Electronic Health Records Ch 4 Key Terms
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| Final review during EHR implementation to ensure that all tests have been preformed and all issues have been resolved, usually triggers the final payment in full for services or materials provided | Acceptance testing
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| A computer software program designed to preent unauthorized use of an information resource | Access controls
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| A committee of the National Standards Institute that develops & maintains standards for the electronic exchange of business transactions | Accredited Standards CommitteeX12N (ASC X12N)
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| The condition of being admitted into evidence in a court of law | Admissibility
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| The organization that accredits all U.S. standards development organizations to ensure that they are following due process in promulgating standards | American National Standards Institute(ANSI)
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| Electronic systems that generate clinical information (such as lab info systems, radiology info systems, pharmacy info systems, and so on) | Ancillary systems
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| The configuration, structure, and relationships of hardware (the machinery of the computer including input/output devices, storage devices, and so on) in an information system | Architecture
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| A system of standards developed primarily for various EHR management process. Formerly known as the American Society for Testing and Materials | ASTM International
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| A chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs), file access) that is used to determine security violations | Audit trail
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| confirmed systems | Authenticiation
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| A vendor strategy used when purchasing an EHR that refers to system applications that are considered the best in their class | Best of Breed
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| A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vendor | Best of fit
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| An effort initiated by the private sector to evaluate & potentially test EHR products against specific criteria, drawn from HL7 standard EHR system functinality | Certification Commission on Health Information Technology (CCHIT)
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| An EHR implementation activity in which data from the paper chart are converted into electronic form | Chart conversion
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| A computer architecture in which multiple computes (clients) are connected to other computers (servers) that store & distribute large amounts of shared data | Client/server architecture
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| A central database that focuses on clinical information | Clinical data respository (CDR)
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| A database that makes it possible to access data from multiple databases & combine the results into a single query & reporting interface; also callled a data warehouse | Clinical data warehouse (CDW)
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| The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, & supplying clinical reminders and alerts | Clinical decision support (CDS)
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| A category of a healthcare information system that includes systems that directly support patient care | Clinical information system (CIS)
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| Technology that electronically stores documents and distributes them with fax, e-mail, Web, and traditional hard-copy print processes | Computer output to laser disk (COLD)
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| Technology that electronically stores documents and distributes them with fax, e-mail, Web, and traditional hard-copy print processes | Computer output ot laser disk/enterprise report management (COLD/ERM)
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| Systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindicaions, or other clinical decision support (aka computerized physician order entry) | Computerized provider order entry (CPOE)
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| Term used to refer to notebook computers mounted on carts and moved with the users | Computers on wheels (COWs)
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| The condition of depending on the parts of a written or spoken statement that precede or follow a specified word or phrase and can influence its meaning or effect | Contextual
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| Documentation of care delivery from one healthcare experience to another | Continuity of care record (CCR)
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| A predefined set of terms & their meanings that may be used in structured data entry or natural language processing to represent expressions | Controlled vocabulary
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| The standardization of vocabulary such that the meanning of a single term is the same each time the term is used in order to produce consistency in information derived form the data | Data comparability
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| The task of moving data from one data structure to another, usually at the time of a new system installation | Data conversion
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| A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology | Data dictionary
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| Protocols that help ensure that data transmitted from one system to another reamin comparable | Data exchange standards
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| Computer software that enables the user to create, modify, delete, and view the data in a database | Database management system (DBMS)
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| A process in which vocal sounds are converted to bits and stored on computer for random access | Digital dictation
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| Data provided in a computer-readable format | Digital images
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| Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values | Discrete data
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| A more expansive view of case management in which patients with the highest risk of incurring high-cost interventions are targeted for standardizing & managing care throughout integrated delivery systems | Disease management (DM)
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| The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed | Document imaging
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| A vendor strategy in which one vendor primarily supplies the financial& administrative applications & another vendor primarily supplies the clinical applications | Dual core (vendor strategy)
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| A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations | Electronic data interchange (EDI)
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| A type of electronic document management system tht uses methods such as bar coding on the forms to identify specific content | Electronic document/content management (ED/CM)
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| 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 document management system (EDMS)
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| A computerized record of health information and associated processes | Electronic health record (EHR)
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| A system designed to prevent medication errors by checking a patient's medication information against his or her barcoded wristband | Electronic medication administration record (EMAR)
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| When a prescription is written from the personal digital assistant and an electronic fax or when an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy's information system | Electronic prescribing (e-Rx)
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| A system that requiress the author of a document to sign onto a patient record using a user ID and password, reviews the document to be signed, and indicated approval | Electronic signature authentication (ESA)
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| Converted into code | Encoded
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| A popular protocol (format) for transmitting data in local area networks | Ethernet
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| Health services based on clinical methods that have throughly tested through controlled, peer-reviewed biomedical studies | Evidence-based medicine
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| A system of connections of private Internet networks outside an organization's firewall that uses Internet technology to enable collaborative applications among enterprises | Extranet
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| A plan in which health information is shared among providers | Health information exchange (HIE)
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| The technology aspects of processing health data and records, including classification and coding, abstracting, registry development, storage, and so on | Health information technology (HIT)
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| The federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information | Health Insurance Portability and Accountability Act of 1966 (HIPPA)
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| A standards development organization accredited by the American National Standards Institute that addresses issues at the seventh, or application, level of healthcare systems interconnections | Health Level Seven (HL7)
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| The comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital | Hospital information system (HIS)
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| Physsicians employed by teaching hospitials to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs | Hopitalist
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| The device used by humans to access and enter data into a computer system, such as a keyboard on a PC, personal digital assisant, voice recognition system, and so on | Human-computer interface
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| A health record that includes both paper and electronic elelments | Hybrid record
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| A form of testing during EHR implementation performed to ensure that the interfaces between applications and systems work | Integration testing
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| The state of being whole or unimpaired | Integrity
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| The ability, generally by adoption of standards, of systems to work together | Interoperability
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| A private information network that is similar to the Internet and whose servers are located inside a firewall or security barrier so that the general public cannot gain access to information housed within the network | Intranet
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| The process of resolving unexpected occurrences (for example, the late delivery of needed supplies or an uncorrected system problem) | Issues management
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| A network that connects multiple computers devices via continuous cable within a relatively small geographic area | Local area network (LAN)
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| The term used to refer to the configuration of a mainframe computer | Mainframe architecture
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| Legislation passed in 2003 designed to expand healthcare services for seniors, with a major focus on prescription drug benefits | Medicare Modernization Act of 2003 (MMA)
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| Protocols that help ensure that data transmitted form one system to another remain comparable | Message format standards
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| A series of steps required to move from one situation to another | Migration path
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| The act of entering data into a primary and a secondary server simultaneously so that the second server can continue to process the data in the event the primary server crashes | Mirrored processing
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| An organization that develops standards for exchanging prescription and payment information | National Council for Prescription Drug Programs (NCPDP)
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| Codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected over-the-counter products | National Drug Codes (NDC)
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| A infrastructure proposed by the National Committee on Vital and Health Statistics 2002 that would be a set of technologies, applications, systems, values, and laws that support all facets of provider healthcare, individual health, and public health | National health information infrastructure (NHI)
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| System that links various healthcare information systems together, allowing patients, physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely | National health information network (NHIN)
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| The world's largest medical library and a branch of the National Institutes of Health | National Library of Medicine (NLM)
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| The extraction of unstructured or structured medical word data, which are then translated into diagnostic or procedural codes for clinical and administrative applications | Natural language processing (NLP)
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| A system in which caregivers enter data into health records | Patient care charting system
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| A type of incentive to improve clinical performance using the electronic health record that could result in addtional reimbursement or eligibility for grants or other subsidies to support further HIT effortsA type of incentive to improve clin | Pay for performance (P4P)
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| A type of incentive to improve the quality of clinical outcomes using the electronic health record that could result in addtional reimbursement or eligibility for grants or other subsidies to support further HIT efforts | Pay for quality (P4Q)
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| A hand-held microcomputer, w/out a hard drive, that is capable of running applications such as e-mail & providing access to data & info, such as notes, phone lists, schedules, & lab results, primarily through a pen device | Personal digital assistant (PDA)
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| The vendor selected by the Bureau of Workers' Compensation to process outpatient medication bills submitted electronically | Pharmacy benefits manager (PBM)
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| An integrated computer system that obtains, stores, retreives, and displays digital images (in healthcare, radiological images) | Picture archiving and communications system (PACS)
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| The place or location where the physician administers services to the patient | Point of care (POC)
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| Special Web pages that offer secure access and entry of data upon authorization of the owner of the page | Portals
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| Software designed to help medical practices run more smoothly and efficiently | Practice management system (PMS)
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| Physician who provides, supervises, & coodinates the healthcare(hc) of a menmber & who manages referrals to other hc providers & utilization of hc services both inside & outside a managed care plan.(makes initial diagnosis of patient's medical condition) | Primary care physicians (PCP)
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| Under HIPAA, all individually identifiable info whether oral or recorded in any form or medium, that is created or received by a healthcare provider or any other entity subject to HIPAA requirements | Protected health information (PHI)
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| Organ. that performs medcl peer review of Medicare & Medicaid claims, incldng review of validity of hospital diagnosis & procedure coding info; completeness, adequacy, & QOC; and appro. of prospective paymnts for outlier cases & nonemergent use of the ER | Quality improvement orgranization (QIO)
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| A service that indicates where a given patient may have health information using probability equations | Record locator service (RLS)
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| A method of ensuring data security | Redundant arrays of independent (or inexpensive) disks (RAID)
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| An organization that manages the local deployment of systems promoting & facilitating the exchange of healthcare data w/in a national health information network | Regional health information organization (RHIO)
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| A type of database that stores data in predefiend tables made up of rows and columns | Relational database
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| A type of business correspondence asking for very specific product & contract info that is often sent to a narrow list of vendors that have been preselected after a review of requests for info during the design phase of the systems development life cycle | Request for proposal (RFP)
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| Situation where two servers are duplicating effort | Server redundancy
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| Situation where speech is converted to text on screen | Speech recognition
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| A vocabulary that is accepted throughout the healthcare industry | Standard vocabulary
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| Storage devices organized into a network so that they can be accessible from any server in the network | Storage area network (SAN)
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| Software used to manage the SAN, keep track of where data are stored, and move older data to less expensive, but still accessible, storage locations | Storage management software
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| Testing performed toward the end of EHR implementation to ensure that the actual number, or load, of transactions that would be performed during peak hours can be performed | Stress testing
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| The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in the systems | System build
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| A type of testing performed by an independent organization to identify problems in information systems | System testing
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| A term referring to the narrative nature of much of clinical documentation to date | Textual
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| The testing step in EHR implementation that ensures that each data element is captured, recorded, and processes appropriately within a given application | Unit testing
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| Referring to the use and disclosure of a patient's personal health information | Uses and disclosures
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| An emerging architecture that utilizes Web-based tools to permit communication among different software applications | Web services architecture (WSA)
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| A computer network that connects devices across a large geographical area | Wide area network (WAN)
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| A data transmission network that uses an unguided medium such as radio waves or microwaves | Wireless local area network (WLAN)
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| Any work process that must be handled by more than one person | Workflow
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