EHR Terms Flashcards
Center for Medicare & Medicaid Services (CMS)
a federal government agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children’s Health Insurance Program (CHIP), and health insurance portability standards (HIPAA).
Joint Commission
An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
Federal deemed status
Health Information Management Systems Society (HIMSS)
A global, private and not-for-profit organization focused on better health through information and technology. HIMSS leads efforts to optimize health engagements and care outcomes using information and technology.
KLAS
A Utah Based Health Informatics research company that “helps healthcare providers make informed technology decisions by offering accurate, honest, and impartial vendor performance information. The company has been collecting ratings on healthcare industry software since 1997. MEITECH has received several KLAS Software and Service awards, the most recent being in 2017.
Meaningful Use
In 2009 the Center for Medicare Medicaid Services as part of the American Recovery and Reinvestment Act (ARRA) put forth legislation called “Meaningful Use”. The intention of this legislation was to bring about the rapid adoption and “meaningful use” of Electronic Health Records for Hospitals and Physician Practices.
Healthcare Reform
In 2010 CMS further extended their goal to improve healthcare in the United States by putting forth Health Care Reform Legislation. There are many aspects of of this legislation but the aspects of interest to us an EHR vendor are the aspects that looks at different ways of paying hospitals and physician by tying their Medicare reimbursement to quality performance metrics. The goal with this aspect of reform is to make healthcare more efficient, less costly, and improve the overall quality of patient care.
Electronic Health Records
EHRs are real-time, patient-centered records - they make patient information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, today’s sophisticated EHRs are built to go beyond clinical data collected in a provider’s office or acute care setting. EHRs are designed to enhance the safety and quality of care by delivering advanced *evidence based guidance and *clinical decision support into the workflow of *providers, nurses, and other *clinicians responsible for caring for the patient.
Standard Nomenclature (Standard Medical Vocabularies)
In order to link patient data and share health information between different healthcare organization using different EHR systems, EHRs require the use of uniform health information standards, including common medical language. Patient data must be collected and maintained in a standardized format, using uniform definitions. Standard clinical terminologies and classifications represent a common medical language, allowing clinical data to be effectively utilized and shared between different EHR systems.
Classification Systems
Classification systems represent combinations of clinical information for use in reimbursement or regulatory reporting. Classification systems are also intended for secondary data uses, including measurement of quality of care, statistical and public health reporting, operational and strategic planning, and other administrative functions. Ex: ICD-10 and a DRG.
Interoperability
Describes the extent to which disparate information systems and medical devices can exchange and interpret data. For two systems to be interoperable, they must be able to exchange data so that it can be understood by a user. EHR systems must be able to both share and consume patient information so that the information is up-to-date and relevant.
Health Level Seven (HL7)
A not for profit organization involved in the development of international health interoperability standards. HL7 for over 20 years has provided a framework of standards for the exchange and sharing of patient health information and the exchange of information from healthcare technology infrastures like heart monitors, and laboratory instruments back to the EHR.
Continuity of Care Document
An electronic document of patient information created by an EHR that can be shared so that patient care is improved. One of the most common CCDs is the Summary which contains information like patient problems, diagnosis, allergies and current medications. This CCD can be shared across EHRs to facilitate patient care making sure that all care providers have a comprehensive up-to-date information on their patient.
FHIR
Is the latest standard to be developed under HL7 for exchanging patient healthcare information. It’s a more granular way to exchange patient data as opposed to CCD Summaries. With FHIR standards providers will be able to request more discreet pieces of patient information.
Direct Messaging
Direct is a national encryption standard for securely exchanging patient healthcare data via the Internet. It is also known as the Direct Project, Direct Exchange and Direct Secure Messaging. Part of Stage 2 Meaningful Use Requirements.
Clinical Decision Support
A simple example would be the EHR providing patient allergy information to a physician while they are ordering medication for a patient or for providing a nurse with recent patient lab test results prior to administering a medication to the patient. CDS ensure that clinical information is provided to make sure that care for the patient is safe and appropriate. CDS can become more complex as patients present with more and more history.
Evidence Based Medicine or Evidence Based Guidance
The use of scientifically based information in healthcare decision-making. An example would be the EHR system providing and evidence based order set to a physician based on the patient’s presenting symptoms or diagnosis.
Order Sets (Evidence Based Order Sets)
An order set allows providers to electronically enter patient orders using predefined groups of tests, procedures, and medications that apply to a specified diagnosis or presenting symptom. Order sets should be based on the latest evidence so that patient outcomes are optimal. An evidence based order set ensures that in light of a patient symptoms or a diagnosis, the most appropriate testing, procedures, medications and care plans are ordered for that patient.
The power of CDS and EBG
Clinical Decision Support and Evidence Based Guidance together orchestrate for safe patient care with the best outcomes. Evidence based guidelines that are effective for a general diagnosis may not be in the best interest of a particular patient.
Surveillance
Broadly speaking for our training purposes , clinical surveillance is the process of the EHR providing real time review of patient data for purposes of identifying opportunities to improve patient care and identify situations before they can compromise patient safety. With clinical surveillance, nurses and physicians have the potential to minimize negative outcomes by being alerted (via the EHR) that a patient has early signs for being at risk for a situation that could compromise their safety or outcome.
Computerized Physician Order Entry (CPOE)
Is the process in which Physicians, Physician Assistants or Nurse Practitioner will use an EHR to enter patient’s orders for medications, tests, procedures and care plans, as opposed to handwriting these orders n paper or verbalizing these orders to a nurse. Clinical Decision Support and Evidence Based Guidance will flow into the hands of these providers to sure the safest and most effective care orders are being used. Certified EHR systems are required to have CPOE functionality.
e-Prescribing
e-Prescribing is a component of CPOE - it’s the process whereby providers (who are legally entitled to initiate patient orders) can order error-free prescriptions electronically to a retail or mail-order pharmacy. CDS and EBG also play a role within the e-Prescribing process to ensure the patient is prescribed the best medication according to evidence.
Medication Administration Record (MAR)
a legally binding document maintained in every hospital which documents the administration of medications to patients; each patient has there own MAR which is utilized by the nursing staff. When the MAR is electronic it is known as an eMAR
Medication Reconciliation
A process of identifying at any time in the patient care cycle, the most accurate list of of medications for that patient. An EHR system will help record medication history and use that history for conflict checking and drug interactions.
Closing the Medication Loop
This is a concept in which the safety of medication administration is considered for inpatient care. The medication loop begins when the provider places an order for a medication electronically, evidence based guidance and clinical decision support confirms this is both a good medication for the patient’s condition and that there are no contraindications, the nurse then administers the medication with the use of bar-code technology to ensure it is the right patient, the right medication, being administered at the right time, at the right dose.
