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Mod 5 Chapter 10

Computers in Health Care

American Health Information Community (AHIC) A public-private federal advisory committee that makes recommendations on how to accelerate adoption of interoperable electronic health information technology
American National Standards Institute (ANSI) Organization that governs standards in many aspects of public and private business; developer of the Health Information Technology Standards Panel
Centers for Medicare and Medicaid Services (CMS) Part of Department of Health and Human Services; responsible for developing healthcare policy, administering Medicare program and federal portion of the Medicaid program, maintain procedural portion of ICD-9-CM
Classification Systems System for grouping similar diseases and procedures; system for assigning numeric or alpha-numeric code numbers to represent specific diseases and/or procedures
Clinical Decision Support System (CDSS) Subcategory of clinical information systems that is designed to help healthcare providers make knowledge based clinical decisions
Clinical Messaging Electronically delivering data and automating the work flow around the management of clinical data
Clinical Provider Order Entry (CPOE) Contains preprogrammed clinical decision support designed to assist the user through making an entry appropriately
Continuity of Care Record (CCR) Snapshot of data from the EHR and includes basic information such as diagnoses, allergies, medications, and future treatment
Current Procedural Terminology Terms used in professional billing
Data Contents Standards Clear guidelines for the acceptable values for specified data fields
Data Repository An open structured database in which data from diverse sources are stored so that an intergrated, multidisciplinary view of the data can be achieved.
Data Set List of recommended data elements with uniform definitions that are relevant for a particular use
Data Warehouse Database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface
Database Organized collection of data, text, references, or pictures in a standardized format
Digital Imaging and Communications in Medicine (DICOM) Standard that promotes a digital image communications format and picture archive and communications systems for use with digital signals
Digital Signature Electronic signature that binds a message to a particular individual and can be used by the receiver to authenticate the identity of the sender
Digitized Signature A scanned image of an individual's actual signature.
Electronic Document Management Systems (EDMS) Storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks
Electronic Health Record (EHR) A health record in an information system designed to provide access to complete and accurate clinical data, practitioner alerts and reminders, clinical decision support systems, and links to medical knowledge
Electronic Medication Administration Record (EMAR) A system designed to prevent medication errors by checking a patient's medication information against his or her barcoded wristband
Electronic Signature Any representation of a signature in digital form, including an image of a handwritten signature
Health Level 7 (HL7) An international organization of healthcare professionals dedicated to creating standards for the exchange, management, and integration of electronic information
Health Information Technology Standards Panel (HITSP) Work collaboratively with public and private sectors to acheive what they call "widespread interoperability among healthcare software applications"
Hybrid Record Combination of paper and electronic records; a health record that includes both paper and electronic elements
International Classification of Diseases, Ninth Edition, Clinical Modification Coding and classification system used to report diagnoses in all healthcare settings and inpatient procedures and services as well as morbidity and mortality information
Interoperability The ability of different information systems and software applications to communicate and exchange data
Logical Observation Identifiers Names and Codes (LOINC) A database protocol developed and aimed at standardizing labratory and clinical codes for use in clinical care, outcomes management, and research
Mapping Creation of a cross map that links the content from one classification or terminology scheme to another
MEDCIN A proprietary clinical terminology developed as a point-of-care tool for electronic medical record documentation at the time and place of patient care
Messaging Standards Support communications between information systems; may be called interoperability standards or data exchange standards
National Council for Prescription Drug Programs(NCPDP) A not-for-profit ANSI-accredited standards development organization that develops standards for exchanging prescription and payment information
National Drug Codes Codes that serve as product identifiers for human drugs, currently limited to prescrition drugs and a few selected over-the-counter products
National eHealth Collaborative (NeHC) Work with others to address "issues and effecting the change needed to enable the secure and reliable exchange of electronic health information nationwide
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
Natural Language Processing (NLP) Conversion of human language into data that can be translated and then manipulated by computer systems; branch of artificial intelligence
Office of the National Coordinator of Health Information Technology (ONC) A department established to advance the development, adoption, and implementation of healthcare information technology standards
Order Entry/Results Reporting A type of information that allows for entry of orders, which are then routed to the appropriate department for action. Once the results are available, they are routed back to the care provider for review
Patient Provider Portal A secure method of communication between the healthcare provider and the patient, just the providers, or the provider and the payer. May include secure e-mail or remote access to test results, and provide patient monitoring
Personal Health Record (PHR) Electronic or paper health record maintained and updated by an individual for himself of herself
Population Health The capture and reporting of healthcare data that is/are used for public health purposes. Allows the healthcare provider to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials
Presentation Layer Controls screen layout, data entry, and data retrieval. The flexibility of the presentation layer is what allows the various healthcare providers to manipulate it
Radiofrequency Identification Device (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
RxNorm A clinical drug nomenclature developed to provide standard names for clinical drugs and administered dose forms
Source System Information systems that populate the EHR. These source systems include electronic medication administration record, laboratory information system, radiology information system, hospital information system, and nursing information systems
Systematized Nomenclature of Medicine (SNOMED) A comprehensive clinical vocabulary which is the most promising set of clinical terms available for a controlled vocabulary for healthcare
Standards Development Organization (SDOs) A private or govermental agency involved in the development of healthcare informatics standards at a national or international level
Structured Data Binary, computer-readable data
Template-based Entry Cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient
Unified Medical Language System Program to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies
Unstructured Data Nonbinary, human-readable data
Use Case Technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements
Vocabulary Standards List or collection of clinical words or phrases with their meanings; set of words used by an individual or group within a particular subject field
Created by: angelab