HIM 4401 Healthcare Information Technology Systems
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218 terms
Terms | Definitions |
|---|---|
 Hardware | "Touchable" Examples: Hard Drive Monitor Mouse Keyboard Printer Modem Scanned Storage Devices |
| CPU | Central Processing Unit |
| Cache | Temporary Memory |
| RAM | Random Access Memory Long Term Memory |
| The personal computer is a...... | Microcomputer |
| These are examples of storage devices.... | Flash Drives CD's DVD's Blue-Ray disc |
| Input Devices | Used to enter data into a computer |
| These are examples of Input Devices | Keyboard Touch Screen Scanner Microphone Optical Character Recognition |
| Three main hardware parts of a computer | CPU (central processing unit) Memory Storage Devices |
| Ports | Commincation Device Enables Computer to "talk" to peripheral devices |
| Output Devices | Used to transmit data to users |
| These are examples of output devices | Monitor Printer Speakers Projectors Scanners Optical Disc |
| Monitor resolution is measured in...... | Dots Per Inch |
| Optical Disk | Used with document imaging systems Uses a format known as "write once read many" (WORM) Allows multiple user access at the same time Allows for variius levels of security Data cannot be altered,lost once in the system This is a output device |
| Operating System | Instructions that direct the computer in its operation, regulate the hardware, and allow several programs to run simultaneously. |
| These are examples of Operating Systems | Windows XP Vista Mac Os UNIX |
| Application Programs (software) | Enables user to perform specific types of work Can work with text, numbers, graphs, images |
| These are examples of application programs (software) | Microsoft Office Software developed internally by an organizations IT staff Enterprise Software-used throughout an organization/facility |
| Programming Languages | Language encoded into a computer that tells it what to do and how to operate. Communication between user and computer Allows computers to enteract with each other |
| These are examples of Programming Languages | COBOL FORTRAN BASIC JAVA |
| Bit | Basic unit of storage whithin a computer |
| Byte | a string of 8 numbers |
| These are 2 types of networks | LAN (local area network) WAN (wide area network) |
| Local Area Network (LAN) | connect PC's within a local area and to a host server |
| Wide Area Network (WAN) | connect PC's in a large geographical area not geographically located near each other |
| Networks | enable communication among linked PC's Connect PC's to a central server (hub computer) Can link internally and externally |
| These are internet connections used within networks...... | Ethernet Wireless Fiberoptic Modem Wireless Cards |
| These are types of LAN networks | Bus Network Star Network Token Ring Network |
| Bus Network | Computers "lines up" on a single cable Dependent upon the device before it |
| Star Network | Most common type of LAN network All computers connected to a hub (star) Data flows to hub, then passed on to each computer |
| Token Ring Network | A ring of computers Data flows around the ring until reaches destination computer. |
| Interfaces | Allow computers to connect with a network Allow networks to connect with one another Allows transmission of data from one system to another |
| These are 2 types of network security | Firewalls Routers |
| Firewalls | control access from the internet to a LAN |
| Router | route data between networks |
| Internet | Networks and computers linked together enable data/information sharing around the world |
| Intranet | Private network Firewall security restricts unauthorized users |
| Extranet | Allows authorized users to access private network |
| Which of the following types of data storage devices has the largest storage capacity? | Blu-Ray |
| Within the hardware of the personal computer, temporary memory is known as? | Cache |
| If you wanted to convert some old Kodak photos into digital data so that you could insert them into a PowerPoint presentation, you would first use a ..... | scanner |
| A common programming language used with the Internet is? | HTML |
| The quality of the resolution of computer monitors is dependent on the number of pixels or...... | dots per inch |
| Within a LAN the security device used to control access from the internet is known as.... | a firewall |
| Which of the following data storage measurements has the largest memory size? | terabyte |
| Networks | enable communication among linked PC's |
| Optical Character Recognition | A common input device, commonly known as barcoding, used in HIM departments which enables staff to be more efficient and accurate |
| Operating System | The PC software that instructs the computer in its operations and regulates the hardware |
| Star Network | The most common type of LAN network in which data flows to a hub, and then is passed on to each computer linked in the network |
| Hard Drive | This is the brain of the computer |
| Cache Memory | Temporary memory used when computer needs to borrow memory temporarily used when speed is needed by the computer |
| RAM | long term memory |
| DRG Grouper | computer software program that assigns appropriate DRG's according to the info provided for each episode of care |
| Peripherals | Anything that is added to the computer |
| Graphical User Interface | used to present images or data to the user |
| This is also known as "barcoding" | Optical Character Recognition |
| What are the main parts to the personal computer? | CPU memory storage |
| ROM | memory programmed onto a chip at the factory and cannot be changed Read Only Memory purchased at a predetermined amount |
| System Files | small disk files that contain software codes that are instructions for the computer are the 1st files a computer reads when "booting up" |
| RAM | temporary memory need by the computer at startup and backup can be volatile or dynamic |
| WAP | wireless application protocol |
| Routers | provide firewall security for networks and route data between networks using IP addresses |
| Hub | device where all computers on a network connect |
| Peer to Peer Network | when a network does not use a hub |
| Ethernet Connection | a network that sends data from node to another in packets |
| Modem | bridge between digital and analog signals converts digital data on and off |
| Clinical Information Systems | collect and maintain information related to patient care data is patient identifiable lab radiology nursing pharmacy patient monitoring |
| Computer Provider Order Entry | Designed for orders to be entered by a healthcare professional Alerts and reminders built into the system |
| Picture Archival Communication System | radiological images stored digitally PACS |
| Teleradiology | ability for images to be viewed from any location by the radiologist |
| Lab Information System | collects, stores and maintains lab tests and their respective results blood chemistry microbiology blood banks pathology virology |
| Nursing Information System | assist in planning/monitoring patient care documents nursing care provided provides nursing protocols provides access to reference guides enables documentation at the point of care assists in management of nursing department |
| Patient Monitoring System | capture data from monitoring systems blood pressure oxygen saturation fetal monitoring |
| Telehealth | communication about health information between patient and care provider |
| HIPAA requires accounting of disclosures to be available to the patient for how long? | 6 years |
| Encoder | used by coders to select the appropriate code for diagnosises and procedures |
| What are the 2 types of encoders? | Rules Based Automated codebook encoder |
| Rules Based Encoder | require the user to type in the name a portion of the dx or procedure Ex. 3M |
| Administrative Information Systems | Computer systems used to manage the business side of healthcare Financial or Administrative in nature |
| These are the major administrative information systems | Financial information systems Human Resources information systems Decision Support Systems The Master Patient Index Patient Registration Systems Practice Management Systems Materials Management Information Systems Facilities Management Systems |
| These are functions related to the Financial Information Systems | Patient Accounting Accts Receivable Accts Payable Investment management Contract Management Payroll |
| Revenue Cycle | management of the accounts receivable and the accounts payable on a daily basis by the faciity |
| Chargemaster | automates the coding process for routine procedures |
| General Ledger | records credits and debits to the various accounts managed by the financial information system |
| Decision Support System | takes data collected by the healthcare facility, turns them into information and uses the info to make decisions about the healthcare facility DSS |
| Executive Information Systems | a type of DSS that is designed to be used by top level healthcare administrators lots of graphs and charts are generally used facilitates quick decision making |
| Master Patient Index | info in MPI collected by registration personnel info collected flows to other hospital systems permanently maintained key to locating a patients health record in a paper based environment uses soundex capabilities |
| These are errors that can occur during patient registration and impact MPI integrity. | Overlays, 2 people with same medical record number Duplicate Medical Record Numbers,2 medical record numbers for same person |
| What are the 3 types of Algorithms used in a MPI system to prevent duplication of patient records and medical record numbers? | Deterministic Rules-Based Probabilistic |
| Deterministic Algorithm | look for exact matches |
| Rules-Based Algorithm | "fuzzy logic" uses a weight based system to rank potential matches |
| Probabilistic Algorithm | can identify transpositions/name changes This is the most sophisticated type of Algorithm |
| Patient Registration ADT | Admission,Discharge,Transfer |
| Practice Management | used by physician office groups Scheduling,patient accounting, patient collections, claims submission,appointment scheduling, human resources are all built into one system |
| Materials Management Systems | manage equipment and supplies for facility |
| Facilities Management | supports the management of the building |
| The system that would print out advanced directives, consents and notice of privacy practices is the? | Registration System |
| Updates to the chargemaster ultimately feed into the....... | financial system |
| The following is a function of the chart locator system.... | Productivity Reporting |
| Electronic Data Management System | EDMS An electronic system which manages documents in order to improve business processes |
| COLD Technology | Computer output to laser disk |
| COLD Technology | Transfer of data straight from the computer into imaging system |
| Legacy Systems | transcription system lab system radiology system |
| Data Retrieval Tools | Tools used to identify and extract data from a database |
| SQL | structured query language data retrieval tool allow user to create tables,delete tables and show how something is viewed standard language for RELATIONAL DATABASES |
| QBE | query by example data manipulation language uses GUI to query the database |
| BOOLEAN search | uses boolean operators to control and refine search results "and" "or" "not" |
| These are types of Boolean operators.... | "and" "or" "not" |
| Normalization | breaking data elements into level of detail desired by the facility |
| Primary Data | Data directly from the source ex. medical record |
| Secondary Data | data taken from a primary source and abstracted into another database or registry ex. cancer registries, mpi, disease index |
| Aggregate Data | non patient identifiable data ex. research data |
| ORYX | examines healthcare organizations internal performance over time and then compares the organizations internal performance with that of others Developed and maintained by the Joint Commission |
| Automated Forms Processing | allows user to type data directly into computer eliminating the need to manually complete a paper form and then scan it into computer |
| Optical Character Recognition | OCR encoding text from analog paper into bit mapped images and translating the images and translating the images into a form that is computer readable |
| What is the difference between a document imaging system and an EHR? | A Document imaging system does not assist in documentation like a EHR does. |
| Document Imaging | process of scanning a document into the computer and creating a picture of the document |
| These are some advantages of a document imaging system. | Space saving multiple user access autofaxing users can access anytime, anywhere enhances patient record security |
| Backscanning | Scanning past medical records so that there is an existing database of patient information |
| Target Sheets | pages that are blank except for a barcode that will tell the scanner and ultimately the computer the content of the pages that follow |
| WORM technology | prevents user from altering what is stored write once read many |
| Jukebox | holds and retrieves the individual disks just as a music jukebox does |
| Scanner are rated on..... | pages per minute |
| Document imaging eliminates which function? | Assembly |
| This controls the specific data elements collected? | Data Sets |
| Workflow Technology | software that allows the facility to incorporate procedures and processes into the system based on criteria established by the organization |
| The 1st stage in the scanning process is? | Document preparation |
| This type of backup backups everything on the hard drive | Full Backup |
| This type of backup backups only copies that have changed since the last backup | Incremental Backup |
| Ad Hoc Reporting | reports needed only once |
| Routine Reports | reports that are needed repeatedly |
| Indexing | Comparing scanned documents to the paper documents to ensure the quality of the scanned image is good and the documents are under the correct pt name and document type |
| COLD feed | transfer of data from the computer directly into the document imaging system |
| NCVHS | National Committee on Vital Health Statistics advisory committee to the DHHS |
| What is the role of the NCVHS in regard to the EHR? | to recommend guidelines applicable to the EHR such as standards, data sets, and terminologies |
| Standards development organizations | SDOs the efforts of 2 organizations ANSI (american national standards institute) WEDI (workgroup for electronic data interchange) |
| ANSI | american national standards institute voluntary organization that accredits groups in the private sector for data standards |
| WEDI | workgroup for electronic data interchange identifies ways to increase the use of electronic billing to reduce admin costs |
| HL7 | Health Level 7 Communicates Clinical Data Messaging Format Language |
| These 2 organizations serve to ensure that data elements and data sets are defined and equal so that info can be transmitted. | WEDI ANSI |
| ASC X12 | Communicates financial data Messaging format language |
| Data Set | list of recommended data elements with uniform definitions ensures consistency of data collected ensures consistency of definitions of data elements supports electronic data collection and exchange |
| These are data entry methods used to support data integrity. | required fields edit checks help screens automatic save feature online reference link hot spots streamlining repetitive data |
| Database | large collection of data in a standardized format which allows for data retrieval as meaningful information |
| Database Management System | used to manipulate and control data stored in the database DBMS |
| Primary Key | Unique identifier used in a healthcare data base ex. health record number used in a relational database |
| Foreign Key | when the primary key of one table is included in another table when this happens the nd key is called the foreign key |
| Name the major types of databases. | Relational database Hierarchical database Network database Object-oriented database |
| Relational Database | has at least 2 tables data stored on rows and columns a field can be designated as a "primary key" each row is a record each column represents a single piece of data |
| Hierarchical database | structures data in a hierarchy similar to an organizational chart similar to a tree structure parent child relationship created each piece of data is called a node |
| Network Database | uses pointers to connect data nodes called "owners and members" |
| Object-oriented database | stores text, images, audio, video uses programming tools such as JAVA |
| Data Repository | database that houses data from multiple systems updated by systems in real time ex. Clinical Data Repository: stores clinical info from various clinical information systems |
| Data Mart | subset of a data warehouse designed for purpose or specialized use data is scaled down to what is needed lowers cost to manage |
| Data Warehouses | store data from various source systems designed for specific types of data analysis such as patient care or business not used directly for patient care |
| Data Mining | database exploration used to analyze data to identify patterns process of extracting info from a database and then quantifying and filtering discrete, structured data requires sophisticated software |
| Data Dictionary | defines data elements supports data quality and consistency |
| Entity Relationship Diagram | depicts relationships between entities (people,locations,things,concepts) |
| Name the types of entity relationships | one to one one to many many to many |
| Quantitative Analysis | method to detect whether elements of the patients health record are missing reports are either present or absent in a quantitative review |
| Qualitative Analysis | detailed review of a patients health record for the quality of the documentation contained. "would this record hold up in court?" |
| Business Continuity Plan | an organizations plan for responding to an unexpected failure of the EHR system |
| This is a type of automated indexing | Barcoding |
| These are the stages of image capture | Prepping Scanning Indexing Inserting Workflow triggers Indexing Loose Work Quality Checks |
| Clinical Provider Order Entry | CPOE physicians, clinicians enter orders directly into system system provides alerts/reminders/prompts as orders are entered |
| Clinical Decision Support System | CDSS preprogrammed logic that generates alerts/reminders as data is entered by caregivers controlled by rules engines may be active (user must address alerts/reminders) may be passive (user can ignore or utilize alerts) has benchmarking (compares internal data to external data) |
| Results Trending | test results can be graphed/displayed over one encounter or multiple encounters for comparison |
| Interoperability | ability to receive data from and send data to other information systems |
| SNOMED CT | systems nomenclature of medicine clinical terms captures detailed clinical info enables comparison of aggregate data automatically identifies and tags standard terms |
| Logical Observation Identifiers Names and Codes | LOINC Lab Vocabulary used to order/report lab tests and record clinical observations allows tests from multiple labs to be understood |
| RX Norm | medication vocabulary provides standards for drug ingredients and strength,dose formats,drug relationships |
| NDC | National Drug Codes Universal unique identifier for human drugs |
| A subset of the EHR that is used for subsequent patient care is? | CCR (continuity of care record) |
| The phrase "womb to tomb" refers to: | the longitudinal health record |
| Unified Medical Language System | UMLS thesaurus of medical terms groups terms according to concepts improves data retrieval |
| MEDCIN | nomenclature and knowledge-based system |
| Digital Imaging and Communications in Medicine | Standards for Diagnostic Medical Imaging As well as images related to dentistry,cardiology, and radiology |
| Clinical Data Repository | database that manages data from a variety of source systems receives data in "real time" processes discrete data, paper document images, and clinical images |
| Electronic Health Record | EHR |
| The system that includes patient information from both the patient and the healthcare provider is called the: | Personal Health Record PHR |
| Stark Law | prevents physicians from receiving a fee for referring patients for any healthcare services whose care is paid for by federally funded programs such as Medicare and Medicaid also called "the anti-kickback law" |
| Rules Engines | Controls reminders and alerts |
| Benchmarking | compare internal data to external data used to standardize practice patterns and reduce high cost drugs and other treatments |
| Electronic Medication Administration Record | EMAR designed to help prevent medication errors by automating medication administration processes |
| Benchmarking | compares internal data to external data used to standardize practice patterns and reduce usage of high cost drugs and other treatments |
| ANSI-ASCX12N | Messaging standard for billing and claims transactions |
| ASTM | Addresses standards for EHR record content, continuity care record and lab data exchange |
| What are the 3 main types of authentication? | Digitized Signature Electronic Signature Digital Signature |
| Digitized Signature | A scanned image of an actual signature not the best option for security |
| Electronic Signature | User must enter a username and password prior to signing an entry Sometimes there is even a two tiered user id process users must go through prior to signing an entry |
| Digital Signature | Uses encryption and nonrepudiation and nonrepudiation () |
| Encryption | transmitting text in scrambled form |
| Nonrepudiation | method that positively identifies the user so the user cannot deny sending the message ex. |
| HITSP | Health Information Technology Standards works with both private and public sectors to achieve widespread interoperability among healthcare software applications |
| These are the primary functions of an EHR | Integrate data from multiple sources Provide data capture capabilities at the point of care Support clinicians with decision making Provide links to access resources to further their knowledge |
| These are types of Clinical Information Systems | Electronic Health Record Telemedicine Smart Cards Computer Provider Order Entry CPOE Electronic Medical Administration |
| Chart Locator | Used to locate the paper medical record |
| Overlays | 2 people with the same medical record |
| Duplicate Medical Record | 2 medical record numbers for the same person |
| How is the EHR different from a document imaging system? | The document imaging system does not assist in documentation |
| The HPIAA Security Rule | This rule addresses personal health information that is maintained and processed electronically. |
| The HIPAA Privacy Rule | This rule addresses ALL types of personal health information-in written, oral, or electronic format. |
| These are the 4 sections that make up the HIPAA data security safeguards: | Admin Safeguards Physical Safeguards Technical Safeguards Transmission Security Safeguards |
| Administrative HIPAA data security safeguards | Documented formal practices to manage data security including a data security program and an individual to oversee the program |
| Physical HIPAA data security safeguards | A mechanism by which an organization's computer system will be protected from natural and environmental hazards/intrusion |
| Technical HIPAA data security safeguards | Controls for safeguarding the technical components of a computer system by using computer software |
| Transmission HIPAA data security safeguards | Methods for protecting data integrity and security as it is transmitted via internal and external networks |
| HITECH | Health Information Technology for Economic and Clinical Health Act Section of the ARRA that addresses the |
| ARRA | American Recovery and Reinvestment Act |
| Confidentiality | Health information shared by a patient with a health care provider will only be disclosed/used for the purpose of patient care |
| Privacy | The right of individuals to limit access to their health information |
| Security | Measures taken to protect and safeguard information and the systems that house the information from accidental or intentional disclosures to unauthorized persons |
| These are 3 types of security threats: | Human (intentional and non-intentional) Environmental (natural disasters) Hardware/software (failures or malfunctions) |
| Designated Code Sets | mandates the use of certain coding systems ex. ICD-9-CM,HCPCS,CDT-2 |
| Deguassing | overwriting |
| Checksum Verification | following data sent across a network to validate that the data transmitted was not altered |
| Encryption | enables data to be transmitted via networks in an unreadable form must be decoded to be understood |
| Virtual Private Network | used to connect an organizations users together through the use of virtual connections routed through the internet from the companies private network to the remote site or employee. |
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