HIT-001 Chapter 4 Flashcards
1
Q
__Acceptance testing
A
Final review during EHR implementation to ensure that all tests have been performed and all issues have been resolved; usually triggers the final payment for the system and when a maintenance contract becomes effective.
2
Q
Access control
A
- A computer software program designed to prevent unauthorized use of an information resource. 2. The process of designing, implementing, and monitoring a system for guaranteeing that only individuals with a legitimate need are allowed to view or amend specific data sets.
3
Q
Accredited Standards Committee X12N (ASC X12N)
A
A committee of the National Standards Institute that develops and maintains standards for the electronic exchange of business transactions, such as 837–Health Care Claim, 835–Health Care Claim Payment/Advice, and others.
4
Q
Admissibility
A
The condition of being admitted into evidence in a court of law.
5
Q
American National Standards Institute (ANSI)
A
The organization that accredits all U.S. standards development organizations to ensure that they are following due process in promulgating standards.
6
Q
American Recovery and Reinvestment Act of 2009 (ARRA)
A
Previously known as the “stimulus bill” or HR 1. The actions related to health information technology are spread throughout the law; however, the bulk of the items are in Title XIII–Health Information Technology; also called Health Information Technology for Economic and Clinical Health Act of HITECH.
7
Q
Ancillary systems
A
Electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on).
8
Q
Architecture
A
The configuration, structure, and relationships of hardware (the machinery of the computer including input/output devices, storage devices, and so on) in an information system.
9
Q
ASTM International
A
Formerly known as the American Society for Testing and Materials, a system of standards developed primarily for various EHR management processes.
10
Q
Audit log ( audit trail)
A
A chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) that is used to determine security violations.
11
Q
Authentication
A
- The process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature. 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source.
12
Q
Barcode medication administration record (BC-MAR)
A
Systems that identify the right patient and right drug to be given at the right time, in the right dose, and via the right route.
13
Q
Best of breed
A
A vendor strategy used when purchasing an EHR that refers to systems applications that are considered the best in their class.
14
Q
Best of fit
A
A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vender.
15
Q
Chart conversion
A
An EHR implementation activity in which data from the paper chart are converted into electronic form
16
Q
Client/server architecture
A
A computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amounts of shared data.
17
Q
Clinical data repository (CDR)
A
A central database that focuses on clinical information.
18
Q
Clinical data warehouse (CDW)
A
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface.
19
Q
Clinical decision support (CDS)
A
The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts.
20
Q
Clinical Document Architecture (CDA)
A
HL7 electronic exchange model for clinical documents (such as discharge summaries and progress notes).
21
Q
Clinical information system (CIS)
A
A category of a healthcare information system that includes systems that directly support patient care.
22
Q
Clinician
A
A healthcare provider, including physicians and others who treat patients.
23
Q
Computer output to laser disk/enterprise report management (COLD/ERM)
A
Technology that electronically stores documents and distributes them with fax, e-mail, Web, and traditional hard-copy print processes.
24
Q
Computerized provider order entry (CPOE)
A
Systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindications, or other clinical decision support.
25
Consent directive
A process by which patients may opt in or opt out of having their data exchanged in the HIE
26
Contextual
The condition of depending on the parts of a written or spoken statement that precede or follow a specified word or phrase and can influence its meaning or effect.
27
Continuity of care record (CCR)
Documentation of care delivery from one healthcare experience to another.
28
Controlled vocabulary
A predefined set of terms and their meanings that may be used in structured data entry or natural language processing to represent expressions.
29
Data availability
The extent to which healthcare data are accessible whenever and wherever they are needed.
30
Data comparability
The standardization of vocabulary such that the meaning of a single terms is the same each time the term is used in order to produce consistency in information derived from the data.
31
Data conversion
The task of moving data from one data structure to another, usually at the time of a new system installation.
32
Data dictionary
A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology.
33
Data exchange standards
Protocols that help ensure that data transmitted from one system to another remain comparable.
34
Data integrity
1. The extent to which healthcare data are complete, accurate, consistent, and timely. 2. A security principle that keeps information from being modified or otherwise corrupted either maliciously or accidentally.
35
Data set
A list of recommended data elements with uniform definitions that are relevant for a particular use.
36
Database
An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.
37
Database management system (DBMS)
Computer software that enables the user to create, modify, delete, and view the data in a database.
38
Digital dictation
A process in which vocal sounds are converted to bits and stored on computer for random access.
39
Digital images
Data provided in a computer-readable format.
40
Digital Imaging and Communication in Medicine (DICOM)
A standard that promotes a digital image communications format and picture archive and communications systems for use with digital images.
41
Discrete data
Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values.
42
Disease management (DM)
1. A more expansive view of case management in which patients with the highest risk of incurring high-cost interventions are targeted for standardizing and managing care throughout integrated delivery systems. 2. A program focused on preventing exacerbation of chronic diseases and on promoting healthier life styles for patients and clients with chronic diseases.
43
Document imaging
The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed.
44
Dual core (vender strategy)
A vendor strategy in which one vendor primarily supplies the financial and administrative applications and another vendor primarily supplies the clinical applications.
45
Electronic data interchange (EDI)
A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations.
46
Electronic document/content management (ED/CM)
A type of electronic document management system that uses methods such as bar coding on the forms to identify specific content.
47
Electronic document management system (EDMS)
A storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that care be stored electronically on optical disks.
48
Electronic medication administration record (EMAR)
A system designed to prevent medication errors by checking a patient's medication information against his or her bar coded wristband.
49
Electronic (enterprise) report management (ERM)
Systems that capture data from print files and other report-formatted digital documents, such as e-mail, e-fax, instant messages, Web pages, digital dictation, and speech recognition and store them for subsequent viewing.
50
Electronic signature authentication (ESA)
A system that requires the author of a document to sign onto a patient record using a user ID and password, reviews the document to be signed, and indicates approval.
51
Encoded
Converted into code.
52
Encryption
The process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination.
53
e-Prescribing
Enables prescriptions to be checked for drug contraindications and sent directly to a retail pharmacy of the patient's choosing.
54
Ethernet
A popular protocol (format) for transmitting data in local area networks.
55
Evidence-based medicine
Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies.
56
Extensible markup language (XML)
A standardized computer language that allows the interchange of data as structured text.
57
Extranet
A system of connections of private Internet networks outside an organization's firewall that uses Internet technology to enable collaborative applications among enterprises.
58
Health information exchange (HIE)
A plan in which health information is shared among providers.
59
Health information exchange organization (HIEO)
An organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards.
60
Health information technology (HIT)
The technical aspects of processing health data and records, including classification and coding, abstracting, registry development, storage, and so on.
61
Health Information Technology for Economic and Clinical Health (HITECH) Act
The part of ARRA that is meant to increase the momentum of developing and implementing the EHR by 2014.
62
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information. The act limits exclusion for preexisting medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size of employers.
63
Health Level Seven (HL7)
A standards development organization accredited by the American National Standards Institute that addresses issues at the seventh, or application, level of healthcare systems interconnections.
64
Hospital information system (HIS)
The comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital.
65
Hospitalist
Physician employed by teaching hospitals to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs.
66
Human-computer interface
The device used by humans to access and enter data into a computer system, such as a keyboard on a PC, personal digital assistant, voice recognition system, and so on.
67
Identity matching algorithm
Process used to identify any patient for whom data are to be exchanged.
68
Institute of Medicine (IOM)
A branch of the National Academy of Sciences whose goal is to advance the distribute scientific knowledge with the mission of improving human health.
69
Integrating testing
A form of testing during EHR implementation performed to ensure that the interfaces between applications and systems work.
70
Interface
The zone between different computer systems across which users want to pass information (for example, a computer program written to exchange information between systems or the graphic display of an application program designed to make the program easier to use).
71
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
A classification system used in the United States to report morbidity and mortality information.
72
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
The planned replacement for ICD-9-CM, volumes 1 and 2, developed to contain more codes and allow greater specificity.
73
International Health Terminology Standards Development Organization
A company based in Denmark that is responsible for maintaining SNOMED International (formerly known as the Systematized Nomenclature of Human and Veterinary Medicine), a method for encoding data variables when physicians enter data into a history and physical exam template.
74
Interoperability
The ability, generally by adoption of standards, or systems to work together.
75
Intranet
A private information network that is similar to the Internet and whose servers are located inside a firewall or security barrier so that the general public cannot gain access to information housed within the network.
76
Issues management
The process of resolving unexpected occurrences (for example, the late delivery of needed supplies or an uncorrected system problem).
77
Knowledge database
A database that not only manages raw data but also integrates them with information from various reference works.
78
Local area network (LAN)
A network that connects multiple computer devices via continuous cable within a relatively small geographic area.
79
Logical Observations, Identifiers, Names and Codes (LOINC)
A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research.
80
Meaningful use
Term used in the ARRA/HITECH legislation for providers to quality for incentives for using EHR. There are three types of requirements: 1. Use of certified EHR technology in a meaningful manner (for example, electronic prescribing); 2. that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and 3. that, in using certified EHR technology, the provider submits information on clinical quality measures.
81
Medicare Modernization Act of 2003 (MMA)
Legislation passed in 2003 designed to expand healthcare services for seniors, with a major focus on prescription drug benefits.
82
Medication reconciliation
Process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to intensive care unit (ICU).
83
Message format standards
Protocols that help ensure that data transmitted from one system to another remain comparable.
84
Metadata
Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information.
85
Migration path
A series of steps required to move from one situation to another.
86
Mirrored processing
The act of entering data into a primary and a secondary server simultaneously so that the second server can continue to process the data in the event the primary server crashes.
87
National Alliance for Health Information Technology (NAHIT)
A partnership of government and private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, and operating performance; founded in 2002.
88
National Council for Prescription Drug Programs (NCPDP)
An organization that develops standards for exchanging prescription and payment information
89
National Drug Codes (NDC)
Codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected over-the-counter products.
90
National health information infrastructure (NHII)
An infrastructure proposed by the National Committee on Vital and Health Statistics in 2002 that would be a set of technologies, standards, applications, systems, values, and laws that support all facets of provider healthcare, individual health, and public health; also called a national health information network.
91
National Library of Medicine (NLM)
The world's largest medical library and a branch of the National Institutes of Health.
92
Nationwide health information network (NHIN)
System that links various healthcare information systems together, allowing patients, physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely.
93
Natural language processing (NLP)
A field of computer science and linguistics concerned with the interactions between computers and human (natural) languages that converts information from computer databases into readable human language.
94
Office of the National Coordinator (ONC) for Health Information Technology
Office that provides leadership for the development and implementation of an interoperable health information technology infrastructure nationwide to improve healthcare quality and delivery.
95
Opt-in/opt-out
Patients' choices for having their data exchanged in the HIE.
96
Pay for performance (P4P)
A type of incentive to improve clinical performance using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts.
97
Pay for quality (P4Q)
A type of incentive to improve the quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts.
98
Personal digital assistant (PDA)
A hand-held microcomputer, without a hard drive, that is capable of running applications such as e-mail and providing access to data and information, such as notes, phone lists, schedules, and laboratory results, primarily through a pen device.
99
Pharmacy benefits manager (PBM)
The vendor selected by the Bureau of Workers' Compensation to process outpatient medication bills submitted electronically.
100
Picture archiving and communications system (PACS)
An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images).
101
Point of care (POC)
The place or location where the physician administers services to the patient.
102
Point-of-care charting
A system whereby information is entered into the health record at the time and location of service.
103
Portals
Special Web pages that offer secure access and entry of data upon authorization of the owner of the page.
104
Practice guidelines
Protocols of care that guide the clinical care process.
105
Practice management system (PMS)
Software designed to help medical practices run more smoothly and efficiently.
106
Primary care physican (PCP)
1. The physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a manages care plan. 2. The physician who makes the initial diagnosis of patient's medical condition.
107
Process improvement
A series of actions taken to identify, analyze, and improve existing processes.
108
Protected health information (PHI)
Under HIPAA, all individually identifiable information, whether oral or recorded in any form or medium, that is created or received by a healthcare provider or any other entity subject to HIPAA requirements.
109
Protocol
In healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in medical research, a rule of procedure to be followed in a clinical trail; in a computer network, a protocol is used to address and ensure delivery of data.
110
Record locator service (RLS)
A service that indicates where a given patient may have health information using probability equations.
111
Redundant arrays of independent (or inexpensive) disks (RAID)
A method of ensuring data security.
112
Regional health information organization (RHIO)
A health information organization that brings together healthcare stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community.
113
Registry
A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison.
114
Relational database
A type of database that stores data in predefined tables made up of rows and columns.
115
Remote patient monitoring device
A device that enables a healthcare provider to monitor and treat a patient from a remote location.
116
Request for proposal (RFP)
A type of business correspondence asking for very specific product and contract information that is often sent to a narrow list of vendors that have been preselected after a review of requests for information during the design phase of the systems development life cycle.
117
Results management
Results retrieval technology that permits viewing of data by type and manipulation of several different types of data.
118
Results retrieval
A lookup system that enables a user to access several different types of data from different source systems through a single application screen.
119
Retention
1. The process whereby inactive health records are stored and made available for future use in compliance with state and federal requirement. 2. The ability to keep valuable employees from seeking employment elsewhere.
120
Rip-and-replace
An information technology acquisition strategy in which older technology is replaced with new technology.
121
Server redundancy
Situation where two servers are duplicating effort.
122
Speech recognition
Situation where speech is converted to text on a screen.
123
Standard vocabulary
A vocabulary that is accepted throughout the healthcare industry.
124
Storage area network (SAN)
Storage devices organized into a network so that they can be accessible from any server in the network.
125
Storage management software
Software used to manage the SAN, keep track of where data are stored, and move older data to less expensive, but still accessible, storage locations.
126
Stress testing
Testing performed toward the end of EHR implementation to ensure that the actual number, or load, of transactions that would be performed during peak hours can be performed.
127
Structured data
Binary, computer-readable data.
128
System build
The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system.
129
System testing
A type of testing performed by an independent organization to identify problems in formation systems.
130
Systemized Nomenclature of Medicine Clinical Terminology (SNOMED CT)
A concept-based terminology consisting of more than 110,000 concepts with linkages to more than 180,000 terms with unique computer-readable codes.
131
Template
A pattern used in computer-based patient records to capture data in a structured manner.
132
Textual
A term referring to the narrative nature of much of clinical documentation to date.
133
Unit testing
The testing step in EHR implementation that ensures that each data element is captures, recorded, and processed appropriately within a given application.
134
Universal Medical Device Nomenclature System (UMDNS)
The standard international nomenclature and computer coding system for medical devices, developed by ECRI.
135
Uses and disclosures
Referring to the use and disclosure of a patient's personal health information.
136
Web services architecture (WSA)
An emerging architecture that utilizes Web-based tools to permit communication among different software applications.
137
Wide area network (WAN)
A computer network that connects devices across a large geographical area.
138
Wireless local area network (WLAN)
A data transmission network that uses an unguided medium such as radio waves or microwaves.
139
Wireless on wheels (WOWs)
Notebook computers mounted on carts that can be moved through the facility by users.
140
Wireless wide area network (WWAN)
Networks that use mobile telecommunication cellular network technologies to connect computers across a large area.
141
Workflow
Any work process that must be handled by more than one person.
