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HIT 220- EHR
Electronic Health Record
| Question | Answer |
|---|---|
| American Health Information Community (AHIC) | A public-private federal advisory committee associated w/ the Office of the National Coordinator that makes recommendations to the secretary on how to accelerate adoption of interoperable electronic health information technology |
| American National Standards Institute (ANSI) | An organization that governs standards in many aspects of public & private business |
| Centers for Medicare and Medicaid Services (CMS) | Division of DHHS that is responsible for developing healthcare policy in the US |
| Classification systems | A system for grouping similar disease & procedures & organizing related information for easy retrieval |
| 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 & automating the work flow around the management of clinical data |
| Clinical provider order entry | Contains pre-programmed 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 & includes basic information such as diagnosis...Should be available to all healthcare providers |
| Current Procedure Terminology | The American Procedural Association's Current Procedural Terminology (CPT) are the terms used in professional billing |
| Data content standards | The clear guidelines for the acceptable values for specified data fields |
| Data repository | An open-structure database that is not dedicated to the software of nay particular vendor or data supplier, in which data from diverse sources are stored so that an integrated, multidisciplinary view of the data can be achieved |
| Data set | a list of recommended data elements w/ uniform definitions that are relevant for a particular use |
| Data warehouse | a database that makes it possible to access data from multiple databases & combine the results into a single query & reporting interface |
| Database | an organized collection of data, text, references, or pictures in a standardized 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 & picture archive & communications systems for use with digital images |
| Digital signature | an electronic signature that binds a message to a particular individual & 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 health record in an information system designed to provide access to complete & accurate clinical data, practitioner alerts & reminders, clinical decision support systems, & links to medical knowledge |
| Electronic medication administration record (EMAR) | a system designed to prevent medication errors by checking a patient's medication information against his/her bar-coded wristband |
| Electronic signature | any representation of a signature in digital form, including an image of a handwritten signature |
| Health Level 7 (HL7) | an international organization of healthcare professionals dedicated to creating standards for the exchange, management, & integration of electronic information |
| Health Information Technology Standards Panel (HITSP) | works collaboratively w/ public & private sectors to achieve what they call "widespread interoperability among healthcare software applications" |
| Hybrid record | a combination of paper & electronic records |
| International Classification of Diseases, Ninth Edition, Clinical Modification | a coding & classification system used in the US to report diagnosis in all healthcare settings & inpatient procedures & services as well as morbidity/mortality information |
| Interoperability | the ability of different information systems & software applications to communicate & exchange data |
| Logical Observation Identifiers Names and Codes (LOINC) | a database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory & clinical codes for use in clinical care, outcomes management, & 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 & place of patient care |
| Messaging standards | support communications b/w information systems; also called a interoperability standards or data exchange standards |
| National Council for Prescription Drug Program (NCPDP) | not-for-profit ANSI-accredited standards development organizations (1977) that develops standards for exchanging prescription & payment information |
| National drug code (NDC) | codes that serve as product identifiers for human drugs, currently limited to prescription drugs & few over-the-counter products |
| National eHealth Collaborative (NeHC) | works w/ other stakeholders to address "issues & effecting the change needed to enable the secure & 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...to share clinical information nationwide |
| Natural Language Processing (NLP) | conversion of human language into data that can be translated & manipulated by computer system |
| Office of the National Coordinator of Health Information Technology (ONC) | a department of DHHS- advance the development, adoption & implementation of healthcare information technology standards |
| Order entry/results reporting | information that allows for entry of orders,which are then routed to the appropriate department for action |
| Patient provider portal | a secure method of communication between the healthcare provider & the patient, just the providers, or the provider & the payer |
| Personal health record (PHR) | an electronic or paper health record maintained & updated by an individual for him/herself |
| Population health | capture & reporting of healthcare data that is are used for public health purposes-- allows for healthcare provider to report infectious diseases, immunizations, cancer & other reportable conditions to public health officials |
| Presentation layer | controls screen layout, data entry,& data retrieval- allows various healthcare providers to manipulate it |
| Radiofrequency identification device (RFID) | an automatic recognition technology that uses a device attached to an object to transmit data to a receiver & does not require direct contact |
| RxNorm | a clinical drug nomenclature developed by the FDA, Dept of Veterans Affairs, & HL7 to provide standard names for clinical drugs & administered dose forms |
| Source system | information systems that populate the EHR- include electronic medication administration record, laboratory information system, & nursing information systems |
| Systematized Nomenclature of Medicine (SNOMED) | comprehensive clinical vocabulary developed by the College of American Pathologist- most promising set of clinical terms available |
| Standards development organizations (SDOs) | a private or government agency involved in the development of healthcare informatics standards at a national or international level |
| Structured data | Binary, computer-readable data |
| Template-based entry | cross between free text & structured data entry |
| Unified Medical Language System | a program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words & expressions & their interrelationships |
| 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 w/ their meaning |
Created by:
amantz2439
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