HIT-001 Chapter 4 Flashcards
__Acceptance testing
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.
Access control
- 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.
Accredited Standards Committee X12N (ASC X12N)
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.
Admissibility
The condition of being admitted into evidence in a court of law.
American National Standards Institute (ANSI)
The organization that accredits all U.S. standards development organizations to ensure that they are following due process in promulgating standards.
American Recovery and Reinvestment Act of 2009 (ARRA)
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.
Ancillary systems
Electronic systems that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on).
Architecture
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.
ASTM International
Formerly known as the American Society for Testing and Materials, a system of standards developed primarily for various EHR management processes.
Audit log ( audit trail)
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.
Authentication
- 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.
Barcode medication administration record (BC-MAR)
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.
Best of breed
A vendor strategy used when purchasing an EHR that refers to systems applications that are considered the best in their class.
Best of fit
A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vender.
Chart conversion
An EHR implementation activity in which data from the paper chart are converted into electronic form
Client/server architecture
A computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amounts of shared data.
Clinical data repository (CDR)
A central database that focuses on clinical information.
Clinical data warehouse (CDW)
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface.
Clinical decision support (CDS)
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.
Clinical Document Architecture (CDA)
HL7 electronic exchange model for clinical documents (such as discharge summaries and progress notes).
Clinical information system (CIS)
A category of a healthcare information system that includes systems that directly support patient care.
Clinician
A healthcare provider, including physicians and others who treat patients.
Computer output to laser disk/enterprise report management (COLD/ERM)
Technology that electronically stores documents and distributes them with fax, e-mail, Web, and traditional hard-copy print processes.
Computerized provider order entry (CPOE)
Systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindications, or other clinical decision support.
Consent directive
A process by which patients may opt in or opt out of having their data exchanged in the HIE
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.
Continuity of care record (CCR)
Documentation of care delivery from one healthcare experience to another.
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.
Data availability
The extent to which healthcare data are accessible whenever and wherever they are needed.
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.
Data conversion
The task of moving data from one data structure to another, usually at the time of a new system installation.
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.
Data exchange standards
Protocols that help ensure that data transmitted from one system to another remain comparable.
Data integrity
- 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.
Data set
A list of recommended data elements with uniform definitions that are relevant for a particular use.
Database
An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.
Database management system (DBMS)
Computer software that enables the user to create, modify, delete, and view the data in a database.
Digital dictation
A process in which vocal sounds are converted to bits and stored on computer for random access.
Digital images
Data provided in a computer-readable format.
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.
Discrete data
Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values.
Disease management (DM)
- 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.
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.
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.
Electronic data interchange (EDI)
A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations.
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.
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.
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.
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.
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.
Encoded
Converted into code.
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.
e-Prescribing
Enables prescriptions to be checked for drug contraindications and sent directly to a retail pharmacy of the patient’s choosing.
Ethernet
A popular protocol (format) for transmitting data in local area networks.
Evidence-based medicine
Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies.
Extensible markup language (XML)
A standardized computer language that allows the interchange of data as structured text.