HIT 220 Chapter 10 vocabulary
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| American Health Information Community (AHIC) | A public-private federal advisory committee associated with the Office of the National Coordinator that makes recommendations to secretary on how to accelerate adoption of interoperable electronic health information technology
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| American National Standards Institute (ANSI) | An organization that governs standards in many aspects of public & private business; developer of the Health Information Technology Standards Panel
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| Centers for Medicare & Medicaid Services (CMS) | Division of DHHS that is responsible for developing healthcare policy in the US and for administering the Medicare program & the federal portion of Medicaid & maintaining the procedure portion of the ICD-9-CM Called Health Care Financing Administration
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| Classification Systems | 1. A system for grouping similar diseases & procedures & organizing related information for easy retrieval 2. A system for assigning numeric or alphanumeric code numbers to represent specific diseases and or procedures
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| Clinical Decision support system (CDSS) | A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge- based clinical decisions
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| Clinical Messaging | The function of electronically delivering data and automating the work flow around the management of clinical data
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| Clinical provider order entry(CPOE) | contains per-programmed clinical decision support designed to assist the user through making an entry appropriately
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| Continuity of care record(CCR) | A snapshot of data from the EHR & includes basic information such as medications, allergies, diagnosis, & future treatment, should be available to all healthcare providers so as to improve the continuity of patient care as well as reduce medical errors
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| Current Procedural Terminology | The American Procedural Association's Current Procedural Terminology (CPT) are the terms used in professional billing
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| Data content standards | defined as the "clear guidelines for the acceptable values for specified data fields"
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| Data Repository | An open structure database that is not dedicated to the software of any 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
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| Data Set | A list of recommended data elements with uniform definitions that are relevant for a particular use
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| Data warehouse | A database that makes it possible to access data from multiple databases & combine the results into a single query & reporting interface
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| Database | An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications
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| 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
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| 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
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| Digitized Signature | 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
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| 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
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| Electronic Health Record (EHR) | 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
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| Electronic Medication Administration Record (EMAR) | A system designed to prevent medication errors by checking a patients medication information against his or her bar-coded wristband
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| Electronic Signature | 1. Any representation of a signature in digital form, including an image of a handwritten signature 2. The authentication of a computer entry in a health record made by the individual making the entry
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| Health Level 7 (HL7) | An international organization of healthcare professionals dedicated to creating standards for the exchange, management, and integration of electronic information
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| Health Information Technology Standards Panel (HITSP) | Works collaboratively with public & private sectors to achieve what they call " widespread interoperability among healthcare software applications" , membership is available to anyone interested in participating , they publish their work prior to approval
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| Hybrid Record | A combination of paper & electronic records, health record that includes both paper & electronic elements
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| International Classification of Diseases, Ninth Edition, Clinical Modification | A coding & classification system used in the US to report diagnoses in all healthcare settings and inpatient procedures and services as well as morbidity and mortality information
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| Interoperability | The ability of different information systems and software applications to communicate and exchange data
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| Logical Observation Identifiers Names & 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
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| Mapping | Creation of a cross map that links the consent from one classification or terminology scheme to another
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| 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
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| Messaging Standards | The purpose is to support communications between systems, may also be called interoperability standards or data exchange standards
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| 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
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| 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
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| National eHealth Collaborative (NeHC) | Working with other stakeholders to address "issues and effecting the change needed to enable the secure and reliable exchange of electronic health information nationwide"
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| 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 network of securely
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| Natural 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
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| Office of the National Coordinator of Health Information Technology (ONC) | A department of the US Department of Health and Human Services established by executive order to advance the development, adoption, and implementation of healthcare information technology standards
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| Order Entry/ Results Reporting | 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 healthcare provider for review
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| Patient Provider Portal | A secure method of communication between the healthcare provider and the patient , just the providers, or the provider and the payer , may include secure e-mail or remote access to test results and provide patient monitoring
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| Personal Health Record (PHR) | An electronic or paper health record maintained and updated by an individual for himself or herself
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| 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
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| 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.
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| Radio frequency 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
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| RxNorm | A clinical drug nomenclature developed by the FDA , The Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms
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| Source System | Information systems that populate the EHR. These systems include the electronic medication administration record, laboratory information system, radiology information system, hospital information system, and nursing information systems.
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| Systematized Nomenclature of Medicine (SNOMED) | A comprehensive 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
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| Standards Development Organizations (SDO) | A private or government agency involved in the development of healthcare informatics standards at a national level
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| Structured Data | Binary, computer- readable data
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| 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
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| 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 and their interrelationships; includes concepts & terms from many different source vocabularie
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| Unstructured Data | Non binary, human- readable data
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| 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
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| 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
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