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These are examples of Input Devices
Optical Character Recognition
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.
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)
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
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......
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
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 .....
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....
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
used when computer needs to borrow memory temporarily
used when speed is needed by the computer
computer software program that assigns appropriate DRG's according to the info provided for each episode of care
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"
Clinical Information Systems
collect and maintain information related to patient care
data is patient identifiable
Computer Provider Order Entry
Designed for orders to be entered by a healthcare professional
Alerts and reminders built into the system
Lab Information System
collects, stores and maintains lab tests and their respective results
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
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
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
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
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?
can identify transpositions/name changes
This is the most sophisticated type of Algorithm
used by physician office groups
Scheduling,patient accounting, patient collections, claims submission,appointment scheduling, human resources are all built into one system
The system that would print out advanced directives, consents and notice of privacy practices is the?
Electronic Data Management System
An electronic system which manages documents in order to improve business processes
structured query language
data retrieval tool
allow user to create tables,delete tables and show how something is viewed
standard language for RELATIONAL DATABASES
data taken from a primary source and abstracted into another database or registry
ex. cancer registries, mpi, disease index
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
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.
multiple user access
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
software that allows the facility to incorporate procedures and processes into the system based on criteria established by the organization
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
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
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
These 2 organizations serve to ensure that data elements and data sets are defined and equal so that info can be transmitted.
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.
automatic save feature
online reference link
streamlining repetitive data
large collection of data in a standardized format which allows for data retrieval as meaningful information
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
Name the major types of databases.
has at least 2 tables
data stored on rows and columns
a field can be designated as a "primary key"
each row is a record
each column represents a single piece of data
structures data in a hierarchy similar to an organizational chart
similar to a tree structure
parent child relationship created
each piece of data is called a node
database that houses data from multiple systems
updated by systems in real time
ex. Clinical Data Repository: stores clinical info from various clinical information systems
subset of a data warehouse
designed for purpose or specialized use
data is scaled down to what is needed
lowers cost to manage
store data from various source systems
designed for specific types of data analysis such as patient care or business
not used directly for patient care
used to analyze data to identify patterns
process of extracting info from a database and then quantifying and filtering discrete, structured data
requires sophisticated software
Entity Relationship Diagram
depicts relationships between entities (people,locations,things,concepts)
method to detect whether elements of the patients health record are missing
reports are either present or absent in a quantitative review
detailed review of a patients health record for the quality of the documentation contained.
"would this record hold up in court?"
Business Continuity Plan
an organizations plan for responding to an unexpected failure of the EHR system
These are the stages of image capture
Inserting Workflow triggers
Indexing Loose Work
Clinical Provider Order Entry
physicians, clinicians enter orders directly into system
system provides alerts/reminders/prompts as orders are entered
Clinical Decision Support System
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
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
used to order/report lab tests and record clinical observations
allows tests from multiple labs to be understood
provides standards for drug ingredients and strength,dose formats,drug relationships
Unified Medical Language System
thesaurus of medical terms
groups terms according to concepts
improves data retrieval
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
The system that includes patient information from both the patient and the healthcare provider is called the:
Personal Health Record
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"
compare internal data to external data
used to standardize practice patterns and reduce high cost drugs and other treatments
Electronic Medication Administration Record
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
What are the 3 main types of authentication?
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
method that positively identifies the user so the user cannot deny sending the message
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
Computer Provider Order Entry CPOE
Electronic Medical Administration
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:
Transmission Security Safeguards
Administrative HIPAA data security safeguards
Documented formal practices to manage data security including a data security program and an individual to oversee the program
Physical HIPAA data security safeguards
A mechanism by which an organization's computer system will be protected from natural and environmental hazards/intrusion
Technical HIPAA data security safeguards
Controls for safeguarding the technical components of a computer system by using computer software
Transmission HIPAA data security safeguards
Methods for protecting data integrity and security as it is transmitted via internal and external networks
Health Information Technology for Economic and Clinical Health Act
Section of the ARRA that addresses the
Health information shared by a patient with a health care provider will only be disclosed/used for the purpose of patient care
Measures taken to protect and safeguard information and the systems that house the information from accidental or intentional disclosures to unauthorized persons
These are 3 types of security threats:
Human (intentional and non-intentional)
Environmental (natural disasters)
Hardware/software (failures or malfunctions)
following data sent across a network to validate that the data transmitted was not altered
enables data to be transmitted via networks in an unreadable form
must be decoded to be understood
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