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EHR chapter review for Health Information Tech '
Terms in this set (60)
allows syncing of multiple unrelated function or systems
software with a unique purpose, such as word processing or used for a specific industry
person, usually a physician, who performs healthcare services requiring specialized education and training
service that assists in claims processing by standardizing billing and performing error checks
electonic claims submission
filing of a healthcare claim using a computer rather than paper
a form generated at the completion of an office visit, a portion of which detais the patient's diagnosis, procedures and sercices performed, and charge for each procedure/service.
point of care
procedures that take place at the time of care, rather than at a remote location or at a point in time after care is complete.
Practive Management software
specialized computer software that performs administrative and billing procedures in medical offices
technology that digitally transcribes spoken words
documented patient information such as age, sex, and race.
includes clinical documentation
EHR/EMR software is more comprehensice that Practivem Management software becaust it:
allows for ePrescribing, has mobile applications, assists in information exchange.
A patient is entered into the patient list:
In the long term, costs will ______ when transitioning to an electronic health record system.
Ther process of moving a patient from appointment making through check out is called.
Clinical documentations of a patient's visit is known as the:
An encounter form is also known as a/an:
The ______ is a form used to bill patient claims in physician offices
One factor that might contribute to slow acceptance of EHRs is:
PrimeSUITE's User Guide is accessed through the _____ feature.
plan of care
Which of the following illustrates clinical information collected throught an EHR?
______ is not easily attained when using a manual record system.
A leadership position within a healthcare facility, including chief executive officer, chief operating officer, chief financial officer, chief information officer, or other higher level management positions. May also be referred to as healthcare manager or health systems manager.
Healthcare systems administrator
A leadership position specifically responsible for the information technology (IT) functions within an organization or facility.
Part of the requirements of the Health Information Technology for Economic and Clinical Health (HITECH) Act which is meant to increase the use of an electronic health record throught monetary incentives procided the EHR is used in a meaninful way to improve patient care.
A single raw fact such as a patient's name, height, or weight. Often used interchangeably with information through they are not synonymous terms.
Raw facts that, when viewed as a whole, have meaning. Example: a report of all patients treated at Memorial Medical Center with a principal dignosis of streptococcal pharyngitis (strep throat) sorted by patients age.
Data in the form of words or autdio files that cannot be treacked. e.g. include emails, written narratives, and audio files, from speech recognition technology.
Data that fits a particular model or format, which can be tracked and may be part of a database. e.g. include ICD-10 CM/PCS codes, CPT codes, a paitnets temperature, or a patient's age.
Health Infromation Technology for Economic and Clinical Health (HITECH) Act
A portion of the American Recovery and Reincestment Act (ARRA) that is meant to increase the use of an electronic health record by hospitals and physicians through a monetary incentive program.
Personal health record (PHR)
A record, kept by the patient, that contains a person's health history, immunization status, current and past medications, allergies, and instructions given by a care provider; it often includes patient education materials as well.
Clinical decision support
Allows access to current treatment options for a disease, through electronic or remote methods. Alerts the care provider to possible medication interactions, gives treatment options based on results of clinical trials or research, alers provider that a patient may have a particular diagnosis based on the data found in the patient's electronic record.
Picture Archiving and Communications Systems (PACS)
Computerized system for enhanced viewing and sharing of images such as x-rays, scans, ultra-sounds, and mammograms.
Health Insurance Prtability and Accountability Act (HIPAA)
Passed in 1996 this act includes regulations that afford people who leave their employment the ability to keep their insurance or obtain new health insurance even if they have a pre-existing medical condition. Also sets standards for storing, maintaining, and sharing electonic health information while ensuring its privacy and security.
Regional Health Information Organization (RHIO)
Healthcare organizations in a geographic area that exchange health information with the goal of inproving patient care, reducing duplication, and reducing unnecessary cost.
Health information exchange (HIE)
The movement or sharing of information between healthcare entities in a secure manner, and in keeping with nationally recognized standards.
Institute of Medicine (IOM)
An independent, nonprofit, nongovernmental organization that workds to provide unbiased and authoritative advice to decision makers and the public.
Protected health information (PHI)
Any piece of information that identifies a patient, including a patients name, date of birth, address, email, telephone number, employer, relatives' names, social security number, medical record number, account numbers tied to the patient, finger prints, photographs, and characteristivs about the patient that would automatically disclose his or her identity. PHI also includes any clinical information about an identified patient.
National Provider Identifier (NPI)
A unique identifier that must be used on insurance claims to identify the care provider and or group practive that rendered care to the patient.
American recovery and Reinvestment Act (ARRA)
Signed into law by President Obama on Feb. 19, 2009, this economic "stimulus plan" includes provisions for the Health Information Technology for Economic and Clinical Health (HITECH) Act.
Oficer of the National Coordinator for Health Information Technology (ONC)
Teh principal federal entity charged with coordination, implementation, and use of health information technology and the electronic exchange of health information.
National Health Information Network (NHIN)
A set of standards, services, and policies that enable the secure exchange of health information over the Internet.
Certification Commission for Health Information Technology (CCHIT)
A nonprofit, nongovernmental agency whose purpose is to certify electonic health records for functionality, interoperability, and security.
Reginal extension center
An organization that assists healthcare providers with the selection and implementation of electronic health record systems.
a single fact often used interchangeably with information
the sharing of health information among various entities, using standardized and secure processes
health information exchange
details that cannot be tracked, such as emails and voice recognition technology audio files
staff memeber whose responsibilities include managemetn of a facilitys IT functions
healthcare systems administrator
use of health information in an effective and efficient manner to improve patient care
method of accessing current treatment options for a disease, through electonic or remote methods
clinical decision support
record of the names of all patients seen in a hospital setting
Master Patient Index
any piece of identifying or clinical information about a patient
Protcted Health Information
an independent organization that is responsible for certifying electronic health records for viability
an independent organization that works to provide advice and guidance to the pubic and healthcare decision makers
Institute of Medicine (IOM)
Health information exchange
The acronym HIE stands for:
An advantage of using screen based data collection tools is that the layout of the information can be:
Institute of Medicine (IOM)
The _____ defined the eight core functions of an EHR.
establish standards for keeping of health information
Which of the following is a goal of HIPAA?
the patient signs in at the front desk
In a physician's office, patient data collection begins when:
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