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218 terms

HIM 4401 Healthcare Information Technology Systems

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