HIM 227 Chapter 3, HIM 227 Chapter 4, HIM 227 Chapter 5, HIM 227 Ch. 6, HIM 227 Chapter 7 - Key Terms, HIM 227 Chapter 8 - Key Terms, HIM 227 Chapter 9 - Key Terms, HIM 227 Chapter 10 - Key Terms, HIM 227 Chapter 11 - Key Terms, HIM 227 Chapter 12 -...
Contingency plan
1. Documentation of the process for responding to a system emergency, including the performance of backups, the line-up of critical alternative facilities to facilitate continuity of operations, and the process of recovering from a disaster.
Authentication
1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature.
Default
1. The status to which a computer application reverts in the absence of alternative instructions.
Pareto chart
A bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems, or solutions
Administrative law
A body of rules and regulations developed by various administrative entities empowered by Congress; falls under the umbrella of public law
Courts of Appeal
A branch of the federal court system that has the power to hear appeals on the final judgements of district courts
Disease registry
A centralized collection of data used to improve the quality of care and measure the effectiveness of a particular aspect of healthcare delivery.
Intentional tort
A circumstance where a healthcare provider purposely commits a wrongful act that results in injury
Joinder
A complaint against a third party
Fee schedule
A complete listing of fees used by health plans to pay doctors or other providers
Coding compliance plan
A component of an HIM compliance plan or a corporate compliance plan modeling the OIG Program Guidance for Hospitals and the OIG Supplemental Compliance Program Guidance for Hospitals that focuses on the unique regulations and guidelines with which coding professionals must comply
Risk management
A comprehensive of activities intended to minimize the potential for injuries to occur in a facility and to anticipate and respond ensuring liabilities,
Role-based access control (RBAC)
A control system in which access decisions are based on the roles of individual users as part of an organization
Job interview
A conversation in which a hiring manager and a job applicant exchange information.
Autonomy
A core ethical principle centered on the individual's right to self-determination that includes respect for the individual; in clinical applications, the patient's right to determine what does or does not happen to him or her in terms of healthcare.
Strategy
A course of action designed to produce a desired (business) outcome.
Checksheet
A data collection tool that records and compiles observations or occurrences.
Logical Observations, 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 that enable exchange and aggregation of electronic health data from many independent systems
Clinical data warehouse (CDW)
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface
Clinical data warehouse (CDW)
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface.
Multivoting technique
A decision-making method for determining group consensus on the prioritization of issues or solutions
Consensus building
A decision-making method that seeks consent of all participants to resolve differences so an acceptable result can be found
Data abstracts
A defined and standardized set of data points or elements common to a patient population that can be regularly identified in the health records of the population and coded for use and analysis in a database management system.
Autopsy report
A description of the examination of a patient's body after he/she has died is completed.
Data dictionary
A descriptive list of the names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use
Correlational studies
A design of research that determines the existence and degree of relationships among factors
Ambulatory surgery center (ASC)
A facility used for surgical procedures in outpatient services.
Charge description master
A financial management form that contains information about the organization's charges for the healthcare services it provides to patients; Also called a chargemaster
Chargemaster
A financial management form that contains information about the organization's charges for the healthcare services it provides to patients; Also called charge description master (CDM)
Global payment
A form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payments as lump sums to be distributed between the physician and the healthcare facility
Bureaucracy
A formal organizational structure based on a rigid hierarchy of decision making and inflexible rules and procedures
Grievance
A formal, written description a complaint or disagreement.
Structured brainstorming
A group problem-solving technique wherein the team leader asks each participant to generate a list of ideas for the topic under discussion and then report them to the group in a nonjudgmental manner.
Unstructured brainstorming method
A group problem-solving technique wherein the team leader solicits spontaneous ideas for the topic under discussion from members of the team in a free-flowing and nonjudgmental manner.
Nominal group technique
A group process technique that involves the steps of silent listening, recording each participant's list, discussing, and rank ordering the priority or importance of items; allows groups to narrow the focus of discussion or to make decisions without becoming involved in extended, circular discussions
Overpayment
A higher reimbursement than deserved
Hospital outpatient
A hospital patient who receives services in one or more of a hospital's facilities when he or she is not currently an inpatient or a home care patient
Medicaid
A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if a patient qualifies for both Medicare and Medicaid
Job specifications
A list of a job's required education, skills, knowledge, abilities, personal qualifications, and physical requirements.
Accession registry
A list of cases in a cancer registry in the order in which they were entered.
Physician index
A list of patients and their physicians that is usually arranged according to the physician code numbers assigned by the healthcare facility.
Operation index
A list of the operations and surgical procedures performed in a healthcare facility, which is sequenced according to the code numbers of the classification system in use.
Disease index
A listing in diagnosis code number order of patients discharged from the facility during a particular time period.
Preferred provider organization
A managed care contract coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licenses or organized under state law as an HMO
Theory X and Y
A management theory developed by McGregor that describes pessimistic and optimistic assumptions about people and their work potential
Mode
A measure of central tendency that consists of the most frequent observation in a frequency distribution
Case finding
A method of identifying patients who have been seen or treated in a healthcare facility for the particular disease or condition of interest to the registry.
Ethnography
A method of observational research that investigates culture in naturalistic settings using both qualitative and quantitative approaches
Network controls
A method of protecting data from unauthorized change and corruption at rest and during transmission among information systems
Fee-for-service reimbursement
A method of reimbursement through which providers retrospectively receive payment based on either billed charges for services provided or on annually updated fee schedules
On-the-job training
A method of training in which an employee learns necessary skills and processes by performing the functions of his or her position.
SOAP (Subjective, Objective, Assessment, Plan)
A method used to construct physician progress notes. A technique physicians use to remember what elements of documentation must be included within a progress note.
Systems development lifecycle (SDLC)
A model used to represent the ongoing process of developing (or purchasing) information systems
Collaborative Stage Data Set
A new standardized neoplasm-staging system developed by the American Joint Commission on Cancer.
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 Cancer Registrars Association (NCRA)
A not-for-profit association representing cancer registry professionals and Certified Tumor Registrars (CTR). The primary focus is education and certification with the goal to ensure all cancer registry professionals have the required knowledge to be superior in their field.
Accession number
A number assigned to each case as it is entered in a cancer registry.
Hospital newborn inpatient
A patient born in the hospital at the beginning of the current inpatient hospitalization
Clinic outpatient
A patient who is admitted to a clinical service of a clinic or hospital for diagnosis or treatment on an ambulatory basis
Force-field analysis
A performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced.
Statue
A piece of legislation written and approved by a state of federal legislature and then signed into law by the state's governor or President of the US.
Security program
A plan outlining the policies and procedures created to protect healthcare information
Budget
A plan that converts the organization's goals and objectives into targets for revenue and spending.
Emergency mode of operations
A plan that defines the processes and controls that will be followed until the operations are fully restored
Privacy officer
A position mandated under the HIPAA Privacy Rule- covered entities must designate an individual to be responsible for developing and implementing privacy policies and procedures
Hospital inpatient autopsy
A postmortem (after death) examination performed on the body of a patient who died during an inpatient hospitalization by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility
Hospital autopsy
A postmortem (after death) examination performed on the body of a person who has at some time been a hospital patient by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility
Cloud computing
A practice that uses a vendor to archive data, and in some cases also provide application software, including an EHR, on multiple, disparate servers
National Committee for Quality Assurance (NCQA)
A private not-for-profit organization dedicated to improving healthcare quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the healthcare system, helping to elevate the issue of healthcare quality to the top of the national agenda
Conflict management
A problem-solving technique that focuses on working with individuals to find a mutually acceptable solution
Auto-authentication
A procedure that allows dictated reports to be considered automatically signed unless the health information management department s notified of needed revisions within a certain time limit.
Arbitration
A proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system.
Resource allocation
A process and strategy of deciding where resources should be used in the accomplishment of the mission, values, and goals of the organization.
Consent directive
A process by which patients may opt in or opt out of having their data exchanged in the HIE
Lean
A process improvement methodology focused on eliminated waste and improving the flow of work processes
Compliance program
A process that helps an organization, such as a hospital, accomplish its goal of providing high-quality medical care and efficiently operating a business under various laws and regulations
Chart tracking
A process that identifies the current location of a paper record or information
Record locator service (RLS)
A process that seeks information about where a patient, once identified, may have a health record available to the HIO
Collective bargaining
A process through which a contract is negotiated that sets forth the relationship between employees and the healthcare organization.
Accreditation organization
A professional organization that establishes the standards against which healthcare organizations are measured for criteria.
Unified Medical Language System (UMLS)
A 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 different source vocabularies.
Meaningful Use (MU) program
A program managed by the Centers for Medicare and Medicaid Services. Meaningful Use uses certified electronic health record technology to: (1) Improve quality, safety, efficiency, and reduce health disparities; (2) Engage patients and family; (3) Improve care coordination, and population and public health; and (4) Maintain privacy and security of patient health information
Business continuity plan
A program that incorporates policies and procedures for continuing business operations during a computer system shutdown
Program evaluation and review technique (PERT) chart
A project management tool that diagrams a project's time lines and tasks as well as their interdependencies.
Incident or occurrence report
A quality or performance management tool used to collect data and information about potentially compensable events (events that may result in death or serious injury).
Key indicator
A quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria.
Key indicator
A quantitative measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria
Maternal mortality rate (community-based)
A rate that measures the deaths associated with pregnancy for a specific community for a specific period of time
Downsizing
A reengineering strategy to reduce the cost of labor and streamline the organization by laying off portions of the workforce.
Scales of measurement
A reference standard for data collection and classification
Prospective review
A review of a patient's health records before admission to determine the necessity of admission to an acute care facility and to determine or satisfy benefit coverage requirements
Business records exception
A rule under which a record is determined not to be hearsay if it was made at or near the time by, or from information transmitted by, a person with knowledge; it was kept in the course of a regularly conducted business activity; and it was the regular practice of that business activity to make the record
Chief medical informatics officer (CMIO)
A salaried physician (most often part time so that he or she retains credibility with other practicing physicians) who is heavily involved in policy development, workflow and process improvement, and ongoing maintenance of CDS and other systems requiring significant physician input
Hostile work environment
A setting in which intimidating and abusive conduct takes place that interferes with an employee's job performance.
Consensus-oriented decision-making model
A seven-step progression that allows groups to be flexible enough to come to a consensus by starting important topics with open discussion rather than by presenting a preformulated proposal; gathering a list of all the needs and concerns expressed by the group to form a list of conditions for possible proposals to address; taking turns in a unified attempt to build each proposal idea into the best possible proposal before choosing among them; and using empathy in the closure stage to address any unresolved feelings from the process. The seven CODM steps are: (1) framing the topic, (2) open discussion, (3) identifying underlying concerns, (4) collaborative proposal building, (5) choosing a direction, (6) synthesizing a final proposal, and (7) closure
Explanation of benefits
A statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by a health plan
Affinity grouping
A technique for organizing similar ideas together in natural groupings.
Workflow analysis
A technique used to study the flow of operations for automation.
Natural language processing (NLP)
A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence
Natural language processing (NLP)
A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence.
Natural language processing
A technology that converts human language into data that can be translated then manipulated by computer systems. It is the software used for speech recognition.
Telehealth
A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment
Run chart
A type of graph that shows data points collected over time and identifies emerging trends or patterns.
Accreditation
A voluntary process of institutional or organizatonal review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against pre-established written criteria.
Sentinel event
According to the Joint Commission, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or risk thereof" includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response.
Disciplinary action
Action taken to improve unsatisfactory work performance or behavior on the job.
Addendum
Additional info. provided in the health record. Should be dated the day it was written, not the date it is referencing.
Sale of information
Addressed specifically by ARRA, which prohibits a covered entity or BA from selling (receiving direct or indirect compensation) in exchange for an individual's PHI without that individual's authorization; the authorization must also state whether the individual permits the recipient of the PHI to further exchange the PHI for compensation
Express contract
Agreement between physician and patient that is specifically articulated
Diagnostic studies
All diagnostic services of any type, including history, physical examination, laboratory, x-ray or radiography, and others that are performed or ordered pertinent to the patient's reasons for the encounter
Centralized unit filing system
All of the patient's encounters are filed together in a single location
Right of access
Allows an individual to inspect and obtain a copy of his or her own PHI contained within a designated record set, such as a health record
Premium
Amount of money that a policyholder or certificate holder must periodically pay an insurer in return for healthcare coverage
Expenses
Amounts that are charged as costs by an organization to the current year's activities of operation.
Employee Retirement Income Security Act (ERISA)
An act that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans (Public Law 93-406 1974)
Tort
An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm
Business-related partnerships
An agreement between two parties to cooperate for the advancement of their mutual interests and the entity's strategic goals
Likelihood determination
An estimate of the probability of threats occurring
Potentially compensable event
An event (for example, an injury, accident, or medical error) that may result in financial liability for a healthcare organization.
All patient refined diagnosis-related groups (APR-DRGs)
An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient's illness
Physician Quality Reporting System (PQRS)
An incentive payment system for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries; formerly known as the Physician Quality Reporting Initiative (PQRI)
Federal Trade Commission (FTC)
An independent federal agency tasked with dealing with two areas of economics in the United States: consumer protection and issues having to do with competition in business
Joint Commission
An independent, not-for-profit organization, the Join Commission accredits and certifies more than 20,000 healthcare organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards
Physician champion
An individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes
Beneficiary
An individual who is eligible for benefits from a health plan
Nosocomial (hospital-acquired) infection
An infection acquired by a patient while receiving care or services in a healthcare organization
Newborn (NB)
An inpatient who was born in a hospital at the beginning of the current inpatient hospitalization
Self-directed learning
An instructional method that allows students to control their learning and progress at their own pace.
Third-party payer
An insurance company (for example, Blue Cross/Blue Shield) or healthcare program (for example, Medicare) that pays or reimburses healthcare providers (second party) or patients (first party) for the delivery of medical services
Picture archiving and communications system (PACS)
An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images)
Customer
An internal or external recipient of services, products, or information.
DNV GL Healthcare
An international certification body and classification society with main expertise in technical assessment, advisory, and risk management created in 2013 with the merger of Det Norske Veritas (Norway) and Germanischer Lloyd (Germany).
American Society for Testing and Materials (ASTM) International
An international organization whose purpose is to establish standards on materials, products, systems, and services
Incident
An occurrence in a medical facility that is inconsistent with accepted standards of care.
Deemed status
An official designation indicating that a healthcare facility is in compliance with Medicare Conditions of Participation
Court Order
An official direction issued by a court judge and requiring or forbidding specific parties to perform specific actions
Critical incident method
An ongoing written log of examples of an employee's job-related behavior during the appraisal period.
Performance management
An ongoing, goal-oriented process focused on productivity and continuous improvement of employees and teams.
Medicare Part B
An optional and supplemental portion of Medicare that beneficiaries pay a monthly premium for. Part B assists coverage with doctors' services and outpatient care. It also covers some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists, and some home healthcare. Part B pays for these covered services and supplies when they are medically necessary
Do-not-resuscitate (DNR) order
An order written by the treating physician stating that in the event the patient suffers cardiac or pulmonary arrest, cardiopulmonary resuscitation should not be attempted
Union
An organization formed by employees for the purpose of acting as a unit when dealing with management regarding work issues.
Quality improvement organization (QIO)
An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room. Until 2002, called peer review organization
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
An organization that provides an accreditation program to ensure the quality and safety of medical surgical care provided in ambulatory surgery facilitates.
Health information organization (HIO)
An organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards
Certificate authority
An organization that verifies a person's credentials and can revoke the certificate if the credentials are revoked
Index
An organized (usually alphabetical) list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data.
Table
An organized arrangement of data, usually in columns and rows
Database
An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications.
Referred outpatient
An outpatient who is provided special diagnostic or therapeutic services by a hospital on an ambulatory basis but whose medical care remains the responsibility of the referring physician
Steering committee
An overarching committee comprised of key stakeholders to health information systems in general, or less commonly, a steering committee will be convened for each specific health information system project and include only stakeholders associated with that project
Unintended consequence
An unanticipated and undesired effect of implementing
Special-cause variation
An unusual source of variation that occurs outside a process but affects it.
SWOT analysis
Analysis tool used to outline the organization's strengths (S) and weaknesses (W), which are internal to the organization, and the opportunities (O) and threats (T) external to the organization.
Issues management
Any issues that arise during the implementation are documented, brought to the attention of the vendor, and hopefully resolved, or escalated so that resolution is accomplished
Claim attachment
Any of a variety of hard-copy or electronic forms needed to process a claim in addition to the claim itself, such as a copy of the emergency department note
Anesthesia report
Any preoperative medication and response to it, the anesthesia administered with dose and method, duration, patient's vital signs while under anesthesia and any additional products given to the patient during the procedure.
Surgical procedure
Any single, separate, systematic process upon or within the body that can be complete in itself; is normally performed by a physician, dentist, or other licensed practitioner; can be performed either with or without instruments; and is performed to restore disunited or deficient parts, remove diseased or injured tissues, extract foreign matter, assist in obstetrical delivery, or aid in diagnosis
Workflow
Any work process that must be handled by more than one person.
Ranking method
Appraiser ranks all employees in a group or unit from highest to lowest based on overall performance.
Standards
Are fixed rules that must be followed.
Conditions for Coverage (CFCs)
Are standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid.
Clinical observations
Are the comments of physicians, nurses, and other caregivers in order to create a chronological report of the patient's condition and response to treatment during his/her hospital stay.
Software as a Service (SaaS)
Arranged similar to an application service provider with generally less custom configuration ability and that offers a pay as you go model, where there is payment for only the actual time using the system; may be delivered via dedicated communications technology or cloud computing
Covered entity (CE)
As amended by HITECH, (1) a health plan, (2) a health care clearinghouse, (3) a health care provider who transmits any health information in electronic form.
Notice of privacy practices
As amended by HITECH, a statement (mandated by the HIPAA Privacy Rule) issued by a healthcare organization that informs individuals of the uses and disclosures of patient-identifiable health information that may be made by the organization, as well as the individual's rights and the organization's legal duties with respect to that information
Reasonable cause
As amended by HITECH, an act or omission in which a covered entity or business associate knew, or by exercising reasonable diligence would have known, that the act or omission violated an administrative simplification provision, but in which the covered entity or business associated did not act with willful neglect (45 CFR 160.401 2013)
Administrative simplification
As amended by HITECH, authorizes HHS to: (1) adopt standards for transactions and code sets that are used to exchange health data.
Willful neglect
As amended by HITECH, conscious, intentional failure or reckless indifference to the obligation to comply with the administrative simplification provision violated (45 CFR 160.401 2013)
Workforce
As amended by HITECH, employees, volunteers, trainees, and other persons whose conduct, in the performance of work for a covered entity or business associate, is under the direct control of such covered entity or business associate, whether or not they are paid by the covered entity or business associate
Marketing
As amended by HITECH, means to make a communication about a product or service that encourages recipients of the communication to purchase or use the product or service, or where the covered entity receives financial remuneration in exchange for making communication.
Physical safeguards
As amended by HITECH, security rule measures such as locking doors to safeguard data and various media from unauthorized access and exposures; includes facility access controls, workstation use, workstation security, and device and media controls
Transaction
As amended by HITECH, under HIPAA, the transmission of information between two parties to carry out financial or administrative activities related to health care.
Use
As amended by HITECH, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information
Designated record set (DRS)
As amended by HITECH: (1) A group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered health care provider.
Designated record set (DRS)
As amended by HITECH: (1) A group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered health care provider;
Work measurement
Assessment of internal data collected on actual work performed within the organization and the calculation of time it takes to do the work.
Selection test
Assessment that identifies job skills, abilities, or job-related attitudes that may not surface in an interview.
Clinical coding
Assigning codes to represent diagnoses and procedures, is a key responsibility of the HIM department.
Change control program
Assures that there is documented approval for the change to be made and evidence that all elements of implementation, testing, rollout, training, and such are performed
Identity proofing
Authentication credentials used to electronically sign prescriptions
Structured data
Binary, machine-readable data in discrete fields; data able to be processed by the computer
Structured data
Binary, machine-readable data in discrete fields; data able to be processed by the computer.
Leadership grid
Blake and Mouton's grid that marked off degrees of emphasis toward orientation using a nine-point scale and finally separated the grid into five styles of management based on the combined people and production emphasis
Clinical decision support system (CDSS)
CDS that requires the combination of data from more than one sources and the ability to deliver the alert back to the appropriate system or systems
Clinical decision support system (CDSS)
CDS that requires the combination of data from more than one sources and the ability to deliver the alert back to the appropriate system or systems.
Hospital-acquired conditions (HAC)
CMS identified eight hospital-acquired conditions (not present on admission) as "reasonably preventable", and hospitals will not receive additional payment for cases in which one of the eight selected conditions was not present on admission; the eight originally selected conditions include: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infection, vascular catheter-associated infection, and surgical site infection- mediastinitis after coronary artery bypass graft; additional conditions were added in 2010 and remain in effect: surgical site infections following certain orthopedic procedures and bariatric surgery, manifestations of poor glycemic control, and deep vein thrombosis (DVT)/pulmonary embolism (PE) following certain orthopedic procedures
Hospital-acquired condition (HAC)
CMS identified eight hospital-acquired conditions (not present on admission) as "reasonably preventable," and hospitals will not receive additional payment for cases in which one of the eight selected conditions was not present on admission; the eight originally selected conditions include: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infection, vascular catheter-associated infection, and surgical site infection—mediastinitis after coronary artery bypass graft; additional conditions were added in 2010 and remain in effect: surgical site infections following certain orthopedic procedures and bariatric surgery, manifestations of poor glycemic control, and deep vein thrombosis (DVT)/ pulmonary embolism (PE) following certain orthopedic procedures
Qualitative variables
Categorical variables; all are discrete and include both nominal and ordinal variables
Paper health record
Completely available in paper media
Application safeguards
Controls contained in application software or computer programs to protect the security and integrity of information
Coinsurance
Cost sharing in which the policy or certificate holder pays a pre-established percentage of eligible expenses after the deductible has been met; the percentage may vary by type or site of service
Appellate courts
Courts that hear appeals on final judgments of the state trial courts or federal trial courts.
Certified tumor registrar (CTR)
Credential for a cancer registrar achieved by passing an examination provided by the National Board for Certification of Registrars (NBCR); eligibility requirements for the certification examination include a combination of experience and education.
Internal customers
Customer within an organization, such as employees.
Quantitative study
Data collected for research studies that are collated numerically with descriptive, inferential, or predictive statistics
Decryption
Data decoded and restored back to original readable form
Staffing
Decisions about the types of employees needed, how many employees are needed, how work will be organized, and how employees are scheduled.
Laissez-faire leadership
Delegative leadership style that reflects a leader who holds a title and responsibility, but has everyone else perform the work
Competencies
Demonstrated skills that a worker should perform at a high level.
Documentation standards
Describe those principles, codes, beliefs, guidelines and regulations that guide health record documentation. They also dictate how healthcare providers should document the treatment and services within the health record.
Use case
Describes how the users will interact with the data map in a specific scenario.
Abuse
Describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goal of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced
Operative report
Describes the surgical procedures performed on the patient.
Requirements specification
Determining and documenting the detailed features and functions desired in the system in order to meet the organization's specific goals
Market assessment
Determining the number of positions on the market and the eligible workforce looking for work.
External analysis
Development of the market assessment to determine opportunities and threats to the future of the organization.
Auto-analyzer
Device that analyzes the specimen
Six sigma
Disciplined and data-driven methodology for getting rid of defects in any process.
Acknowlegments
Documents that the patient or patient's authorized personal rep. sign, confirming the receipt of important and applicable info.
Authoritarian leadership
Domineering leadership style where decisions are made at a distance from those affected
Corrections
Drawing a single line through the erroneous info. and writing the word "error" above the mistake.
Disparate treatment
Employment discrimination based on intentional unequal treatment of an individual who is a member of a protected class.
Progressive penalties
Ensures that the minimum penalty appropriate to the level of offense is applied.
Health maintenance organization
Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: (1) an organized healthcare delivery system to a geographic area, (2) a set of basic and supplemental health maintenance and treatment services, (3) voluntarily enrolled members, and 653 (4) predetermined fixed, periodic prepayments for members' coverage
Distributional errors
Errors of inequity like central tendency, where all employees are rated satisfactory regardless of performance in order to avoid conflict, or leniency or strictness where some managers are overly generous or strict compared to other raters.
American College of Surgeons (ACS) Commission on Cancer
Established by the American College of Surgeons (ACoS) in 1922, the multidisciplinary Commission on Cancer (CoC) establishes standards to ensure quality, multidisciplinary, and comprehensive cancer care delivery in healthcare settings.
Clinical Laboratory Improvement Amendments (CLIA) of 1988
Established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test is
Measures of variability
Examination of the spread of different values around the measures of central tendency; these include the range, variance, and standard deviation
General consent
Explicit consent for routine treatment given to by the patient to the healthcare provider or organization
Breach of contract
Failure to perform any term of a contract by any party involved in the contract
Bias
Favoritism, partiality, or prejudice.
Right-to-work laws
Federal legislation dealing with labor rights (examples include workers' compensation, child labor, and minimum wage laws).
Taft-Harley Act
Federal legislation passed in 1947 that imposed certain restrictions on unions while upholding their right to organize and bargain collectively.
Maternal death rate (hospital based)
For a hospital, the total number of maternal deaths directly related to pregnancy for a given time period divided by the total number of obstetrical discharges for the same time period; for a community, the total number of deaths attributed to maternal conditions during a given time period in a specific geographic area divided by the total number of live births for the same time period in the same area
Vendor selection
Formal process by a healthcare organization that is just starting to acquire health information systems or replacing entire set of components with new components.
Source-orientated health record
Format in which the documentation contained within the record is organized by source or originating dept. Ex. All nursing notes are together and physician progress notes are grouped together.
Health Level Seven (HL7)
Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards-developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services
National patient safety goals (NPSGs)
Goals issued by the Joint Commission to improve patient safety in healthcare organizations nationwide
Leader-member relations
Group atmosphere much like social orientation; includes the subordinates' acceptance of, and confidence in, the leader as well as the loyalty and commitment they show toward the leader
Virtuoso teams
Group of experts brought together to address an issue or situation.
Laboratory information system (LIS)
Health information system that includes hardware; software; communications and network technologies; operational and cultural adaptations that people must make to use the technologies in performing diagnostic studies on various specimens collected from patients and to apply professional judgement in evaluating the quality of the data representing the results;
Retrospective review
Health record reviewed after discharge.
Numeric filing system
Health records are filed by the health record number
Delinquent record
Health records remains incomplete for a specified number of days defined in the medical staff rules.
Individual data
Healthcare data that is housed within the electronic health record, data collected from a case study, a focus group of individuals, or during an interview or survey
Disproportionate share hospital
Healthcare organizations that meet governmental criteria for percentages of indigent patients. Hospital with an unequally (disproportionately) large share of low-income patients. Federal payments to these hospitals are increased to adjust for the financial burden
Retrospective documentation
Healthcare providers add documentation after care has been given, possibly for the purpose of increasing reimbursement or avoiding a medical legal action.
Right to request confidential communications
Healthcare providers and health plans must give individuals the opportunity to request that communications of PHI be routed to an alternative location or by an alternative method
Evidence-based medicine
Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies
Preventive services
Healthcare services to prevent illness or early detection tests and diagnostic tools, when treatment is most likely to be effective
Edit check
Helps to ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer
Ambulatory payment classification
Hospital outpatient prospective payment system (OPPS). The classification is a resource-based reimbursement system
Exclusive provider organizations (EPO)
Hybrid managed care organization that provides benefits to subscribers only when healthcare services are performed by network providers; sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organizations
Avoidance
In business, a situation where two parties in conflict ignore that conflict.
Defendant
In civil cases, an individual or entity against whom a civil complaint has been filed; in criminal cases, an individual who has been accused of a crime
Public key infrastructure (PKI)
In cryptography, an asymmetric algorithm made publicly available to unlock a coded message
Claims data
Information required to be reported on a healthcare claim for service reimbursement
Patient portal
Information system that allows patient to log in to obtain information, register, and perform other functions
Patient financial system (PFS)
Information system that manages patient accounts
Classroom-based learning
Instructor-led, face-to-face training including traditional lectures, workshops, and seminars.
Dismissal
Involuntary termination of employment.
Office of Inspector General (OIG)
Mandated by Public Law 95-452 (as amended) to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs. The OIG has a responsibility to report both to the Secretary and to the Congress program and management problems and recommendations to correct them. The OIG's duties are carried out through a nationwide network of audits, investigations, inspections, and other mission-related functions performed by OIG components
Sunsetting
No longer selling or supporting a product
Consent to treatment
Patient gives the physician or other healthcare provider permission to touch them.
Personal representative
Person with legal authority to act on a patient's behalf
Participative leadership
Plans and decisions are made by the team and the leader is there to provide advice and assistance
Guideline
Provides general direction about the design of the form.
Data
Raw facts and figures
ADDIE model
Recommended by numerous experts in the HRM and instructed design fields as a general guide to planning and implementation of employee training programs; the steps in this model are analyze-design-develop-implement-evaluate.
Cash basis accounting
Registering the transaction when it occurs, meaning when money is actually received for services provided, or paid for expenses incurred.
Scorecards
Reports of outcomes measures to help leaders know what they have accomplished.
Research methodologies
Research studies that can range from exploratory or descriptive studies that strive to generate new hypotheses based on data collected to experimental studies that provide interventions or treatments that can reduce the spread of an existing disease
Mixed-methodology
Research study approach that includes using both quantitative and qualitative data
Resource-based relative value scale (RBRVS)
Resource-based relative value scale:
Automated reviews
Reviews performed electronically rather than by humans
Application controls
Security strategies, such as password management, included in application software and computer programs
Asynchronous
Self-paced learning; students and instructor can communicate, but not in real-time.
Progress note
Serves to justify further acute-care treatment in the facility.
Standard
Set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals who are regarded as an authority on a particular subject matter.
Quasi-experimental study
Similar to the experimental study except that randomization of participants is not included in a quasi-experimental study, the independent variable may not be manipulated by the researcher, and there may be no control or comparison group; these studies can be performed over time and may not include individual participants but whole healthcare systems
Cultural competence
Skilled in awareness, understanding, and acceptance of beliefs and values of the people of groups other than one's own.
Onboarding
Socialization into the values and culture of an organization.
Malware
Software applications that can take over partial or full control of a computer and can compromise data security and corrupt both data and hard drives
Statistical packages
Software that can be used to facilitate the data collection and analysis process; these packages simplify the statistical analysis of data and are often used in addition to spreadsheet software
Presentation software
Software used to build slides when presenting a specific topic, idea, research data or any type of information
Kiosk
Special form of input device geared more to people less familiar with computers
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
Core measures
Standardized performance measures developed to improve the safety and quality of healthcare
SMART goals
Statements that identify results that are: Specific, Measurable, Attainable, Relevant, and Time-based
Population-based statistics
Statistics based on a defined population rather than on a sample drawn from the same population
Health reform
Steps taken to make major policy changes in how providers are reimbursed for healthcare services
Serial work division
Tasks or steps in a process are handled separately in sequence by individual workers, as with a factory assembly line, to complete a process.
Requisition
Tells the HIM dept the name, health rec #, dept name, date or request and name of requester and where the record needs to be delivered.
Contingent or contract work
Temporary workers supplement full-time employees, often as part-time workers.
Centers for Medicare and Medicaid Services (CMS)
The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid. Historically, CMS has maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set
SCRIPT
The NCPDP standard developed for electronically transmitting a prescription
Medicare severity diagnosis-related groups (MS-DRGs)
The US government's 2007 revision of the DRG system, the MS-DRG system better accounts for severity of illness and resource consumption
World Health Organization (WHO)
The United Nations specialized agency created to ensure the attainment by all peoples of the highest possible levels of health; responsible for a number of international classifications, including ICD-10 and ICF
Medical Literature, Analysis, and Retrieval System Online (MEDLINE)
The United States National Library of Medicine's (NLM) premier bibliographic database that contains over 19 million references to journal articles in life sciences with a concentration on biomedicine
Referent power
The ability of the team members to identify with leaders who have desirable resources or personal traits
Selection
The act or process of choosing.
Budget adjustment
The approval to move funds from one budget to another.
Judicial law (common law)
The body of law created as a result of court (judicial) decisions
Constitutional Law
The body of law that deals with the amount and types of power and authority that governments are given
Interoperability
The capability of different information systems and software applications to communicate and exchange data
Private law
The collective rules and principles that define the rights and duties of people and private businesses
Data consistency
The extent to which the healthcare data are reliable and the same across applications
Independent variable
The factors in experimental research that researches manipulate directly
Indian Health Service
The federal agency within the Department of Health and Human Services that is responsible for providing federal healthcare services to American Indians and Alaska natives
Centers for Medicare and Medicaid Services (CMS)
The federal agency within the US Department of HHS. Known for its operational oversight of the Medicare program and in collaboration with state governments.
Civilian Health and Medical Program—Veterans Administration (CHAMPVA)
The federal healthcare benefits program for dependents (spouse or widow[er] and children) of veterans rated by the Veterans Administration (VA) as having a total and permanent disability, for survivors of veterans who died from VA-rated service-connected conditions or who were rated permanently and totally disabled at the time of death from a VA-rated service-connected condition, and for survivors of persons who died in the line of duty
Occupational Safety and Health Act
The federal legislation that established comprehensive safety and health guidelines for employers (Public Law 91-596 1970)
Equal Pay Act
The federal legislation that requires equal pay for men and women who perform substantially the same work (Public Law 88-38 1963)
Plaintiff
The group or person who initiates a civil lawsuit
Data abstraction
The identification of data elements by an individual through health record review.
Risk of mortality (ROM)
The likelihood of an inpatient death for a patient
District court
The lowest tier in the federal court system, which hears cases involving felonies and misdemeanors that fall under federal statute and suits in which a citizen of one state sues a citizen of another state
Controlling
The management function in which performance is monitored according to policies and procedures.
Middle management
The management level in an organization that is concerned primarily with facilitating the work performed by supervisory- and staff-level personnel as well as by executive leaders.
Veterans Health Administration
The nation's largest integrated healthcare system with more than 1,700 hospitals, clinics, community living centers, domiciliaries, readjustment counseling centers, and other facilities operated by the US Department of Veterans Affairs
Outputs
The outcomes of inputs into a system (for example, the output of the admitting process is the patient's admission to the hospital).
Cultural diversity
The perceived or actual difference among people.
Office of the National Coordinator for Health Information Technology (ONC)
The principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.
Job evaluation
The process of applying predefined compensable factors to jobs to determine their relative worth.
Team building
The process of organizing and acquainting a team and building skills for dealing with later team processes
Encryption
The process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination
American Recovery and Reinvestment Act (ARRA)
The purposes of this act include the following: (1) To preserve and create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health.
Privacy
The quality or state of being hidden form, or undisturbed by, the observation or activities of other persons, or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of protected health information.
Continuity of care document (CCD)
The result of ASTM's Continuity of Care Record standard content being represented and mapped into the HL7's Clinical Document Architecture specifications to enable transmission of referral information between providers; also frequently adopted for personal health records
Chief financial officer (CFO)
The senior manager responsible for the fiscal management of an organization
Chief information officer (CIO)
The senior manager responsible for the overall management of information resources in an organization
Enterprise information management
The set of function created by an organization to plan, organize, and coordinate the people, processes, technology, and content needed to manage information for the purposes of data quality, patient safety, and ease of use.
Medical staff by laws
The standards governing the practice of medical staff members typically voted upon by the organized medical staff and the medical staff executive committee and approved by the facility's board of directors.
Human capital
The sum of knowledge, skills, and abilities of an organization's workforce.
Inpatient discharge
The termination of hospitalization through the formal release of an inpatient from a hospital
Turnaround time
The time between receipt of request and when the request is sent to requester.
Hospital autopsy rate
The total number of autopsies performed by a hospital pathologist for a given time period divided by the number of deaths of hospital patients (inpatients and outpatients) whose bodies were available for the autopsy at the same time period
Proportionate mortality rate (PMR)
The total number of deaths due to a specific cause during a given time period divided by the total number of deaths due to all causes
Contingency theory
Theory that states leadership exists between persons in social situations, and persons who are leaders in one situation may not necessarily be leaders in other situations
Internal threats
Threats that originate within an organization
Single-key encryption
Two or more computers share the same secret key and that key is used to both encrypt and decrypt a message; however, the key must be kept secret and if it is compromised in any way, the security of the data is likely to be eliminated; see also private key infrastructure
Power user
Users who are able to use technology to significantly improve their productivity
Interval variables
Variables that have equal units with an arbitrary zero point
Eligibility verification
Verification that determines if a patient's health plan will provide reimbursement for services to be performed, and sometimes prior-authorization management systems where a health plan requires review and approval of a procedure (or referral) prior to performing the service
Deficiency slip
When a document or signature is missing. Identifies the pertinent document and what needs to be done.
Enterprise master patient index (EMPI)
When a healthcare enterprise has more than one facility and the patient is seen at two or more places links the patient's information at the different facilities.
e-Prescribing (e-RX)
When a prescription is written from the personal digital assistant and an electronic fax or an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy's information system
Alert fatigue
When an excessive number of alerts are used in an information system, users get tired of looking at the alerts and may ignore them
Derived classification
a derived classification is one based on a reference classification such as ICD or ICF by adopting the reference classification structure and categories and providing additional detail or through rearrangement or aggregation of items from one or more reference classifications.
Data set
a list of recommended data elements with uniform definitions.
Data dictionary
a listing of all the data elements within a specific system that defines each individual data element, standard input of the data element and specific data lenght.
Overlay
a patient is erroneously assigned another person's health record number.
Clinical terminology
a set of terms representing the system of concepts for the medical field.
Straight numeric filing system
files the records in straight numeric order based on the health record number.
Information governance (IG)
focuses on principles and oversight to manage the information that is produced from the different systems within an organization.
Aggregate data
include data on groups of people or patients without identifying any particular patient individually.
Disability
physical or mental condition that either temporarily or permanently renders a person unable to work for which he or she is qualified and educated.
Analytics
refers to statistical processing of data to reveal new information
Coding
the process of assigning numeric or alphanumeric representations to clinical documentation
Chart
1. (noun) The health record of a patient 2. (verb) To document information about a patient in a health record
Ratio
1. A calculation found by dividing one quantity by another 2. A general term that can include a number of specific measures such as proportion, percentage, and rate
Audit trail
1. A chronological set of computerized records that provides evidence of information system activity (logins and logouts, file accesses)
Utilization management
1. A collection of systems and processes to ensure that facilities and resources, both human and nonhuman, are used maximally and are consistent with patient care needs 2. A program that evaluates the healthcare facility's efficiency in providing necessary care to patients in the most effective manner
Utilization management (UM)
1. A collection of systems and processes to ensure that facilities and resources, both human and nonhuman, are used maximally and are consistent with patient care needs. 2. A program that evaluates the healthcare facility's efficiency in providing necessary care to patients in the most effective manner.
Access control
1. A computer software program designated to prevent unauthorized use of an information resource
Case mix
1. A description of a patient population based on any number of specific characteristics, including age, gender, type of insurance, diagnosis, risk factors, treatment received, and resources used 2. The distribution of patient into categories reflecting differences in severity of illness or resource consumption
Procedure
1. A document that describes the steps involved in performing a specific function. 2. An action of a medical professional for treatment or diagnosis of a medical condition. 3. The steps taken to implement a policy.
Corporate compliance
1. A facility-wide program that comprises a system of policies, procedures, and guidelines that are used to ensure ethical business practices, identify potential fraudulence, and improve overall organizational performance. 2. A program that became common after the Federal Sentencing Guidelines reduced fines and penalties to organizations found guilty of fraud if the organization has a prevention and detection program in place.
Audit
1. A function that allows retrospective reconstruction of events, including who executed the events in question, why, and what changes were made as a result 2. To conduct an independent review of electronic system records and activities in order to test the adequacy and effectiveness of data security and data integrity procedures and to ensure compliance with established policies and procedures
Confidentiality
1. A legal and ethical concept that establishes the health care provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure
Confidentiality
1. A legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure. 2. As amended by HITECH, the practice that data or information is not made available or disclosed to unauthorized persons or processes (45 CFR 164.304 2013)
Informed consent
1. A legal term referring to a patient's right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed.
Complication
1. A medical condition that arises during an inpatient hospitalization (for example, a postoperative wound infection) 2. Condition that arises during the hospital stay that prolongs the length of stay at least one day in approximately 75 percent of the cases (as in complication and comorbidity [CC])
Comorbidity
1. A medical condition that coexists with the primary cause for hospitalization and affects the patient's treatment and length of stay 2. Pre-existing condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by at least one day in approximately 75 percent of the cases (as in complication and comorbidity [CC])
Job classification
1. A method of job evaluation that compares a written position description with the written descriptions of various classification grades. 2. A method used by the federal government to grade jobs.
Consent
1. A patient's acknowledgement that he or she understands a proposed intervention, including that intervention's risks, benefits, and alternatives
Consent
1. A patient's acknowledgement that he or she understands a proposed intervention, including that intervention's risks, benefits, and alternatives.
Business associate (BA)
1. A person or organization other than a member of a covered entity's workforce that performs functions or activities on behalf of or affecting a covered entity that involve the use or disclosure of individually identifiable health information
Data model
1. A picture or abstraction of real conditions used to describe the definitions of fields and records and their relationships in a database 2. A conceptual model of the information needed to support a business function or process
Case management
1. A process used by a doctor, nurse, or other health professional to manage a patient's healthcare (CMS 2013) 2. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient
Appeal
1. A request for reconsideration of a denial of coverage or rejection of claim decision.
Standard
1. A scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured. 2. A model or example established by authority, custom, or general consent or a rule established by authority as a measure of quantity, weight, extent, value, or quality. 3. Under HITECH, a technical, functional, or performance-based rule, condition, requirement, or specification that stipulates instructions, fields, codes, data, material, characteristics or actions (45 CFR 170.102 2012)
Source systems
1. A system in which data was originally created 2. Independent information system application that contributes data to an EHR, including departmental clinical applications (for example laboratory information system, clinical pharmacy information system) and specialty clinical applications (for example, intensive care, cardiology, labor and delivery)
Coaching
1. A training method in which an experienced person gives advice to a less-experienced worker on a formal or informal basis. 2. A disciplinary method used as the first step for employees who are not meeting performance expectations.
Pay for performance
1. A type of incentive to improve clinical performance using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts 2. The Integrated Healthcare Association initiative in California based on the concept that physician groups would be paid for documented performance
Diagnosis-related group
1. A unit of case-mix classification adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases are placed into groups because related diseases and treatments tend to consume similar amounts of healthcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and length-of-stay patterns. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual. 2. A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual
Accreditation
1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria.
Third-party administrator
1. An entity required to make or responsible for making payment on behalf of a group health plan 2. A business associate that performs claims administration and related business functions for a self-insured entity
Authorization
1. As amended by HITECH, except as otherwise specified, a covered entity may not use or disclose protected health information without an authorization that is valid under section 164.508 2.
Authorization
1. As amended by HITECH, except as otherwise specified, a covered entity may not use or disclose protected health information without an authorization that is valid.
Policy
1. Governing principles that describe how a department or an organization is supposed to handle a specific situation or execute a specific process 2. Binding contracts issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury; such contracts may also be referred to as health plan agreements and evidence of coverage
Planning
1. Governing principles that describe how a department or an organization is supposed to handle a specific situation or execute a specific process. 2. Binding contracts issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury; such contracts may also be referred to as health plan agreements and evidence of coverage.
Policies
1. Governing principles that describe how a department or an organization is supposed to handle a specific situation or execute a specific process. 2. Binding contracts issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury; such contracts may also be referred to as health plan agreements and evidence of coverage.
Cross-claim
1. In law, a complaint filed against a codefendant 2. A claim by one party against another party who is on the same side of the main litigation
Managed care
1. Payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care 2. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare
Managed care
1. Payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care. 2. Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare.
Primary care physician (PCP)
1. Physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan.
Inferential statistics
1. Statistics that are used to make inferences from a smaller group of data to a large one 2. A set of statistical techniques that allows researchers to make generalizations about a population's characteristics (parameters) on the basis of a sample's characteristics
Deductible
1. The amount of cost, usually annual, that the policyholder must incur (and pay) before the insurance plan will assume liability for remaining covered expenses. 2. Under Medicare, the amount a beneficiary must pay for healthcare before Medicare begins to pay, either for each benefit period for Part A, or each year for Part B, these amounts can change every year
Cryptography
1. The art of keeping data secret through the use of mathematical or logical functions that transform intelligible data into seemingly unintelligible data and back again 2. In information security, the study of encryption and decryption techniques
Validity
1. The extent to which data correspond to the actual state of affairs or that an instrument measures what it purports to measure. 2. A term referring to a test's ability to accurately and consistently measure what it purports to measure.
Data integrity
1. The extent to which healthcare data are complete, accurate, consistent, and timely 2. A security principle that keeps information from being modified or otherwise corrupted either maliciously or accidentally
Clinical trial
1. The final stages of a long and careful research process that tests new types of medical care to see if they are safe (CMS 2013) 2. Experimental study in which an intervention or treatment is given to one group in a clinical setting and the outcomes compared with a control group that did not have the intervention or treatment or that had a different intervention or treatment.
Medical necessity
1. The likelihood that a proposed healthcare service will have a reasonable beneficial effect on the patient's physical condition and quality of life at a specific point in his or her illness or lifetime 2. As amended by HITECH, a covered entity or business associate may not use or disclose protected health information, except as permitted or required (45 CFR 164.502 2013) 3. The concept that procedures are only eligible for reimbursement as a covered benefit when they are performed for a specific diagnosis or specified frequency (42 CFR 405.500 1995)
Security
1. The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss 2. The physical protection of facilities and equipment from theft, damage, or unauthorized access.
Security
1. The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized persons and from unauthorized alteration, destruction, or loss. 2. The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems.
Document imaging
1. The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed; 2. The process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end-user
Risk
1. The probability of incurring injury or loss. 2. The probable amount of loss foreseen by an insurer in issuing a contract. 3. A formal insurance term denoting liability to compensate individuals for injuries sustained in a healthcare facility.
Certification
1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a specified set of requirements
Certification
1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements.
Accounting
1. The process of collecting, recording, and reporting an organization's financial data. 2. A list of all disclosures made of a patient's health information.
Compliance
1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization's ethical and business policies 2. The act of adhering to official requirements 3. Managing a coding or billing department according to the laws, regulations, and guidelines that govern it
Revenue cycle
1. The process of how patient financial and health information moves into, through, and out of the healthcare facility, culminating with the facility receiving reimbursement for services provided 2. The regularly repeating set of events that produces revenue
Authentication
1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature
Outcome measures
1. The process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status, for the purpose of improving care. 2. A measure that indicates the result of the performance (or nonperformance) of a function or process.
Integrity
1. The state of being whole or unimpaired. 2. The ability of data to maintain its structure and attributes, including protection against modification or corruption during transmission, storage, or at rest. Maintenance of data integrity is a key aspect of data quality management and security.
Health Care Quality Improvement Act of 1986
A 1986 act that requires facilities to report professional review actions on physicians, dentists, and other facility-based practitioners to the National Practitioner Data Bank.
Merger
A business situation where two or more companies combine, but one of them continues to exist as a legal business entity while the others cease to exist legally and their assets and liabilities become part of the continuing company.
Clinical data repository (CDR)
A central database that focuses on clinical information
Clinical data repository (CDR)
A central database that focuses on clinical information.
Graphic rating scale
A checklist is used to numerically rate employees on general traits related to job performance, like teamwork.
Litigation
A civil lawsuit or contest in court
RxNorm
A clinical drug nomenclature developed by the Food and Drug Administration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms
Registry
A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison
Impact analysis
A collective term used to refer to any study that determines the benefit of a proposed project including cost-benefit analysis, return on investment, benefits realization study, or qualitative benefit study
Impact analysis
A collective term used to refer to any study that determines the benefit of a proposed project, including cost-benefit analysis, return on investment, benefits realization study, or qualitative benefit study.
Subpoena
A command to appear at a certain time and place to give testimony on a certain matter
Accredited Standards Committee X12 (ASC X12)
A committee accredited by ANSI responsible for the development and maintenance of EDI standards for many industries. The ASC "X12N" is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms
Ethics committee
A committee tasked with reviewing clinical ethics violations to determine the course of action required to remedy the violations.
Common Clinical Data Set
A common set of data types and elements and associated standards for use across several certification criteria
Legal hold
A communication issued because of current or anticipated litigation, audit, government investigation, or other such matters that suspend the normal disposition or processing of records.
Risk management
A comprehensive program of activities intended to minimize the potential for injuries to occur in a facility and to anticipate and respond to ensuring liabilities for those injuries that do occur. The processes in place to identify, evaluate, and control risk, defined as the organization's risk of accidental financial liability
Risk management program
A comprehensive program of activities intended to minimize the potential for injuries to occur in a facility and to anticipate and respond to ensuring liabilities for those injuries that do occur. The processes in place to identify, evaluate, and control risk, defined as the organization's risk of accidental financial liability.
Incidence rate
A computation that compares the number of new cases of a specific disease for a given time period to the population at risk for the disease during the same time period
Firewall
A computer system or a combination of systems that provides a security barrier or supports an access control policy between two networks or between a network and any other traffic outside the network
Decision support system
A computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision-making tasks associated with nonroutine and nonrepetitive problems.
Present on admission (POA)
A condition present at the time of inpatient admission
National Practitioner Data Bank (NPBD)
A confidential information clearinghouse created by Congress with the primary goals of improving healthcare quality, protecting the public, and reducing healthcare fraud and abuse in the United States.
National Practitioner Data Bank (NPDB)
A confidential information clearinghouse created by Congress with the primary goals of improving healthcare quality, protecting the public, and reducing healthcare fraud and abuse in the United States. The NPBD is primarily an alert or flagging system intended to facilitate comprehensive review of the professional credentials of healthcare practitioners, healthcare entities, providers, and supplies.
Database Life Cycle (DBLC)
A cycle that traces the history of a database within an information system. The cycle is divided into six phases: initial study, design, implementation and testing and evaluation, operation and maintenance, and evaluation
Online analytical processing (OLAP)
A data access architecture that allows the user to retrieve specific information from a large volume of data
Medicare Provider Analysis and Review (MEDPAR) File
A database containing information submitted by fiscal intermediaries that is used by the Office of the Inspector General to identify suspicious billing and charge practices
Registry
A database on specific diseases and procedures. Ex. cancer and transplant registries.
Dysfunctional conflict
A destructive type of struggle that becomes emotionally draining and harms productivity.
Job description
A detailed list of a job's duties, reporting relationships, working conditions, and responsibilities.
Clinical practice guidelines
A detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society or government agency.
Budget variance
A difference in the budgeted revenue or expense amount.
Facility directory
A directory of patients being treated in a healthcare facility
Variance
A disagreement between two parts; the square of the standard deviation; a measure of variability that gives the average of the squared deviations from the mean; in financial management, the difference between the budgeted amount and the actual amount of a line item; in project management, the difference between the original project plan and current estimates
Variance
A disagreement between two parts; the square of the standard deviation; a measure of variability that gives the average of the squared deviations from the mean; in financial management, the difference between the budgeted amount and the actual amount of a line item; in project management, the difference between the original project plan and current estimates.
Notifiable disease
A disease that must be reported to a government agency so that regular, frequent, and timely information on individual cases can be used to prevent and control future cases of the disease
Team charter
A document that explains the issues the team was initiated to address, describes the team's goal or vision, and lists the initial members of the team and their respective departments
Authorization card
A document that indicates an employer's interest in having a union represent him or her.
Authorization
A document that is required under the Privacy Rule of HIPAA for the use and disclosure of PHI
Bona fide occupational qualification
A factor (for example, age) is shown to be directly related to job performance based on documented job analysis.
Healthcare Cost and Utilization Project (HCUP)
A family of databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by AHRQ. HCUP databases are derived from administrative data and contain encounter-level clinical and nonclinical information including all-listed diagnoses and procedures, discharge status, patient demographics, and charges for all patients, regardless of payer (such as, Medicare, Medicaid, private insurance, uninsured), beginning in 1988.
Quid pro quo
A favor or advantage given for something expected in return; often in sexual harassment instances, sexual favors are requested in exchange for a job benefit or continued employment.
Centers for Disease Control and Prevention (CDC)
A federal agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability. Committed to programs that reduce the health and economic consequences of the leading causes of death and disability, thereby ensuring a long, productive, healthy life for all people
Centers for Disease Control and Prevention (CDC)
A federal agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability. Committed to programs that reduce the health and economic consequences of the leading causes of death and disability, thereby ensuring a long, productive, healthy life for all people.
Affordable Care Act
A federal statute that was signed into law on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the act is the product of the healthcare reform agenda of the Democratic 111th Congress and the Obama administration
Medicare
A federally funded health program established in 1965 to assist with the medical care costs of Americans 65 years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities
Minimum Data Set (MDS) for Long-Term Care
A federally mandated standard assessment form that Medicare and Medicaid certified nursing facilities must use to collect demographic and clinical data on nursing home residents.
Ethics
A field of study that deals with moral principles, theories, and values; in healthcare, a formal decision-making process for dealing with the competing perspectives and obligations of the people who have an interest in a common problem.
Project management
A formal set of principles and procedures that help control the activities associated with implementing a usually large undertaking to achieve a specific goal, such an information system project.
Clinical transformation
A fundamental change in how medicine is practiced using health IT systems to aid in diagnosis and treatment
Recovery audit contractor (RAC)
A governmental program whose goal is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments
Scatter charts
A graph that visually displays the linear relationships among factors
Pie chart
A graphic technique in which the proportions of a category are displayed as portions of a circle (like pieces of a pie); used to show the relationship of individual parts to the whole
Bar chart
A graphic technique used to display frequency distributions of nominal or ordinal data that fall into categories
Histogram
A graphic technique used to display the frequency distribution of continuous data (interval or ratio data) as either numbers or percentages in a series of bars
Line graph
A graphic technique used to illustrate the relationship between continuous measurements; consists of a line drawn to connect a series of points on an arithmetic scale; often used to display time trends
Flow charts
A graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process.
Gantt chart
A graphic tool used to plot tasks in project management that shows the duration of project tasks and overlapping tasks.
Graph
A graphic tool used to show numerical data in a pictorial representation
New employee orientation
A group of activities that welcome new employees and introduce them to the organization, to the assigned department, unit or workgroup and to the specific job to be performed.
eHealth Exchange
A group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange.
eHealth Exchange
A group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. Participating organizations mutually agree to support a common set of standards and specifications that enable the establishment of a secure, trusted, and interoperable connection among all participating Exchange organizations for the standardized flow of information.
Brainstorming
A group problem-solving technique that involves the spontaneous contribution of ideas from all members of the group.
Commission for the Accreditation of Birth Centers
A group that surveys and accredits birth centers in the United States
Patient advocacy
A healthcare organization program where an employee speaks on a patient's behalf and helps get any information or services needed.
Opportunity for improvement
A healthcare structure, product, service, process, or outcome that does not meet its customers' expectations and, therefore, could be improved
Warrant
A judge's order that authorizes law enforcement to seize evidence and conduct a search
Living will
A legal document, also known as a medical directive, that states a patient's wishes regarding life support in certain circumstances, usually when death is imminent
Accountable Care Organization (ACO)
A legal entity that is recognized and authorized under applicable state, federal, or tribal law, is identified by a Taxpayer Identification Number (TIN), and is formed by one or more ACO participant(s) that is (are) defined at 425.102(a) and may also include any other ACO participants described at 425.102(b) (42 CFR 425.20 2011)
Durable power of attorney for healthcare decisions (DPOA-HCD)
A legal instrument through which a principal appoints an agent to make healthcare decisions on the principal's behalf in the event the principal becomes incapacitated
Nonmaleficence
A legal principle that means "first do no harm."
Beneficence
A legal term that means promoting good for others or providing services that benefit others, such as releasing health information that will help a patient receive care or will ensure payment for services received.
Negligence
A legal term that refers to the result of an action by an individual who does not act the way a reasonably prudent person would act under the same circumstances
Mean
A measure of central tendency that is determined by calculating the arithmetic average of the observations in a frequency distribution
Median
A measure of central tendency that shows the midpoint of a frequency distribution when the observations have been arranged in order from lowest to highest
Reliability
A measure of consistency of data items based on their reproducibility and an estimation of their error of measurement.
Range
A measure of variability between the smallest and largest observations in a frequency distribution
Standard deviation
A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement; the square root of the variance
Performance indicators
A measure used by healthcare facilities to assess the quality, effectiveness, and efficiency of their services.
Percentile
A measure used in descriptive statistics that shows the value below which a given percentage of scores in a given group of scores fall
Rate
A measure used to compare an event over time; a comparison of the number of times an event did happen (numerator) with the number of times an event could have happened (denominator)
Case definition
A method of determining criteria for cases that should be included in a registry.
Deposition
A method of gathering information to be used in a litigation process
Emergency patient
A patient who is admitted to the emergency services department of a hospital for the diagnosis and treatment of a condition that requires immediate medical, dental, or allied health services in order to sustain life or to prevent critical consequences
Hospital inpatient
A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight
Outpatient
A patient who receives ambulatory care services in a hospital-based clinic or department
Outpatient visit
A patient's visit to one or more units located in the ambulatory services area (clinic or physician's office) of an acute care hospital in which an overnight stay does not occur
Template
A pattern used in computer-based patient records to capture data in a structured manner
Skilled nursing facility prospective payment system
A per-diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries
Team leader
A performance improvement team role responsible for championing the effectiveness of performance improvement activities in meeting customers' needs and for the content of a team's work
Timekeeper
A performance improvement team role responsible for notifying the team during meetings of time remaining on each agenda item in an effort to keep the team moving forward on its performance improvement project
Team member
A performance improvement team role responsible for participating in team decision making and plan development; identifying opportunities for improvement, gathering, prioritizing, and analyzing data; and sharing knowledge, information, and data that pertain to the process under study
Fishbone diagram
A performance improvement tool used to identify or classify the root causes of a problem or condition and to display the root causes graphically.
Fetal death rate
A proportion that compares the number of intermediate or late fetal deaths to the total number of live births and intermediate or late fetal deaths during the same period of time
Facility-based registry
A registry that includes only cases from a particular type of healthcare facility, such as a hospital or clinic.
Meaningful Use
A regulation that was issued by CMS on July 28, 2010, outlining an incentive program for professionals (EPs) eligible hospitals, and CAHs participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology
Traditional fee-for-service reimbursement
A reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers
Balance billing
A reimbursement method that allows providers to bill patients for charges in excess of the amount paid by the patients' health plan or other third-party payer (not allowed under Medicare or Medicaid)
Claim
A request for payment for services, benefits, or costs by a hospital, physician or other provider that is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider
User-based access control (UBAC)
A security mechanism used to grant users of a system access based on identity
Password
A series of characters that must be entered to authenticate user identity and gain access to a computer or specified portions of a database
Training
A set of activities and materials that provide the opportunity to acquire job-related skills, knowledge, and abilities.
Financial indicators
A set of measures designed to routinely monitor the current financial status of a healthcare organization or of one of its constituent parts.
Productivity indicators
A set of measures designed to routinely monitor the output and quality of products or services provided by an individual, an organization, or one of its constituent part; used to help determine status of productivity bonus.
Business process
A set of related policies and procedures that are performed step by step to accomplish a business-related function.
Descriptive statistics
A set of statistical techniques used to describe data such as means, frequency distributions, and standard deviations; statistical information that describes the characteristics of a specific group or a population
Two-factor authentication
A signature type that includes at least two of the following three elements: something known, such as a password; something held, such as a token or digital certificate; and something that is personal, such as a biometric in the form of a fingerprint, retinal scan, or other
Security threat
A situation that has the potential to damage a healthcare organization's information system
Sniffers
A software security product that runs in the background of a network, examining and logging packet traffic and serving as an early warning device against crackers
Statue of limitations
A specific time frame allowed by a statue or law for bringing litigation.
Statute of limitations
A specific time frame allowed by a statute or law for bringing litigation
Capitation
A specified amount of money paid to a healthcare plan or doctor, used to cover the cost of a healthcare plan member's services for a certain length of time
Occasion of service
A specified identifiable service involved in the care of a patient that is not an encounter (for example, a lab test ordered during an encounter
Quality indicator
A standard against which actual care may be measured to identify a level of performance for that standard.
Patient assessment instrument (PAI)
A standardized tool used to evaluate the patient's condition after admission to, and at discharge, from the healthcare facility.
Code of ethics
A statement of ethical principles regarding business practices and professional behavior.
Full-time equivalent (FTE)
A statistic representing the number of full-time employees as calculated by the reported number of hours worked by all employees, including part-time and temporary, during a specific time period.
Anti-Kickback Statute
A statute that establishes criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce business for which payment may be made under any federal healthcare program
Discipline without punishment
A step where the employee is given a one- to two-day paid decision-making leave following oral and written warnings and attempts to problem solve.
Cultural audit
A strategy to define an organization's values, symbols, and routines and identify areas for improvement.
Prospective study
A study designed to observe outcomes or events that occur after the identification of a group of subjects to be studied
Subpoena ad testifcandum
A subpoena that seeks testimony
Drug knowledge database
A subscription service that provides current information about drugs and is accessible to users and CDS
Universal chart order
A system in which the health record is maintained in the same format while the patient is in the facility and after discharge
Inpatient prospective payment system
A system of payment for the operating costs of acute-care hospital inpatient stays under Medicare Part A656 based on prospectively expressed in the Social Security Act
Moral values
A system of principles by which one guides one's life, usually with regard to right or wrong.
Executive information system
A system that facilitates and supports senior managerial decisions.
Intrusion detection system (IDS)
A system that performs automated intrusion detection; procedures should be outlined in the organization's data security plan to determine what action should be taken in response to a probable intrusion
Point-of-care (POC) charting
A system whereby information is entered into the health record at the time and location of service
Point-of-care charting
A system whereby information is entered into the health record at the time and location of service.
Root-cause analysis
A technique used in performance improvement initiatives to discover the underlying causes of a problem. Analysis of a sentinel event from all aspects (human, procedural, machinery, material) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence.
Layoff
A temporary dismissal where employees are told there is no work available now, but that they may be recalled; there is no guarantee of being recalled.
Strike
A temporary work stoppage called in an effort to express an employment contract negotiation demand.
Accept assignment
A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided
Normal distribution
A theoretical family of continuous frequency distributions characterized by a symmetric bell-shaped curve, with an equal mean, median, and mode; any standard deviation; and with half of the observations above the mean and half below it
Grounded theory
A theory about what is actually going on instead of what should go on
Application service provider (ASP)
A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing
Simulation
A training technique for experimenting with real-world situations by means of a computerized model that represents the actual situation.
System integration
A translation process that hardwires the applications together in order to be able to interoperate and exchange data seamlessly across the different applications
Bench trial
A trial in which a judge reviews the evidence and makes a determination, without a sitting jury.
Data Use and Reciprocal Support Agreement (DURSA)
A trust agreement entered into when exchanging information with other organizations using an agreed upon set of national standards, services, and policies developed in coordination with the Office of the National Coordinator for Health Information Technology
Opt in/opt out
A type of HIE model that sets the default for health information of patients to be included automatically, but the patient can opt out completely
Medicare Advantage Plan
A type of Medicare health plan offered by a private company that contracts with Medicare to provide the beneficiary with all Part A and Part B benefits. These plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. Enrollees in Medicare Advantage Plans have their services are covered through the plan are not paid for under original Medicare
Medical malpractice
A type of action in which the plaintiff must demonstrate that a healthcare provider-patient relationship existed at the time of the alleged wrongful act
Registration-Admission, Discharge, Transfer (R-ADT)
A type of administrative information system that stores demographic information and performs functionality related to registration, admission, discharge, and transfer of patients within the organization
Mentoring
A type of coaching and training in which an individual is matched with a more experienced individual who serves as an advisor or counselor.
Parallel work division
A type of concurrent work design in which one employee does several tasks and takes the job from beginning to end.
Sexual harassment
A type of harassment that may include verbal comments, unwanted physical contact, sexual advances or requests for sexual favors.
Medical identity theft
A type of healthcare fraud that includes both financial fraud and identity theft, it involves either (a) the inappropriate or unauthorized misrepresentation of one's identity (for example, the use of one's name and Social Security number) to obtain medical services or goods, or (b) the falsifying of claims for medical services in an attempt to obtain money.
Managed care organization (MCO)
A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, or limiting access to care
Public law
A type of legislation that involves the government and its relations with individuals and business organizations
Frequency polygon
A type of line graph that represents a frequency distribution
Point of service plans
A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost
Nonfeasance
A type of negligence meaning failure to act
Population-based registry
A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region.
Prospective payment system
A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided; specifically, one of several Medicare reimbursement systems based on predetermined payment rates or periods and linked to the anticipated intensity of services delivered as well as the beneficiary's condition
Retrospective study
A type of research conducted by reviewing records from the past (for example, birth and death certificates or health records) or by obtaining information about past events through surveys or interviews
Statistical process control chart
A type of run chart that includes both upper and lower control limits and indicates whether a process is stable or unstable.
Bubble charts
A type of scatter plot with circular symbols used to compare three variables; the area of the circle indicates the value of a third variable
Severity of illness (SOI)
A type of supportive documentation reflecting objective clinical indicators of a patient illness (essentially the patient is sick enough to be at an identified level of care) and referring to the extent of physiologic decompensation or organ system loss of function
Single sign-on
A type of technology that allows a user access to all disparate applications through one authentication procedure, thus reducing the number and variety of passwords a user must remember and enforcing and centralizing access control
Computer-based training
A type of training that is delivered partially or completely using a computer.
SNOMED CT identifier
A unique integer assigned to each SNOMED CT component
Inpatient service day (IPSD)
A unit of measure that reflects the services received by one inpatient during a 24-hour period
Best of fit
A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vendor
Best of breed
A vendor strategy used when purchasing an EHR that refers to system applications that are considered the best in their class
Stem and leaf plots
A visual display that organizes data to show its shape and distribution, using two columns with the stem in the left-hand column and all leaves associated with that stem in the right-hand column; the "leaf" is one digits of the number, and the other digits form the "stem"
Organizational chart
A visual graphic or diagram showing the structure and reporting relationships between positions, departments, and employees of an organization.
Telecommuting
A work arrangement in which at least a portion of the employee's work hours is spent outside the office (usually in the home) and the work is transmitted back to employer via electronic means.
Job sharing
A work schedule in which two or more individuals share the tasks of one full-time or one full-time-equivalent position.
Flextime
A work schedule that gives employees some choice in the pattern of their work hours, usually around a core of midday hours.
Compressed workweek
A work schedule that permits a full-time job to be completed in less than the standard five days of eight-hour shifts.
Traumatic injury
A wound or other injury caused by an external physical force such as an automobile accident, a shooting, a stabbing, or a fall.
Hearsay
A written or oral statement made outside of court that is offered in court as evidence
Subponea duces tecum
A written order commanding a person to appear, give testimony, and bring all documents, papers, books, and records described in the subpoena. The devices are used to obtain documents during pretrial discovery and to obtain testimony during trial
Malfeasance
A wrong or improper act
Nonexempt employees
All groups of employees covered by the provisions of the Fair Labor Standards Act.
Unstructured data
Also known as free text. data entered into the system with no format specified.
Results management
An EHR application that enables diagnostic study results (primarily lab results) to be both reviewed in a report format and the data within the reports to be processed
Chart conversion
An EHR implementation activity in which data from the paper chart are converted into electronic form
Clinical Document Architecture (CDA)
An HL7 XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes).
Digital Imaging and Communications in Medicine (DICOM)
An ISO standard that promotes a digital image communications format and picture archive and communications systems for use with digital images
Context-based access control (CBAC)
An access control system which limits users to accessing information not only in accordance with their identity and role, but to the location and time in which they are accessing the information
Inpatient admission
An acute care facility's formal acceptance of a patient who is to be provided with room, board, and continuous nursing service in an area of the facility where patients generally stay at least overnight
Institutional Review Board (IRB)
An administrative body that provides review, oversight, guidance, and approval for research projects carried out by employees serving as researchers, regardless of the location of the research (such as a university or private research agency); responsible for protecting the rights and welfare of the human subjects involved in the research. IRB oversight is mandatory for federally funded research projects
Abbreviated Injury Scale (AIS)
An anatomically-based, consensus-derived global severity scoring system that classifies each injury by region according to its relative importance on a 6-point ordinal scale (1 = minor and 6 = maximal). AIS is the basis for the Injury Severity Score (ISS) calculation of the multiply injured patient.
Web services architecture (WSA)
An architecture that utilizes web-based tools to permit communication among different software applications
Public health
An area of healthcare that deals with the health of populations in geopolitical areas, such as states and counties.
Stereotyping
An assumption that everyone within a certain group are the same.
Radio-frequency identification (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
Digital certificate
An electronic document that establishes a person's online identity
Digital certificates
An electronic document that establishes a person's online identity
Personal health record (PHR)
An electronic or paper health record maintained and updated by an individual for himself or herself;
Personal health record (PHR)
An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care
Personal health record (PHR)
An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care.
Electronic health record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
Digital signatures
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
Part-time employee
An employee who works less than the full-time standard of 40 hours per week, 80 hours per two-week period, or 8 hours per day.
Accommodation
An employer providing a reasonable adjustment for an employee.
Virtual private network (VPN)
An encrypted tunnel through the Internet that enables secure transmission of data
Standard of care
An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines.
Remittance advice
An explanation of payments (for example, claim denials) made by third-party payers
Remittance advice (RA)
An explanation of payments (for example, claim denials) made by third-party payers
Outcome indicators
An indicator that assesses what happens or does not happen to a patient following a process; agreed upon desired patient characteristics to be achieved; undesired patient conditions to be avoided.
Right to request restrictions of PHI
An individual can request that a covered entity restrict the uses and disclosures of PHI to carry out treatment, payment, or healthcare operations
Dual eligible
An individual covered by both Medicare and Medicaid
Right to request accounting of disclosures
An individual has the right to receive an accounting of certain disclosures made by a covered entity
Policyholder
An individual or entity that purchases healthcare insurance coverage
Summons
An instrument used to begin a civil action or special proceeding and is a means of acquiring jurisdiction over a party
Commission on Accreditation of Rehabilitation Facilities (CARF)
An international, independent, nonprofit accreditor of health and human services that develops customer-focused standards for areas such as behavioral healthcare, aging services, child and youth services, etc.
Cause-and-effect diagram
An investigational technique that facilitates the identification of the various factors that contribute to a problem.
Systems thinking
An objective way of looking at work-related ideas and processes with the goal of allowing people to uncover ineffective patterns of behavior and thinking and then finding ways to make lasting improvements.
Incident
An occurrence in a medical facility that is inconsistent with accepted standards of care
Injury Severity Score (ISS)
An overall severity measurement maintained in the trauma registry and calculated from the abbreviated injury scores for the three most severe injuries of each patient.
Respect
Appreciation of the value of differing perspectives, enjoyable experiences, courteous interaction, and celebration of achievements that advance our common cause.
Business associate agreement (BAA)
As amended by HITECH, a contract between the covered entity and a business associate must establish the permitted and required uses and disclosures of protected health information by the business associate and provides specific content requirements of the agreement.
Breach notification
As amended by HITECH, a covered entity shall, following the discovery of a breach of unsecured protected health information, notify each individual whose unsecured protected health information has been, or is reasonably believed by the covered entity to have been, accessed, acquired, used, or disclosed as a result of such breach
Protected health information (PHI)
As amended by HITECH, individually identifiable health information: (1) Except as provided in paragraph (2) of this definition, that is: (i) transmitted by electronic media; (ii) maintained in electronic media; or (iii) transmitted or maintained in any other form or medium.
Individually identifiable health information
As amended by HITECH, information that is a subset of health information, including demographic information collected from an individual, and: (1) is created or received by a health care provider, health plan, employer, or health care clearinghouse.
Reasonable diligence
As amended by HITECH, means the business care and prudence expected from a person seeking to satisfy a legal requirement under similar circumstances (45 CFR 160.401 2013)
Implementation specifications
As amended by HITECH, specific requirements or instructions for implementing a privacy or security standard
Technical safeguards
As amended by HITECH, the Security Rule means the technology and the policy and procedures for its use that protect electronic protected health information and control access to it
Disclosure
As amended by HITECH, the release, transfer, provision of access to, or divulging in any manner of information outside the entity holding the information
Employee relations
Broad term referencing the general management and planning of activities related to developing and improving employees relationships through communication and fair handling of disputes.
Online learning
Broad term referring to the use of electronic media instead of classroom-based learning to deliver training.
Value-based purchasing (VBP)
CMS incentive plan that links payments more directly to the quality of care provided and rewards providers for delivering high-quality and efficient clinical care.
Mandatory eligibility groups
Children, pregnant women, elderly adults, people with disabilities and low-income adults that qualify for Medicaid
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
Job analysis
Collecting and analyzing information about a job in order to better understand the significant component duties of the job, and to identify the skills and characteristics required of an employee who can successfully perform the job.
Emergency Medical Treatment and Active Labor Act (EMTALA)
Combat patient dumping- the transferring, discharging or refusal to treat indigent emergency dept. patients because of their inability to pay
Private healthcare insurance
Commercial insurance purchased by individuals, self-employed business people, and groups of people (such as associations and religious organizations), for themselves and for their dependents; typically these plans have high deductibles or limited covered services; a premium for coverage is paid each month to the third-party payer and those funds are used to help pay for the healthcare services
Professional component
Commercial insurance purchased by individuals, self-employed business people, and groups of people (such as associations and religious organizations), for themselves and for their dependents; typically these plans have high deductibles or limited covered services; a premium for coverage is paid each month to the third-party payer and those funds are used to help pay for the healthcare services
Reimbursement
Compensation or repayment for healthcare services
Employment at will
Concept that employees can be fired at any time and for almost any reason based on the idea that employees can quit at any time and for any reason.
Ethical principles
Concepts such as altruism, beneficence, consequentialism, deontology, egoism, least harm, and utilitarianism, upon which ethical decisions are made.
Medical device integration
Connecting medical devices to the EHR
Implied consent
Consent that is inferred by the patient's action or inaction and most commonly asserted by the patient when he or she presents to the emergency department.
Problem-oriented health record
Consists of a problem list, the history and physical exam and initial lab findings, (lab findings) initial plan, (test, procedures) and progress notes.
Red Flags Rule
Consists of five categories of red flags that are used as triggers to alert the organization to a potential identity theft; the categories are: (1) alerts, notifications, or warnings from a consumer reporting agency; (2) suspicious documents; (3) suspicious personally identifying information such as a suspicious address; (4) unusual use of, or suspicious activity relating to, a covered account; (5) Notices from customers, victims of identity theft, law enforcement authorities, or other businesses about possible identity theft in connection with an account
Copayment
Cost-sharing measure in which the policy or certificate holder pays a fixed dollar amount (flat fee) per service, supply, or procedure that is owed to the healthcare facility by the patient. The fixed amount that the policyholder pays may vary by type of service, such as $20.00 per prescription or $15.00 per physician office visit
Health Care Fraud Prevention and Enforcement Action Team (HEAT)
Created by HHS and the Department of Justice, this team's mission is to: prevent waste, fraud, and abuse; identify those who participate in fraud and abuse; reduce healthcare costs; improve the quality of care provided to Medicare and Medicaid patients; provide best practices in combating fraud and abuse; and expand partnership between HHS and the Department of Justice
Secondary data source
Data derived from the primary patient record, such as an index or a database.
Inputs
Data entered into a hospital system (for example, the patient's knowledge of his or her condition, the admitting clerk's knowledge of the admission process, and the computer with its admitting template are all inputs for the hospital's admitting system).
Aggregate data
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
Aggregate data
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed.
Information
Data processed into usable form
Vital statistics
Data related to births, deaths, marriages, and fetal deaths
Vital statistics
Data related to births, deaths, marriages, and fetal deaths.
Nominal-level data
Data that fall into groups or categories that are mutually exclusive and with no specific order (for example, patient demographics such as third-party payer, race, and sex
Information
Data that has been turned into something meaningful
Continuous data
Data that represent measurable quantities but are not restricted to certain specified values
Discrete data
Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values
Discrete variable
Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values
Discrete data
Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values.
Ordinal-level data
Data where the order of the numbers is meaningful, not the number itself
Ratio-level data
Data where there is a defined unit of measure, a real zero point, and the intervals between successive values are equal
Interval-level data
Data with a defined unit of measure, no true zero point, and equal intervals between successive values
Problem list
Describes any significant current and past illnesses and conditions as well as the procedures the patient has undergone.
Metadata
Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data:
Metadata
Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data: for example, creation date, date sent, date received, last access date, last modification date
Pathology report
Dictated by a pathologist after examination of tissue received for evaluation.
Interrogatories
Discovery devices consisting of a set of written questions given to a party, witness, or other person who has information needed in a legal case
Continuous variable
Discrete variables measured with sufficient precision
Leadership criteria
Division of leadership traits that includes leader emergence, leader effectiveness, and leader advancement and promotion
Distal attributes
Division of leadership traits that includes personality, cognitive abilities, motives, and values that surround the leader as a person
Proximal attributes
Division of leadership traits that includes problem-solving skills, social appraisal skills, and expertise and tacit knowledge derived from the distal attributes and are part of a leader's operating environment
Certified EHR Technology
EHRs that have been approved for use in the MU program by organizations hired by CMS to evaluate EHRs
Computerized provider order entry (CPOE)
Electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically. \
Americans with Disabilities Act (ADA)
Federal legislation which ensures equal opportunity for and elimination of discrimination against persons with disabilities (Public Law 110-325 2008)
National Labor Relations Act (NLRA)
Federal pro-union legislation that provides, among other things, procedures for union representation and prohibits unfair labor practices by unions, such as coercing nonstriking employees, and by employers, such as interference with the union selection process and discrimination against employees who support a union.
Go-live
First use of the system in actual practice
Equal employment opportunity law
Government efforts to ensure equal access to and fairness in employment without regard to race, religion, age, disability, gender, or other characteristics not related to a job.
Analysis
HIM dept. personnel determines the completeness of the health record
Consolidated Clinical Document Architecture (C-CDA)
HL7-created document templates
Access safeguards
Identification of which employees should have access to what data; the general practice is that employees should have access only to data they need to do their jobs
Protected class
Identified groups, such as racial minorities and women, that are protected by law based on past employment discrimination. Title VII of the Civil Rights Act of 1964 prohibits discrimination in employment based on an individual's membership.
e-Prescribing for Controlled Substances (EPCS)
In 2010, the Drug Enforcement Administration (DEA), which previously banned use of e-prescribing for controlled substances (EPCS) such as narcotics, set special requirements allowing for use of EPCS. These requirements include use of a product that provides identity proofing (authentication credentials used to electronically sign such prescriptions) and two-factor authentication
Fully specified name (FSN)
In SNOMED CT, the unique text assigned to a concept that completely describes that concept
Counterclaim
In a court of law, a countersuit
Injury (harm)
In a negligence lawsuit, one of four elements, which may be economic (hospital expenses and loss of wages) and non economic (pain and suffering), that must be proved to be successful
Complex review
In a revenue audit contractor (RAC) review, this type of review results in an overpayment or underpayment determination based on a review of the health record associated with the claim in question
Protocol
In healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in medical research, a rule or procedure to be followed in a clinical trial;
Protocol
In healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in medical research, a rule or procedure to be followed in a clinical trial; in a computer network, a rule or procedure used to address and ensure delivery of data
Causation
In law, a relationship between the defendant's conduct and the harm that was suffered
Preemption
In law, the principle that a statute at one level supersedes or is applied over the same or similar statute at a lower level (for example, the federal HIPAA privacy provisions trump the same or similar state law except when state law is more stringent)
Mediation
In law, when a dispute is submitted to a third party to facilitate agreement between the disputing parties
Complaint
In litigation, a written legal statement from a plaintiff that initiates a civil lawsuit
Resident Assessment Instrument (RAI)
In skilled nursing facilities, the care plan is based on a format required by federal regulations.
Fundraising
In these activities that benefit the covered entity, the covered entity may use or disclose to a BA or an institutionally related foundation, without authorization, demographic information and dates of healthcare provided to an individual
Structure indicators
Indicators that measure the attributes of the setting, such as number and qualifications of the staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures.
Comparative data
Individual data that is organized numerically and collated to make some comparisons against standards or benchmarks
External customers
Individuals from outside the organization who receive products or services from within the organization.
Patient portal
Information system that allows patient to log in to obtain information, register, and perform other functions.
Billing system
Information system that generates a bill for healthcare services performed
Closed-loop medication management
Information systems used to provide patient safety when ordering and administering medications
Demographic data
Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person
Demographics (demographic data)
Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person.
Deidentified information
Information where personal characteristics have been stripped from it in such a way that it cannot be later constituted or combined to re-identify an individual; it is commonly used in research
Medicare Part A
Insurance that assists in covering inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also assists in covering hospice care and some home healthcare. Beneficiaries must meet certain conditions to get these benefits
Workers' compensation
Insurance that employers are required to have to cover employees who get sick or injured on the job
Strategic planning
Involves how the organization will react to changes in the external environment in the foreseeable future.
Continuity of care record (CCR)
Is a core data set of the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters.
Federal Health IT Strategic Plan 2015-2020
Issued by the Office of the National Coordinator for Health Information Technology (ONC), this plan describes a vision of high-quality care, lower costs, healthy population, and engaged people and mission to improve the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most
Direct Project
Launched in March 2010 to offer a simpler, standards-based way for participants to send authenticated, encrypted health information directly to known recipients over the internet
Fair and Accurate Credit Transactions Act
Law passed in 2003 that contains provisions and requirements to reduce identity theft
Power and influence theory
Leadership theory noting there are various ways that leaders use authority, control, and their impact to get things done
Health Information Technology for Economic and Clinical Health (HITECH)
Legislation created to promote the adoption and meaningful use of health information technology in the United States.
Health Information Technology for Economic and Clinical Health Act (HITECH)
Legislation created to promote the adoption and meaningful use of health information technology in the United States. Subtitle D of the Act provides for additional privacy and security requirements that will develop and support electronic health information, facilitate information exchange, and strengthen monetary penalties.
False Claims Act
Legislation passed during the Civil War, amended in 1986, that prohibits contractors from making a false claim to a governmental program.
False Claims Act
Legislation passed during the Civil War, amended in 1986, that prohibits contractors from making a false claim to a governmental program; used to reinforce the prevention of healthcare fraud and abuse (Public Law 99-562 1986)
Genetic Nondiscrimination Act (GINA)
Legislation that prohibits genetic discrimination by health insurers and employers.
Career planning
Looking beyond simply getting a job to position oneself for more challenging and diverse work in the long term.
Consumer-directed health plans
Managed care organization characterized by influencing patients and clients to select cost-efficient healthcare through the provision of information about health benefit packages and through financial incentives
Supply management
Management and control of the supplies used within an organization.
Supervisory management
Management level that oversees the organization's efforts at the staff level and monitors the effectiveness of everyday operations and individual performance against preestablished standards.
Ambulatory
Means that treatment is provided on an outpatient basis.
Medicare Part D
Medicare drug benefit created by the Medicare Modernization Act of 2003 (MMA) that offers outpatient drug coverage to beneficiaries for an additional premium. Starting January 1, 2006, new Medicare prescription drug coverage became available to everyone with Medicare. This coverage assists in lowering prescription drug costs and protect against higher costs in the future
Contraindication
Medication should not be prescribed due to another medication or condition
Speech dictation
Method of collecting information in an information system through spoken word
Lean Six Sigma
Methodology that utilizes elements of elimination of waste from Lean and critical process quality characteristics from Six Sigma
Alternative dispute resolution
Methods of resolving legal disputes outside of the court system such as arbitration or mediation.
Incident detection
Methods used to identify both accidental and malicious events; detection programs monitor the information systems for abnormalities or a series of events that might indicate that a security breach is occurring or has occurred
Transitional model
Model created by William Bridges that defines three stages: (1) ending, losing, and letting go; (2) a neutral zone; and (3) new beginnings; each stage identifies the emotions employees have as their daily work is either changed or replaced
Semantic interoperability
Mutual understanding of the meaning of data exchanged between information systems
e-visits
Non face-to-face interaction between patient and provider
Unstructured data
Nonbinary, human-readable data
Workstations on wheels (WOWs)
Notebook computers mounted on carts that can be moved through the facility by users
Quantitative variables
Numerical variables; can be broken down into interval and ratio variables
Shared Nationwide Interoperability Roadmap
ONC's three stage vision for interoperability; 2015-2017: Nationwide ability to send, receive, find, and use a common clinical data set
Synchronous
Occurring at the same time.
Prejudice
Occurs when a person is judged solely based on cultural factors such as ethnicity, religion, age, gender, sexual orientation, or such.
Halo-horns effect
Occurs when an employee is strong or weak in one rated area and the supervisor unfairly generalizes that performance to rate the employee high or low across all other areas on the performance appraisal.
Negligent hiring
Occurs when employees with prior criminal records were not subjected to thorough pre-employment screening.
Double billing
Occurs when two providers bill for one service provided to one patient.
Health insurance marketplace or exchange
Offers the purchase of federally regulated and subsidized health insurance to uninsured, eligible Americans based on their income
Bed count day
One inpatient bed, set up and staffed for use in a 24-hour time period
Right to request amendment
One may request that a covered entity amend PHI or a record about the individual in a designated record set
Leading
One of four management functions in which people are directed and motivated to achieve goals
Leading
One of the four management functions in which people are directed and motivated to achieve goals.
Surgical operation
One or more surgical procedures performed at one time for one patient via a common approach or for a common purpose
CONNECT
Open-source software that implements health exchange specifications; it enables discovery of where there may be information as well as directly retrieving it from the source
Rules and regulations
Operating documents that describe the rules and regulations under which a healthcare organization operates
North American Association of Central Cancer Registries (NAACCR)
Organization that has a certification program for state population-based registries; Certification is based on the quality of data collected and reported by the state registry; NAACCR has developed standards for data quality and format and works with other cancer organizations to align their various standards.
Healthcare research organizations
Organizations that conduct, promote, or support research across healthcare organizations
High Reliability Organization (HRO)
Organizations that focus on creating an environment that eliminates or minimizes error.
Offshoring
Outsourcing jobs to countries overseas, wherein local employees abroad perform jobs that domestic employees previously performed.
Democratic leadership
Participative leadership style that supports collective decision making by offering choices to the group members and facilitating discussing and member involvement
Stage of the neoplasm
Pathological data characterizing the cancer, specifically the amount of metastasis, if any.
Out of pocket
Paying for the services provided with one's own funds
Radiology information system (RIS)
Performs functions similar to LIS, receiving an order for a procedure, scheduling it, notifying hospital personnel or the patient if performed as an outpatient, tracking the performance of the procedure and its output, tracking preparation of the report, performing quality control, maintaining an inventory of equipment and supplies, and managing departmental staffing and budget
Patient-identifiable data
Personal information that can be linked to a specific patient, such as age, gender, date of birth, and address.
End user
Persons who will use the system for their daily processes
Provider
Physician, clinic, hospital, nursing home, or other healthcare entity (second party) that delivers healthcare services
Information Technology Asset Disposition (ITAD)
Policy that identifies how all data storage devices are destroyed and purged of data prior to repurposing or disposal
Reward power
Power based on the leader's ability to give rewards to team members for commendable work, such as letters of recommendation, compliments, additional training or responsibilities, and additional compensation for working on the team
Legitimate power
Power derived from your position or status within the organization
Coercive power
Power in which a team leader uses threats and punishments to get his or her way
Patient safety
Preventing harm to patients, learning from errors, and building a culture of safety
Ambulatory care
Preventive or corrective healthcare services provided on a nonresident basis in a provider's office clinic setting, or hospital emergency setting
Justice
Principle that recognizes the importance of treating people fairly, of applying rules consistently, and of fairly distributing cost and risk.
Principles of organization
Principles that include specialization, functional definition, span of control, hierarchical chain, and unity of command used by managers at all levels.
Document imaging
Process by which paper based documentation is captured, digitized, stored, and made available for retrieval by the end user.
Coordination of benefits
Process for determining the respective responsibilities of two or more health plan that have some financial responsibility for a medical claim
Voir dire
Process of jury selection
Precertification
Process of obtaining approval from a healthcare insurance company before receiving healthcare services
Prior approval
Process of obtaining approval from a healthcare insurance company before receiving healthcare services
Prior authorization
Process of obtaining approval from a healthcare insurance company before receiving healthcare services
Medication reconciliation
Process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to ICU
Trait theory
Proposes that leaders possess a collection of traits or qualities that distinguish them from nonleaders
Healthcare insurance
Protection from having to pay the full cost of healthcare by prepaying for a plan for healthcare coverage
Message format standards
Protocols that help ensure that data transmitted from one system to another remain comparable
Children's Health Insurance Program
Provides health coverage to eligible children through both Medicaid and individual state CHIP programs; like all Medicaid programs, CHIP is administered by states according to federal requirements and is funded jointly by states and the federal government
Identity management
Provides security functionality, including determining who (or what information system) is authorized to access information, authentication services, audit logging, encryption, and transmission controls
Balanced Budget Act of 1997
Public Law 105-33 enacted by Congress on August 5, 1997, that mandated a number of additions, deletions, and revisions to the original Medicare and Medicaid legislation; the legislation that added penalties for healthcare fraud and abuse to the Medicare and Medicaid programs and also affected the hospital outpatient prospective payment system (HOPPS) and programs of all-inclusive care for elderly (PACE) (Public Law 105-33 1997)
Ordinal variables
Ranked variables in which a number is assigned to rank a category in an ordered series but does not indicate the magnitude of the difference between any two data points
Forced distribution
Ranking method similar to grading on a curve, where managers place subordinates into predetermined performance categories.
Case fatality rate
Rate that measures the total number of deaths among the diagnosed cases of a specific disease, most often acute illness
Behaviorally anchored rating scale
Rating system that links specific examples of job-related performance to each rating.
Accrual accounting
Recording known transactions in the appropriate time period before cash payment (receipts) are expected or due.
E-discovery
Refers to Amendments to Federal Rules of Civil Procedure and Uniform Rules Relating to Discovery of Electronically Stored Information; wherein audit trails, the source code of the program, metadata, and any other electronic information that is not typically considered the legal health record is subjected to motion for compulsory discovery
System
Refers to all the components (technology, standards, people, policy, and process) that must work together to achieve a desired goal (interoperability)
Development
Refers to educational programs with a longer-term focus, designed to stimulate an individual's professional growth by increasing or enhancing his or her skills, knowledge, or abilities.
Expert power
Refers to leaders who are experts in their field or have knowledge or skills that are in short supply
Implementation
Refers to technology having been installed, configured to meet the basic requirements of the healthcare organization, and demonstrated to users
Value
Refers to the combination of quality and cost
Revenue cycle management (RCM)
Refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services
Exit interview
Refers to the final meeting an employee has with his or her employer; the meeting provides an opportunity to collect feedback on issues or problem areas, including what may have caused the employee to leave
Performance appraisal
Refers to the formal system of review and evaluation methods used to assess employee and team performance.
Employee engagement
Refers to the level of commitment employees demonstrate, their willingness to continue working for the organization, and to go above and beyond the minimum expectations.
Critical thinking
Refers to the process of analyzing, assessing, and reconstructing a situation to provide enhanced solutions and outcomes to a problem
Adjudication
Refers to the process of paying, denying, and adjusting claims based on the patient's health insurance coverage benefits
Transactional leadership
Refers to the role of the manager who strives to create an efficient workplace by balancing task accomplishment with interpersonal satisfaction
Optimization
Reflects not only good adoption for all routine operations, but also an understanding and appropriate use of the technology's features
Adoption
Reflects the fact that the organization has implemented all of the major components of technology, although there may be some available technology that is more specialized, costly, or time consuming to implement that has not yet been implemented
Episode-of-care reimbursement
Reimbursement methods that include a period of continuous medical care performed by healthcare professionals in relation to a particular clinical problem or situation, and one or more healthcare services given by a provider during a specific period of relatively continuous care in relation to a particular health or medical problem or situation
Misfeasance
Relating to negligence or improper performance during an otherwise correct act
Access report
Report that provides a list of individuals who accessed patient information during a given period
Electronic clinical quality measures (eCQM)
Reporting electronic clinical quality measures (eCQM) is also a requirement for earning MU incentives. However, going forward, it is anticipated that not only must quality measures be reported, but there must be the ability to demonstrate improvement in the measures over time
Dashboard
Reports of process measures to help leaders follow progress to assist with strategic planning.
Dashboards
Reports of process measures to help leaders follow progress to assist with strategic planning.
Physical examination
Represents the physicians assessment of the patient's current health status after evaluating the patient's condition.
Medicare administrative contractors
Required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, CMS is completing the process of awarding Medicare claims processing contracts through competitive procedures resulting in replacing its current claims payment contractors, fiscal intermediaries and carriers, with new contract entities called MACs. Initially 19 MACs were expected through three procurement cycles. Currently there are 15 A/B MAC jurisdictions that have served as the foundation for CMS's initial series of A/B MAC procurements. CMS will continue to consolidate to 10 A/B MAC jurisdictions
Minimum necessary standard
Requires that uses, disclosures, and requests must be limited to only the amount needed to accomplish an intended purpose
Health Services Research
Research conducted on the subject of healthcare delivery that examines organizational structures and systems as well as the effectiveness and efficiency of healthcare services.
Qualitative research
Research design that collects types of data that include a participant's perceptions, attitudes, feelings or attitudes about a certain subject; methods used to collect qualitative data can include observations, focus groups, case studies, informal conversational interviews, and in-depth interviews
Descriptive studies
Research that is exploratory in nature and generate new hypotheses from the data that is collected
Variable costs
Resources expended that vary with the activity of the organization, for example, medication expenses vary with patient volume.
Trigger events
Review of access logs, audit trails, failed logins, and other reports generated to monitor compliance with the policies and procedures
Workforce planning
Reviewing national demographic, social, and economic data and trends and relating these to an organization's local staffing needs.
Internal analysis
Reviewing the inner working of the healthcare organization to determine strengths and weaknesses of the business practice and process.
Semi-automated reviews
Reviews that start with an automated review but also incorporate health record documents analyzed by humans
Federal Rules of Evidence (FRE)
Rules established by the US Supreme Court guiding the introduction and use of evidence in federal court proceedings that are an important benchmark for state and other courts.
Federal Rules of Civil Procedure (FRCP)
Rules established by the US Supreme Court setting the "rules of the road" and procedures for federal court cases. FRCP include electronic records and continue to be very important as benchmarks in how these records can be used in courts, not only federal, but state and other courts as well
Identity matching algorithm
Rules established in an information system that predicts the probability that two or more patients in the database are the same patient
Operating rules
Rules that further explain the business requirements so their use is consistent across health plans
Concurrent review
Screening for medical necessity and the appropriateness and timeliness of the delivery of medical care from the time of admission until discharge
Nonconvered services
Services not reimbursable under a managed care plan
Exempt employees
Specific groups of employees who are identified as not being covered by some or all of the provisions of the Fair Labor Standards Act.
Clinical protocols
Specific instructions for performing clinical procedures established by authoritative bodies, such as medical staff, committees, and intended to be applied literally and universally.
Process indicators
Specific measures that enable the assessment of the steps taken in rendering a service.
Experimental study
Study that strives to establish cause and effect; it entails exposing participants to different interventions in order to compare the result of these interventions with the outcome
Client/server system
System in which the healthcare organization has commercial software installed on servers housed and maintained within the organization itself, housed within the organization and managed by an outsourced company, or housed and maintained by a contractor for the healthcare organization
Automated drug dispensing machines
System that makes drugs available for patient care
Nursing information system
System that manages the nursing department, including staffing, credentialing, training, budgeting, and other managerial functions
Clinical documentation system
System that supplies templates to the user to be completed primarily via point-and-click, drop-down, type-ahead, and other data entry tools
Barcode medication administration record (BC-MAR)
System that uses barcoding technology for positive patient identification and drug information
Consent management systems
Systems that help maintain patient preferences about who may have access to their health information
Ancillary systems
Systems that serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR
Ancillary service
Test and procedures sometimes ordered by a physician to assist with diagnosing and treating the patient.
Qui tam
The "whistle-blower" provisions of the False Claims Act which provides that private persons, known as relators, may enforce the Act filing a complaint, under seal, alleging fraud committed against the government
ISO 9000 certification
The ISO 9000 family addresses various aspects of quality management and contains some of ISO's best known standards. The standards provide guidance and tools for companies and organizations who want to ensure that their products and services consistently meet customers' requirements, and that quality is consistently improved
Ambulatory surgery center (ASC) payment rate
The Medicare ASC reimbursement methodology system referred to as the ambulatory surgery center (ASC) payment system. The ASC payment system is based on the ambulatory payment classifications (APCs) utilized under the hospital OPPS
Outpatient Prospective Payment System
The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications
Treatment, payment, and operations (TPO)
The Privacy Rule provides a number of exceptions for PHI that is being used or disclosed for TPO purposes; treatment means providing, coordinating, or managing healthcare or healthcare-related services by one or more healthcare providers; payment includes activities by a health plan to obtain premiums, billing by healthcare providers or health plans to obtain reimbursement, claims management, claims collection, review of the medical necessity of care, and utilization review;
Harassment
The act of bothering or annoying someone repeatedly.
Spoliation
The act of destroying, changing, or hiding evidence intentionally
Termination
The act of ending something (for example, a job).
Due diligence
The actions associated with making a good decision, including investigation of legal, technical, human, and financial predictions and ramifications of proposed endeavors with another party
Conditions of Participation (CoPs)
The administrative and operational guidelines under which facilities are allowed to take part in the Medicare and Medicaid programs.
Learning health system
The alignment of science, informatics, incentives, and culture for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience
Active listening
The application of effective verbal communication skills as evidenced by the listener's restatement of what the speaker said
Randomization
The assignment of subjects to experimental or control groups based on chance
Line authority
The authority to manage subordinates and to have them report back, based on relationships illustrated in an organizational chart.
Clinical privileges
The authorization granted by a healthcare organization's governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits
Bed turnover rate
The average number of times a bed changes occupants during a given period of time
Case-mix index (CMI)
The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system; calculated by dividing the sum of the weights of diagnosis-related groups for patients discharged during a given period by the total number of patients discharged
Great Person theory
The belief that some people have natural (innate) leadership skills
Agency for Healthcare Research and Quality (AHRQ)
The branch of US Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services.
Agency for Healthcare Research and Quality (AHRQ)
The branch of the US Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services
Agency for Healthcare Research and Quality (AHRQ)
The branch of the United States Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services.
Department of Health and Human Services (HHS)
The cabinet-level federal agency, and principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves
Home health prospective payment system
The case mix reimbursement system developed by the Centers for Medicare and Medicaid Services in 2008, to cover home health services, including therapy visits and different resource costs provided to Medicare beneficiaries
Admissibility
The condition of being admitted into evidence in a court of law
Admissibility
The condition of being admitted into evidence in a court of law.
Performance improvement (PI)
The continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired outcomes.
Cost sharing
The cost for medical care that patients pay for themselves, like a copayment, coinsurance, or deductible
System configuration
The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system; also known as system build
System build
The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system; also known as system configuration
Data
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions
Fetal death (stillborn)
The death of a product of human conception before its complete expulsion or extraction from the mother regardless of the duration of the pregnancy
Quality
The degree of or grade of excellence of goods or services, including, in healthcare, meeting expectations for outcomes of care.
Variability
The dispersion of a set of measures around the population mean
Strategic plan
The document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity.
Disaster recovery plan
The document that defines the resources, actions, tasks, and data required to manage the businesses recovery process in the event of a business interruption
RxNorm concept unique identifier (RXCUI)
The drug name and all of its synonyms, which represent a single concept
Health information exchange (HIE)
The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies
Health information exchange (HIE)
The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies.
Data availability
The extent to which healthcare data are accessible whenever and wherever they are needed
Encounter
The face-to-face contact between a patient and a provider who has primary responsibility for assessing and treating the condition of the patient at a given contact and exercises independent judgement in the care of the patient
Age Discrimination in Employment Act of 1967
The federal act that states, it is unlawful for an employer to discriminate against an individual in any aspect of employment because that individual is 40 years old or older, unless one of the statutory, exceptions applies. Favoring an older individual over a younger individual because of age is not unlawful discrimination under the ADEA, even if the younger individual is at least 40 years old. However, the ADEA does not require employers to prefer older individuals and does not affect applicable state, municipal, or local laws that prohibit such preferences (72 FR 36875 2007).
National Center for Health Statistics (NCHS)
The federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the United States; developed the clinical modification to the International Classification of Diseases, Ninth Revision (ICD-10) and is responsible for updating the diagnosis portion of the ICD-10-CM.
TRICARE
The federal healthcare program that provides coverage for the dependents of armed forces personnel and for retirees receiving care outside military treatment facilities in which the federal government pays a percentage of the cost; formerly known as Civilian Health and Medical Program of the Uniformed Services
Consolidated Omnibus Budget Reconciliation Act (COBRA)
The federal law requiring every hospital that participates in Medicare and has an emergency room to treat any patient in an emergency condition or active labor, whether or not the patient is covered by Medicare and regardless of the patient's ability to pay; COBRA also requires employers to provide continuation benefits to specified workers and families who have been terminated but previously had healthcare insurance benefits (Public Law 99-272 1986)
Health Insurance Portability and Accountability Act (HIPAA)
The federal legislation enacted to provide continuity of health coverage, control fraud, and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The federal legislation enacted to provide continuity of health coverage, control fraud, and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information;
Health Insurance Portability and Accountability Act (HIPAA)
The federal legislation enacted to provide continuity of health coverage, control fraud, and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for pre-existing medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size; requires covered entities (most healthcare providers and organizations to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifies in HIPAA transactions (Public Law 104-191 1996)
Family and Medical Leave Act (FLMA)
The federal legislation that allows full-time employees time off from work (up to 12 weeks) to care for themselves or their family members with the assurance of an equivalent position upon return to work (Public Law 103-3 1993)
Civil Rights Act (CRA) of 1991
The federal legislation that focuses on establishing an employer's responsibility for justifying hiring practices that seem to adversely affect people because of race, color, religion, sex, or national origin (Public Law 102-166 1991)
Pregnancy Discrimination Act
The federal legislation that prohibits discrimination against women affected by pregnancy, childbirth, or related medical conditions by requiring that affected women be treated the same as all other employees for employment-related purposes, including benefits (Public Law 95-555)
Title VII of the Civil Rights Act of 1964
The federal legislation that prohibits discrimination in employment on the bases of race, religion, color, sex, or national origin (Public Law 88-352 1964)
Fair Labor Standards Act (FLSA)
The federal legislation that sets the minimum wage and overtime payments regulations (52 Stat. 1060 1938)
Privacy Rule
The federal regulations created to implement the privacy requirements of the simplification subtitle of the Health Insurance Portability and Accountability Act of 1996, afforded patients certain rights to and about their protected health information
Health informatics
The field of information science concerned with the management of all aspects of health data and information through the application of computers and computer technologies.
Change management
The formal process of introducing change, getting it adopted, and diffusing it through the organization
Change management
The formal process of introducing change, getting it adopted, and diffusing it throughout to organization.
Organizational structure
The framework of authority and supervision for the employees within the healthcare organization.
Medical identity theft
The fraudulent use of an individual's identifying information in a healthcare setting
Primary data source
The health record is this type of source because it contains information about a patient that has been documented by the professionals who provided care or services to that patient.
Supreme courts
The highest courts in a system, which hear final appeals from intermediate courts of appeal
Outsourcing
The hiring of an individual or a company external to an organization to perform a function either on site or off site.
Federal poverty level
The income qualification threshold established by the federal government for certain government entitlement programs
Clinical data
The information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services
Knowledge
The information, understanding, and experience that gives individuals the power to make informed decisions
Fraud
The intentional deception or misrepresentation that an individual knows (or should know) to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s)
Leading by example
The leader is in a role model position and team members follow or emulate the leader's behavior
Consultative leadership
The leader remains open to input from members of the team but still retains full decision-making authority
Exploitive autocracy
The leader wields absolute power and uses the team to serve his or her own personal interests
Transformational leadership
The leadership of a visionary who strives to change an organization
Licensure
The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)
Trial court
The lowest tier of state court, usually divided into two courts: the court of limited jurisdiction, which hears cases pertaining to a particular subject matter or involving crimes of lesser severity or civil matters of lower dollar amounts; and the courts of general jurisdiction, which hears more serious criminal cases or civil cases that involve large amounts of money
Average length of stay (ALOS)
The mean length of stay for hospital inpatients discharged during a given period of time
Average daily census
The mean number of hospital inpatients present in the hospital each day for a given period of time
Financial management
The mechanism that all organizations and businesses use to fully comprehend and communicate their financial activities and status.
Audit control
The mechanisms that record and examine activity in information systems
Ratio variables
The most common quantitative variables used in healthcare; these variables include numbers that can be compared meaningfully with one another; zero is truly zero on the ratio scale
Fetal autopsy rate
The number of autopsies performed on intermediate and late fetal deaths for a given time period divided by the total number of intermediate and late fetal deaths for the same time period
Newborn autopsy rate
The number of autopsies performed on newborns who died during a given time period divided by the total number of newborns who died during that same time period
Neonatal mortality rate
The number of deaths of infants under 28 days of age during a given time period divided by the total number of births for the same time period
Postneonatal mortality rate
The number of deaths of persons aged 28 days and up to, but not including, one year during a given time period divided by the number of live births for the same time period
Hospital-acquired (nosocomial) infection rate
The number of hospital-acquired infections for a given time period divided by the total number of inpatient discharges for the same time period
Postoperative infection rate
The number of infections that occur in clean surgical cases for a given time period divided by the total number of operations within the same time period
Gross autopsy rate
The number of inpatient autopsies conducted during a given time period divided by the total number of inpatient deaths for the same time period
Bed count
The number of inpatient beds set up and staffed for use on a given day
Hospital death rate
The number of inpatient deaths for a given period of time divided by the total number of live discharges and deaths for the same time period
Gross death rate
The number of inpatient deaths that occurred during a given time period divided by the total number of inpatient discharges, including deaths, for the same time period
Daily inpatient census
The number of inpatients present at census-taking time each day, plus any inpatients who were both admitted and discharged after the census-taking time the previous day
Census
The number of inpatients present in a healthcare facility at any given time
Crude birth rate
The number of live births divided by the population at risk
Newborn death rate
The number of newborns who died divided by the total number of newborns, both alive and dead
Patient acuity staffing
The number of nurses and other care providers is based on how sick the patient is
Frequency
The number of times something occurs in a particular population or sample over a specific period of time
Coroner
The official (elected or appointed, physician or nonphysician) who is responsible for determining the cause, time, and manner of death in unattended, violent, or unexplained deaths, or a case where a law may have been broken
National Vital Statistics System (NVSS)
The oldest and most successful example of intergovernmental data sharing in public health, and the shared relationships, standards, and procedures that form the mechanism by which NCHS collects and disseminates the nation's official vital statistics. These data are provided through contracts between NCHS and vital registration systems operated in the various jurisdictions and legally responsible for the registration of vital events- births, deaths, marriages, divorces, and fetal deaths
Data governance
The overall management of the availability, usability, integrity, and security of the data employed in an organization or enterprise. Focuses on managing the data as it is created within a system.
Waste
The overutilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act
Retrospective review
The part of the utilization review process that concentrates on a review of clinical information following patient discharge
Care area assessment (CAA)
The patient is assessed and reassessed at defined intervals as well as whenever there is a significant change in his/her condition.
Blanket authorization
The patient signs an authorization allowing the release of information specialist to release any and all information from that point forward.
Inpatient hospitalization
The period during an individual's life when he or she is a patient in a single hospital without interruption except by possible intervening leaves of absence
Project management life cycle
The period in which the processes involved in carrying out a project are completed, including project definition, project planning and organization, project tracking and analysis, project revisions, change control, and communication.
Individual
The person who is the subject of the protected health information
Biometrics
The physical characteristics of users (such as fingerprints, voiceprints, retinal scans, iris traits) that systems store and use to authenticate identity before allowing the user access to a system
Organization
The planned coordination of the activities of multiple people to achieve a common purpose or goal.
Technical component
The portion of radiological and other procedures that is facility based or non physician based (for example, radiology films, equipment, overhead, endoscopic suites, and so on
Jurisdiction
The power and authority of a court to hear, interpret, and apply the law to and decide specific types of cases
Upcoding
The practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that actually reflect the services provided to patients
Upcoding
The practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that actually reflect the services provided to patients.
Healthcare data analytics
The practice of using data to make business decisions in healthcare.
Unbundling
The practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure
Unbundling
The practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure.
Discovery
The pretrial stage in the litigation process during which both parties to a suit use various strategies to identify information about the case, the primary focus of which is to determine the strength of the opposing party's case
Office of the National Coordinator (ONC) for Health Information Technology
The principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.
Clinical documentation improvement (CDI)
The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes
Clinical data analytics
The process by which health information is captured, reviewed, and used to measure quality.
Career development
The process by which individuals assess their existing skills, knowledge and experience, explore and establish current and future career objectives, and develop an appropriate course of action.
Informed consent
The process by which the healthcare provider informs or makes the patient knowledgeable about the risks and benefits of the proposed treatment orprocedure.
Clinical decision support (CDS)
The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts
Human resources management (HRM)
The process of acquiring, training, appraising and compensating employees, and of attending to their labor relations, health and safety, and fairness concerns.
Charge capture
The process of collecting all services, procedures, and supplies provided during patient care
Performance measurement
The process of comparing the outcomes of an organization, work unit, or employee against pre-established performance plans and standards; results are typically expressed in quantifiable terms.
Storage management
The process of determining on what type of media to store data, how rapidly data must be accessible, arranging for replication of storage for back up and disaster recovery, and where storage systems should be maintained
Release of information (ROI)
The process of disclosing patient-identifiable information from the health record to another party
Computer-assisted coding (CAC)
The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-10-CM and CPT evaluation and management codes for billing and coding purposes
Recruitment
The process of finding, soliciting, and attracting employees.
Work analysis
The process of gathering information about what it takes to get a job done.
Strategic information systems planning
The process of identifying and prioritizing various upgrades and changes that might be made in an organization's information systems.
Risk analysis
The process of identifying possible security threats to the organization's data and identifying which risks should be proactively addressed and which risks are lower in priority
Data security
The process of keeping data, both in transit and at rest, safe from unauthorized access, alteration, or destruction
Budget management
The process of maintaining financial viability by ensuring operating revenues for the year are sufficient to cover the operating expenditures.
Claims management
The process of managing the legal and administrative aspects of the healthcare organization's response to injury claims (injuries occurring on the facility's property).
Management
The process of planning, organizing, leading and controlling organizational activities.
Data capture
The process of recording healthcare-related data in a health record system or clinical database.
Credentialing
The process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services
Prevalence rate
The proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time
Privileged communication
The protection afforded to the recipients of professional services that prohibits medical practitioners, lawyers, and other professionals from disclosing the confidential information that they learn in their capacity as professional service providers
American Recovery and Reinvestment Act (ARRA)
The purposes of this act include the following: (1) To preserve and create jobs and promote economic recovery. (2) To assist those most impacted by the recession.
Privacy
The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons, or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of protected health information
Turnover
The rate at which employees leave a firm and have to be replaced.
Cause-specific mortality rate
The rate of death due to a specified cause
Net autopsy rate
The ratio of inpatient autopsies compared to inpatient deaths calculated by dividing the total number of inpatient autopsies performed by the hospital pathologist for a given time period by the total number of inpatient deaths minus unautopsied coroners' or medical examiners' cases for the same time period
Online transaction processing (OLTP)
The real-time processing of day-to-day business transactions from a database
Revenue
The recognition of income earned and the use of appropriated capital from the rendering of services during the current period.
Proportion
The relation of one part to another or to the whole with respect to magnitude, quantity, or degree
Need-to-know principle
The release-of-information principle based on the minimum necessary standard.
Data quality
The reliability and effectiveness of data for its intended uses in operations, decision making, and planning
Medicare Fraud Strike Force
The result of the Health Care Fraud Prevention and Enforcement Action Team, this group uses data analytics to look for evidence of fraud and abuse
Medication five rights
The right drug, in the right dose, through the right route, at the right time, and to the right patient
Team norms
The rules, both explicit and implied, that determine both acceptable and unacceptable behavior for a group
Data analytics
The science of examining raw data with the purpose of drawing conclusions about that information. It includes data mining, machine language, development of models, and statistical measurements. Analytics can be descriptive, predictive, or prescriptive.
Executive management
The senior management of a healthcare organization, the people who oversee a broad functional area or group of departments or services; this level of management sets the organization's future direction and monitors the organization's operations in those areas.
Chief executive officer (CEO)
The senior manager appointed by a governing board to direct an organization's overall long-term strategic management
Values
The social and cultural belief system of a person or healthcare organization.
Common-cause variation
The source of variation in a process that is inherent within the process.
Operational planning
The specific day-to-day tasks that are required in operating a healthcare organization or an HIM department.
Data definition
The specific meaning of a healthcare-related data element
Process redesign
The steps in which focused data are collected and analyzed, the process is changed to incorporate the knowledge gained from the data collected, the new process is implemented, and the staff is educated about the new process.
Total length of stay (discharge days)
The sum of length of stay for all patients discharged for a given period of time
Benchmarking
The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization; or the systematic comparison of one organization's outcomes with regional or national standards
Benchmark
The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization; or the systematic comparison of one organization's outcomes with regional or national standards.
Benchmarking
The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization; or the systematic comparison of one organization's outcomes with regional or national standards.
Measurement
The systematic process of data collection, repeated over time or at a single point in time
Data conversion
The task of moving data from one data structure to another, usually at the time of a new system installation
Crude death/mortality rate
The total number of deaths in a given population for a given period of time divided by the estimated population for the same period of time
Consultation rate
The total number of hospital inpatients receiving consultations for a given period divided by the total number of discharges and deaths for the same period
Net death rate
The total number of inpatient deaths minus the number of deaths that occurred less than 48 hours after admission for a given time period divided by the total number of inpatient discharges minus the number of deaths that occurred less than 48 hours after admission for the same time period
Inpatient bed occupancy rate (percentage of occupancy)
The total number of inpatient service days for a given time period divided by the total number of inpatient bed count days for the same time period
Measures of central tendency
The typical or average numbers that are descriptive of the entire collection of data for a specific population
Statistics-based modeling
The use of analytical and graphical techniques to assist in the display and interpretation of raw data.
Culture
The values, beliefs, attitudes, languages, symbols, rituals, behaviors, and customs unique to a particular group of people.
National Library of Medicine
The world's largest medical library and a branch of the National Institutes of Health.
Interface
The zone between different computer systems across which users want to pass information (for example, a computer program written to exchange information between systems or the graphic display of an application program designed to make the program easier to use)
Cause of action
Theories under which lawsuits are brought that are related to professional liability such as breach of contract, intentional tort, and negligence
Behavior theory
Theory in which proponents believe that leaders can be made and that successful leadership is based on definable, learnable behavior
Bargaining unit
Those individuals who will be represented by the union.
External threats
Threats that originate outside an organization
Time ladders
Tools that support the collection of data that must be oriented by time; they specify intervals of time necessary to address the problem under consideration listed down the right side of one, two, or three columns; then, as the data collector observes, he or she records them next to the time of occurrence.
Discrete reportable transcription (DRT)
Transcription system that combines speech dictation with natural language processing
Discrimination
Treating a person differently based upon individual characteristics or group membership.
Private key infrastructure
Two or more computers share the same secret key and that key is used to both encrypt and decrypt a message; however the key must be kept secret and if it is compromised in any way, the security of the data is likely to be eliminated; see also single key encryption
Implied contract
Type of agreement between physician and patient that is created by actions
Usual,customary, and reasonable charges
Type of retrospective fee-for-service payment method in which the third-party payer pays for fees that are usual, customary, and reasonable, wherein "usual" is usual for the individual provider's practice; "customary" means customary for the community; and "reasonable" is reasonable for the situation
Security breach
Unauthorized data or system access
Administrative safeguards
Under HIPAA, are administrative actions and policies and procedures, to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information.
Health IT
Under HITECH, hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information
Eligible professional
Under HITECH, specific to the Medicare program, means a physician as defined in section 1861(r) of the Act, which includes, with certain limitations, all of the following types of professionals: (1) a doctor of medicine of osteopathy, (2) a doctor of dental surgery or medicine, (3) a doctor of podiatric medicine, (4) a doctor of optometry, (5) a chiropractor (45 CFR 495.100 2012)
Breach
Under HITECH, the acquisition, access, use, or disclosure of protected health information in a manner not permitted under subpart E of this part that compromises the security or privacy of the protected health information
Breach
Under HITECH, the acquisition, access, use, or disclosure of protected health information in a manner not permitted under subpart E of this part that compromises the security or privacy of the protected health information (45 CFR 164.402 2013)
Breach
Under HITECH, the acquisition, access, use, or disclosure of protected health information in a manner not permitted under subpart E of this part that compromises the security or privacy of the protected health information.
Ambulatory surgery center (ASC)
Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation
Ambulatory surgery center/ambulatory surgical center (ASC)
Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation.
Disparate impact
Unequal effect of a discriminatory employment practice on a protected class, even if unintentional.
Wrongful discharge
Unfair dismissal of employment due to failure of the employer to comply with law, organizational policy, or a contract.
National Labor Relations Board (NLRB)
United States government agency that holds elections for labor union representation and that reviews and looks into unfair labor practices.
Claims status inquiry and response
Used to determine if a health plan has ended a claim for additional information or is processing the claim
Computer assisted coding
Uses EHR data to assign the codes.
Grouper
Uses the codes assigned to determine the diagnostic related group or other grouping.
Medical examiner
Usually an appointed official who is a physician, commonly holding a specialty in pathology or forensic medicine with duties similar to a coroner
Nominal variables
Variables in which a number is assigned to a specific category; such as 1= male and 2=female
Eligibility
Verification that the patient is currently covered by the plan on the date of service and the services being provided are covered by the plan
Big data
Very large volume of data that offers greater reliability and validity
Leadership
Visionary thinking, decisions responsive to membership and mission, and accountability for actions and outcomes.
Portals
Windows into information systems
Statutory law
Written law established by federal and state legislatures
Query
a communication tool for CDI staff to communicate with providers to obtain clinical clarification, provide a documentation alert, clarify, or ask additional questions regarding documentation.
Data mapping
a process that allows for connections between two systems. Mapping two different coding systems to show the equivalent codes allows for initially captured for one purpose to be translated and used for another purpose.
Unified Medical Language System (UMLS)
a 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 different source vocabularies
Index
a report or list from a database that provides guidance, indication, or other references to the data contained in the database.
Data wharehouse
a single database that makes it possible to access data that exits in multiple databases through one single query and reporting interface.
Classifications
a system where related entities are organized together.
Code system
an accumulation of numeric or alphanumeric representations or codes for exchanging or storing information.
Data sets
are a recommended list of data elements that have defined and uniform definitions that are relevant for a particular use or are specific to a type of healthcare industry.
Data
are a representation of basic facts and observations about people, processes, measurements, and conditions
Data interchange standards
are developed in order to support and create structure with data exchanges to sustain interoperability. Facilitate consistent, accurate and reproducible capture of clinical data.
Standards
are fixed rules that must be followed for every form.
Standards development organizations (SDOs)
are private or government agencies that are involved in the creation and implementation of healthcare standards.
Concepts
are unique units of knowledge or thoughts created by a unique combination of characteristics.
Bylaws
are written documents that provide details and information regarding the rules and regulations established by a healthcare organization to help support healthcare operations.
Data element
can be single or individual fact that represents the smallest unique subset of a larger database sometimes referred to as the raw facts and figures. Ex. Age, gender, blood pressure, temp.
International classification of functioning, disability and health (ICF)
classification of health and health related domains that describe body functions and structures, activities, and participation.
Data stewardship
creates responsibility for data through principles and practices to ensure the knowledgeable and appropriate use of data derived from individuals personal health information.
Structured data
data that are able to be read and interpreted by a computer.
Object-oriented database (OODB)
designed to store different types of data including images, aduio files, documents, videos and data elements. Fetal monitoring strips, electrocardiograms, PACS. Provides image and document.
Unsecured electronic protected health information (e-PHI)
e-PHI that has not been made unusable, unreadable, or indecipherable to unauthorized persons
Database
is a collection of data organized in such a way that its contents can be easily accessed, managed, reported and updated.
Target data
is the location from which the data is mapped or to where it is sent.
Source data
is the location from which the data originates, such as a database or a data set
Clinical documentation
manual or electronic notation made by a doctor or other healthcare clinician related to a patient's medical condition or treatment. Foundation of every patients record for care and reimbursement.
Information assets
refer to the information collected during dat to day operations of a healthcare organization that has value within an organization. Ex. patient data collected to support care.
Data management
refers to the definition and structure of data elements and the creation, storage and transmission of data elements.
Granularity
refers to the level of detail in the model or the decision-making process
Critical thinking
refers to the process of analyzing, assessing, and recontructing a situation to provide enhanced solutions and outcomes to a problem.
Enterprise information management
set of functions created by an organization to plan, organize, and coordinate the people, processes, technology, and content needed to manage info. for the purpose of data quality, safety and ease of use.
Medical staff privileges
specific services and procedures that the medical staff member is deemed qualified to perform, to practice medicine at a particular healthcare provider organization.
Relational database
stores data in tables that are predefined and contain both rows and columns of information. Easy to build, use and query within the application.
Data integrity
the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so.
Interoperability
the capability of two or more information systems and software applications to communicate and exchange information.
Hospital information system (HIS)
the comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital
Pre-ferred term
the description or name assigned to a concept that is used most commonly.
Business intelligence (BI)
the end product or goal of knowledge management
HIPAA Security Rule
the federal regulations created to implement the security requirements of HIPAA
Benevolent autocracy
the leader wields absolute power but is generally kind and sincere in the use of the team for the good of the organization
Semantic interoperability
the mutual understanding of the meaning of data exchanged between information systems.
Infant mortality rate
the number of deaths of individuals under one year of age during a given time period divided by the number of live births reported for the same time period
Biometrics
the physical characteristics of users (such as fingerprints, voiceprints, retinal scans, iris traits) that systems store and use to authenticate identity before allowing the user access to a system
Data warehousing
the process of collecting the data from different data sources within an organization and storing it in a single database that can be used for decision making.
System characterization
the process of creating an inventory of all systems that contain data, including documenting where the data are stored, what type of data are created or stored, how they are managed, with what hardware and software they interact with, and providing basic security measures for the systems.
Intrusion detection
the process of identifying attempts or actions to penetrate a system and gain unauthorized access
Data mining
the processing of extracting from a database or data warehouse information stored in discrete, structured data format, that is , data that has a specific value/.
Morbidity
the state of being diseased including illness, injury, or deviation from normal health.
Length of stay (LOS)
the total number of patient days for an inpatient episode, calculated by subtracting the date of admission from the date of discharge
Functioning
the umbrella term for Body functions, body structure, activities and participation.
Pharmacy information system
this system receives an order for a drug in a hospital, aids the hospital's pharmacist in checking for contraindications, directs staff in compounding any drugs requiring special preparation, aids in dispensing the drug in the appropriate dose and for the appropriate route of administration.
Relationships
type of connection between two concepts.
nomenclatures
used to identify clinical data. Consist of a system of terms that follows pre-estblished naming conventions. Ex. clinical terminologies, classifications, and code systems.
Probabilistic Algorithm
uses mathematical probabilities to determine the possibility that two patients are the same.
Health Information Exchange (HIE)
when health information is electronically traded between providers and others with the same level of interoperability.
Amendement
Clarification made to healthcare docs after the original doc as been signed. Should be dated, timed, and signed.
Administrative data
Coded information contained in secondary records describing patient identification, diagnosis, procedures, and insurance.
Electronic health record
Collection of a patient's health care and treatment in a digital format
Alphanumeric filing system
Combination of alphabetic letters (usually the first two letters of the patient's last name) and numbers to identify individual records
Expressed consent
Consent given by the patient by either his or her words or in writing.
Health record
Contains info. relating to the physical or mental health or conditions of an individual as made by or on behalf of a health professional in connection with the care ascribed the individual.
Overlap
patient has more than one health record number at different locations in a enterprise.
Serial numbering system
patient is issued a unique numerical identifier for every encounter at the healthcare facility. If patient is admitted to the facility 5 times he/she will have 5 different record numbers.
Deterministic Algorithm
requires exact matches in data elements such as the patient name, date of birth, ssn#
History and Physical
Must be documented for every patient no more than 30 days before or 24 hours after admission to the hospital.
Data mining
The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors.
Demographics
Are basic information about the patient such as their name, address, and date of birth, insurance information.
Physician orders
Are the instructions the physician gives to other healthcare professionals who actually perform diagnostic test and treatments, administer medications, and provide specific services to a particular patient.
Authentication
The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature.
Documentation
The recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers.
Transfer record
A brief review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions. Also called a referral form.
Audit trail
A chronological set of computerized records that provides evidence of information system activity used to determine security violations.
Hybrid health record
A combination of the paper record and the EHR.
Voice recognition technology
A computer captures the dictation and converts what is said directly into text and no transcriptionist is needed.
Discharge summary
A concise account of the patient's illness, course of treatment, response to treatment, and condition at the time of patient discharge.
Medical Staff
A group of physicians and nonphysicians such as nurse practitioners and physician assistants who have medical staff privileges.
Care plan
A summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions.
Integrated health record
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments.
Recovery room report
A type of health record documentation used by nurses to document the patient's reaction to anesthesia and condition after surgery.
Encoder
Assigns the diagnosis and procedure codes. Can query the coder to determine if related codes should be assigned
Clinical decision support (CDS)
Assists physicians and other users when making decisions regarding medications, diagnoses, and such based on the information entered into the EHR.
Legal health record
Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information
Consultation report
Documents the clinical opinion of a physician other than the primary or attending physician
Terminal-digit filing system
Most efficient of the numeric filing systems. it distributes charts evenly throughout the filing units. Records are filed by the 2 digits.
Outguide
Identifies where the health record is located and when it was removed
Loose Material
Includes dictated reports, reports not filed in the nursing units, etc.
Patient account number
Number assigned by a healthcare facility for billing purposes that is unique to a particular episode of care.
Concurrent review
Ongoing review throughout the patient's hospital stay
Standing orders
Orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure. Authorizes other healthcare providers to begin treating the patient before the physician actually examines the patient.
Joint Commission
Industry leader in the area of healthcare provider organization accreditation. Also provides its memeber organizations with education and compliance outreach services.
Master Patient Index (MPI)
Is the permanent record of all patients treated at a healthcare facility.
Indexing
Linking of patient name, health record number, doc type, and other identifying info. to the scanned document.
Qualitative Analysis
Monitoring the quality of the documentation. Reviews legibility, timeliness of docs, use of approved abbreviations.
Clinical data
The information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services.
Licensure
The legal authority or formal permission from the authorities to carry on certain activities that require such permission and federal and state regulatory agencies mandate the content, specially the breadth and depth of these bylaws as well as the application of the bylaws.
Certification
The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements.
Release of information
The process of disclosing patient-identifiable information from the health record to another party
Assembly
The process of ensuring that each page in the health record is organized in a standardized format
Medical history
Portion of clinical data addresses the patient's current complaints and symptoms and lists his or her past medical, personal, and family history.
Abstracting
Process of extracting info. from a document to create a brief summary of patient's illness, treatment, and outcomes or the process of extracting elements of data source documents or database and entering them into an automated system.
Quantitative analysis
Review of the health record to determine if there are any missing reports, forms, or signatures.
Document management system
Scans the paper record and stores it digitally.
Record Reconciliation
The health record is taken to the HIM dept after patient discharged for processing. Ensures all health records have been received.
Free-text data
The unstructured narrative data that is the result of a person typing data into an information system.
Alphabetic filing system
Used by small clinics and physician offices. The folders are filed alphabetically by the patient's last name.
Meaningful Use
Using certified electronic health record technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and family; improve care coordination, and population and public health; maintain privacy and security of patient health information.
Duplicate health record
When the patient has two or more health record numbers issued.
Serial-unit numbering system
a combination of the serial and unit numbering systems. Patient is issued a new health record number with each encounter but all of the documentation is moved from the last number to the new number.
Rules-Based Algorithm
assigns weights to specific data elements and uses those weights to compare one record or another.
Unit numbering system
commonly used in large healthcare facilities as it does not have many of the inefficiencies of the serial numbering systems. Patient is issued a health record number at the first encounter and that number is used for all subsequent encounter.
