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DI definitions

Pharmacy Informatics

QuestionAnswer
Clinical Reminder a context-sensitive electronic prompt to the provider to perform an intervention or procedure based on the patient’s specific clinical data as applied to a set of logical conditions
Alert patient and context-sensitive warning presented to the ordering provider at the time an order is being entered. AKA: “order checks”
CPOE Computerized Provider Order Entry- direct entry of medical orders into a healthcare system’s EHR by licensed independent practitioners or other staff with specific ordering privileges, and not by clinical or administrative support staff
Corollary Orders orders entered as adjuncts to a primary order, e.g. orders for laboratory tests to monitor effects of a medication order, and orders for special diets in preparation for a medical procedure
Downtime the period of time during which the healthcare facility’s computer system is unavailable and electronic order entry is not possible
e- iatrogenesis patient harm caused at least in part by the application of health information technology
EHR systems Electronic Health Records software programs designed for use by healthcare systems to electronically place, store, and retrieve clinical orders, results, notes, reports, and other information related to the care of patients
File Architect also referred to as the medication masterfile, a complication of interconnected files and records that contain data elements that compose the medication and clinical information presented for use in an EHR system
Notification a patient- and context- sensitive prompt to the ordering providers, attending physician, primary provider, or care team to alert them of new information (i.e. abnormal lab results) or tasks in need of completion (i.e. unsigned order or note).
Order menu a listing of orders from which clinicians may select individual orders, organized to support a specific purpose, ordering environment, or type of order
Order set a group of medication and procedure orders that can be accessed and ordered from a single source in the EHR, to facilitate entry of multiple orders and standardize ordering for a specific purpose. These are analogous to pre-printed paper order forms.
Quick Order a pre-configured order in which the components (e.g. medication, dose, route, schedule, amount, number of refills, etc) are specified, allowed for faster order entry and limiting opportunities for entry errors (AKA order sentences)
ASC X12N Accredited Standards Committee X12, creates standards for the cross industry electronic transmission of business information.
ePrescribing commonly defined as “ambulatory computerized provider order entry” or ambulatory CPOE. There are many variations on this definition based on the needs of the definer
NCPDP National Council for Prescription Drug Programs is an organization that creates and promotes standards for the transfer of data to and from the pharmacy services sector of the healthcare industry
PDP Medicare Prescription Drug Plan (PDP) is the prescription drug plan that was created with the Medicare Prescription Drug improvement and Modernization Act of 2003
RXNORM clinical drug nomenclature standard produced by the NLM and provides standard names for clinical drugs, strengths and dosage forms; also links between the standard semantic clinical description and the branded representation
Alert Fatigue irritability, exhaustion, or bewilderment triggered in clinicians who have been exposed to too many alerts, or alerts with a perceived history of irrelevance- cause the user to ignore some or all of the alerts, reducing the safety
BCMA Bar code medication administration an inpatient CDSS to assist nurses with the five-rights of medication administration (right patient, right drug, right dose, right route, and right time).
CMS Centers for Medicare and Medicaid Services the federal healthcare program for the elderly and indigent
CDS Clinical Decision Support providing clinicians or patients with clinical knowledge and patient related information, intelligently filtered or presented at appropriate times, to enhance patient care
CDSS Clinical Decision Support System a system (computer or otherwise) intended to provide CDS to clinicians, caregivers, and healthcare consumers
HIT Health Information Technology any computer system designed to automate and/or enhance a healthcare process or workflow. HIT can be a small apparatus such as an IV infusion pump or a glucometer
Informational Notice may be a patient specific automated rule, such as an MLM, to inform of a change in patient status. This type of informational notice maybe urgent (change in renal function) or non-urgent (to report a hospital admission of a potential study patient).
Knowledge Base a collection of stored facts, rules, algorithms, and models for problem solving. May be organized in a database or even a simple table in which explicit relationships exist. (ex: drug-drug interaction and drug-allergy alerting systems)
LOINC Logical Observation Identifiers Names and Codes a standard to facilitate the exchange of clinical laboratory results
LASA Look-Alike, Sound-Alike a medication safety designation to prevent confusion between drugs with similar spelling or pronunciation.
MLM Medical Logic Module a rule for an Arden Syntax based clinical rules engine. HL7 defines it as an encoded clinical rule that contains enough logic to make a single clinical decision.
PHI Protected Health Information information about a person that must remain secure, as defined by Health Insurance Portability and Accountability Act (HIPPA)
Recommendation an automated rule, such as an MLM, that suggests a course of action, for example, a patient-specific dosage or a suggestion for a laboratory test, ideally, all recommendations are evidence-based and intuitionally approved
Reminder automated rule, such as an MLM, that suggests the clinician has overlooked or forgotten to perform an action such as documenting a decision, event, or finding
RHIO Regional Health Information Organization governance entity comprising separate and independent healthcare-related organizations that have come together to improve the quality, safety, and efficiency of healthcare for communities
Created by: gigglechuck