EHR Terms

Question 1

Center for Medicare & Medicaid Services (CMS)

Answer 1

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).

Question 2

Joint Commission

Answer 2

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

Question 3

Health Information Management Systems Society (HIMSS)

Answer 3

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.

Question 4

KLAS

Answer 4

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.

Question 5

Meaningful Use

Answer 5

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.

Question 6

Healthcare Reform

Answer 6

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.

Question 7

Electronic Health Records

Answer 7

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.

Question 8

Standard Nomenclature (Standard Medical Vocabularies)

Answer 8

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.

Question 9

Classification Systems

Answer 9

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.

Question 10

Interoperability

Answer 10

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.

Question 11

Health Level Seven (HL7)

Answer 11

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.

Question 12

Continuity of Care Document

Answer 12

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.

Question 13

FHIR

Answer 13

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.

Question 14

Direct Messaging

Answer 14

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.

Question 15

Clinical Decision Support

Answer 15

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.

Question 16

Evidence Based Medicine or Evidence Based Guidance

Answer 16

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.

Question 17

Order Sets (Evidence Based Order Sets)

Answer 17

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.

Question 18

The power of CDS and EBG

Answer 18

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.

Question 19

Surveillance

Answer 19

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.

Question 20

Computerized Physician Order Entry (CPOE)

Answer 20

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.

Question 21

e-Prescribing

Answer 21

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.

Question 22

Medication​ ​Administration​ ​Record​ ​(MAR)

Answer 22

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

Question 23

Medication Reconciliation

Answer 23

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.

Question 24

Closing the Medication Loop

Answer 24

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.

Question 25

Clinician

Answer 25

A clinician is a health professional who is directly involved with patient care such as a physician, psychologist, nurse, respiratory or physical therapist etc. A physician is a clinician, but not all clinicians are physicians

Question 26

Provider

Answer 26

A term reserved for Physicians, Physician Assistants, and Nurse Practitioners (the people who can initiate care for a patient ) and in some cases the term can be broadened to include caregivers (all (nurses and doctors) and care settings (Hospital, Physician Practice, Home Care etc).

Question 27

Care Continuum

Answer 27

Refers to the range of medical services and care settings including acute care in an inpatient setting or hospital, rehabilitative care in a rehab setting, home care, care in a physician practice, oncology care, behavioral health care, etc.

Question 28

Care Coordination

Answer 28

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.

Question 29

IDN (Integrated Delivery Network)

Answer 29

a network of healthcare organizations under a parent holding company. IDS is not to be confused with software or and integrated EHR. They provide patient care in a number of settings (hospitals and physician practices and home health agencies …) under one corporate umbrella. The different hospital campuses or physician practices under this corporate umbrella may or may not be using the same EHR system.

Question 30

ACO (Accountable Care Organization)

Answer 30

a healthcare model whose payments for providing patient care are tied to quality metrics. CMS and other third party payers will sponsor ACOs. The third party payer will identify a number of quality metrics and care coordination strategies as part of their ACO model. Healthcare organizations who voluntarily participate in these ACO models will share in the third party cost savings.

Question 31

HIE (Health Information Exchange)

Answer 31

a voluntary participation of healthcare organizations that join together for the purpose of sharing patient information electronically. Typically formed by healthcare organization that are in a geographical area and have the potential to share patients. Can also be used in the healthcare industry as a verb as opposed to a noun.

Question 32

Population Health

Answer 32

One characteristic of Population Health is that the definition can vary depending on who you ask. Healthcare organizations have varying definitions and ways of deploying population health efforts to match their definitions. What is common among these definitions are a focus on some aspect of patient outcomes, on accountability of care, and measurement of care for the population of patients assigned to a particular healthcare organization or physician practice.