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HIT 220 - Ch 10

Electronic Health Record

AMERICAN HEALTH INFORMATION COMMUNITY (ahic) A public - private federal advisory committee assocated with the Office of the National Coordinator that makes recommendations to the secretary on how to accelerate adoption of the interoperable electronic health information technology.
AMERICAN NATIONAL STANDARDS INSTITUTE (ansi) An organization that governs standards in many aspects of public and private business, developer of the Health Information Technology Standards.
CENTERS FOR MEDICARE AND MEDICAID SERVICES (cms) A dept of DHHS. Responsible for developing health care policy in the US & for administering the Medicare and federal portion of Medicaid. Maintenance the UCD 9 - CM.
CLASSIFICATION SYSTEMS A system for grouping similar diseases and procedures and organizing related info for easy retrieval. A system for assigning numeric or alpha numeric code numbers to represent specific diseases and or procedures.
CLINICAL DESCISION SUPPORT SYSTEM (cdss) A special subcategory of clincial information systems that is designed to help healthcare providers make knowledge based clinical decisions.
CLINICAL MESSAGING The function of electornically delivering data and automating the work flow around the management of clinical data.
CLINICAL PROVIDER ORDER ENTRY (cpoe) THE CPOE contains preprogrammed clinical decision support designed to assist the user thru making an entry appropriately.
COMMUNITY OF CARE RECORD (ccr) The CCR is a snapshot of data from the EHR and includes basic info such as diagnoses, allergies, medications, & future treatment. Healthcare providers will have access to improve the continuity of patient care as well as reduce medical errors.
CURRENT PROCEDURE TERMINOLOGY The American Procedural Association's Current Procedural Terminology (CPT) are the terms used in profession billing.
DATA CONTENT STANDARDS Defined as the "clear guidelines for the acceptable values for specified data field"
DATA REPOSITORY Data from diverse sources are stored in a database so that an integrated, multidisciplinary view of the data can be achieved. aka clinical data repository, central data repository.
DATA SET A list of recommended data elements, how the data is entered, and how data is shared.
DATA WAREHOUSE A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface.
DATABASE An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.
DIGITAL IMAGING AND COMMUNICATIONS IN MEDICINE (dicom) A standard that promotes a digital image communications format and picture archive and communications systems for use with digital images.
DIGITAL SIGNATURE An 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. This method is very insecure because anyone who has access to the image can use the signature.
ELECTRONIC DOCUMENT MANAGEMENT SYSTEMS (edms) A 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 info 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 bar coded wristband.
ELECTRONIC SIGNATURE Any representation of a signature in digital form, including image of handwritten signature. Also authentication of a computer entry in a health record made by the individual making the entry.
HEALTH LEVEL 7 (hl7) A international organization of healthcare professionals dedicated to creating standards for the exchange, management, and integration of electronic information.
HEALTH INFORMATION TECHNOLOGY STANDARDS PANEL (hitsp) Works with public and private sectors to achieve what they call "widespread interoperability among healthcare software applications".
HYBRID RECORD A combination of paper and electronic records. A health record that contains both paper and electronic elements.
INTERNATIONAL CLASSIFICATION OF DISEASES. 9TH EDITION CLINICAL MODIFICATION A coding and classification system used in US to report diagnoses in all healthcare settings and inpatient procedures and services as well as morbidity and mortality info.
INTEROPERABILITY The ability of different info systems and software applications to communicate and exchange data.
LOGICAL OBSERVATION IDENTIFIERS NAMES AND CODES (loinc) A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory 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. aka interoperability standards or data exchange standards.
NATIONAL COUNCIL FOR PRESCRIPTION DRUG PROGRAMS (ncpdp) Non-profit ANSI accredited standards development organization founded in 1977 that develops standards for exchanging prescription and payment information.
NATIONAL DRUG CODES (ndc) Codes that serve as an identifiers for human drugs, currently limited to prescription drugs and a few selected OTC products.
NATIONAL eHEALTH COLLABORATIVE (NeHC) Works with other stakeholders 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 info infrastructure that links various healthcare info systems together. Allows patients, physicians, institutions, and other entities nationwide to share clinical info privately and securely.
NATURAL LANGUAGE PROCESSING (nlp) Conversion of human language into data that can be translated and then manipulated by computer systems. Brand of artificial intelligence.
OFFICE OF THE NATIONAL COORDINATOR OF HEALTH INFORMATION TECHNOLOGY (ONC) Dept ordered to advance the development, adoption, and implementation of healthcare information technology standards. Part of DHHS,
ORDER ENTRY/RESULTS REPORTING Allows for entry of orders which ae then routed to the appropriate department for actions. Once the results are available, they are routed back to the care provider for review.
PATIENT PROVIDER PORTAL Secure method of communication between healthcare provider and the patient, or just providers, the provider and payer. Includes email or remote access to test results, or provide patient monitoring.
PERSONAL HEALTH RECORD (phr) An electronic or paper health reocrd maintained and updated by an individual for himself or herself.
POPULATION HEALTH The capture and reporting of healthcare data that is are used for public health purposes. It allows the healthcare provider to report infectious disease, immunizations, cancer, and other reportable conditions to public health officials.
PRESENTATION LAYER Controls screen layout, data entry, and data retrieval. The flexibility 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 by the FDA, Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms.
SOURCE SYSTEM Source code is the programming code that was used to develop the system.
SYSTEMATIZED NOMENCLATURE OF MEDICINE (snomed) A comprehensive clinical vocabulary developed by the College of American Pathologist, which is the most promising set of clinical terms available for a controlled vocabulary for healthcare.
STANDARDS DEVELOPMENT ORGANIZATIONS (sdos) A private or government agency involved int he development of healthcare informatics standards at a national or international level.
STRUCTURED DATA Binary, computer-readable data.
TEMPLATE-BASED ENTRY A 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 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 Non-binary, human-readable data.
USE CASE A technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements.
VOCABULARY STANDARDS A list or collection of clinical words or phrases with their meanings. The set of words used by an individual or group within a particular subject field.
Created by: mrblbit