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EHR-final terms
| Question | Answer |
|---|---|
| Aggregate data | Data extracted from individual health records and combined to form the identified information about groups of patients that can be compared and analyzed. |
| American Recovery and Reinvestment Act of 2009 (AARA) | Signed into law by President Obama in February of 2009; also known as the "stimulus plan". It is an economic stimulus plan that includes provisions for the Health Information technology for Economic and Clinical Health Act (HITECH). |
| Audit controls | As relating to security services, hardware, software, and/or procedural mechanisms that record and examine activity in information systems. |
| Authentication (cont.) originate from an authorized source. | a) The process of identifying the source of health record entries by attaching a hand-written signature, the author's initials, or an electronic signature. b) Proof of authorship that ensures, as much as possible, that logins and messages from a user |
| Certifying Commission for Health Information Technology (CCHIT) | A non-profit, non-governmental agency whose purpose is to certify electronic health records for functionality, interoperability, and security. |
| Chart conversion | An EHR implementation activity in which data from the paper chart are converted into electronic form. |
| Clinical documentation system | Also called point-of-care charting; an application that guides clinicians in capturing documentation, such as nurse assessments, history, physical exams, and progress notes, not otherwise captured in other clinical applications such as bar code medication |
| Clinical documentation system (cont.) | administration record systems (e-MAR) or computerized provider order entry systems (CPOE). |
| Computerized Physician Order Entry (CPOE) | System that allows physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindications, or other clinical decision support. |
| Consolidated Health Informatics (CHI) Initiative | One of the 24 Presidential eGovernment initiatives with the goal of adopting vocabulary and messaging standards to facilitate communication of clinical information across federal health enterprise. CHI now falls under FHA. |
| Continuity of Care Record (CCR) (cont.) personal health records. | A core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It is widely used now as a standard specification for patient health summaries and |
| Core objectives | Related to Meaningful Use of electronic health records (EHR); these are the basic functions that an EHR would include. Some examples are: recording of a problem list, recording of a medication list, electronic prescribing. |
| Data mining | The process of extracting information from a database and then quantifying and filtering discrete, structure data. |
| Decision-Support System (DSS) | Computer tools or applications to assist physicians in clinical decisions by providing evidence-based knowledge in the context of patient specific data. Examples include: drug interaction alerts at the time medication is prescribed and reminders for |
| DSS (cont.) | specific guideline-based interventions during the care of patients with chronic disease. Info. should be presented in a patient-centric view of individual care and also in a population/aggregate view to support population mgmnt. and quality improvement. |
| Electronic Health Record (EHR) (cont.) organization. | An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare |
| Electronic Medication Administration (e-MAR) | Application in which a schedule of medications, their dose, route, and time for administration is provided to nursing staff and which is used to document such administration. |
| Electronic prescribing (E-Rx or e-prescribing) | When a prescription is written from an electronic device with 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 signature | A form of electronic signature in which the individual utilizes a password, biometric, token, or combination thereof to provide authentication. |
| Enterprise architecture | A strategic resource that aligns business and technology, leverages shared assets, builds internal and external partnerships, and optimizes the value of information technology services. |
| Federal Health Architecture (FHA) | A collaborative body composed of several federal departments and agencies including: the Dept. of Health and Human Services(HHS), the Dept. of Homeland Security(DHS), the Dept. of Veterans Affairs(VA), the Environmental Protection Agency(EPA), US Dept. of |
| FHA (cont.) (cont.) outcomes. | Agriculture(USDA), the Dept. of Defense(DOD), and the Dept. of Energy(DOE). FHA provides a framework for linking health business processed to technology solutions and standards and for demonstrating these solutions to achieve improved health performance |
| Health Informatics | The management of automated health information; the technological side of managing health information-the design, development, structure, implementation, integration, and management of the technical aspects of EHR maintenance. |
| Health Information Exchange (HIE) | The movement of sharing of information between healthcare entities in a secure manner and in keeping with nationally recognized standards. |
| Health Information Technology (HIT) | The application of information processing, involving both computer hardware and software, that deals with the storage, retrieval, sharing, and use of healthcare info., data, and knowledge for communication and decision making. |
| Health Insurance Portability and Accountability Act (HIPAA) | This act helps to set standards for storing, maintaining, and sharing electronic health information while ensuring the privacy and security of health information. |
| Interoperability | Through a single database, many different functions can take place and information can be shared. |
| Meaningful Use | This is part of the HITECH Act that is meant to increase the use of an EHR through monetary incentives provided that the EHR is used in a meaningful way to improve patient care. |
| National Health Information Network (NHIN) | A set of standards, services, and policies that enable the secure exchange of health information over the Internet. |
| Personal Health Record (PHR) | An electronic application through which individuals can maintain and manage their health info. (and that of others for whom they are authorized) in a private, secure, and confidential environment. |
| Portal | Based on web portal technology, a point of secure access to an organization's information system applications. |
| Practice management | Software used in physicians' offices to gather data on every patient and perform administrative functions in an electronic format. |
| Protected Health Information (PHI) | 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 regulations. |
| Regional Health Information Organization | Healthcare organization in a geographic area that exchange electronic health info. with the goal of improving patient care, reducing duplication, and reducing unnecessary costs. |
Created by:
Aprilnl1983