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EHR Ch 10

Key Terms

What was an advisory committee to the U.S. Department of Health and Human Services American Health Information Community
An organization that governs standards in many aspects of public and private business ANSI American National Standards Institute
The division of the Department of Health and Human Services that is responsible for developing healthcare policies CMS Centers for Medicare and Medicaid Services
A system for grouping similar diseases and procedures and organizing related information for easy retrieval Classification systems
A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions Clinical decision support system
The function of electronically delivering data and automating the work flow around the management of clinical data Clinical messaging
contains preprogrammed clinical decision support designed to assist the user through making an entry appropriately Clinical provider order entry
It is a snapshot of data from the EHR includes basic information such as diagnosis, allergies, medications and future treatment Continuity of care record CCR
Terms used in professional billing Current Procedural Terminology
Clear guidelines for the acceptable values for specified data fields Data content standards
An open-structure database that is not dedicated to the software of any particular vendor or data supplier Data repository
A list of recommended data elements with uniform definitions that are relevant for a particular use Data set
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface Data warehouse
An organized collection of data, text, references, or pictures in a standard format Database
A standard that promotes a digital image communications format and picture archive and communications systems Digital Imaging and Communications in Medicine DICOM
An electronic signature that binds a message to a particular individual Digital signature
A storage solution based on digital scanning technology in which source documents are scanned to create digital images of the document Electronic document management systems EDMS
A health record in an information system designed to provide access to complete and accurate clinical data, practitioner alerts and reminders, clinical decision support systems and links to medical knowledge Electronic health record EHR
A system designed to prevent medication errors Electronic medication administration record EMAR
Any representation of a signature in digital form, including an image of a handwritten signture Electronic signature
works collaboratively with public and private sectors to achieve what is called "widespread interoperability among healthcare software applications Health Information Technology standards Panel HITSP
An international organization of healthcare professionals dedicated to creating standards for the exchange , management and integration of electronic information Health Level 7 HL7
A company that provides connections to the internet Internet service provider ISP
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 Logical Observation Identifiers Names and Codes LOINC
Creation of a cross map that links the content from one classification or terminology scheme to another Mapping
A proprietary clinical terminology developed as a point of care tool for electronic medical record documentation at the time and place of patient care MEDCIN
This supports communication between information systems Messaging standards
A not-for-profit ANSI accredited standards development organization that develops standards for exchanging prescription and payment information National Council for Prescription Drug Programs NCPDP
Codes that serve as product identifiers for human drugs currently limited to prescription drugs and a few selected over-the-counter products National drug codes NDC
Addresses issues effecting thje change needed to enable the secure and reliable exchange of electronic health information nationwide National eHealth Collborative NeHC
Interoperable information infrastructure that links various healthcare information systems together National health information network NHIN
Conversion of human language into data that can be translated and then manipulated by computer systems Natural language processing NLP
A department of the U.S. Department of Health and Human Services to advance the development,adoption and implementation of healthcare information technology standards Office of the National Coordinator for Health Information Technology ONC
A type of information that allows for entry of orders, which are then routed to the appropriate department for action. Once the results are available they are routed back to the care provider for review Order entry/results reporting
Is a secure method of communication between the healthcare provider and the patient, or the provider and the payer Patient provider portal
This captures and reports healthcare data that is used for public health purposes Population health
controls screen layout, data entry and data retrieval Presentation layer
An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and doesn't require direct contact Radiofrequency identification device RFID
A clinical drug nomenclature developed by the FDA to provide standard names for clinical drugs and administered dose forms RxNorm
These systems include the electronic medication administration record, laboratory information system, radiology system, hospital information system and nursing information system Source system
A private or government agency involved in the development of healthcare informatics standards st a national or international level Standards development organization SDO
Binary,computer-readable data structured data
A comprehensive clinical vocabulary, which is the most promising set of clinical terms available for a controlled vocabulary for healthcare Systematized Nomenclature of Medicine SNOMED
Entry that is 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 Template-based entry
A program to build an intelligent, automated system that can understand biomedical concepts, words, expressions and their interrelationships Unified medical Language System
Nonbinary, human-readable data Unstructured data
A technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements Use case
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 Vocabulary standards
Created by: GinaMGarrett