Used with document imaging systems Uses a format known as "write once read many" (WORM) Allows multiple user access at the same time Allows for variius levels of security Data cannot be altered,lost once in the system This is a output device
Instructions that direct the computer in its operation, regulate the hardware, and allow several programs to run simultaneously.
These are examples of Operating Systems
Windows XP Vista Mac Os UNIX
Application Programs (software)
Enables user to perform specific types of work Can work with text, numbers, graphs, images
These are examples of application programs (software)
Microsoft Office Software developed internally by an organizations IT staff Enterprise Software-used throughout an organization/facility
Language encoded into a computer that tells it what to do and how to operate. Communication between user and computer Allows computers to enteract with each other
These are examples of Programming Languages
COBOL FORTRAN BASIC JAVA
Basic unit of storage whithin a computer
a string of 8 numbers
These are 2 types of networks
LAN (local area network) WAN (wide area network)
Local Area Network (LAN)
connect PC's within a local area and to a host server
Wide Area Network (WAN)
connect PC's in a large geographical area not geographically located near each other
enable communication among linked PC's Connect PC's to a central server (hub computer) Can link internally and externally
These are internet connections used within networks......
Ethernet Wireless Fiberoptic Modem Wireless Cards
These are types of LAN networks
Bus Network Star Network Token Ring Network
Computers "lines up" on a single cable Dependent upon the device before it
Most common type of LAN network All computers connected to a hub (star) Data flows to hub, then passed on to each computer
Token Ring Network
A ring of computers Data flows around the ring until reaches destination computer.
Allow computers to connect with a network Allow networks to connect with one another Allows transmission of data from one system to another
These are 2 types of network security
control access from the internet to a LAN
route data between networks
Networks and computers linked together enable data/information sharing around the world
Which of the following types of data storage devices has the largest storage capacity?
Within the hardware of the personal computer, temporary memory is known as?
If you wanted to convert some old Kodak photos into digital data so that you could insert them into a PowerPoint presentation, you would first use a .....
A common programming language used with the Internet is?
The quality of the resolution of computer monitors is dependent on the number of pixels or......
dots per inch
Within a LAN the security device used to control access from the internet is known as....
Which of the following data storage measurements has the largest memory size?
enable communication among linked PC's
Optical Character Recognition
A common input device, commonly known as barcoding, used in HIM departments which enables staff to be more efficient and accurate
The PC software that instructs the computer in its operations and regulates the hardware
The most common type of LAN network in which data flows to a hub, and then is passed on to each computer linked in the network
This is the brain of the computer
Temporary memory used when computer needs to borrow memory temporarily used when speed is needed by the computer
long term memory
computer software program that assigns appropriate DRG's according to the info provided for each episode of care
Anything that is added to the computer
Graphical User Interface
used to present images or data to the user
This is also known as "barcoding"
Optical Character Recognition
What are the main parts to the personal computer?
CPU memory storage
memory programmed onto a chip at the factory and cannot be changed Read Only Memory purchased at a predetermined amount
small disk files that contain software codes that are instructions for the computer are the 1st files a computer reads when "booting up"
temporary memory need by the computer at startup and backup can be volatile or dynamic
wireless application protocol
provide firewall security for networks and route data between networks using IP addresses
device where all computers on a network connect
Peer to Peer Network
when a network does not use a hub
a network that sends data from node to another in packets
bridge between digital and analog signals converts digital data on and off
Clinical Information Systems
collect and maintain information related to patient care data is patient identifiable lab radiology nursing pharmacy patient monitoring
Computer Provider Order Entry
Designed for orders to be entered by a healthcare professional Alerts and reminders built into the system
Picture Archival Communication System
radiological images stored digitally PACS
ability for images to be viewed from any location by the radiologist
Lab Information System
collects, stores and maintains lab tests and their respective results blood chemistry microbiology blood banks pathology virology
Nursing Information System
assist in planning/monitoring patient care documents nursing care provided provides nursing protocols provides access to reference guides enables documentation at the point of care assists in management of nursing department
Patient Monitoring System
capture data from monitoring systems blood pressure oxygen saturation fetal monitoring
communication about health information between patient and care provider
HIPAA requires accounting of disclosures to be available to the patient for how long?
used by coders to select the appropriate code for diagnosises and procedures
What are the 2 types of encoders?
Rules Based Automated codebook encoder
Rules Based Encoder
require the user to type in the name a portion of the dx or procedure Ex. 3M
Administrative Information Systems
Computer systems used to manage the business side of healthcare Financial or Administrative in nature
These are the major administrative information systems
Financial information systems Human Resources information systems Decision Support Systems The Master Patient Index Patient Registration Systems Practice Management Systems Materials Management Information Systems Facilities Management Systems
These are functions related to the Financial Information Systems
management of the accounts receivable and the accounts payable on a daily basis by the faciity
automates the coding process for routine procedures
records credits and debits to the various accounts managed by the financial information system
Decision Support System
takes data collected by the healthcare facility, turns them into information and uses the info to make decisions about the healthcare facility DSS
Executive Information Systems
a type of DSS that is designed to be used by top level healthcare administrators lots of graphs and charts are generally used facilitates quick decision making
Master Patient Index
info in MPI collected by registration personnel info collected flows to other hospital systems permanently maintained key to locating a patients health record in a paper based environment uses soundex capabilities
These are errors that can occur during patient registration and impact MPI integrity.
Overlays, 2 people with same medical record number Duplicate Medical Record Numbers,2 medical record numbers for same person
What are the 3 types of Algorithms used in a MPI system to prevent duplication of patient records and medical record numbers?
Deterministic Rules-Based Probabilistic
look for exact matches
"fuzzy logic" uses a weight based system to rank potential matches
can identify transpositions/name changes This is the most sophisticated type of Algorithm
Patient Registration ADT
used by physician office groups Scheduling,patient accounting, patient collections, claims submission,appointment scheduling, human resources are all built into one system
Materials Management Systems
manage equipment and supplies for facility
supports the management of the building
The system that would print out advanced directives, consents and notice of privacy practices is the?
Updates to the chargemaster ultimately feed into the.......
The following is a function of the chart locator system....
Electronic Data Management System
EDMS An electronic system which manages documents in order to improve business processes
Computer output to laser disk
Transfer of data straight from the computer into imaging system
transcription system lab system radiology system
Data Retrieval Tools
Tools used to identify and extract data from a database
structured query language data retrieval tool allow user to create tables,delete tables and show how something is viewed standard language for RELATIONAL DATABASES
query by example data manipulation language uses GUI to query the database
uses boolean operators to control and refine search results "and" "or" "not"
These are types of Boolean operators....
"and" "or" "not"
breaking data elements into level of detail desired by the facility
Data directly from the source ex. medical record
data taken from a primary source and abstracted into another database or registry ex. cancer registries, mpi, disease index
non patient identifiable data ex. research data
examines healthcare organizations internal performance over time and then compares the organizations internal performance with that of others Developed and maintained by the Joint Commission
Automated Forms Processing
allows user to type data directly into computer eliminating the need to manually complete a paper form and then scan it into computer
Optical Character Recognition
OCR encoding text from analog paper into bit mapped images and translating the images and translating the images into a form that is computer readable
What is the difference between a document imaging system and an EHR?
A Document imaging system does not assist in documentation like a EHR does.
process of scanning a document into the computer and creating a picture of the document
These are some advantages of a document imaging system.
Space saving multiple user access autofaxing users can access anytime, anywhere enhances patient record security
Scanning past medical records so that there is an existing database of patient information
pages that are blank except for a barcode that will tell the scanner and ultimately the computer the content of the pages that follow
prevents user from altering what is stored write once read many
holds and retrieves the individual disks just as a music jukebox does
Scanner are rated on.....
pages per minute
Document imaging eliminates which function?
This controls the specific data elements collected?
software that allows the facility to incorporate procedures and processes into the system based on criteria established by the organization
The 1st stage in the scanning process is?
This type of backup backups everything on the hard drive
This type of backup backups only copies that have changed since the last backup
Ad Hoc Reporting
reports needed only once
reports that are needed repeatedly
Comparing scanned documents to the paper documents to ensure the quality of the scanned image is good and the documents are under the correct pt name and document type
transfer of data from the computer directly into the document imaging system
National Committee on Vital Health Statistics advisory committee to the DHHS
What is the role of the NCVHS in regard to the EHR?
to recommend guidelines applicable to the EHR such as standards, data sets, and terminologies
Standards development organizations
SDOs the efforts of 2 organizations ANSI (american national standards institute) WEDI (workgroup for electronic data interchange)
american national standards institute voluntary organization that accredits groups in the private sector for data standards
workgroup for electronic data interchange identifies ways to increase the use of electronic billing to reduce admin costs
Health Level 7 Communicates Clinical Data Messaging Format Language
These 2 organizations serve to ensure that data elements and data sets are defined and equal so that info can be transmitted.
Communicates financial data Messaging format language
list of recommended data elements with uniform definitions ensures consistency of data collected ensures consistency of definitions of data elements supports electronic data collection and exchange
These are data entry methods used to support data integrity.
required fields edit checks help screens automatic save feature online reference link hot spots streamlining repetitive data
large collection of data in a standardized format which allows for data retrieval as meaningful information
Database Management System
used to manipulate and control data stored in the database DBMS
Unique identifier used in a healthcare data base ex. health record number used in a relational database
when the primary key of one table is included in another table when this happens the nd key is called the foreign key
CPOE physicians, clinicians enter orders directly into system system provides alerts/reminders/prompts as orders are entered
Clinical Decision Support System
CDSS preprogrammed logic that generates alerts/reminders as data is entered by caregivers controlled by rules engines may be active (user must address alerts/reminders) may be passive (user can ignore or utilize alerts) has benchmarking (compares internal data to external data)
test results can be graphed/displayed over one encounter or multiple encounters for comparison
ability to receive data from and send data to other information systems
systems nomenclature of medicine clinical terms captures detailed clinical info enables comparison of aggregate data automatically identifies and tags standard terms
Logical Observation Identifiers Names and Codes
LOINC Lab Vocabulary used to order/report lab tests and record clinical observations allows tests from multiple labs to be understood
medication vocabulary provides standards for drug ingredients and strength,dose formats,drug relationships
National Drug Codes Universal unique identifier for human drugs
A subset of the EHR that is used for subsequent patient care is?
CCR (continuity of care record)
The phrase "womb to tomb" refers to:
the longitudinal health record
Unified Medical Language System
UMLS thesaurus of medical terms groups terms according to concepts improves data retrieval
nomenclature and knowledge-based system
Digital Imaging and Communications in Medicine
Standards for Diagnostic Medical Imaging As well as images related to dentistry,cardiology, and radiology
Clinical Data Repository
database that manages data from a variety of source systems receives data in "real time" processes discrete data, paper document images, and clinical images
Electronic Health Record
The system that includes patient information from both the patient and the healthcare provider is called the:
Personal Health Record PHR
prevents physicians from receiving a fee for referring patients for any healthcare services whose care is paid for by federally funded programs such as Medicare and Medicaid also called "the anti-kickback law"
Controls reminders and alerts
compare internal data to external data used to standardize practice patterns and reduce high cost drugs and other treatments
Electronic Medication Administration Record
EMAR designed to help prevent medication errors by automating medication administration processes
compares internal data to external data used to standardize practice patterns and reduce usage of high cost drugs and other treatments
Messaging standard for billing and claims transactions
Addresses standards for EHR record content, continuity care record and lab data exchange
What are the 3 main types of authentication?
Digitized Signature Electronic Signature Digital Signature
A scanned image of an actual signature not the best option for security
User must enter a username and password prior to signing an entry Sometimes there is even a two tiered user id process users must go through prior to signing an entry
Uses encryption and nonrepudiation and nonrepudiation ()
transmitting text in scrambled form
method that positively identifies the user so the user cannot deny sending the message ex.
Health Information Technology Standards works with both private and public sectors to achieve widespread interoperability among healthcare software applications
These are the primary functions of an EHR
Integrate data from multiple sources Provide data capture capabilities at the point of care Support clinicians with decision making Provide links to access resources to further their knowledge
These are types of Clinical Information Systems
Electronic Health Record Telemedicine Smart Cards Computer Provider Order Entry CPOE Electronic Medical Administration
Used to locate the paper medical record
2 people with the same medical record
Duplicate Medical Record
2 medical record numbers for the same person
How is the EHR different from a document imaging system?
The document imaging system does not assist in documentation
The HPIAA Security Rule
This rule addresses personal health information that is maintained and processed electronically.
The HIPAA Privacy Rule
This rule addresses ALL types of personal health information-in written, oral, or electronic format.
These are the 4 sections that make up the HIPAA data security safeguards: