pharmacist can fill it without having to try to decipher potentially poor provider handwriting
CDS
Clinical Decision Support
- -system uses EMR data to generate alerts and reminders to clinicians and care providers
- –examples
- —-system generates alerts during CPOE and E-Prescribing
- —-system generates alert during radiology procedure that patient is allergic to dye
- —-during outpatient visit, system generates a list that patient needs pneumonia vaccination
- —-for chromic disease management, system generates a list of diabetic patients who have not a retinal exam in the last two years
MPI module
a database within an HIS containing unique patient identification codes for all the patients in a healthcare system
EMPI
Enterprise Master Patient Index
- used when there are multiple systems each with its own MPI
- –uses query and response
- –local registration system uses EMPI to determine if patient already exists in system
Medication Reconcilitation
Prevents errors by comparing medications orders to medications patient has been taking
- –done at all transition: ADT
- –avoids medication errors like omissions of medications and duplicate medications
EMR
Electronic Medical Record
-a digital patient record used within a single care setting or environment
EHR
Electronic Health Record
-a digital patient record that can be used across more than one healthcare organization
Lifelong patient record
a health record that is with the patient for life
PHR
Electronic or digital personal health record
-this may contain the information a person wishes to maintain for private use without the information being accessible to any HIS
iEHR
both the patient and doctor have access to the patient record. Also known as a hybird.
bio-surveillance
Public health experts who track communicable diseases through EHRs
DRG
Diagnostic-related group (DRG) coding
–DRG coding modules assist medical record and other personnel to properly categorize a diagnosis that a patient has so that the organization can get reimbursed from the insurance companies or other payers.
POE
Provider (or physician) order entry (POE)
- providers directly enter orders for medication and often other tests or services into the POE system
- also know as computerized provider (or physician) order entry (CPOE)
- basic POE enables legible, standardized, complete orders this markedly reduces to eliminates errors due to poor handwriting, ambiguous abbreviations, or incomplete orders.
- more sophisticated POE
- -performs drug allergy checks, drug-laboratory value checks, drug-drug interaction checks, and so on which reduces not only medical errors of commission but also of omission.
Clinical docmentation
- allows clinicians to document or chart information about the patient usually immediately following an encounter
- can include history and physical, nursing shift assessment, respiratory care assessment patient plans of care etc.
CDM
Charge Description Management
Pharmacy
- receives, and process medication orders
- has features such as pharmacy billing, inventory management, generation of medication labels, fills lists, patients profiles, and support for clinical pharmacy activities such as advanced drug information for pharmacists
- has tight intergration with provider order entry and clinical decision support systems or modules
