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Chapter 10

American Health Information Community A public-private federal advisory committee associated with the office of the National Cordinator that makes recommendations to the secretary on how to accelerate adoption of interoperable electronic health information technology.
AHIC American Health Information Community
American National Standards Institute An organization that governs standards in many aspects of public and private business; developer of the Health Information Technology Standards Panel.
ANSI American National Standards Institute
Centers for Medicare and Medicaid Services The division of the Department of Health and Human Services that is responsible for developing healthcare policy and for administering the Medicare program and the federal portion of the Medicaid program and maintaining the procedure portion of the ICD-9-
CMS Centers for Medicare and Medicaid Services
Classification Systems 1. A system for grouping similar diseases and procedures and organizing related information for easy retrieval; 2. A system for assigning # or ABC code # to represent diseases or procedures.
Clinical decision support system A special subcategory of clinical information systems that directly support patient care.
Clinical messaging The function of electronically delivering data and automating the workflow around the management of clinical data.
Clinical provider order entry The CPOE contains preprogrammed clinical decision support designed to assist the user through making an entry appropiately.
Continuity of care record CCR The CCR is a snapshot of data from the EHR and includes basic information such as diagnoses, allergies, meds, and future treatment. The CCR should be availible to all healthcare providers so as to improve the care and reduce medical errors.
Current Procedural Terminology The american procedural association's current procedural terminology are the terms used in professional billing.
Data content standards Clear guidelines for acceptable values for specified date fields.
Data repository An open-structured databae that is not dedicated to the software of any particular vendor or data supplier, in which data from diverse sources are stored so thatAKA central data repository,clinical data repository
Data set A list of recommended data elements with uniform definitions relevant for a particular use
Data warehouse A database that makes it possible to access data from multiple databases and combine results into a single query and reporting interface
Database An organized collection of data,text,references, or pictures in a standarized 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.
digitized signature The digitized signature is 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 recor in information system designed to provide access to complete and accurate clinical data, practioner alerts, and reminders, clinical decision support systems, and links to medical knowledge.
Electronic medication administration record EMAR A system designed to prevent medications errors by checking a patient's medication information against his or her barcoded wrist band
electronic signature 1. Any representation of a signature in digital form, including an image of a hand written one 2. authentication of a computer entry in a health record made by the individual making the entry
Health level 7 HL7 An international organization of health care professionals dedicated to creating standards for the exchange, management, and intergration of electronic information
Health Information Technology Standards HITSP HITSP works collaboratively with public and praivate sectors to achieve"widespread interoporatively among healthcare software applications.
Hybrid Record A combination of paper and electronic records
International Classification of Diseases Ninth Edition A coding and classification system used in the united states to report diagnoses in all healthcare settings and inpatient procedures and services as well as mobidity and motality 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 by the Regenstrief Institute for Health Care aimed at standarizing laboratory and clinical codes for use in clinical 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 AKA interoperability standards or data exchange standards The purpose of messaging standards to support communications between information systems.
National Council for Prescription Drug Programs NCPDP A not-for-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 product identifiers for human drugs, currently limited to prescription drugs and a few selected over-the-counter products
National eHealth Information Network NeHC NeHC is working 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 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 network of network
National Language Processing NLP Conversion of human language(structured or unstructured) 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 of the U.S Department of Health and Human Services establioshed by executive order 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 appropiate department for action. Once the results are available, they are routed back to the care provider for review.
Patient provider portal The patient provider portal is a secure method of communication between the healthcare provider and patient, just provider, or the provider and the payer. May include secure e-mail or remote access to test results and provide patient monitoring
Personal health record An electronic or paper health record maintained and updated by an individual for himself or herself.
Population health The capture and reporting of healthcare data that is used for public health purposes.
Presentation layer The presentation layer controls screen layout, and data retrieval
Radiofrequency identification device RFID An automatic recognition technology that uses a device attached to an object to transmit data to a reciever and does not require direct contact.
RxNorm A clinical drug nomenclature developed by the Food and Drug Adminstration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms.
Source system Information systems that populate the EHR.
Systematized Nomenclature of Medicine SNOMED A comprhensive clinical vocabulary developed by the College of American Pathologists, which is the most promising set of clinical terms available for a controlled vocabulary for healthcare.
Standards development organizations SDOs A private or goverment agency involved in the 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
Unified Medical Language System A program initiated by the National Library of Medicine to build an intelligent, atomated system that can understand biomedical concepts, words, and expressions and thier interrelationships; includes concepts and terms from many different source vocabular
Unstructured data Nonbinary, 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; also, the set of words used by an individual or group within a particular sbject field.
Created by: mhorne