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Chapter 10-Comp.HIT

QuestionAnswer
AHIC American Health Information Community
ANSI American National Standards Institute
CMS Centers for Medicare and Medicaid Services
Classification Systems A system for grouping similar material together. Such as diseases and procedures in the ICD codes.
Clinical decision support system (CDSS) A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions.
Clinical messaging The function of electronically delivering data and automating the work flow around the management of clinical data.
Clinical provider order entry (CPOE) Contains preprogrammed clinical decision support designed to assist the user through making an entry appropriately.
Continuity of Care record (CCR) A snapshot of data from the EHR which includes basic inf. such as diagnoses, allergies, medications and future treatment. Should be available to all healthcare providers so as to improve the continuity of patient care as well as reduce medical errors.
Current Procedural Terminology The terms used in professional billing.
Data content standards "The clear guidelines for the acceptable values for specified data fields"
Data Repository Also "clinical data repository" - and open-structure database that is not dedicated to the software of any particular vendor , in which data from diverse sources are stored so an integrated, multidisciplinary view of the data can be achieved
Data set A list of recommended data elements with uniform definitions that are relevant for a particular use
Data Warehouse a database that makes it possible to access data from multiple databases and combine the results in 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 apps.
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 Retrieves images and other information from imaging equipment
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. Very insecure b/c 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 computerized record of health information and associated processes
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
Health Level 7 (HL7) A standards development organization accredited by the American National Standards Institute that addresses issues at the application, (7th) level of healthcare systems
Health information technology Standards Panel (HITSP) "widespread interoperability among healthcare software apps". HITSP membership is available to anyone interested. and includes standards development organizations. HITSP publishes their work products prior to apprival in order to obtain public feedback
Hybrid record A health record that includes both paper and electronic elements
International Classification of Diseases, Ninth Edition, Clinical Modification 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 morbidity and mortality information (AHIMA 2010)
Interoperability The ability, generally by adoption of standards, of systems to work together
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 (AHIMA 2010)
Mapping Creation of a cross map that links the content from one classification or terminology scheme to another (AHIMA 2010)
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 (AHIMA 2010)
Messaging standards Also called interoperability standards or data exchange standards. The purpose of messaging standards is to support communications between information systems.
National Council for Prescription Drug Programs (NCPDP) An organization 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 Collaborative (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" (AHIMA 2010)
National health information network (NHIN) System that links various healthcare information systems together, allowing patients, physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely
Natural language processing (NLP) The extraction of unstructured or structured medical word data, which are then translated into diagnostic or procedural codes for clinical and administrative applications
Office of the National Coordinator of Health Information Technology (ONC) A dept. of the U.S. Dept. of health and Human Services established by executive order to advance the development, adoption and implementation of healthcare information technology standards (AHIMA 2010)
Order entry/results reporting A type of info. that allows for entry of orders, which are then routed to the appropriate dept. for action. Once the results are available, they are routed back to the care provider for review.
Patient provider portal a secure method of communication between the healthcare provider and the patient, just the providers or the provider and the payer. The patient provider portal may include secure e-mail or remote access to test results, and provide patient monitoring.
Personal health record (PHR) An electronic or paper health record maintained and updated by an individual for himself or herself (AHIMA 2010)
Population health The capture and reporting of healthcare data that is used for public health purposes. It allows the healthcare provider to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials.
Presentation Layer Controls screen layout, data entry and data retrieval. The flexibility of the presentation layer is what allows the various healthcare providers to manipulate it (Amatayakul, 2007)
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 (AHIMA 2010)
RxNorm A clinical drug nomenclature developed by the FDA, the Dept. of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms (AHIMA2010)
Source System Information systems that populate the EHR. Include the electronic medication administration record, laboratory information system, radiology info. system, hospital info. system and nursing info. systems.
Systematized Nomenclature of Medicine (SNOMED) A comprehensive clinical vocabulary developed by the College of American pathologists, which is the nost promising set of clinical terms available for a controlled vocabulary for healthcare (AHIMA 2010)
Standards development organizations (SDO's) A private or government agency involved in the development of healthcare informatics standards at a national or international level (AHIMA 2010)
Structured Data Binary, computer-readable data (AHIMA 2010)
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 (Amatayakul, 2007)
Unified medical Language System Program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships: includes concepts and terms from many source Vocabs. (AHIMA 2010
Unstructured Data Nonbinary, human-readable data (AHIMA 2010)
Use case A technique that develops scenarios based on how users will use information to assist in developing info. systems that support the information requirements (AHIMA 2010)
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 subject field (AHIMA 2010)
Created by: Ltlewonder