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"Generally defined by E/M services as: problem focused (chief complaint; brief history of present illness or problem); expanded problem focused (chief complaint; brief history of present illness; problem-pertinent system review); detailed (chief complaint; extended history of present illness; extended system review; pertinent past, family, and/or social history); and comprehensive (chief complaint; extended history of present illness; complete system review; complete past, family, and social history)"
"The activities relating to medical care performed by physicians, nurses, and other healthcare professional and technical personnel under the direction of a physician"
Voluntary Disclosure Program
"A program unveiled in 1998 by the OIG that encourages healthcare providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs"
Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another
Health insurance prospective payment system (HIPPS) code
"A five-character alphanumeric code used in the home health prospective payment system (HHPPS) and in the inpatient rehabilitation facility prospective payment system (IRF PPS). In the HHPPS, the HIPPS code is derived or computed from the home health resource group (HHRG); in the IRF PPS, the HIPPS code is derived from the case mix group and comorbidity. Reimbursement weights for each HIPSS code correspond to the levels of care provided"
"Advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries. Applicants for the status of new technology must submit a formal request, including a full description of the clinical applications of the technology and the results of any clinical evaluations demonstrating that the new technology represents a substantial clinical improvement, along with data to demonstrate the technology meets the high cost threshold"
"1. The vocabulary used in a language or a subject area or by a particular speaker or group of speakers 2. A collection of words or terms and their meanings for a particular domain, used in healthcare for drug terms"
"International Classification of Impairments
Disabilities, and Handicaps (ICIDH)","Published by the World Health Organization to measure the consequences of disease and divided into three classifications: impairments, disabilities, and handicaps; the precursor to ICF"
A physician licensed to practice in osteopathy (a system of medical practice that is based on the manipulation of body parts as well as other therapies)
A type of testing performed by an independent organization to identify problems in information systems
A list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use
Medicare",An organization under contract with the Centers for Medicare and Medicaid Services to serve as the financial agent that works with providers and the federal government to locally administer Medicare eligibility and payments
Traditional fee-for-service (FFS) reimbursement
A reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers
"Also known as HCPCS Level III Codes, these codes were developed by local Medicare and/or Medicaid carriers and were eliminated December 31, 2003, to comply with HIPAA"
"The ability of a computer to create a graphic representation of a text block, photograph, drawing, or other image and make it available throughout an information system"
"The pretrial stage in the litigation process during which both parties to a suit use various strategies to identify information about the case, the primary focus of which is to determine the strength of the opposing party's case"
Computers on wheels (COWs)
Term affectionately used to refer to notebook computers mounted on carts and moved with the users
Hospital inpatient autopsy
A postmortem (after death) examination performed on the body of a patient who died during an inpatient hospitalization by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility
Highly active antiretroviral therapy (HAART)
A type of therapy that consists of multiple drugs commonly given to HIV-positive individuals before they develop AIDS
Global payment method
Method of payment in which the third party payer makes one consolidated payment to cover the services of multiple providers who are treating a single episode of care
"A new, separate company formed by a parent company whose shares are distributed to existing shareholders of the parent company in proportion to the new entity's relationship to the parent company"
Temporary budget variance
The difference between the budgeted and actual amounts of a line item that is expected to reverse itself in a subsequent period; the timing difference between the budget and the actual event
"1. The ability of a subject to view, change, or communicate with an object in a computer system 2. One of the rights protected by the Privacy Rule; an individual has a right of access to inspect and obtain a copy of his or her own PHI that is contained in a designated record set, such as a health record "
The standardization of vocabulary such that the meaning of a single term is the same each time the term is used in order to produce consistency in information derived from the data
Certified coding specialist-physician based (CCS-P)
"An AHIMA credential awarded to individuals who have demonstrated coding expertise in physician-based settings, such as group practices, by passing a certification examination"
"The extent to which the healthcare data is valid, accurate, usable and has integrity, so that each end user has a consistent view of the data"
A physician or another healthcare professional who is a member of a managed care network
Systems analysis and design
A performance improvement methodology that can be applied to any type of system
A completed insurance claim form that contains all the required information (without any missing information) so that it can be processed and paid promptly
Group practice without walls (GPWW)
A type of managed care contract that allows physicians to maintain their own offices and share administrative services
Medical savings account (MSA) plans
"Plans that provide benefits after a single, high deductible has been met whereby Medicare makes an annual deposit to the MSA and the beneficiary is expected to use the money in the MSA to pay for medical expenses below the annual deductible"
Randomized clinical trial (RCT)
A special type of clinical trial in which the researchers follow strict rules to randomly assign patients to groups
"Assets whose value to the organization extends beyond one fiscal year, for example, buildings, land, and equipment are long-term assets"
The action taken to eliminate the balance of a bill after the bill has been submitted and partial payment has been made or payment has been denied and all avenues of collecting the payment have been exhausted
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
Preoperative anesthesia evaluation
An assessment performed by an anesthesiologist to collect information on a patient's medical history and current physical and emotional condition that will become the basis of the anesthesia plan for the surgery to be performed
National provider file (NPF)
"A file developed by the Centers for Medicare and Medicaid Services that includes all healthcare providers, including nonphysicians, and sites of care"
Essential Medical Data Set (EMDS)
A recommended data set designed to create a health history for an individual patient treated in an emergency service
Newborn autopsy rate
The number of autopsies performed on newborns who died during a given time period divided by the total number of newborns who died during the same time period
Applications and data criticality analysis
"A covered entity's formal assessment of the sensitivity, vulnerabilities, and security of its programs and the information it generates, receives, manipulates, stores, and/or transmits"
The field of information science concerned with the management of all aspects of health data and information through the application of computers and computer technologies
The ability of different information systems and software applications to communicate and exchange data
Aging of accounts
"The practice of counting the days, generally in thirty-day increments, from the time a bill was sent to the payer to the current day"
The first stage of Lewin's change process in which people are presented with disconcerting information to motivate them to change
No man's land
The zone in the palmar or volar surface of the hand between the distal palmar crease (the crease in the palm closest to the fingers) and the middle of the middle phalanx (middle finger)
"A situation in contingency theory describing how well the leader is liked, respected, and followed"
A Medicare regulation that states the day preceding a leave of absence becomes a nonbillable day for Medicare purposes when a Part A beneficiary takes a leave of absence and is not present in the skilled nursing facility at midnight
Clinical Care Classification (CCC)
"Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings"
Behavioral healthcare information
"Information related to treatment for conditions such as mental disorders, mental retardation, and other developmental disabilities"
Object request broker (ORB)
The messenger at the heart of the object-oriented framework that acts as a relay station between client and server
"A computer-based information system that keeps track of an organization's business transactions through inputs (for example, transaction data such as admissions, discharges, and transfers in a hospital) and outputs (for example, census reports and bills)"
A structured data collection tool that risk managers use to gather information about potentially compensable events
Organizational pull model
A model in which the organization views information systems technology as the means to enable people in the organization to work more efficiently and effectively
Institute of Electrical and Electronics Engineers Standards Association (IEEE-SA)
An activity of the IEEE that develops standards in a broad-range of industries including healthcare
Companies outside the healthcare facility that specialize in the deciphering and typing of medical dictation
"The right of individuals to ask that a covered entity amend their health records, as provided in Section 164.526 of the Privacy Rule "
An addition to the health record when a pertinent entry was missed or was not written in a timely manner
An information management system providing decision makers with regularly updated information on an organization's key strategic measures
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"
A graphic representation of security measures in which each depends on the one below it
A training method in which participants are required to respond to specific problems they may actually encounter in their jobs
Health information services department
The department in a healthcare organization that is responsible for maintaining patient care records in accordance with external and internal rules and regulations
Center for Drug Evaluation and Research (CDER) Data Standards Manual
A compilation of standardized nomenclature monographs for sharing information regarding manufactured drug dosage forms
Episode-of-care (EOC) reimbursement
A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period; also called bundled payments because they include multiple services and may include multiple providers of care
Data Elements for Emergency Department Systems (DEEDS)
A data set designed to support the uniform collection of information in hospital-based emergency departments
The short-term objectives set by an organization to improve its methods of doing business and achieve its planned outcomes
Prior healthcare coverage that is taken into account to determine the allowable length of preexisting condition exclusion periods (for individuals entering group health plan coverage)
Medically needy option
An option in the Medicaid program that allows states to extend eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups but whose income and/or resources fall above the eligibility level set by their state
"A role in organizational innovation in which an idea is challenged, compared to stringent criteria, and tested against reality"
A process in which vocal sounds are converted to bits and stored on computer for random access
Hospital-based outpatient care
"A subset of ambulatory care that utilizes a hospital's staff, equipment, and resources to render preventive and/or corrective healthcare services"
"Healthcare costs paid by the insured (for example, deductibles, copayments, and coinsurance) after which the insurer pays a percentage (often 80 or 100 percent) of covered expenses"
Parents and children
A name for exploding charges wherein the parent is the item that explodes into other items and appears on the bill
Generally accepted accounting principles (GAAP)
"An accepted set of accounting principles; or standards, and recognized procedures central to financial accounting and reporting"
"A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight"
A standard language for encoding medical knowledge representation for use in clinical decision support systems
Inpatient rehabilitation facility PPS (IRFPPS)
Utilizes the patient assessment instrument to assign patients to case-mix groups according to their clinical situation and resource requirements
Performance measure/measurement system
System designed to improve performance by providing feedback on whether goals have been met
"A set of activities designed to familiarize new employees with their jobs, the organization, and its work culture"
A type of research instrument with which the members of the population being studied are asked questions and respond orally
"A structured, action-oriented list of sequential steps involved in carrying out a specific task or solving a problem"
"A paper document or electronic screen on which all details of an intended purchase are reported, including authorizations"
"A list of the operations and surgical procedures performed in a healthcare facility, which is sequenced according to the code numbers of the classification system in use"
Civilian Health and Medical Program - Uniformed Services (CHAMPUS)
"A federal program providing supplementary civilian-sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees and their dependents, and certain others"
A measure of central tendency that is determined by calculating the arithmetic average of the observations in a frequency distribution
Ambulatory care organization
"A healthcare provider or facility that offers preventive, diagnostic, therapeutic, and rehabilitative services to individuals not classified as inpatients or residents"
"The branch of law involving court actions among private parties, corporations, government bodies, or other organizations, typically for the recovery of private rights with compensation usually being monetary"
"The disposition of the patient at discharge (that is, left against medical advice, discharged to home, transferred to skilled nursing facility, or died)"
A software program that attacks computer systems with the intention of damaging or destroying files
"A listing of psychiatric disorders that includes corresponding ICD-9-CM codes (i.e. 315.31, Expressive Language Disorder)"
Indicator measurement system
An indicator-based monitoring system developed by The Joint Commission for accredited organizations and meant to provide hospitals with information on their performance
Unique physician identification number (UPIN)
A unique numerical identifier created by the Centers for Medicare and Medicaid Services for use by physicians who bill for services provided to Medicare patients
An infection acquired by a patient while receiving care or services in a healthcare organization
Any learning technique that has as its purpose to classify or predict attributes of objects or individuals
A program that directs the hardware components of a computer system to perform the tasks required
A patient admitted to the hospital for an intended stay of less than twenty-four hours and who is considered an outpatient and not included in inpatient hospital census statistics
Workgroup on Electronic Data Interchange (WEDI)
A subgroup of Accreditation Standards Committee X12 that has been involved in developing electronic data interchange standards for billing transactions
Anesthesia death rate
The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time
A statement of those conditions coexisting during a hospital episode that affect the treatment received or the length of stay
An integrated data dictionary (which is a component of a database management system) that generally contains information on data tables and relationships in addition to data definitions
Patient encounters that take place on an outpatient basis in a clinic within a teaching environment
"Any injury, disease, or physical condition occurring prior to an arbitrary date before the insured's enrollment date of coverage, medical advice, diagnosis, care, or treatment was recommended or received; Healthcare coverage may be denied for a period of time for a pre-existing condition, but the Health Insurance Portability and Accountability Act constrains the use of exclusions for pre-existing conditions and establishes requirements exclusions for pre-existing conditions must satisfy"
A specific description of the services or deliverable goods to be provided as the result of a business process
Equal Pay Act of 1963 (EPA)
The federal legislation that requires equal pay for men and women who perform substantially the same work
Continuous speech technology
A computer technology that automatically translates voice patterns into written language in real time. Sometimes called continuous speech recognition
Singleton ambulatory patient groups
"An ambulatory patient group assigned to a patient claim that, after consolidation of significant procedures and packaging of ancillaries, is part of a visit with no remaining multiple significant procedures"
"A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility"
"The oversight of facilities, equipment, and other resources, including human resources and technology, to reduce the possibility of harm to or theft of these assets of an organization"
Capital budget process
A four-stage process organizations follow to determine what capital projects to include in the budget
"A mental or physical limitation affecting major life activities, arising before adulthood, and usually lasting throughout life"
Health Care Quality Improvement Program (HCQIP)
"A quality initiative begun in 1992 by the Health Care Financing Administration and implemented by peer review organizations that uses patterns of care analysis and collaboration with practitioners, beneficiaries, providers, plans, and other purchasers of healthcare services to develop scientifically based quality indicators and to identify and implement opportunities for healthcare improvement"
"A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region"
American Hospital Association (AHA)
"The national trade organization that provides education, conducts research, and represents the hospital industry's interests in national legislative matters; membership includes individual healthcare organizations as well as individual healthcare professionals working in specialized areas of hospitals, such as risk management; one of the four Cooperating Parties on policy development for the use of ICD-9-CM"
Mohs' micrographic surgery
"A type of surgery performed to remove complex or ill-defined skin cancer, requiring a single physician to act in two integrated, but separate and distinct, capacities: surgeon and pathologist"
Community health information network (CHIN)
"An integrated collection of computer and telecommunications capabilities that facilitates communications of patient, clinical, and payment information among multiple providers, payers, employers, and related healthcare entities within a community"
Request for information (RFI)
A written communication often sent to a comprehensive list of vendors during the design phase of the systems development life cycle to ask for general product information
Continuing medical education (CME)
"Activities such as accredited sponsorship, nonaccredited sponsorship, medical teaching, publications that advance medical care and other learning experiences, proof of which is required for a physician to maintain certification"
"Civil Rights Act
Title VII (1964)","The federal legislation that prohibits discrimination in employment on the basis of race, religion, color, sex, or national origin"
A risk management strategy that includes developing and revising policies and procedures that are both facilitywide and department specific
"The daily publication of the U.S. Government Printing Office that reports all changes in regulations and federally mandated standards, including HCPCS and ICD-9-CM codes"
Healthcare information system (HIS)
"A transactional system used in healthcare organizations (for example, patient admitting, accounting, and receivables)"
An international network of computer servers that provides individual users with communications channels and access to software and information repositories worldwide
"A patient who presents with a medical condition with a significant degree of instability and disability and who needs to be monitored, evaluated, and assessed to determine whether he or she should be admitted for inpatient care or discharged for care in another setting"
Major teaching hospital
A hospital that provides clinical education to one hundred or more resident physicians
An event or a factor that is outside a study but occurs concurrently with the study
Healthcare information standards
"Guidelines developed to standardize data throughout the healthcare industry (for example, developing uniform terminologies and vocabularies)"
Radio frequency identification (RFID)
An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and does not require direct contact
Average record delinquency rate
The monthly average number of discharges divided by the monthly average number of delinquent records
Centers for Disease Control and Prevention (CDC)
A group of federal agencies that oversee health promotion and disease control and prevention activities in the United States
Application service provider (ASP)
"A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage or transaction-based pricing"
Digits or bits summed according to arbitrary rules and used to verify the integrity of numerical data
A biomedical research study in which both the exposure and the disease outcome are determined at the same time in each subject
Chief medical informatics officer (CMIO)
"An emerging position, typically a physician with medical informatics training, that provides physician leadership and direction in the deployment of clinical applications in healthcare organizations"
A study designed to observe outcomes or events that occur after the identification of a group of subjects to be studied
"Data that provides a detailed description about other data; Information about a particular data set or document that describes how, when, and by whom it was collected, created, accessed, or modified and how it is formatted. Metadata can be altered intentionally or inadvertently and can be extracted when native files are converted to images. Some metadata, such as file dates and sizes, can easily be seen by users; other metadata can be hidden or embedded and unavailable to computer users who are not technically adept. Metadata is generally not reproduced in full form when a document is printed. (The Sedona Conference 2005, 28)"
A work schedule in which two or more individuals share the tasks of one full-time or one full-time-equivalent position
Coordination of benefits (COB) transaction
The electronic transmission of claims and/or payment information from a healthcare provider to a health plan for the purpose of determining relative payment responsibilities
"1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements"
Public Company Accounting Oversight Board (PCAOB)
A not-for-profit organization that oversees the work of auditors of public companies
Nominal group technique
"A group process technique that involves the steps of silent listing, recording each participant's list, discussing, and rank ordering the priority or importance of items; allows groups to narrow the focus of discussion or to make decisions without becoming involved in extended, circular discussions"
Software that evaluates the clinical consistency and completeness of health record information and identifies potential errors that could affect accurate prospective payment group assignment
Group model health maintenance organization
A type of health plan in which an HMO contracts with an independent multispecialty physician group to provide medical services to members of the plan
"The application of e-commerce to the healthcare industry, including electronic data interchange and links among healthcare entities"
Professional standards review organization (PSRO)
An organization responsible for determining whether the care and services provided to hospital inpatients were medically necessary and met professional standards in the context of eligibility for reimbursement under the Medicare and Medicaid programs
"Health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay"
"Resources expended that vary with the activity of the organization, for example, medication expenses vary with patient volume"
Galen Common Reference Model (CRM)
A computer-based clinical terminology developed in Europe for representing medical concepts
Durable power of attorney for healthcare (DPAHC)
A third party designated by a competent individual to make healthcare decisions for that individual should he or she become incompetent
Clinical practice guidelines
"A detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society or government agency"
A list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan
A group formed by a HIPAA-covered entity to review research studies where authorization waivers are requested and to ensure the HIPAA privacy rights of research subjects
The process of performing an impact analysis and obtaining approval before modifications to the project scope are made
"An activity, event, occurrence, or outcome that is to be monitored and evaluated under The Joint Commission standard in order to determine whether those aspects conform to standards; commonly relates to the structure, process, and/or outcome of an important aspect of care; also called a criterion 2. A measure used to determine an organization's performance over time"
Data with inherent order and with higher numbers usually associated with higher values
"A category; in ICPC, the two digits following the first character of an ICPC code and representing the second axis, components"
Incident report review
An analysis of incident reports or an evaluation of descriptions of adverse events
Radioimmunoprecipitation assay (RIPA)
One of the tests used to confirm a diagnosis of acquired immunodeficiency syndrome (AIDS)
The impartial administration of policies or laws that takes into consideration the competing interests and limited resources of the individuals or groups involved
A research design that resembles experimental research but lacks random assignment to a group and manipulation of treatment
American Medical Association (AMA)
"The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters; maintains and publishes the Current Procedural Terminology (CPT) coding system"
"A field of study that applies ethical principles to decisions that affect the lives of humans, such as whether to approve or deny access to health information"
Priority focus process (PFP)
"A process used by the Joint Commission to collect, analyze, and create information about a specific organization being accredited in order to customize the accreditation process"
An implicit form of group consensus in which openness and effective decision making are sacrificed to conformity
Medicare volume performance standard (MVPS)
A goal for the annual rate of growth in Part B expenditures for physicians' services
Medicare secondary payer
"One of the edits in the outpatient and inpatient code editors that reviews claims to determine if the claim should be paid by another form of insurance, such as workers' compensation or private insurance in the event of a traffic accident"
"Documentation of the process for responding to a system emergency, including the performance of backups, the line-up of critical alternative facilities to facilitate continuity of operations, and the process of recovering from a disaster"
The management level in an organization that is concerned primarily with facilitating the work performed by supervisory- and staff-level personnel as well as by executive leaders
Geometric mean length of stay (GMLOS)
"A statistically adjusted value of all cases of a given diagnosis-related group (MS-DRG), allowing for the outliers, transfer cases, and negative outlier cases that would normally skew that data; used to compute hospital reimbursement for transfer cases"
Patient's expected sources of payment
"Regardless of payment method, the primary source expected to be responsible for the largest percentage of a patient's current bill"
"The process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record; the formatting and/or structuring of captured information"
A process that involves the use of algorithms to translate or map clinical nomenclatures among each other or to map natural language to a clinical nomenclature or vice versa
All patient refined diagnosis-related groups (APR-DRGs)
"An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient's illness"
"The particular strategy used by a researcher to collect, analyze, and present data"
"The process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care "
Retrospective payment system
Type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered
"The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"
Commission on Accreditation of Rehabilitation Facilities (CARF)
"A private, not-for-profit organization that develops customer-focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards"
Regenstrief LOINC Mapping Assistant (RELMA)
A free Microsoft Windows software download that provides LOINC users help in working with LOINC database files
"The numerical assignment that is part of the formula by which a specific dollar amount, or reimbursement, is calculated for each diagnosis-related group or each ambulatory payment classification"
Long-term care diagnosis related group (LTC-DRG)
"Inpatient classification that categorizes patients who are similar in terms of diagnoses and treatments, age, resources used, and lengths of stay. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. LTC-DRGs are exactly the same as the DRGs for the inpatient prospective payment system (IPPS)."
Health information management services (HIMS)
One of several names for the health record department. This name is meant to provide a better description of the function of the department- the management of health information
Not otherwise specified (NOS)
A type of classification that denotes a lack of information in the record and means unspecified rather than not elsewhere classified
The process of coordinating the activities related to the release of a patient when inpatient hospital care is no longer needed
"The granting of permission to disclose confidential information; as defined in terms of the HIPAA privacy rule, an individual's formal, written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment, or healthcare operations"
"1. Review by like professionals, or peers, established according to an organization's medical staff bylaws, organizational policy and procedure, or the requirements of state law; the peer review system allows medical professioanls to candidly critique and criticize the work of their colleagues without fear of reprisal 2. The process by which experts in the field evaluate the quality of a manuscript for publication in a scientific or professional journal"
Current Procedural Terminology (CPT) Category II Code
A CPT code the represents services and/or test results that contribute to positive health outcomes and quality patient care
"A learning delivery mode in which the instructor, the classroom, and the students are not all present in the same location and at the same time"
A specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports
"The individuals involved in installing, configuring, managing, monitoring, securing, and maintaining network computer applications and responsible for supporting the network infrastructure and controlling user access"
Decision support system that focuses on providing access to the various data sources within the organization through one system
"An infection occurring in a patient in a hospital or healthcare setting in whom the infection was not present or incubating at the time of admission, or the remainder of an infection acquired during a previous admission"
The procedure performed for the definitive treatment of a condition (as opposed to a procedure performed for diagnostic or exploratory purposes) or for care of a complication
Advanced decision support
Automated clinical practice guidelines that are built in to electronic health record systems and designed to support clinical decision making
Universal chart order
A system in which the health record is maintained in the same format while the patient is in the facility and after discharge
"Any account set up to adjust the historical value of a balance sheet account (for example, cumulative depreciation is a contra-account to an equipment [fixed-asset] account)"
Total billed charges
All charges for procedures and services rendered to a patient during a hospitalization or encounter
Chart order policy
A policy that provides a detailed listing of all documents and defines their order and section location within the health record
"An increase in a case-mix index that occurs through the coding of higher-paying principal diagnoses and of more complications and comorbidities, even though the actual severity level of the patient population did not change"
"A broad array of psychiatric services provided in acute, long-term, and ambulatory care settings; includes treatment of mental disorders, chemical dependency, mental retardation, and developmental disabilities, as well as cognitive rehabilitation services"
1. A training method in which an experienced person gives advice to a less-experienced worker on a formal or informal basis 2. A disciplinary method used as the first step for employees who are not meeting performance expectations
Health care record
"As distinguished from a medical record. The health care record is the service provider's care data collection and processing tool as well as the documentation of care in a broader sense. This term includes that information processing that, while useful, would not meet the definitional requirements of a medical record, thus encompassing purposes that extend outside or do not qualify as meeting requirements for the more well-defined domain of a medical record. This also then is inclusive of those documentation and data gathering activities that may not meet the validity requirements of a true medical record. "
Procedures and services (outpatient)
"All medical procedures and services of any type (including history, physical examination, laboratory, x-ray or radiograph, and others) that are performed pertinent to the patient's reasons for the encounter, all therapeutic services performed at the time of the encounter, and all preventive services and procedures performed at the time of the encounter"
"The total membership each month accumulated for a given time period (for example, one hundred members serviced each month for six months equals six hundred member months)"
Clinical data manager
"The person responsible for managing the data collected during the research project, developing data standards, conducting clinical coding for specific data elements, determining the best database to house the data, choosing appropriate software systems to analyze the data, and conducting data entry and data analysis; various responsibilities according to the research study protocol"
Resource-based relative value scale (RBRVS)
A Medicare reimbursement system implemented in 1992 to compensate physicians according to a fee schedule predicated on weights assigned on the basis of the resources required to provide the services
The tax status assigned to business entities that are owned by one or more individuals or organizations and that earn revenues in excess of expenditures that are subsequently paid out to the owners or stockholders
Mathematical computations that compare elements of an organization's financial statements to past and future performance trends and industry benchmarks
Ancillary service visit
"The appearance of an outpatient in a unit of a hospital or outpatient facility to receive services, tests, or procedures; ordinarily not counted as an encounter for healthcare services"
"Logical Observation 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"
An organized form of charting narrative notes in which nursing terminology is used to explain the resident's health status and resulting nursing action
Dollars in accounts receivable
The amount of money owed a healthcare facility when claims are pending
"The process of realigning the needs of the organization with the skills and interests of the employee and then designing the job to meet those needs (for example, in order to introduce new tools or technology or provide better customer service)"
"The pertinent information about a patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems"
Skilled nursing facility (SNF)
"A long-term care facility with an organized professional staff and permanent facilities (including inpatient beds) that provides continuous nursing and other health-related, psychosocial, and personal services to patients who are not in an acute phase of illness but who primarily require continued care on an inpatient basis"
A situational leadership theory that emphasizes the role of the leader in removing barriers to goal achievement
Decision support system (DSS)
A computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision-making tasks associated with nonroutine and nonrepetitive problems
Medical classification system
A method of arranging related diseases and conditions into groups to be reported as quantitative data for statistical purposes
Internal rate of return (IRR)
An interest rate that makes the net present value calculation equal zero
The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements
"In the language of The Joint Commission (JC), the degree to which the treatment intervention used for a patient has been shown to accomplish the desired/projected outcomes"
Scope of command
The number and type of employees who report to a specific management position in a defined organizational structure
Integrated health record format
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
A computer program that assigns inpatient cases to diagnosis-related groups and determines the Medicare reimbursement rate
Reports of outcomes measures to help leaders know what they have accomplished; sometimes called dashboards
"A decision that involves careful and deliberate thought and discussion because of a unique, complex, or changing situation"
"A type of research that focuses on the use of scientific theories to improve actual practice, as in medical research applied to the treatment of patients"
Ambulatory surgery center or ambulatory surgical center (ASC)
"Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, record keeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation"
Ethical decision making
"The process of requiring everyone to consider the perspectives of others, even when they do not agree with them"
Outcomes and Assessment Information Set (OASIS)
A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs
Health services research
Research conducted on the subject of healthcare delivery that examines organizational structures and systems as well as the effectiveness and efficiency of healthcare services
Early fetal death
The death of a product of human conception that is fewer than twenty weeks of gestation and 500 grams or less in weight before its complete expulsion or extraction from the mother
An information transmission system in which data are encoded into short units (packets) and sent through an electronic communications network
"Type of prospective payment method in which the third party payer reimburses the provider a fixed, pre-established payment for each case"
Health information exchange (HIE)
The electronic movement of health-related information among organizations according to nationally recognized standards
An inpatient who was born in a hospital at the beginning of the current inpatient hospitalization
Department of Health and Human Services (HHS or DHHS)
The cabinet-level federal agency that oversees all the health- and human-services-related activities of the federal government and administers federal regulations
The federal regulations created to implement the security requirements of the Health Insurance Portability and Accountability Act of 1996
Healthcare practitioner identification
A unique national identification number assigned to the healthcare practitioner of record for each encounter
Health Information Security and Privacy Collaboration (HISPC)
An organization for exchanging ideas and developing solutions to promote interoperability
"Data that fall into groups or categories that are mutually exclusive and with no specific order (for example patient demographics such as third party payer, race, and sex)"
World Organization of Family Doctors (Wonca)
"The organization instrumental in the development of the International Classification of Primary Care; formerly called the World Organization of National Colleges, Academics, and Academic Associations of General Practitioners/Family Physicians (Wonca)"
A computer architecture built with a single central processing unit to which dumb terminals and/or personal computers are connected
A Minimum Data Set for Long-Term Care completed solely for the purpose of Medicare rate setting for skilled nursing facilities
Acute care prospective payment system
"The Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare Severity Diagnosis Related Groups (MS-DRGs) classification system, which determines payment rates"
Omnibus Budget Reconciliation Act (OBRA) of 1989
"The federal legislation that mandated important changes in the payment rules for Medicare physicians; specifically, the legislation that requires nursing facilities to conduct regular patient assessments for Medicare and Medicaid beneficiaries"
"The lowest tier of state court, usually divided into two courts: the court of limited jurisdiction, which hears cases pertaining to a particular subject matter or involving crimes of lesser severity or civil matters of lower dollar amounts; and the court of general jurisdiction, which hears more serious criminal cases or civil cases that involve large amounts of money"
The proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time
Simultaneous analysis of data from multiple dimensions using different data elements
Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism
A health record of an individual who is a currently hospitalized inpatient or an outpatient
One or more surgical procedures performed at one time for one patient via a common approach or for a common purpose
Patient assessment instrument (PAI)
"A standardized tool used to evaluate the patient's condition after admission to, and at discharge from, the healthcare facility"
Maternal mortality rate (community based)
A rate that measures the deaths associated with pregnancy for a specific community for a specific period of time
"Undetermined aspects of a project that are considered to be true (for example, assuming that project team members have the right skill set to perform their duties)"
Diagnosis chiefly responsible for services provided (outpatient)
"The diagnosis, condition, problem, or reason for an encounter/visit that is chiefly responsible for the services provided"
Hospital newborn inpatient
A patient born in the hospital at the beginning of the current inpatient hospitalization
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
Nursing assessment record (NAR)
A form used to track patients' functional status; supports the Minimum Data Set (MDS) process
The formal acceptance by a healthcare organization of a patient whose condition permits adequate time to schedule the availability of a suitable accommodation
A person in an ambulatory care or a physician office setting who is generally responsible for processing the superbill
Outpatient prospective payment system (OPPS)
The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications
A hypothesis that states that there is an association between independent and dependent variables
Information used for administrative and healthcare operations purposes such as billing and quality oversight
Entity relationship diagram (ERD)
A specific type of data modeling used in conceptual data modeling and the logical-level modeling of relational databases
"Rules, conditions, or requirements developed to ensure the privacy of patient information"
Per diem (per day)
Type of prospective payment method in which the third party payer reimburses the provider a fixed rate for each day a covered member is hospitalized
National Regulatory Commission
A body that has oversight responsibility for the medical use of ionizing radiation and to which medical events must be reported
Unified Medical Language System (UMLS) SPECIALIST Lexicon
An English-language lexicon containing biomedical terms
Chief operating officer (COO)
An executive-level role responsible at a high level for day-to-day operations of an organization
Qui tam litigation
'Provisions within the law that allow for persons or entities with evidence of fraud against federal programs or contracts to sue the wrongdoer on behalf of the government' (Source: The False Claims Act Legal Center)
Blue Cross and Blue Shield Federal Employee Program (FEP)
A federal program that offers a fee-for-service plan with preferred provider organizations and a point-of-service product
Geographic adjustment factor (GAF)
Adjustment to the national standardized Medicare fee schedule relative value components used to account for differences in the cost of practicing medicine in different geographic areas of the country
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
National Vital Statistics System (NVSS)
A federal agency responsible for the collection of official vital statistics for the United States
Evaluation and management (E/M) services
"The history, examination, and medical decision-making services that physicians must perform in evaluating and treating patients in all healthcare settings "
Critical performance measures
"Those outputs by which the quality of an organization's services will be measured by patients, clients, visitors, and the community"
A reimbursement method that allows providers to bill patients for charges in excess of the amount paid by the patients' health plan or other third-party payer (not allowed under Medicare or Medicaid)
A continuous or intermittent procedure in which dialyzing solution is introduced into and removed from the peritoneal cavity to cleanse the body of metabolic waste products
"The testing step in EHR implementation that ensures that each data element is captured, recorded, and processed appropriately within a given application"
A type of ordinal data where the group of observations is first arranged from highest to lowest according to magnitude and then assigned numbers that correspond to each observation's place in the sequence
"A concise statement, usually stated in the patient's words, describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for a healthcare encounter"
Newborn bassinet count day
"A unit of measure that denotes the presence of one newborn bassinet, either occupied or vacant, set up and staffed for use in one 24-hour period"
"Logic (algorithms) within computer software that evaluates data. Medicare's Standard Claims Processing System (or PSC Supplemental Edit Software) and its Outpatient Code Editor (OCE) contain editors that select certain claims, evaluate, or compare information on the selected claims or other accessible source, and depending on the evaluation, take actions on the claims, such as pay in full, pay in part, or suspend for manual review"
Department of a provider
"A facility, organization, or physician's office that is either created or acquired by a main provider for the purpose of furnishing healthcare services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of the ambulatory payment classification final rule"
The continuous and comprehensive care provided at first contact with the healthcare provider in an ambulatory care setting
Rate of return method
A method used to justify a proposed capital expenditure in which the organization tries to find out what rate of return it would get if it invests in a particular project
"Resources expended that can be identified as pertaining to specific goods and/or services (for example, medications pertain to specific patients)"
An employee who is not assigned to a particular shift or function and who may fill in as needed in cases of standard employee absence or vacation
The legal protection from confidential communications between physicians and patients related to diagnosis and treatment from being disclosed during civil and some misdemeanor litigation
Underlying cause or origin of a problem that leads to a certain diagnosis or condition
Designated individual who monitors the compliance process at a healthcare facility
National conversion factor (CF)
A mathematical factor used to convert relative value units into monetary payments for services provided to Medicare beneficiaries
"A provider that either creates or owns another entity in order to deliver additional healthcare services under its name, ownership, and financial and administrative control"
"Descriptions (including, where possible, the national drug code, dosage, strength, and total amount prescribed) of all medications prescribed or provided by the healthcare practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients)"
The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients
"The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization; or the systematic comparison of one organization's otucomes with regional or national standards"
Need for intervention
A term that relates to the severity-of-illness consequences that would result from the lack of immediate or continuing medical care
Integrated delivery system (IDS)
"A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care"
An organization that processes and/or reformats electronic claims to insurers on behalf of multiple healthcare providers
Plan of care (POC)
A term referring to Medicare home health services for homebound beneficiaries that must be delivered under a plan established by a physician
A method of research in which researchers act as neutral observers who do not intentionally interact or affect the actions of the population being observed
"Four types of data (nominal, ordinal, interval, and ratio) that represent values or observations that can be sorted into a category"
Physician assistant (PA)
A healthcare professional licensed to practice medicine with physician supervision
"A set of concepts and relationships that provide a common consultation point for the comparison and aggregation of data about the entire healthcare process, recorded by multiple individuals, systems, or institutions"
The time required to acquire and apply certain skills so that new levels of productivity and/or performance exceed prelearning levels (productivity often is inversely related to the learning curve)
The location where the bodies of deceased persons are kept until identified and claimed or are released for burial
Civil proceeding (action)
"An action brought to enforce, redress, or protect private rights or to protect a private right or compel a civil remedy in a dispute between private parties (in general, all types of actions other than criminal proceedings)"
A type of short-term care provided during the day or overnight to individuals in the home or institution to temporarily relieve the family home caregiver
American College of Surgeons (ACS)
The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice
Notice of Proposed Rulemaking (NPRM)
Notice published in the Federal Register calling for public comment on its policy; the public at large has a specified time period to submit comments
The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes
A set of conventions that governs the exchange of data between hardware and/or software components in a communications network
Multidimensional online analytical processing (MOLAP)
A data access methodology that is coupled tightly with a multidimensional database management system to allow the user to perform business analyses
Available for hospital autopsy
A situation in which the required conditions have been met to allow an autopsy to be performed on a hospital patient who has died
A recapitulation of an individual's stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility
"The foundations of caregiving, which include buildings (environmental services), equipment (technical services), professional staff (human resources), and appropriate policies (administrative)"
"A method of performance evaluation in which the supervisors, peers, and other staff who interact with the employee contribute information"
Resident assessment protocol (RAP)
A summary of a long-term care resident's medical condition and care requirements
A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time; a relatively continuous period in relation to a particular clinical problem or situation; they include multiple services and may include multiple providers of care
The process of writing off an unpaid balance on a patient account to make the account balance
"A listing of drugs, classified by therapeutic category or disease class; in some health plans, providers are limited to prescribing only drugs listed on the plan's formulary. The selection of items to be included in the formulary is based on objective evaluations of their relative therapeutic merits, safety, and cost"
One of the four management functions in which performance is monitored in accordance with organizational policies and procedures
The regular and frequent assessment of healthcare processes and their outcomes and related costs
Average payment rate (APR)
The amount of money the Centers for Medicare and Medicaid could pay a health maintenance organization for services rendered to Medicare recipients under a risk contract
A type of employee coaching and training in which an individual is matched with a more experienced individual who serves as an advisor or counselor
A care-planning tool similar to a clinical practice guideline that has a multidisciplinary focus emphasizing the coordination of clinical services; also known as clinical algorithm
Applied healthcare informatics
"Automated information systems applied to healthcare delivery business and work-flow processes, including the diagnosis, therapy, and systems of managing health data and information within the healthcare setting"
"Specific instructions for performing clinical procedures established by authoritative bodies, such as medical staff committees, and intended to be applied literally and universally"
Type of health maintenance organization (HMO) in which the HMO contracts with two or more medical groups and reimburses the groups on a fee-for-service or capitation basis
"A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences"
Program evaluation and review technique (PERT) chart
A project management tool that diagrams a project's time lines and tasks as well as their interdependencies
A leadership model proposed by Blake and Mouton and based on a grid measure of concern for people and production
A type of coding that takes place after the patient has been discharged and the entire health record has been routed to the health information management department
A coder who is hired as an independent contractor on temporary basis to assist with coding backlog
Management information system (MIS)
A computer-based system that provides information to a healthcare organization's managers for use in making decisions that affect a variety of day-to-day activities
An opportunity to improve patient safety-related practices based on a condition or incident with potential for more serious consequences
Medical staff organization (MSO)
A self-governing entity that operates as a responsible extension of the governing body and exists for the purpose of providing patient care
Administrative information systems
"A category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions"
Wireless local-area network (WLAN)
A data transmission network that uses an unguided medium such as radio waves or microwaves
A documented response that alerts a skilled nursing facility resident assessment instrument assessor to the fact that further research is needed to clarify an assessment
A type of survey in which the members of the population are questioned through the use of electronic or paper forms
"The very large, multipurpose, and multilingual vocabulary database that is the central vocabulary component of the Unified Medical Language System"
"The data collected for the purpose of managing the assets and expenses of a business (for example, a healthcare organization, a product line); in healthcare, data derived from the charge generation documentation associated with the activities of care and then aggregated by specific customer grouping for financial analysis"
disclosures, and requests","Three types of situations in which personal health information is handled: use, which is internal to a covered entity or its business associate; disclosure, which is the dissemination of PHI from a covered entity or its business associate; and requests for PHI made by a covered entity or its business associate"
A transitional staffing solution wherein workers are brought in for specific projects or to cover in busy times
An alternative hypothesis in which the researcher makes a prediction in one direction
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"
"1. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient 2. A process that integrates and coordinates patient care over time and across multiple sites and providers, especially in complex and high-cost cases, with goals of continuity of care, cost-effectiveness, quality, and appropriate utilization 3. The process of developing a specific care plan for a patient that serves as a communication tool to improve quality of care and reduce cost"
Behavioral description interview
An interview format that requires applicants to give specific examples of how they have performed a specific procedure or handled a specific problem in the past
"A statement of ethical principles to prevent the unethical use of human subjects in research, sponsored by the Department of Health and Human Services"
"A study design in which (typically) the investigator but not the subject, knows the identity of the treatment and control groups"
A single encounter with a healthcare professional that includes all of the services supplied during the encounter
Simulation and inventory modeling
The key components of a plan that are computer simulated for testing and experimentation so that optimal operational procedures can be found
Object-oriented database (OODB)
"A type of database that uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways"
The response by one healthcare professional to another healthcare professional's request to provide recommendations and/or opinions regarding the care of a particular patient/resident
Inpatient Rehabilitation Validation and Entry (IRVEN)
A computerized data-entry system used by inpatient rehabilitation facilities (IRFs). Captures data for the IRF Patient Assessment Instrument (IRF PAI) and supports electronic submission of the IRF PAI. Also allows data import and export in the standard record format of the Centers for Medicare and Medicaid Services (CMS)
"A group of clinical specialties that concentrates on the provision of nonsurgical care by physicians who have received advanced training in internal medicine, pediatrics, cardiology, endocrinology, psychiatry, oncology, nephrology, neurology, pulmonology, gastroenterology, dermatology, radiology, and nuclear medicine, among many other concentrations"
An information system that operates independently of a CPR system but provides data to it
A type of professional or scientific journal for which content experts evaluate articles prior to publication
Inpatient psychiatric facility PPS (IPFPPS)
"A per diem prospective payment system that is based on fifteen diagnosis-related groups, which became effective on January 1, 2005"
1. The probability of incurring injury or loss; 2. The probable amount of loss foreseen by an insurer in issuing a contract 3. A formal insurance term denoting liability to compensate individuals for injuries sustained in a healthcare facility
Registered health information administrator (RHIA)
A type of certification granted after completion of an AHIMA-accredited four-year program in health information management and a credentialing examination
An Internet technology that consolidates documents from different information systems within an organization into a tightly integrated workflow
Application programming interface (API)
A set of definitions of the ways in which one piece of computer software communicates with another or a programmer makes requests of the operating system or another application; operates outside the realm of the direct user interface
Chief knowledge officer (CKO)
"A position that oversees the entire knowledge acquisition, storage, and dissemination process and that identifies subject matter experts to help capture and organize the organization's knowledge assets"
Accreditation Association for Ambulatory Health Care (AAAHC)
"A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single-specialty and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers"
The level of voltage (low or high) in a computer that provides the binary states of 0 and 1 that computers use to represent characters
reproducible, and useful (URU) principle","The guiding principal for modeling concepts in SNOMED CT, which states that all concepts must be understandable, reproducible, and useful"
American Association of Medical Record Librarians (AAMRL)
The name adopted by the Association of Record Librarians of North America in 1944; precursor of the American Health Information Management Association
Pharmacy and therapeutics (P and T) committee
"The multidisciplinary committee that oversees and monitors the drugs and therapeutics available for use, the administration of medications and therapeutics, and the positive and negative outcomes of medications and therapeutics used in a healthcare organization"
Freedom of Information Act (FOIA)
"The federal law, applicable only to federal agencies, through which individuals can seek access to information without the authorization of the person to whom the information applies"
Universal patient identifier
"A personal identifier applied to a patient, such as a number or code, that is used permanently for many and varied purposes"
An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm
prevailing and reasonable (CPR) charge payment method","Type of retrospective fee-for-service payment method, used by Medicare until 1992 to determine payment amounts for physician services, in which the third party payer pays for fees that are customary, prevailing, and reasonable"
An accounting concept in which assets are classified at historical cost or current value
A type of graph that shows data points collected over time and identifies emerging trends or patterns
"A predetermined period of time, such as a fiscal year, in which a project budget will be spent"
Legal health record (LHR)
The form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization's legal health record varies depending on how the organization defines it
"Statistical technique that uses an independent variable to predict the value of a dependent variable. In the inpatient psychiatric facility prospective payment system (IPF PPS), patient demographics and length of stay (independent variables) were used to predict cost of care (dependent variable)"
A type of care that is not directed toward a cure or restoration to a previous state of health but includes medical or nonmedical services provided to maintain a given level of health without skilled nursing care
A management system in which practices based on research evidence will be effective and produce the outcomes they claim
Registered health information technician (RHIT)
A type of certification granted after completion of an AHIMA-accredited two-year program in health information management and a credentialing examination
"The form in which data are stored, as in a file, a database, a data repository, and so on"
Metropolitan statistical area (MSA)
"Core-based statistical area associated with at least one urbanized area that has a population of at least 50,000. The MSA comprises the central county or counties containing the core, plus adjacent outlying counties"
Any neonate whose birth occurs through the end of the last day of the thirty-eighth week (two hundred sixty-sixth day) following onset of the last menstrual period
A provisional description of the reason why a patient requires care in an inpatient hospital setting
Discharge and readmit
A situation in which a home health provider receives a prorated partial episode payment for the original episode when a beneficiary is discharged and readmitted to the same agency within the same sixty-day period
Chief privacy officer
"A position that (1) oversees activities related to the development, implementation, and maintenance of, and adherence to, organizational policies and procedures regarding the privacy of and access to patient-specific information and (2) ensures compliance with federal and state laws and regulations and accrediting body standards concerning the confidentiality and privacy of health-related information"
The type of permission that is inferred when a patient voluntarily submits to treatment
Extended care facility
"A healthcare facility licensed by applicable state or local law to offer room and board, skilled nursing by a full-time registered nurse, intermediate care, or a combination of levels on a twenty-four-hour basis over a long period of time"
Acceptance theory of authority
A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions
"The marital state of the patient at the start of care (for example, married, living together, not living together, never married, widowed, divorced, separated, or unknown/not stated)"
A means of gathering data about a process in which participants in the process are observed
"A type of highly specialized care provided by specialists (such as neurosurgeons, fertility specialists, or immunologists) who use sophisticated technology and support services"
Health management information system (HMIS)
"An information system whose purpose is to provide reports on routine operations and processing (for example, a pharmacy inventory system, radiological system, or patient-tracking system)"
"The ability to apply research results, data, or observations to groups not originally under study"
Health systems agency (HSA)
A type of organization called for by the Health Planning and Resources Development Act of 1974 to have broad representation of healthcare providers and consumers on governing boards and committees
Private branch exchange (PBX)
A switching system for telephones on private extension lines that allows access to the public telephone network
Managers who oversee small (two- to ten-person) functional workgroups or teams and often perform hands-on functions in addition to supervisory functions
Context-based access control
"An access control system which limits users to accessing information not only in accordance with their identity and role, but to the location and time in which they are accessing the information "
A situation that has the potential to damage a healthcare organization's information system
"A measurement of the end results of a clinical process (for example, complications, adverse effects, patient satisfaction) for an individual patient or a group of patients within a specific diagnostic category"
"An individual who has not received professional services from the physician, or any other physician of the same specialty in the same practice group within the past three years"
"Software module in a Medicare claim-processing systems, specific to certain benefits, used in pricing claims and calculating payment rates and payments, most often under prospective payment systems"
Inpatient coding compliance
"The accurate and complete assignment of ICD-9-CM diagnostic and procedural codes, along with appropriate sequencing (for example, identification of principal diagnosis) to determine the appropriate diagnosis-related group and resultant payment"
"A four-step process for shaping employee behavior to conform to the requirements of the employee's job position that begins with a verbal caution and progresses to written reprimand, suspension, and dismissal upon subsequent offenses"
Corporate Code of Conduct
A part of the compliance plan which expresses the organization's commitment to ethical behavior
"An acute care facility's formal acceptance of a patient who is to be provided with room, board, and continuous nursing service in an area of the facility where patients generally stay at least overnight"
Medical malpractice insurance
Insurance that protects a party from claims for medical negligence or other tortious injury arising out of care provided to patients
"Business-related services provided by an insurance organization to self-insured employers or other parties according to an administrative services only contract (for example, actuarial support, benefit plan design, claims processing, data recovery and analysis, employee benefits communication, financial advice, medical care conversions, stop-loss coverage, and other services as requested)"
A classification of surgery that does not have to be performed immediately to prevent death or serious disability
"A subdivision of assets, liabilities, and equities in an organization's financial management system"
"1. Mechanisms for storing records, providing for timely retrieval, and establishing the length of times that various types of records will be retained by the healthcare organization 2. The ability to keep valuable employees from seeking employment elsewhere"
Managed care organization (MCO)
"A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, and/or limiting access to care; also known as a coordinated care organization"
History of present illness (HPI)
A chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present
A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement; the square root of the variance
Carriers (Medicare Part B)
Financial agents that serve under contract with the Centers for Medicare and Medicaid Services to work with providers and the federal government to locally administer Medicare Part B claims
National Uniform Billing Committee (NUBC)
The national group responsible for identifying data elements and designing the CMS-1500
"The circumstance when a bill has been accepted, but payment has been denied for any of several reasons (for example, sending the bill to the wrong insurance company, patient not having current coverage, inaccurate coding, lack of medical necessity, and so on)"
Creation of a cross map that links the content from one classification or terminology scheme to another
Public health services (PHS)
Services concerned primarily with the health of entire communities and population groups
Resident assessment instrument (RAI)
"A uniform assessment instrument developed by the Centers for Medicare and Medicaid Services to standardize the collection of skilled nursing facility patient data; includes the Minimum Data Set 2.0, triggers, and resident assessment protocols"
A disease-specific format developed by the individual provider for the purpose of establishing standard clinical documentation forms
An ingested or injected substance that enhances the appearance of anatomical structures when they undergo imaging
"A method of determining which insurance company is the primary carrier for dependents when both parents carry insurance on them. The rule states that the policyholder with the birthday earliest in the calendar year carries the primary policy for the dependents. If the policyholders are both born on the same day, the policy that has been in force the longest is the primary policy. Birth year has no relevance in this method"
Corporate compliance program
"A facilitywide program that comprises a system of policies, procedures, and guidelines that are used to ensure ethical business practices"
The application of a set of procedures specifically designed to minimize or eliminate the passage of infectious disease agents from one individual to another during the provision of healthcare services
"Skilled in awareness, understanding, and acceptance of beliefs and values of the people of groups other than one's own"
Organization that promotes healthcare safety by giving consumers the information they need to make better-informed choices about the hospitals they choose
"1. A type of information technology that connects different computers and computer systems so that they can share information 2. Physicians, hospitals, and other providers who provide healthcare services to members of a managed care organization; providers may be associated through formal or informal contracts and agreements"
To calculate or predict some future event or condition through study and analysis of available pertinent data
The defined certainty percentage rate with which an occurrence must present itself to satisfy quality standards
Hospital-based ambulatory care center
An organized hospital facility that provides nonemergency medical or dental services to patients who are not assigned to a bed as inpatients during the time services are rendered (an emergency department in which services are provided to nonemergency patients is not considered an ambulatory care center)
A list of patients and their physicians that is usually arranged according to the physician code numbers assigned by the healthcare facility
Private right of action
1. The right of an injured person to secure redress for violation of his or her rights 2. A legal right to maintain an action growing out of a given transaction or state of facts and based thereon or a legal term pertaining to remedy and relief through judicial procedure
A venture with one owner in which all profits are considered the owner's personal income
A communications service that allows a group of people to exchange information over a network by using a combination of video and computer technology
"The form in which a drug is administered to a patient, as opposed to the form in which the manufacturer had supplied it"
An umbrella term used to describe health plans that are funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees' medical expenses and retain control over the funds but bear the risk of paying claims greater than their estimates
"A device for tracking information (for example, reports) missing from a paper-based health record"
A measurable variable in a research study that depends on an independent variable
Regenstrief Medical Records System (RMRS)
One of the nation's first electronic medical record systems and the keystone of Regenstrief Institute activities
A type of active computer technology that sends information directly to the end user as the information becomes available
Clinical Laboratory Improvement Act (CLIA)
"The 1988 reenactment of the 1967 Clinical Laboratory Improvement Act; A law that provides that clinical laboratories are only to disclose test results or reports to 'authorized persons,' who are defined by the law as the person who orders the test unless state law defines them otherwise"
Graphical user interface (GUI)
"A style of computer interface in which typed commands are replaced by images that represent tasks (for example, small pictures [icons] that represent the tasks, functions, and programs performed by a software program)"
Financial Accounting Standards Board (FASB)
An independent organization that sets accounting standards for businesses in the private sector
Any court order or decree whose purpose is to protect a person from personal harassment or service of process or discovery
The process of providing visual or auditory evidence to a person on the status of an autonomic body function (such as the sounding of a tone when blood pressure is at a desirable level) so that he or she learns to exert control over the function
A type of research that determines and reports the current status of topics and subjects
"The process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status, for the purpose of improving care"
Care provided to patients who have been released from an acute care facility to recuperate at home
Community Health Dimension (CHD)
One aspect of a national health information network infrastructure that acknowledges the importance of population-based health data and resources that are necessary to improve public health
A type of medical care designed to relieve the patient's pain and suffering without attempting to cure the underlying disease
American Society for Quality (ASQ)
"A quality improvement organization whose members' interests are related to statistical process control, quality cost measurement and control, total quality management, failure analysis, and zero defects"
Occupational Safety and Health Administration (OSHA)
Federal Occupational Safety and Health Administration (OSHA) regulations ensure that an employee (or designated representative) is given access to his or her own medical and exposure records within 15 days of a request
"The process of organizing and documenting the specific goals in the treatment of an individual patient, amending the goals as the patient's condition requires, and assessing the outcomes of care"
"Unusual situations such as extreme age, total body hypothermia, controlled hypotension, and emergency situations that complicate the provision of anesthesia"
Computer viruses that infect the system areas of diskettes or the hard drive of a computer
Clinical information system (CIS)
A category of a healthcare information system that includes systems that directly support patient care
An investigational technique that facilitates the identification of the various factors that contribute to a problem
Credential verification organization (CVO)
"An organization that verifies healthcare professionals' background, licensing, and schooling, and tracks continuing education and other performance measures"
The release-of-information principle based on the minimum necessary standard that means that only the information needed by a specific individual to perform a specific task should be released
Patient Care Data Set (PCDS)
"A terminology of patient problems, patient care goals, and patient care orders that represents and captures clinical data for inclusion in patient care information systems"
A visual representation of the cause-and-effect relationships among the components of an organization's strategy
Operating documents that describe the rules and regulations under which a healthcare organization operates
"Involves the creation of knowledge through collection, generation, synthesis, identification and organization of knowledge through codification, storage, packaging, and coordination"
Medicare economic index (MEI)
"An index used by the Medicare program to update physician fee levels in relation to annual changes in the general economy for inflation, productivity, and changes in specific health-sector expense factors including malpractice, personnel costs, rent, and other expenses"
A public officer whose principal duty is to inquire via an inquest into the cause of death that there is reason to suppose is not due to natural causes
The process of studying the amount of work accomplished and how long it takes to accomplish work in order to define and monitor productivity
United Nations International Standards Organization (ISO)
An international standards organization that coordinates all international standards development
Forces in the external environment of organizations or industries that force organizations or industries to change the way they operate in order to survive
Type of health maintenance organization that provides hospitalization and physicians' services through its own staff and facilities; beneficiaries are allowed to use only those specified facilities and physicians or dentists who accept the plan or organization's conditions of membership and reimbursement
Virtual reality (VR)
An artificial form of reality experienced through sensory stimuli and in which the participant's actions partly affect what happens
Skilled nursing facility prospective payment system (SNF PPS)
"A per-diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries"
"A cynical belief that employees will advance to their highest level of competence, and then be promoted to their level of incompetence where they will remain (named after the 1993 book by Laurence J. Peter)"
Limitations on the ability of parties to discover pretrial information held by another
"The Joint Commission's initiative designed to assess accreditation models, develop a continuous accreditation process, and test alternative processes for reporting survey findings to hospitals"
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Records removal policy
A policy that outlines how and when records may be removed from the health record department
"The process of restoring a disabled insured to maximum physical, mental, and vocational independence and productivity (commensurate with their limitations) through the identification and development of residual capabilities, job modifications, or retraining"
"A well-organized, user-centered, searchable database system that usually draws information from a data warehouse to meet the specific needs of users"
Physician query process
A communication tool and educational mechanism that provides a clearer picture of specific resident diagnoses when in question
"A rule established by a local branch of government such as a town, city, or county"
The process of applying predefined compensable factors to jobs to determine their relative worth
A field of information science concerned with the management of data and information used to support the practice and delivery of dental healthcare through the application of computers and computer technologies
"The universal insurance claim form developed and approved by the American Medical Association and the Centers for Medicare and Medicaid Services. Physicians use it to bill Medicare, Medicaid, and private insurers for professional services provided"
"A method of determining reimbursement based on predetermined factors, not individual services"
"Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance"
Nursing Information and Data Set Evaluation Center (NIDSEC)
"The Nursing Information and Data Set Evaluation Center was established by the American Nurses Association (ANA) to review, evaluate against defined criteria, and recognize information systems from developers and manufacturers that support documentation of nursing care within automated nursing information systems (NIS) or within computer-based patient record systems (CPR)"
Uniformed Services Employment and Reemployment Rights Act (1994)
"Federal legislation that prohibits discrimination against individuals because of their service in the Armed Forces Reserves, National Guard, or other uniformed services"
Plan-do-study-act (PDSA) cycle
A performance improvement model designed specifically for healthcare organizations
Specified low-income Medicare beneficiaries (SLMBs)
"Medicare beneficiaries who have resources similar to qualified Medicare beneficiaries, but higher incomes, although still less than 120 percent of the federal poverty level"
A system for the prevention of communicable diseases that concentrates on protecting healthcare workers and patients against exposure to disease-causing organisms and promotes compliance with applicable legal requirements through early identification of potential sources of contamination and implementation of policies and procedures that limit the spread of disease
Bar coding technology
"A method of encoding data that consists of parallel arrangements of dark elements, referred to as bars, and light elements, referred to as spaces, and interpreting the data for automatic identification and data collection purposes"
"An entity that performs both covered and noncovered functions under the Privacy Rule; for example, a university that educates students and maintains student educational records is not covered by the Privacy Rule; however, the same university that operates a medical center is covered by the Privacy Rule as it meets the definition of 'healthcare provider'"
The shift of decision-making authority and responsibility to lower levels of the organization
Management level that oversees the organization's efforts at the staff level and monitors the effectiveness of everyday operations and individual performance against preestablished standards
"International Classification on Functioning
Disability and Health (ICF)","Classification of health and health-related domains that describe body functions and structures, activities, and participation"
1. A formal process applied to relational database design to determine which variables should be grouped together in a table in order to reduce data redundancy across and within the table 2. Conversion of various representational forms to standard expressions so that those that have the same meaning will be recognized by computer software as synonymous in a data search
Evidence of insurability
A statement or proof of a person's physical condition and/or other factual information necessary to obtain healthcare insurance in certain situations
"A rule that created standardized procedures and substantive requirements for investigating complaints and imposing civil monetary penalties (CMPs) for HIPAA violations, as well as a uniform compliance and enforcement mechanism that addresses all of the Administrative Simplification regulations, including privacy, security, and transactions and code sets"
Codes that represent the concept in a controlled medical terminology are not reused; therefore meanings do not change
The redetermination of the ambulatory payment classification weights to reflect changes in relative resource consumption
A geographic pricing area historically used by Medicare carriers to calculate physicians' customary and prevailing charges for payment of Part B services
A proprietary clinical terminology developed as a point-of-care tool for electronic medical record documentation at the time and place of patient care
Minimum Data Set for Post Acute Care (MDS-PAC)
"A patient-centered assessment instrument that must be completed for every Medicare patient, which emphasizes a patient's care needs instead of provider characteristics"
"Shortened forms of words or phrases; in healthcare, when there is more than one meaning for an approved abbreviation, only one meaning should be used or the context in which the abbreviation is to be used should be identified"
Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure
"A word or phrase used by a physician to identify a disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care"
A method of approaching conflict in which both parties meet with an objective third party to explore perceptions and feelings
Fax on demand
A service in which a user may select from a list of available fax sources by keying the corresponding number of a fax title or from multiple fax messages via a twelve-digit telephone keypad
Medicare summary notice (MSN)
A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided
An educational technique that requires learning a large amount of material at one time
The construction of pictures generated from computer data in three dimensions
"The development, implementation, and analysis of systems that track financial transactions for management control purposes, including both budget systems and cost analysis systems"
Uniform Ambulatory Care Data Set (UACDS)
A dataset developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient/client-specific data elements to be collected in ambulatory care settings
A computer information system developed exclusively to meet the needs of one healthcare organization
Data Encryption Standard (DES)
A private key encryption algorithm adopted as the federal standard for the protection of sensitive unclassified information and also used extensively for the protection of commercial data
Medical care evaluation studies
Audits required by the Medicare Conditions of Participation that dictate the use of screening criteria with evaluation by diagnosis and/or procedure
Resident's right to access
A term encompassing the mechanisms in place to allow residents to review their own health information
A review of deaths as part of an analysis of ongoing outcome and performance improvement
Geographic area outside an urban area and its constituent counties or count equivalents. Any area not designated as a metropolitan statistical area for the purposes of case-mix index sets and wage index adjustments to federal Medicare reimbursement rates
Coordination of benefits (COB)
A method of integrating benefits payments from all health insurance sources to ensure that they do not exceed 100 percent of a plan member's allowable medical expenses
The adjustment of all ambulatory payment classification weights to reflect changes in relative resource consumption
"The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care; serves as the primary source for ongoing documentation of the resident's care, condition, and needs"
Analysis of discharged health records policy
A policy that outlines steps to be taken to process discharged resident records
E code (external cause of injury code)
"A supplementary ICD-9-CM classification used to identify the external causes of injuries, poisonings, and adverse effects of pharmaceuticals"
"A method of examination in which technologists using a special camera introduce radioactive substances into the body orally, intravenously, or by ventilated aerosol or gas. A special camera is used to detect the radioactive substances as they circulate through the body and produce an image"
"A policy that is implemented when resident confidentiality is require by the resident, family, or responsible party"
"An attorney who prosecutes a defendant accused for a crime on behalf of a local, state, or federal government"
Quality improvement (QI)
"A set of activities that measures the quality of a service or product through systems or process evaluation and then implements revised processes that result in better healthcare outcomes for patients, based on standards of care"
A set of ICD-9-CM codes used to classify occasions when circumstances other than disease or injury are recorded as the reason for the patient's encounter with healthcare providers
Semantic clinical drug component (SCDC)
"One of the two types of semantic normal forms created in RxNorm for every clinical drug, the SCDC consists of an active ingredient and strength"
Total quality management (TQM)
A management philosophy that includes all activities in which the needs of the customer and the organization are satisfied in the most efficient manner by using employee potentials and continuous improvement
A statement that exempts the signer from incurring liabilities or penalties
Studies that are concerned with finding the causes and effects of diseases and conditions
"A generic term for reimbursement and delivery systems that integrate the financing and provision of healthcare services by means of entering contractual agreements with selected providers to furnish comprehensive healthcare services and developing explicit criteria for the selection of healthcare providers, formal programs of ongoing quality improvement and utilization review, and significant financial incentives for members to use providers associated with the plan"
A type of data display tool used to plot information on the progress of a process over time
Physician query process policy
A policy that addresses request from physicians for additional information as part of the coding and reimbursement process
"The measure of a system to grow relative to various measures of size, speed, number of users, volume of data, and so on"
A set of statistical techniques that examines the psychometric properties of measurement instruments
Reports of process measures to help leaders follow progress to assist with strategic planning- sometimes called scorecards
Physician work (WORK)
"Component or element of the relative value unit (RVU) that should cover the physician's salary. This work is the time the physician spends providing a service and the intensity with which that time is spent. The four elements of intensity are:(a) mental effort and judgment, (b) technical skill, (c) physical effort, and (d) psychological stress"
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; 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; requires covered entities (most healthcare providers and organizations) to transmit healthcare claims in a specific format; develop, implement, and comply with the standards of the Privacy Rule and the Security Rule, and mandates that covered entities apply for and utilize national identifiers in HIPAA transactions. Also known as Public Law 104-191 and the Kassebaum-Kennedy Law"
Category III codes
"CPT codes that describe new and emerging technology. They may be published at any time during the year, rather than on the annual publication cycle, and can be found on the AMA Web site (www.ama-assn.org) and immediately preceding the alphabetic index in the CPT codebook "
Documentation guideline (DG)
A statement that indicates what health information must be recorded to substantiate use of a particular CPT code
"Statements that describe the processes and procedures meant to ensure that patient-identifiable health information remains confidential and protected from unauthorized disclosure, alteration, and destruction"
Standard of law
"A statute or regulation, or common practice, established by professional associations to identify what an individual is expected to do or not do in a given situation unless determined otherwise by a court"
Release and disclosure
The processes that make health record information available to legitimate users
"A process whereby a health record is analyzed to gather specific information about the diagnoses, treatments, or providers"
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"
A training technique for experimenting with real-world situations by means of a computerized model that represents the actual situation
The medical and income insurance coverage for certain employees in unusually hazardous jobs
Clinical Special Product Label (SPL)
A LOINC standard that provides information found in the approved FDA drug label or package insert in a computer readable format for use in electronic prescribing and decision support
Allied health professional
"A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)"
Labor-Management Relations Act (Taft-Hartley Act)
Federal legislation passed in 1947 that imposed certain restrictions on unions while upholding their right to organize and bargain collectively
Certificate authority (CA)
An independent licensing agency that vouches for a person's identity in encrypted electronic communications
"The document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity"
A two-digit numeric code listed after a procedure code that indicates that a service was altered in some way from the stated CPT descriptor without changing the definition; also used to enhance a code narrative to describe the circumstances of each procedure or service and how it individually applies to a patient
The capability of a software or hardware product to work with earlier versions of itself
"A computer program, typically hidden, that attaches itself to other programs and has the ability to replicate and cause various forms of harm to the data"
Applied artificial intelligence
An area of computer science that deals with algorithms and computer systems that exhibit the characteristics commonly associated with human intelligence
"A physical device, such as a key card, inserted into a door to admit an authorized person or into a computer to authenticate a computer user"
Chief financial officer (CFO)
The senior manager responsible for the fiscal management of an organization
Retaliation and waiver
"Rights protected under the Privacy Rule; to ensure the integrity of individuals' right to complain about alleged Privacy Rule violations, covered entities are expressly prohibited from retaliating against anyone who exercises his rights under the Privacy Rule, assists in an investigation by the HHS or other appropriate investigative authority, or opposes an act or practice that the person believes is a violation of the Privacy Rule and individuals cannot be required to waive the rights that they hold under the Privacy Rule in order to obtain treatment, payment, or enrollment/benefits eligibility"
Fully Specified Name
"In SNOMED CT, the unique text assigned to a concept that completely describes that concept"
"A type of nonparticipant observation in which researchers investigate one person, one group, or one institution in depth"
"A work arrangement in which employees can choose, at specific intervals, the number of hours they want to work each month over the next year"
"As defined by HIPAA, a request that PHI be routed to an alternative location or by an alternative method"
Clinical pertinence review
A review of medical records performed to assess the quality of information using criteria determined by the healthcare organization; includes quantitative and qualitative components
A systematic and continuous effort to search for important cues about how the world is changing outside and inside the organization
Market basket index
Relative measure that averages the costs of a mix of goods and services; used in the home health prospective payment system to reflect changes over time in the prices of an appropriate mix of goods and services and to develop the national sixty-day episode payment rates
A computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amounts of shared data
Policies and procedures designed to protect an organization's assets and to reduce the exposure to the risk of loss due to error or malfeasance
"The AMA initiative to improve CPT to address the needs of hospitals, managed care organizations, and long-term care facilities"
Institute for Clinical Systems Improvement (ICSI)
A collaboration of healthcare organizations that provides an objective voice dedicated to supporting healthcare quality and helping its members identify and achieve implementation of best practices for their patients
Home Assessment Validation and Entry (HAVEN)
"A type of data-entry software used to collect Outcome and Assessment Information Set (OASIS) data and then transmit them to state databases; imports and exports data in standard OASIS record format, maintains agency/patient/employee information, enforces data integrity through rigorous edit checks, and provides comprehensive online help. HAVEN is used in the home health prospective payment system (HHPPS)"
At risk contract
A type of managed care contract between Medicare and a payer or a payer and a provider according to which patients receive care during the entire term of the contract even if actual costs exceed the payment established by the agreement
The elective transfer of a patient from one home health agency to another during a sixty-day episode
"A personal computer characterized by its relatively small size and fast processing speed; also called desktop computer, laptop computer, or PC"
"1. A case in a prospective payment system with unusually long lengths of stay or exceptionally high costs; day outlier or cost outlier, respectively 2. An extreme statistical value that falls outside the normal range"
A type of clinical trial conducted with strict procedures for randomization in which neither researcher nor subject knows whether the subject is in the control group or the experimental group
A type of training that is delivered partially or completely using a computer
A computation that compares the number of new cases of a specific disease for a given time period to the population at risk for the disease during the same time period
"A person who is employed for a temporary, definite period of time, such as to complete a specific project or to fill in for a permanent employee on vacation or other leave; or a person who is employed for an indefinite period of time but who receives none of the fringe benefits offered to permanent employees"
Conditions of Participation
"The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services"
A method of protecting data from unauthorized change and corruption during transmission among information systems
"The actions, experiences, ideals, values, and emotions of an individual that tend to be highly personal and difficult to communicate (for example, corporate culture, organizational politics, and professional experience)"
"An agreement in which a vendor assumes at least part of the responsibility, from a financial perspective, for the successful implementation of a computer system"
"Programs created to advance specific organizational goals such as promoting a new center or service, establishing a new program, or positioning the organization as a center of excellence in a specific discipline such as cardiology or oncology"
Role-based access control (RBAC)
A control system in which access decisions are based on the roles of individual users as part of an organization
"A provider of diagnostic, medical, and surgical care as well as the services or supplies related to the health of an individual and any other person or organization that issues reimbursement claims or is paid for healthcare in the normal course of business. A provider is legally responsible for the patient's diagnosis and treatment"
"Committees that are put in place to oversee ongoing and cross-functional issues (examples include the medical staff committee, a quality improvement committee, or an infection control committee)"
Managed fee-for-service reimbursement
A healthcare plan that implements utilization controls (prospective and retrospective review of healthcare services) for reimbursement under traditional fee-for-service insurance plans
"A business situation where two or more companies combine, but one of them continues to exist as a legal, business entity, while the others cease to exist legally and their assets and liabilities become part of the continuing company"
Civil Monetary Penalties Act (CMP)
"Section 1128A of the Social Security Act, passed in 1981 as one of several administrative remedies to combat increases in healthcare fraud and abuse, which authorized the Secretary and Inspector General of Health and Human Services (HHS) to impose, civil monetary penalties, assessment, and program exclusions on individuals and entities whose wrongdoing caused injury to HHS programs or their beneficiaries "
"1. A data transmission type based on data that have been binary encoded 2. A term that refers to the data or information represented in an encoded, computer-readable format"
The process of maintaining a copy of all software and data for use in the case that the primary source becomes compromised
Occasion of service
"A specified identifiable service involved in the care of a patient that is not an encounter (for example, a lab test ordered during an encounter)"
"Evaluation of the risk of infection among patients and healthcare providers, looking for, preventing, and controlling the risk"
The individual with primary responsibility for the design and conduct of a research project
Global Medical Device Nomenclature (GMDN)
"A collection of internationally recognized terms used to accurately describe and catalog medical devices, in particular, the products used in the diagnosis, prevention, monitoring, treatment or alleviation of disease or injury in humans"
Medical Group Management Association (MGMA)
A national organization composed of individuals actively engaged in the business management of medical groups consisting of three or more physicians in medical practice
Concept that employees can be fired at any time and for almost any reason based on the idea that employees can quit at any time and for any reason
"Specific amount, in a certain timeframe such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan"
"The part of a fraction below the line signifying division that functions as the divisor of the numerator and, in fractions with 1 as the numerator, indicates into how many parts the unit is divided"
National Health Care Survey
A national public health survey that contains data abstracted manually from a sample of acute care hospitals or from discharged inpatient records or that are obtained from state or other discharge databases
A service that provides diagnostic and therapeutic services for patients under the age of fourteen years
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
Clinical decision support system (CDSS)
A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions
Information about the overall organization's budget planning that sometimes includes an estimation of how revenues will increase or decrease and what limits will be placed on expenses
A type of computer virus that infects Microsoft Word or similar application by inserting unwanted words or phrases; most are relatively harmless
"A payment under the Medicare outpatient prospective payment system that includes items such as anesthesia, supplies, certain drugs, and the use of recovery and observation rooms"
Ratio that represents the relationship between the average wages in a healthcare setting's geographic area and the national average for that healthcare setting. Wage indexes are adjusted annually and published in the Federal Register.
The process by which the ambulatory patient group classification system determines whether separate payment is appropriate when a patient is assigned multiple significant procedure groups
Operational decision making
A process for addressing problems that come up in the day-to-day operation of a business unit or the day-to-day execution of a work task
Intracapsular lens extraction
"The surgical removal of the entire lens and its capsule, generally followed by insertion of an anterior chamber intraocular lens"
"A collection of one or more tables of data, assembled in a fashion that allows for dynamic analysis to be conducted on the joins, intersections, and overall integration of these predefined tables"
Temporary National Codes
Codes established by insurers when a code is needed before the next January 1 annual update for permanent national codes; these codes are independent of the permanent national codes
Temporary assistance for needy families (TANF)
"A federal program that provides states with grants to be spent on time-limited cash assistance for low-income families, generally limiting a family's lifetime cash welfare benefits to a maximum of five years and permitting states to impose other requirements; replaced the Aid of Families with Dependent Children program"
Breast Imaging Reporting and Data System Atlas (BI-RADS)
"A comprehensive guide providing standardized breast imaging terminology, and a report organization, assessment structure, and a classification system for mammography, ultrasound, and MRI of the breast"
"Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies"
Electronic data interchange (EDI)
A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations
Disproportionate share hospital (DSH)
Healthcare organizations that meet governmental criteria for percentages of indigent patients
A bill generated and issued to the patient at the time of service or any other time outside the normal accounting cycle
A destructive piece of programming code hidden in another piece of programming code (such as a macro or e-mail message) that looks harmless
"Systems developed by data-processing companies in the 1960s and 1970s to address the computing needs of healthcare organizations that could not afford, or chose not to purchase, their own mainframe computing systems"
"Infectious diseases such as HIV, hepatitis B, and hepatitis C that are transported through contact with infected body fluids such as blood, semen, and vomitus"
Business process reengineering (BPR)
The analysis and design of the work flow within and between organizations
Health record ownership
The generally accepted principle that individual health records are maintained and owned by the healthcare organization that creates them but that patients have certain rights of control over the release of patient-identifiable (confidential) information
"The application of risk control and risk financing techniques to determine how a risk should be treated, often aimed at preventing or reducing the chances and/or effects of a loss occurrence"
The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes
1. Data elements within an entity that become the column or field names when the entity relationship diagram is implemented as a relational database 2. Properties or characteristics of concepts; used in SNOMED CT to characterize and define concepts
Special care unit
"A medical care unit in which there is appropriate equipment and a concentration of physicians, nurses, and others who have special skills and experience to provide optimal medical care for critically ill patients or continuous care of patients in special diagnostic categories"
A policy that outlines the steps to take for faxing individually identifiable health information and business records and usually limits what information may be faxed
The official publication of American Medical Association that addresses CPT coding issues
"An entity that provides certain agreed-upon services for the facility, such as transcription, coding, or copying"
Hospital ambulatory care
"All hospital-directed preventive, therapeutic, and rehabilitative services provided by physicians and their surrogates to patients who are not hospital inpatients"
Intraoperative anesthesia record
Health record documentation that describes the entire surgical process from the time the operation began until the patient left the operating room
"International Classification of Diseases
Tenth Revision (ICD-10)",The most recent revision of the disease classification system developed and used by the World Health Organization to track morbidity and mortality information worldwide (not yet adopted by the United States)
Return on assets
"The return on a company's investment, or earnings, after taxes divided by total assets"
"The death of a liveborn infant within the first twenty-seven days, twenty-three hours, and fifty-nine minutes following the moment of birth"
Unified modeling language (UML)
A common data-modeling notation used in conjunction with object-oriented database design
Not elsewhere classified (NEC)
A type of classification that indicates that there is no separate code for the condition even though the diagnostic statement is specific
"1. The state of being whole or unimpaired 2. In the context of data security, data integrity means the protection of data from accidental or unauthorized intentional change. (JC 2004 IM-12) "
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
Regional health information network (RHIN)
"System that links various healthcare information systems in a region together so that patients, healthcare institutions, and other entities can share clinical information"
The document in which an employee's information relating to job performance and so on is kept
The design of a data-entry screen of a computer in which categories of functions or structured data elements may be accessed through that category element
"The systematic process of data collection, repeated over time or at a single point in time"
"A filing system, sometimes used in clinic settings, in which an entire family is assigned one number"
Use case diagram
A systems analysis technique used to document a software project from a user's perspective
A one-way method of delivering education through speaking in which the teacher delivers the speech and the student listens
Medical staff unit
"One of the departments, divisions, or specialties into which the organized medical staff of a hospital is divided"
A security procedure that ends a computer session after a predetermined period of inactivity
"Related to movement of muscles and coordination; includes both large motor skills, such as walking, and fine motor skills, such as buttoning and zipping clothing"
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 Context Object Workgroup (CCOW)
A standard protocol developed by HL7 to allow clinical applications to share information at the point of care
"Functionally autonomous units (departments, services, or divisions) of the medical staff organization in a hospital"
"A report that shows the total dollar amounts in accounts, expressed in accounting equation format, at a specific point in time"
"The lowest level of the U.S. judicial system, where state and local criminal and civil cases are tried"
The period of time following the eligibility date (usually thirty-one days) during which a member of an insured group may apply for insurance without evidence of insurability
"A health plan that processes Part B claims for services by physicians and medical suppliers (for example, the Blue Shield plan in a state)"
Categorically needy eligibility groups
Categories of individuals to whom states must provide coverage under the federal Medicaid program
Home health (HH)
An umbrella term that refers to the medical and nonmedical services provided to patients and their families in their places of residence
"The senior governing, administrative, and management groups of a healthcare organization that are responsible for setting the mission and overall strategic direction of the organization"
An attribute of a study's design that allows its findings to be applied to other groups
Protected health information (PHI)
"Individually identifiable health information, transmitted electronically or maintained in any other form, that is created or received by a healthcare provider or any other entity subject to HIPAA requirements"
A type of legislation that involves the government and its relations with individuals and business organizations
Fair Labor Standards Act of 1938 (FLSA)
The federal legislation that sets the minimum wage and overtime payment regulations
Longitudinal health record
"A permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death"
A system for grouping cases that are clinically similar and ordinarily consume similar resources; used to provide information about the types of patients treated by a facility
"International Classification of Diseases
Ninth Revision, Clinical Modification (ICD-9-CM)",A coding and classification system used in the United States to report diagnoses in all healthcare settings and inpatient procedures and services as well as morbidity and mortality information
"An employment category provided in a special industry or workshop for the physically, mentally, emotionally, or developmentally handicapped"
Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT)
"A comprehensive, controlled clinical vocabulary developed by the College of American Pathologists"
Medical Data Interchange Standard (MEDIX)
A set of hospital system interface transaction standards developed by the Institute of Electrical and Electronic Engineers
Project management life cycle
"The period in which the processes involved in carrying out a project are completed, including project definition, project planning and organization, project tracking and analysis, project revisions, change control, and communication"
"The separation of two layers of the retina from each other, which usually occurs when the vitreous adheres to the retina (the sensitive layer of the eye) and 'pulls,' resulting in retinal holds that tears that may lead to retinal detachment"
A system whereby information is entered into the health record at the time and location of service
Nursing Home Quality Initiative
A six-state pilot project performed in 2002 by the Centers for Medicare and Medicaid Services (CMS) that identifies quality measures that reflect the quality of care in nursing homes
Common Object Request Broker Architecture (CORBA)
A component computer technology developed by a large consortium of vendors and users for handling objects over a network from various distributed platforms; the subset of standards for healthcare covered in CORBAmed
American Standard Code for Information Interchange (ASCII)
"Electronic code that represents text, which makes it possible to transfer data from one computer to another "
Operating room (OR)
The area in a healthcare facility that is equipped and staffed to provide facilities and personnel for the performance of surgical procedures
"A research study that found that novelty, attention, and interpersonal relations have a motivating effect on performance"
"A budgeting concept in which overhead costs are distributed once, beginning with the area that provides the least amount of non revenue-producing services"
Maternal death rate (hospital based)
"For a hospital, the total number of maternal deaths directly related to pregnancy for a given time period divided by the total number of obstetrical discharges for the same time period; for a community, the total number of deaths attributed to maternal conditions during a given time period in a specific geographic area divided by the total number of live births for the same time period in the same area"
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"
Partial episode payment (PEP) adjustment
A reduced episode payment that may be based on the number of service days in an episode
"The positive difference between the budgeted amount and the actual amount of a line item, that is, when actual revenue exceeds budget or actual expenses are less than budget"
"Recommended methods for assigning unique identifiers to individuals (patients and clinical providers), corporate providers, and healthcare vendors and suppliers"
A financial analysis technique for determining the level of sales at which total revenues equal total costs beyond which revenues become profits
"Total dollar amount that a healthcare insurance company will pay for covered healthcare services during a specified period, such as a year or lifetime"
Periodic performance review (PPR)
An organizational self-assessment conducted at the halfway point between triennial on-site accreditation surveys conducted by The Joint Commission
Semantic differential scale
"A measure that records a group's perception of a product, organization, or program through bipolar adjectives on a seven-point continuum, resulting in a profile"
National Cancer Registrars Association (NCRA)
An organization of cancer registry professionals that promotes research and education in cancer registry administration and practice
Management by objectives (MBO)
A management approach that defines target objectives for organizing work and comparing performance against those objectives
A computer system developed by a commercial company not affiliated with the healthcare organization
Product trade name
"Name (also referred to as catalog name) assigned or supplied by the labelers (firms) as required under the Food, Drug, and Cosmetic Act"
"A method of job evaluation that arranges jobs in a hierarchy on the basis of each job's importance to the organization, with the most important jobs listed at the top of the hierarchy and the least important jobs listed at the bottom"
Accounting of disclosures
A list of all disclosures made of a patient's health information; Section 164.528 of the Privacy Rule states that an individual has the right to receive an accounting of certain disclosures made by a covered entity within the six years prior to the date on which the accounting is requested
"Investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories, or laws in the light of new facts, or practical application of such new or revised theories or laws; the collecting of information about a particular subject"
Hospital Outpatient Prospective Payment System (HOPPS)
The reimbursement system created by the Balanced Budget Act of 1997 for hospital outpatient services rendered to Medicare beneficiaries; maintained by the Centers for Medicare and Medicaid Services (CMS)
School special education
"Specifically designed instruction provided by qualified teachers within the context of school with the goal of helping students acquire academic, vocational, language, social, and self-care skills (includes adapted physical education and the use of specialized techniques to overcome intrinsic learning deficits)"
"The process of extracting information from a database and then quantifying and filtering discrete, structured data"
Illnesses or injuries that coexist with the condition for which the patient is primarily seeking healthcare
Team group dynamics
"Models of team development uniformly define four stages of progression in team group dynamics (Montebello 1997 and Buzzotta 1993): cautious affiliation, competitiveness, harmonious cohesiveness, and collaborative teamwork"
The process of releasing confidential health record information that was originally created and disclosed by another healthcare provider
A method of observational research that investigates culture in naturalistic settings using both qualitative and quantitative approaches
The planned coordination of the activities of more than one person for the achievement of a common purpose or goal
A type of communications technology that converts high-level language statements into machine language one at a time
A photographic process that reduces an original paper document into a small image on film to save storage space
Balanced Budget Act (BBA) of 1997
"Public Law 105-33 enacted by Congress on August 5, 1997, that mandated a number of additions, deletions, and revisions to the original Medicare and Medicaid legislation; the legislation that added penalties for healthcare fraud and abuse to the Medicare and Medicaid programs and also affected the hospital outpatient prospective payment system (HOPPS) and programs of all-inclusive care for elderly (PACE)"
An area of computer science that studies algorithms and computer programs that improve employee performance on some task by exposure to a training or learning experience
Systematized Nomenclature of Medicine Reference Terminology (SNOMED RT)
"A concept-based terminology consisting of more than 110,000 concepts with linkages to more than 180,000 terms with unique computer-readable codes"
Executive information system (EIS)
An information system designed to combine financial and clinical information for use in the management of business affairs of a healthcare organization
A type of database (both object oriented and relational) that stores both objects and traditional tables
K-nearest neighbor (K-NN)
A classic technique used to discover associations and sequences when the data attributes are numeric; nonparametric estimator of a function
"Person(s) who is (are) responsible and accountable for the health information creation, content, accuracy, and completeness for each documented event or health record entry"
Numeric filing system
A system of health record identification and storage in which records are arranged consecutively in ascending numerical order according to the health record number
"In a controlled medical vocabulary, a description is the combination of a concept and a term"
Skilled nursing facility (SNF) market basket index
"An index consisting of the most commonly used cost categories for skilled nursing facility routine services, ancillary services, and capital-related expenses that reflects changes over time in the prices of an appropriate mix of goods and services included in covered skilled nursing facility services"
The implementation specifications of the HIPAA Security Rule that are designated 'required' rather than 'addressable;' required standards must be present for the covered entity to be in compliance
Unique identification number
A combination of numbers or alphanumeric characters assigned to a particular patient
Inpatient rehabilitation facility (IRF)
"A healthcare facility that specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self-care, and independence"
"A specific functionality in project management software that automates the assignment of task start-and-finish dates and, as a result, the expected project finish date"
The examination of a healthcare facility and its processes and infrastructures as required by state laws and regulations
"The removal of breast tissue, leaving the skin of the breast and nipple intact. This type of mastectomy usually requires that a breast implant be inserted "
"The medical and/or personal care provided to individuals and families in their place of residence with the goal of promoting, maintaining, or restoring health or minimizing the effects of disabilities and illnesses, including terminal illnesses"
Term used to refer to services that have been deemed effective and efficient with certain groups of clients
A system of connections of private Internet networks outside an organization's firewall that uses Internet technology to enable collaborative applications among enterprises
"An individual such as a parent, caregiver, or other family member who receives lodging at a healthcare facility but is not a patient"
"A field of study that deals with moral principles, theories, and values; in healthcare; a formal decision-making process for dealing with the competing perspectives and obligations of the people who have an interest in a common problem"
Hay method of job evaluation
"A modification of the point method of job evaluation that numerically measures the levels of three major compensable factors: know-how, problem-solving ability, and accountability"
Computer system security
"The protection of computer hardware, software, and data from accidental or malicious access, use, modification, destruction, and/or disclosure"
Respect for Persons
The principle that all people are presumed to be free and responsible and should be treated accordingly
Medicare Provider Analysis and Review (MEDPAR) File
A collection of data from reimbursement claims submitted to the Medicare program by acute care hospitals and skilled nursing facilities that is used to evaluate the quality and effectiveness of the care being provided
1. Statistics that are used to make inferences from a smaller group of data to a large one 2. A set of statistical techniques that allows researchers to make generalizations about a population's characteristics (parameters) on the basis of a sample's characteristics
Physicians employed by teaching hospitals to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs
History and physical documentation requirements policy
A policy that specifies the detail required in the history and physical examination done by the physician or physician extender
Designated record set
"A group of records maintained by or for a covered entity that may include patient medical and billing records; the enrollment, payment, claims adjudication, and cases or medical management record systems maintained by or for a health plan; or information used, in whole or in part, to make patient care-related decisions"
"A term referring to the Health Insurance Portability and Accountability Act (HIPAA) provisions which include standards for transactions and code sets that are used to exchange health data, standard identifiers for use on transactions, and privacy and security standards to protect personal health information. HIPAA included these administrative simplification provisions in order to improve the efficiency and effectiveness of the healthcare system."
"A bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems, or solutions"
"The implementation specifications of the HIPAA Security Rule that are designated 'addressable' rather than 'required;' to be in compliance with the Rule, the covered entity must implement the specification as written, implement an alternative, or document that the risk for which the addressable implementation specification was provided either does not exist in the organization, or exists with a negligible probability of occurrence"
Physician practice management (PPM)
"A type of software that automates a physician office's patient appointment scheduling, registration, billing, and payroll functions"
Affiliated covered entity
"Legally-separate covered entities, affiliated by common ownership or control; for purposes of the Privacy Rule; these legally separate entities may refer to themselves as a single covered entity"
Functional status domain
"A classification made up of six activities of daily living, including upper and lower body dressing, bathing, toileting, transferring, and moving"
"Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries"
The process or program for reducing a message without significantly losing information
Secondary patient record
"A record, derived from the primary record, that contains selected data elements to aid nonclinical persons in patient care support, evaluation, or advancement"
"In healthcare, a price assigned to a unit of medical or health service, such as a visit to a physician or a day in a hospital; may be unrelated to the actual cost of providing the service"
Indirect medical education (IME) adjustment
Percentage increase in Medicare reimbursement to offset the costs of medical education that a teaching hospital incurs
A chart depicting the location of furniture and equipment in a work area and showing the usual flow of individuals or materials as they progress through the work area
Unique personal identifier
"A unique number assigned by a healthcare provider to a patient that distinguishes the patient and his or her medical record from all others in the institution, assists in the retrieval of the record, and facilitates the posting of payment"
The third phase of the systems development life cycle during which a comprehensive plan is developed and instituted to ensure that the new information system is effectively implemented within the organization
Catastrophic expense limit
"Specific amount, in a certain time frame such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan"
Stem and leaf plot
"A visual display that organizes data to show its shape and distribution, using two columns with the stem in the left-hand column and all leaves associated with that stem in the right-hand column; the 'leaf' is the ones digit of the number, and the other digits form the 'stem'"
A branch of law based on common law that deals with written or oral agreements that are enforceable through the legal system
National Information Infrastructure--Health Information Network Program (NII--HIN)
A national quasi-governmental organization that provides oversight of all healthcare information standards in the United States
"First step in the project management life cycle that sets expectations for the what, when, and how of a project the organization wants to undertake "
Utilization Review Act
The federal legislation that requires hospitals to conduct continued-stay reviews for Medicare and Medicaid patients
1. The movement of a patient from one treatment service or location to another 2. Discharge of a patient from a hospital and readmission to postacute care or another acute care hospital on the same day
"The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure"
"A budgeting concept in which overhead costs are allocated twice, taking into consideration that some overhead departments provide services to each other"
Clinician/physician Web portals
The media for providing physician/clinician access to the provider organization's multiple sources of data from any network-connected device
Knowledge management system (KMS)
"A type of system that supports the creation, organization, and dissemination of business or clinical knowledge and expertise to providers, employees, and managers throughout a healthcare enterprise"
The offering of health maintenance organization coverage as well as indemnity insurance by the same carrier
A written statement that sets forth the core purpose and philosophies of an organization or PI team.; defines why an organization exists and what it is for
Severity of illness (SI or SOI)
A type of supportive documentation reflecting objective clinical indicators of a patient illness (essentially the patient is sick enough to be at an identified level of care) and referring to the extent of physiologic decompensation or organ system loss of function
Material safety data sheet (MSDS)
"Documentation maintained on the hazardous materials used in a healthcare organization; the documentation outlines such information as common and chemical names, family name, and product codes; risks associated with the material, including overall health risk, flammability, reactivity with other chemicals, and effects at the site of contact; descriptions of the protective equipment and clothing that should be used to handle the material; and other similar information"
Diagnostic image data
"Bit-mapped images used for medical or diagnostic purposes (for example, chest x-rays or computed tomography scans)"
"A pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent; has a clinical drug name, which includes the routed generic, the strength, and dose form"
Emergency Medical Treatment and Active Labor Act (EMTALA)
"A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat 'patient-dumping'-the transferring, discharging, or refusing to treat indigent emergency department patients because of their inability to pay "
Ambulatory payment classification (APC) relative weight
"A number reflecting the expected resource consumption of cases associated with each APC, relative to the average of all APCs, that is used in determining payment under the Medicare hospital outpatient prospective payment system (OPPS)"
National health information network (NHIN)
"Interoperable information infrastructure that links various healthcare information systems together, allowing patients, physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely; network of networks"
Sample size calculation
The qualitative and quantitative procedures to determine an appropriate sample size
A clinical professional who is directly responsible for providing patient services
Payments for healthcare services made by an insurance company or health agency on behalf of the insured
An objective way of looking at work-related ideas and processes with the goal of allowing people to uncover ineffective patterns of behavior and thinking and then finding ways to make lasting improvements
Intermediate care facility
A facility that provides health-related care and services to individuals who do not require the degree of care or treatment that a hospital or a skilled nursing facility provides but who still require medical care and services because of their physical or mental condition
Aggregate amount withheld from all providers' capitation payments as an amount to cover expenditures in excess of targets
"The status of Medicare patients who are formally released from a hospital, die in a hospital, or are transferred to another hospital or unit excluded from the prospective payment system"
North American Nursing Diagnosis Association International Taxonomy (NANDA II)
Nursing terminology used to develop and classify nursing diagnoses in a taxonomy
"Documents produced during the completion of a task that may be a component of, or contribute to, a project deliverable"
The complex task of ensuring that all elements and platforms in an information system communicate and act as a uniform entity; or the combination of two or more benefit plans to prevent duplication of benefit payment
The legal authorization granted by a state to an entity that allows the entity to provide healthcare services within a specific scope of services and geographical location; states license both individual healthcare professionals and healthcare facilities; licensure usually requires an applicant to pass an examination to obtain the license initially and then to participate in continuing education activities to maintain the license thereafter
"A cycle of reflection, interpretation, application of learning, and action that is the basis of total quality management and other continuous improvement philosophies"
Speech-language therapy (SLP)
A treatment intended to improve or enhance the resident's ability to communicate and/or swallow
Systematic literature review
"Methodical approach to literature review that reduces the possibility of bias; characterized by explicit search criteria to identify literature, inclusion and exclusion criteria to select articles and information sources, and evaluation against consistent methodological standards"
Structure and content standards
Common data elements and definitions of the data elements to be included in an electronic patient record
Notes recorded in any medium by a mental health professional to document or analyze the contents of conversations between therapists and clients during private or group counseling sessions
"An abbreviation for the term picture element, which is defined by many tiny bits of data or points"
"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 "
"A small, low-cost computer (embedded chip) installed in an appliance or electronic device to perform a specific task or program"
Standard normal distribution
A normal distribution with a mean equal to zero and standard deviation equal to one
Data definition language (DDL)
"A special type of software used to create the tables within a relational database, the most common of which is structured query language"
Interagency transfer form (W-10)
A form that contains sufficient information about a patient to provide continuity of care during transfer or discharge
Facility quality indicator profile
"A report based on the data gathered during the Minimum Data Set for Long-Term Care that indicates what proportion of the facility's residents have deficits in each area of assessment during the reporting period and, specifically, which residents have which deficits; the profile also provides data comparing the facility's current status with a preestablished comparison group"
Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another
A list of unpaid invoices; sometimes a cumulative list of all transactions between purchaser and vendor during a specific time period
An individual within an organization whose primary responsibility is to facilitate change
Data quality review
An examination of health records to determine the level of coding accuracy and to identify areas of coding problems
Extracapsular lens extraction
"The surgical removal of the front portion and nucleus of the lens, leaving the posterior capsule in place. A posterior chamber intraocular lens is generally inserted after this procedure "
Statement of changes in net assets
The accounting statement that explains the differences in net assets from period to period on the balance sheet
Coordinated care plans
"Organized patient care plans that meet the standards set forth in the law for managed care plans (for example, health maintenance organizations, provider-sponsored organizations, and preferred provider organizations)"
Concept Unique Identifier (CUI)
"A numeric identifier in RxNorm that designates the same concept, no matter the form of the name or the table where it is located; also represent an opaque identifier found in the UMLS Metathesaurus "
"The cycle of gathering, recording, processing, storing, sharing, transmitting, retrieving, and deleting information"
A research method in which researchers also participate in the observed actions
Data backup plan
A plan that ensures the recovery of information that has been lost or becomes inaccessible
A short description that communicates an organization's social and cultural belief system
"Outside companies such as consultants and those who sell equipments and supplies, perform release-of-information functions, provide laundry or food services, or repair equipment, who have a presence in a healthcare facility and may or may not be business associates"
A legal term that refers to the result of an action by an individual who does not act the way a reasonably prudent person would act under the same circumstances
Program for Evaluation Payment Patterns Electronic Report (PEPPER)
A benchmarking database maintained by the Texas Medical Foundation that supplies individual QIOs with hospital data to determine state benchmarks and monitor hospital compliance
Universal Medical Device Nomenclature System (UMDNS)
"A standard international nomenclature and computer coding system for medical devices, developed by ECRI"
A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided
Technical component (TC)
"The portion of radiological and other procedures that is facility based or nonphysician based (for example, radiology films, equipment, overhead, endoscopic suites, and so on)"
1. The amount of financial resources consumed in the provision of healthcare services 2. The dollar amount of a service provided by a facility
Adverse drug event
"A patient injury resulting from a medication, either because of a pharmacological reaction to a normal dose, or because of a preventable adverse reaction to a drug resulting from an error. Source: TJC)"
Regional health information organization (RHIO)
A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community
Standard cost profile (SCP)
"A set of data that identifies, analyzes, and defines the activities, including the costs, of departments within the organization to produce a service unit"
"Messages sent to increase awareness of, and to enhance the image of, a product in the marketplace"
Online/real-time transaction processing (OLTP)
The real-time processing of day-to-day business transactions from a database
"The performance of internal and/or external reviews (audits) to identify variations from established baselines (for example, review of outpatient coding as compared with CMS outpatient coding guidelines)"
AHA Coding Clinic for HCPCS
"The official coding advice resource for coding information on HCPCS CPT codes for hospital providers and certain HCPCS Level II codes for hospitals, physicians, and other healthcare professionals"
Relational database management system (RDBMS)
A database management system in which data are organized and managed as a collection of tables
Business continuity plan
A program that incorporates policies and procedures for continuing business operations during a computer system shutdown; sometimes called contingency and disaster planning
Patient's bill of rights
The protections afforded to individuals who are undergoing medical procedures in hospitals or other healthcare facilities
A hospital patient who receives services in one or more of a hospital's facilities when he or she is not currently an inpatient or a home care patient
"A broad based coalition of physicians, consumers, purchasers, health insurance plans, and others who are committed to effectively and efficiently improve performance measurement, data aggregation, and reporting in the ambulatory care setting"
A cataract extraction technique that uses ultrasonic waves to fragment the lens and aspirate it out of the eye
TRICARE Senior Prime
"A managed care demonstration TRICARE program designed to better serve the medical needs of military retirees, dependents, and survivors who are sixty-five years old and over"
A reengineering strategy to reduce the cost of labor and streamline the organization by laying off portions of the workforce
A computer station located within a healthcare facility that patients and families can use to access information
Hospital information system (HIS)
"The comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital"
Pre-established statements of the criteria against which the performance of participating healthcare organizations will be assessed during a voluntary accreditation
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
A method used in cancer registers to identify specific and separate different stages or aspects of the disease
"A work schedule that gives employees some choice in the pattern of their work hours, usually around a core of midday hours"
"Cost containment measure to prevent unnecessary tests, treatments, medical devices, or surgical procedures"
"A real-time, sensitive, operationally oriented form of data warehousing, retaining small amounts of key indicators to run day-to-day processes"
"Data with a defined unit of measure, no true zero point, and equal intervals between successive values"
The combination of the hardware and operating system on which an application program can run
Daily inpatient census
"The number of inpatients present at census-taking time each day, plus any inpatients who were both admitted and discharged after the census-taking time the previous day"
A procedure that is surgical in nature or carries a procedural or an anesthetic risk or requires specialized training
Chief executive officer (CEO)
The senior manager appointed by a governing board to direct an organization's overall long-term strategic management
"A branch of law that addresses crimes that are wrongful acts against public health, safety, and welfare, usually punishable by imprisonment and/or fine"
Specific measures that enable the assessment of the steps taken in rendering a service
Human relations movement
A management philosophy emphasizing the shift from a mechanistic view of workers to concern for their satisfaction at work
An entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and federal governments and legislated by the Social Security Act
Minimum Data Set for Long-Term Care Version 2.0 (MDS 2.0)
"A federally mandated standard assessment form that Medicare- and/or Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements"
The act of entering data into a primary and a secondary server simultaneously so that the secondary server can continue to process the data in the event the primary server crashes
American Medical Informatics Association (AMIA)
"A professional association for individuals, institutions, and corporations that promotes the development and use of medical informatics for patient care, teaching, research, and healthcare administration "
Access control system
A system that defines who has access to what information in a computer system and specifies each user's rights and/or restrictions with respect to that information
"In law, the principle that a statute at one level supercedes or is applied over the same or similar statute at a lower level (for example, the federal HIPAA privacy provisions trump the same or similar state law with certain exceptions)"
"In a not-for-profit setting, the entity's net assets or resources remaining after subtracting liabilities that are owed; in a for-profit organization, the owner's equity"
"Systems that have standards, controls, and feedback mechanisms built in to them"
A procedure that combines the use of radioactive chemicals and antibodies to detect hormones and drugs in a patient's blood
"A quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria"
"A newborn born at term, under sterile conditions, with no diseases, conditions, disorders, syndromes, injuries, malformations, or defects diagnosed, and no operations other than routine circumcisions performed"
Case-mix group (CMG) relative weights
Factors that account for the variance in cost per discharge and resource utilization among case-mix groups
A policy that outline the way in which charts are signed out of the permanent files and how requests for records are handled
Office of Research Integrity (ORI)
"Organization that provides integrity in biomedical and behavioral research, monitoring incidents of research misconduct and facilitating responsible research conduct through educational, preventive, and regulatory activities"
Office of the Inspector General (OIG)
1. The office through which the federal government established compliance plans for the healthcare industry 2. A division of the Department of Health and Human Services (DHHS) that investigates issues of noncompliance in the Medicare and Medicaid programs such as fraud and abuse; overseen by the Department of Justice
Nursing Minimum Data Set (NMDS)
A data set that provides uniform definitions and categories of nursing care; built on the uniform minimum health data sets (UMHDS)
Radioactive elements packaged in a small configuration used for permanent implantation into tumors
Hospitalization that is five-sixths of the geometric length of stay for the long-term care diagnosis related group (LTC-DRG)
Certified medical transcriptionist (CMT)
A certification that is granted upon successfully passing the Association of Healthcare Documentation Integrity (AHDI) certification examination for medical transcriptionists with generally at least two years of experience
Transfer of records
"The movement of a record from one medium to another (for example, from paper to microfilm or to an optical imaging system) or to another records custodian "
National Research Act of 1974
"An act that required the Department of Health, Education, and Welfare (now the Department of Health and Human Services) to codify its policy for the protection of human subjects into Federal regulations, and created a commission that generated the Belmont Report "
An action instituted and conducted for the purpose of preventing the commission of a crime or for fixing the guilt of a crime already committed and punishing the offender