214 terms

HIT Chapters 2-4 Definitions

HIT Chapters 2-4 Definitions
Health record
Principal repository for data and information about the healthcare services provided to an individual patient. who, what, when, where, & why
Represents basic facts about people, processes, measurements, conditons, etc. (facts)
After data has been collected and analyzed and converted into a form that can be used for a specific purpose (meaning)
Personal health record (PHR)
health record initiated & maintained by an individual
healthcare reimbursement
Based on the documentation contained in the health record
Quality improvement organizations (QIO) & utilization management organizations
evaluate the adequacy & appropriateness of the care provided by healthcare organizations
Centers for Medicare & Medicaid (CMS)
responsible for administering the ferderal MC program and federal portion of MA program. Used to be called HCFA-health care financing administration until 2001.
Data applications
the purposes for which data are collected
Data collection
the processes by which data are collected
Data warehousing
The processes & systems by which data are archived (saved for future use)
Data analysis
Process by which data are translated into information that can be used for designated application
Data quality management
Data accuracy
Means data are correct. Should represent what was intended or definied by the original source of the data
Data accessibility
Means that the data are easily obtainable
Data comprehensiveness
means that all required data elements are included in the health record
Data consistency
Means that the data are reliable
Data currency/timeliness
Means that healthcare data should be up-to-date & recorded at or near the time of the event or observation
Data definition
Means that the data & information documented in the health record are defined
Data granularity
Requires that the attributes & values of data be definied at the correct level of detail for the intended use of the data
Data precision
Term used to describe expected data values
Data relevancy
Means that the data in the health record are useful
Right of individual to control access to their personal health information
Refers to the expectation that the personal information shared by an individual with a healthcare professional during the course of care will be used only for its intended purpose
The protection of the privacy of individuals & the confidentiality of health records
Refers to the capacity of health record systems to provide communicaton linkages & allow the exchange of health record data among information systems
Health record format
refers to the organizations of electronic information or paper forms within the individual record
Source-oriented health record format
format that organizes the information according to the patient care department that provided the care (used in most acute care hospitals)
Problem-oriented health record format
Format that is a documentation approach in which the physician definies each clinical problems individually. organized into 4 components: database, problem list, initial plans, & progress notes
Integrated health record format
Format that organized all the paper forms in strict chronological order & mixes the forms created by different departments
Health record
Represents the main communicatoin mechanism used by healthcare providers. Tool for documenting patient care
Clinical data
documents the patient's medical condition, diagnosis, & procedures performes as well as the healthcare treatment provided
Administrative data
included demographic & financial as well as various consents & authorizations related to the provision of care & the handling of confidential patient information
Conditions of participation/coverage
Standards that are applied to facilities that choose to participate in MC and MA
Registration record
Documents demographic information about the patient
Medical history
Documents the patient's curent & past health status
Physical examination
Contains the provider's findings based on exam of the patient
clinical observation
Provides a chronological summary of the patient's illness & treatment as documented by physicans, nurses, and all allied healthcare professionals
Physician's orders
Document the physician's instructions to other parties involved in providing the patient's care including orders for medications and diagnostic/therapeutic procedures
Reports of diagnostic & therapeutic procedures
Describes the procedures performed and give the names of providers, includes findings of x-ray, mammograms, ultrasounds, scans, lab tests, & other diagnostic procedures
Consultation reports
Document opinions about a patient;s condition furnished by providers other than the attending physician
Discharge summary
concisely summarizes the patient's stay in the hospital
patient instructions
Document the instructions for follow-up care that the provider gives to the patient or patient's caregiver
Consents, authorizations, & acknowledgements
Documents the patient's agreement to undergo treatment or services, permission to release confidentialy information, or recognition that information has been received
Provisional diagnosis
Admitting or working diagnosis identified by the condition or illness for which the patient needs medical care
Chief complaint
Nature & duration of the symptoms that caused the patient to seek medical attention as stated in his/her own words
Present illness
Detailed chronological description of the development of the patient's illness, from the appearance of the first sympton to the present situation
Past medical history
Summary of childhood & adult illness & conditions, such as infectious diseases, allergies & drug sensitivities, accidents, operations, hospitalizations, & current medications
Social & personal history
marital status, dietary, sleep, & exercise patterns, use of tobacco, coffee, alcohol, & other drugs, occupation, home environment, daily routine, etc.
Family medical history
Diseases among relatives in which heredity or contact might play a role
Review of systems
Systemic inventory designed to uncover current or past subjective symptoms
Progress notes
Purpose is to create a chronological report of the patient's condition & response to treatment during their hospital stay and serve to justify further acute care treatment in the facility
Care plan
Summary of the patient's problems from the healthcare professional's perscpective for a specific patient admission & discharge documenting the patient's condition at regular intervals throughout the hospital stay
Implied consent
Is consent assumed by the patient voluntarily submitting to treatment
Expressed consent
consent that is either spoken or written
Anesthesia report
includes any preoperative medication & response to it, the anesthesia administered with dose & method of administration, the duration of administration, patient's vital signs under anesthesia, & any additional products given to the patient during the procedure
operative report
report that describes the surgical procedures performed on the patient
recovery room report
Report that includes the postanesthesia note, nurses notes regarding the patient's conditon & surgical site, vital signs, IV fluids, and other medical monitoring
Pathology report
Report dictated by pathologist after exam of tissue received for evaluation includes description of tissue from a macroscopic level & representative cells at microscopic level along with interpretive findings
Consultation report
Report documenting the clinical opinion of a physician based on his/her exam of patient at the request of attending physician
discharge summary
Concise account of the patient's illness, course, of treatment, response to treatment, & conditon at time of discharge. includes instructions for followup care
Transfer record/referral form
Report that includes a brief review of patients acute stay along with current status, discharge, & transfer order & additional orders sent to the facility patient being transferred to.
Autopsy report
Report that contains a description of the exam of a patients body after death
The study of the statistical characteristic of human population
Permission granted by the patient or patient's representative to release information
Term used when the permission is for treatment, payment, or healthcare operations
authorization to disclose information
Term used to allow the healthcare facility to verbally disclose or send health information to other organizations
Advance directive
Written document that that names the patient's choice of legal representative for healthcare purposes. the person is then empowered to make healthcare decison on behalf of the patient in the event the patient is not capable of expressing his/her preferences
patient self-determination Act (PSDA)
Requires healthcare facilities to provide written information on the patients rights to execute advance directives & to accept or refuse medical treatment. went into effect in 1991.
Resident assessement instrument (RAI)
Based on minimum data ses for long-term care includes the MDS, triggers, utilization guidelines, & resident assessment protocols.
Outcomes & Assessment information set (OASIS)
Foundation for the plan of care. MC uses this to determine payment
Basic principles of health record documentation
principles address the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, & format of health record entries
Deemed status
Status obtained after facilities receive accreditation from agencies such as Joint Commission
Det Norske Veritas (DNV)
International accreditating organization
Integrated health record
health record is arranged so that documentation from various sources is intermingled in strict chronological order
Personal health record
An electronic record of health-related information on an individual that conforms to nationally recognized interoperabiity standards & that can be drawn from multiple sources while being managed, shared, & controlled by the individual
Qualified EHR
Includes patient demographic & clinical health information such as medical history & problem lists, & has capacity to provide clinical decision support, support physician order entry, capture & query information relevant to healthcare quality, & exchange electronic health information with & integrate such information form other sources
Computer-based patient record (CPR)
A system specifically designed to support users thru availability of complete & accurate data, practitioner reminders & alerts, clinical decision support, links to bodies of medical knowledge, & other aids
Electronic medical record
An electronic record of health-related information on an individual that can be created, gathered, managed, & consulted by authorized clinicians & staff within ONE healthcare organization
Electronic health record
An electronic record of health-related information on an individual that conforms to nationally interoperability standards & that can be created, managed, & consulted by authorized clinicians & staff across MORE THAN ONE healthcare organization
evidence-based medicine
The practice of medicine that utilizes guidance-based information gleaned from research studies
special application to provide secure access to a specific application such as a physicians office to a hospital
special software that aids formatting of data for transmission among systems with a hospital, lab, or other providers. special program where specific data are identified as needing to be exchanged & then rules about how those data are structured are applied.
Discrete data/structured data
Consists of data elements that are raw facts or figures that can be processed by the computer such as lab values
Textual data
physicians describe patient conditions in narrative form
Computer output to laser disk (COLD) also referred to as electronic document/content management ED/CM systems
Systems that capture print images of lab results & other documents that are in a stand-alone electronic systems & make them available for viewing on a computer monitor
Electronic signature authentication (ESA)
System that require the author to sign into the system using a user ID & password, reivew the document to be signed, & indicate approval.
Clinical data repository (CDR)
A special kind of database that manages data from different source systems in the hospital or other provider settings, including direct entry of discrete data by the clinician.
Ensure that the appropriate data are collected & guide users in adhering to professional practice standards
Practice guidelines
Recommendation based on what experts believe should be done
Evidence-based guidance
Drawn from scientific research & clinical trials
Electronic medication administration record systems (EMAR)
An application that identifies when a drug is administered & aids in documenting the administration
Barcode medication administration record (BC-MAR)
Five rights of patients: right patient, right, drug, right time, right dose, & right route
Health information portability & accountability act (HIPAA) 1996
Encouraging the development of health information systems thru the establishment of standards & requirements for electronic transmission of certain health information.
identity matching algorithm
algorithm uses sophisticated probability equations to identify patients
Record locator service (RLS)
Process that seeks information about where a patient may have a health record available to the organization
national health information infrastructure (NHII)
Set of technologies, standards, applications, systems, values, & laws that support all facets of provider healthcare, individual health, & public health
natiinwide health information network (NGIN)
provide the technology to support national health information infrastructure. goal establish privately financed consortium to ensure public policy goals are execute & rapid adoption of interoperability is applied.
Meaningful use
Ability to demonstrate quality improvements thru use of EHR
Refers to the use of standard protocols to enable 2 different computers to share data with each other
Pay for performance (p4P) or pay for quality (P4Q)
Insurance company incentives to providers to reward data collections & in reporting clinical outcomes
Collection of specific data form a predefined data set which are used to dvelop reports across multiple patients
Integrated or tethered Personal health record
Generally integrated with an existing EHR in a hospital or clinic system
Automated personal health records
Health plans started offering these PHR that are largely controlled by provider or health plan with limited data entry directly by the patient
stand-alone or untethered personal health records
may be paper or automated often acquired thru a commercial vendor ususally thru a Web site
organized collection of data
Relational database
stores data in predefined tables that contain rows & columns similar to spreadsheet
Database management system (DBMS)
Software that organize, provide access to, & otherwise manage a database
Clinical data warehouse (CDW)
Form of database that are optomized to perform analysis on date on many different things at one time. used to analyze a large set of clinical data
data exchange standards/ message format standards/ interoperability standards
makes sure the interface is written correctly & the exchange of data occurs reliably
Defined ways to do something
helps exchange clinical images such as x-rays, CT, scans, etc.
National Council for prescription drug programs (NCPDP)
Enable the communicaiton of retail pharmacy eligibility inquiries & claims and exchange of prescriptions from physicians office
American national standard institute (ANSI) Accredited Standards committee X12 (ASC X12)
Provides standards for hospital, professional, & dental claims, eligibility inquiries, electronic remittance advice, & other standards
ASTM international
E31 Committee on health information has developed guidelines primary for various EHR management processes
Data comparability
Terms must have same meaning from one clinical system to another
Term used to describe fact that value of the data in the message has standardized meaning. message format standard specifies vocabulary which data is encoded
Standard vocabulary
Developed thru a process that confirms consensus on meaning of the term included in the vocabulary
SNOMED International
most comprehensive effort to standardize vocabulary for representation of medical knowledge, incorporates microglossaries that address nursing & other ancillary terminology
Refers to the set of all terms that may be used in a language
Grouping of the terms into various categories such as diseases of respiratory system
logical observation identifies, names & codes (LOINC)
provides names & codes for lab test results & other observations
Provides description of medications in clinical form
Universal medical device nomenclature system (UMDNS)
Provides standard terminology for medical devices
National drug codes (NDC)
used to maintain inventories of drugs in pharmacies or links to CPT in physicians offices
enterprise report management ((ERM)
Captures data from print files & other report-formatted digital documents such as emails
results retrieval
may be basic lookup where a query is made to access certain data from specific system such as lab results
Results management sytem
results retrieval technology couples with CDR permits not only viewing of data by type but also manipulation of several different types of data such as plotting lab results on graph against medication administered, vital signs, etc.
Human-computer interface
Technologies that make data capture easier for ex. point & click, drop down menus, etc
Discrete data
Entry thru point & click fields, drop-down menus, structured templates, or macros. make data entry & processing easier.
Speech & handwriting recognition
Can be very effective in certain situations when data entry is fairly repetitive & vocabulary used is fairly limited
Natural language processing (NLP)
Takes narrative text & converts to structured data
Refers to the configuration, structure, & relationships of all components of computer system
Client/server architechture
uses combination of computers to capture & process data.
Web services architecture (WSA)
utilizes web-based tools to permit communicaiton among different software applications
Local area networks (LAN)
Using hardware cable transmit data securely at very high speeds thru out a building, campus, or small geographic area
Wireless local are network (WLAN)
utilize radio waves or microwaces to transmit data without cable. ex. is bluetooth that beams data using infrared light. IrDA ports must be in close proximity. RFID similar to barcode scanning but can be done greater distance.
Wide area network (WAN)
Data are transmitted across wide geographic areas general depend on high density trunk lines such as T-1 or T-3
Wireless wide area network (WWAN)
Mobile communications cellular network technologies such as 3G
is called a protocol that aids data transmission by establishing standards for indicating the start & end of a message, by performing error checking to ensure data are transmitting correctly
one of most popular LAN protocols.
TCP/IP transmission control protocol/internet protocol
most healthcare organization use this to simplify their networking and to take advantage of web-based technology
A LAN that uses TCP/IP
Redundant array of independent disks (RAID)
inexpensive disks used as a storage media
Server redundancy
accomplished thru mirrored processes means that data set are entered & processed by 1 server, they are entered, & processed simultaneously by a second server
audit logs
is element of retention schedule
Best of fit
when most systems are from one vendor
dual core
vendor strategy where one vendor supplies the financial & administrative applications & another vendor supplies the clinical applications
Best of breed
a system was selected for each application & is considered to be the best in its class
When the care delivery organization already has a fair amount of automation but is not satisfied with level of functionality is more clinically oriented applications that would comprise the EHR
process improvement
Series of actions taken to identify, analyze, & improve existing processes
Chart conversion
Process whereby data from paper chart are converted to electronic form
Data conversion
Ensures that data in one system can be converted over to new system
Unit testing
Ensures that each data element is captured, recorded, & processed appropriately within a given application
System testing
Tests the various parts of the applications work together within a system work
Stress testing
Peformed toward the end of implementation to ensure the acutal number or load of transactions that would be performed during peak hours can be performed
Acceptance testing
Done at the end may be a review of all tests performed, assurance that all issues resolved, and some measure of adoption. final payment usually at this point
Authentication systems
Access controls, audit logs, & other measures for security
Process that converts human readable data into a format that cannot be read except with a special process to decrypt the data
includes data & file attributes, audit logs, software codes, temporay information such as sticky notes & alerts, pop-ups, & even some information about system maintenance
Health information management (HIM)
An allied health profession that is responsible for ensuring the availability, accuracy, & protection of the clinical information that is needed to deliver healthcare services & make appropriate healthcare-related decisions.
American Health information management association (AHIMA)
The provessional membership organization for managers of health record services & healthcare information systems as well as coding services; provides accreditation, certification, & educational services.
Institute of Medicine (IOM)
Branch of the National academy of sciences whose goal is to advance & distribute scientific knowledge with the mission of improving health.
Computerized provider order entry (CPOE)
Provides physicians & other providers the ability to order via the computer from any number of locations & adds decision support capability to enhance patient safety.
Accreditation Associaton for Ambulatory health care (AAAHC)
Professional organization that offers accreditation programs for ambulatory & outpatient organizations such as single or multipspecialty group practices, ambulatory surgery centers, college/university health services & community health centers
Accreditation commission for heatlh care (ACHC)
private, nonprofit accreditation organization offering accreditation services for home health, hospice, & alternate site healthcare such as infusion nursing, & home/durable medical equipment
American assoiciation for accreditation of ambulatory surgery facilities (AAAASF)
an organization that sets standards for accrediting ambulatory surgical facilities
American osteopathic associaton (AOA)
professional association of osteopathic physicians, surgeons, & graduates of approved colleges of osteopathic medicine that inspects & accredits osteopathic colleges & hospitals
commission on accreditation of rehabilitation facilities (CARF)
private,not for profit organization that develops customer-focused standards for behavioral healthcare & medical rehab programs & accredits such programs on the basis of its standards
Minimum data set for long-term care (MDS)
the instrument specified by CMS that requires nursing facilities (both MC/MA certified) to conduct a comprehensive, accurate, standardized, reproducible assessemtn of each resident's functional capacity
National committee for quality assurance (NCQA)
private, not for private accreditation organization whose mission is to evaluate & report on the quality of managed care organizations in the US
patient assessment instrument (PAI)
standardized tool used to evaluate the patient's condition after admission to, and discharge from, the healthcare facility
resident assessment protocol (RAP)
Summary of a long-term care residents medical conditions & care requirements
An acronym for a component of the problem-oriented medical record that refers to how each progress note contains documentation relative to subjective observation, objective observation, assessments, & plan
Do not resuscitate
Do not attempt intubation
Intermediate care facility for mentally retarded/disabled
Integrated delivery systems (IDS)
system that combines the financial & clinical aspects of healthcare & uses a group of healthcare providers, selected on basis of quality & cost management criteria to furnish comprehensive health services across the continuum of care
regional health information organization (RHIO)
health information organization that brings together healthcare stakeholders within a defined geographic area & governs HIE among them for the purpose of improving health & care in the community
national alliance for health information technology (NAHIT)
partnership of government & private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, & operating performance founded in 2002.
American recovery & reinvestment act (ARRA)
previously known as stimulus bill or HR 1. action related to HIT are spread throughout the law however bulk of the items are in title XIII or HITECH
Clinical decision support (CDS)
the process by which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, & supplying clinical reminders & alerts
clinical document architecture (CDA)
HL7 electronic exchange model for clinical documents such as discharge summaries & progress notes
clinical information systems (CIS)
category of healthcare information system that includes systems that directly support patient care
Continunity of care document (CCD)
combines the content that physicians have agreed should be included in patient referrals with a means to format that data for electronic transmission
Continunity of care record (CCR)
documentation of care delivery from one healthcare experience to another
disease management (DM)
more expansive view of case management in which patients with the highest risk of incurring high-cost interventions are targeted for standardizing & managing care throughout integrated delivery systems
electronic data interchange (EDI)
standard transmission using strings of data for business information communicated among the computer systems of independent organizations
electronic document/content manager (ED/CM)
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)
storage solution based on digital scanning technology in which source documents are scanned to create digital images that can be stored on optical disks
Extensible markup language (XML)
standardized computer language that allows the interchange of data as structure test
health information exchange (HIE)
health information is shared among providers
the part of AARA that is meant to increase the momentum of developing & implementing EHR by 2014
health level 7 (HL7)
standards development organization accredited by the American national standards institute that addresses issues at the 7th or application level of healthcare system interconnections
Hospital information system (HIS)
comprehensive database containing all the clinical, administrative, financial, & demographic information about each patient served by a hospital
Medicare modernization act of 2003 (MMA)
legislation passed in 2003 designed to expand healthcare services for seniors with major focus on prescription drug benefits
national alliance for health information technology (NAHIT)
partnership of government & private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, & operating performance founded in 2002
national committee for quality assurance (NCQA)
private, not for profit accreditation organization whose mission is to evaluate & report on the quality of managed care organizations in the US
national library of medicine (NLM)
world's largest medical library & branch of national institute of health
Office of the national coordinator (ONC) for HIT
provides leadership for the development & implementation of an interoperable health information technology infrastrurture nationwide to improve healthcare quality & delivery
Pharmacy benefit manager (PBM)
vendor selected by bureau of workers comp to process outpatient medication bills submitted electronically
picture archieving & communications system (PACS)
integrated computer system that obtains, stores, retrieves, & displays digital images of radiological images
point of care (POC)
place or location where physician renders care to the patient
practice management system (PMS)
software designed to help medical practices run more smoothly & efficiently
Primary care physician (PCP)
physician who provides, supervises, & coordinated the healthcare of a member & who manges referrals to other healthcare providers & utilization of healthcare services both inside & outside a managed care plan
protected health information (PHI)
all individually identifable information oral or recorded in any medium that is created or received by a healthcare provider or any other entity subject to HIPAA requirements
regional health information organization (RHIO)
health information organization that brings together healthcare stakeholdres within a defined geographic area & governs HIE among them for the purpose of improving care & health in the community
request for proposal (RFP)
correspondence asking for a very specific product or contract information
storage area network (SAN)
storage devices organized into a network so that they can be accessible from any server in the network
Problem list
List of illnesses, injuries, & other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification & resolution
Migration path
A series of steps required to move from one situation to another. Plan that describes what systems will be implemented and what order the transition to the EHR will follow.
Primary users of health records
physicians, nurses, & all allied health professionals that provide medical care
operative report contains?
*patients preoperative & postoperative diagnosis
*description of procedures performed
*description all normal/abnormal findings
*decription of patients medical condition before, during & after operation
*estimated blood loss
*description of specimens removed
*description any unique/unusual events during surgery
*names surgeons & assistants
*date & duration of surgery
What setting includes bereavement counseling?
ambulatory care record whose funciton is to facilitate ongoing patient care management?
problem list