Informatics Module 4

Minimum data set

A list of categories of data, each of which has an agreed definition as to what it includes; they specify the type of data that will meet the essential needs of users for a specific purpose.

Maethtesaurus

A list of concepts and terms from health-related standardized vocabularies and is used by the UMLS to index literature.

Personal health Record (PHR)

A record of health information owned by the individual; may be maintained using computer document or paper record.

Patient portal

A secure online website that gives patients convenient 24-hour access to personal health information; patients have a secure user name and password to view their health information.

Patient Portals

A secure website that provides patients access to their EHR data.

Unique patient identifier

A single source that links each patient with his or her individual health record.

Disjunctive

A taxonomy where each term can belong to only one overall concept or have only one parent.

Combinatorial vocabulary

A term is created by combining terms from lists in different axes or categories.

Lexical

A word for word match when mapping terminology.

Semantic interoperability

Information transmitted is understandable, and at its highest level, the interpretation and action on messages exchanged by two computers occurs without human intervention.

USB port

Installed on a computer that allows a device with a universal serial bus connection to be plugged in and accessed on the computer.

Unified Medical Language System (UMLS)

Integrates and distributes key terminology, classification, and coding standards to promote creating of more effective interoperable information services, including electronic health records

Readbility

The difficulty of reading text.

Electronic medical record

The focus of most healthcare providers today, the institution or provider that creates EMRs owns and manages them; outside agencies cannot interface with them.

Ontology

The highest level of organization of a terminology; complex and powerful, it provides the ability for concepts to be represented and linked to more than one concept.

Granularity

The most specific terms, which are on the lowest level of a taxonomy of a database.

HONcode

This icon signifies certification of the website certifies the quality of the website health information by the Health on the Net Foundation, an international nonprofit.

Regional Extension Centers (RECs)

a component of the Health information Technology Extension Program; trained staff members assist healthcare providers to understand and implement the electronic health record adoption, and educational components include vendor selection, workflow analysis necessary to decide on a vendor, and how to meet meaningful use requirements.

Flash drive

a data storage device that connects to a computer using a universal serial bus (USB).

Mapping

a form of matching concepts from one standardized terminology with those having similar meaning from another

Nationwide Health Information Network (NHIN)

a foundation for secure information exchange of healthcare data over the Internet using a "a set of standards, services, and policies," according to HealthIT.gov

Health Insurance Portability and Accountability Act (HIPPA)

a law passed in 1996 that protects the privacy and security of health information and provides patients the right to see their own healthcare records.

Semantic

a match on the same meaning or a synonym when mapping terminology.

Personal identification number (PIN)

an identifier used to gain computer access

Confidentiality

authorized care providers maintaining all personal health information as secret, except to other care providers who need access to that information and to others that the patient has consented to allow access.

Image map

clickable spots on a graphic, which have hyperlinks to other websites

De-identified data

data stripped of subject identifiers

Health Information Exchange (HIE)

exchange of health information facilitated by the Office of the National Coordinator for Health Information Technology (ONC); includes three types of exchanges: directed, query-based, and consumer mediated.

Navigation bars

graphical bars across the top of a page that provide multiple choices and need alternative methods of access

Pre-coordinated term

taxonomy terms prepared by experts in a field by combining the terms from the various axes.

Post-coordinated term

taxonomy terms used in documentation that follow the axes and categories determined for combinational vocabulary

Linear list

an alphabetical list such as a dictionary

Smart card

A card that has embedded information; requires the appropriate computer system and access code to read and write.

Multiaxial taxonomy

A classification system with two or more axes, used for standardizing nursing language in computer documentation.

Monoaxial

A device that transmits digital information.

Consumer informatics

A field of study related to healthcare information that is accessible to consumers in a useful, understandable manner.

Nationwide Health Information Network (NwHIN)

A foundation for secure information exchange of healthcare data over the internet using "a set of standards, services, and policies," according to HealthIT.gov.

Electronic health record

An electronic record of the patient's health history; one's health information is available from any location where there is Internet access and a health information exchange.

Flesch-Kincaid Grade Level

Calculates a US school grade level with a formula that uses the average number of words per sentence and the average number of syllables per word.

Screen reader

Computer accessibility feature with speech recognition for those with limited eyesight.

Interoperable

Data can be shared electronically, such as in an electronic health record.

Axes

Divisions that include a list of terms with agreed upon definitions that can be used to create a combinational vocabulary.

Taxonomic vocabularies

Grouping terms with conceptual similarities into groups that share a common concept; examples include NANDA and NIC.

Braille reader

a screen reader that can send information to a Braille reader placed near or under the keyboard; users then use their fingers to "read" the information

Subset

a smaller set of terms from a larger group of terms.

Protocol

a system of rules required for data transfers

Alt tag

a text alternative for a graphic because screen readers cannot "read" a graphic; the tag should provided either textual information used by a screen reader in place of the illustration or a link to a site that explains the illustration in text.

Harmonization

all the degrees of making standardized terminologies partially interoperable

Standards

an agreement to use a given protocol, term, or other criterion formally approved by a nationally or internationally recognized professional trade association of governmental body.

Interoperability

is the ability of two or more systems to pass information between them and to use the exchanged information; in healthcare, it means that healthcare information systems can transmit and receive information within and across organizational boundaries to provide the delivery of optimum healthcare to individuals and communities.

Flesch Reading Ease

measures how easy it is to read text from a formula using the average sentence length and the average number of syllables per word; the recommended score is between 60 and 70

Linked

one term is related or often used, with another; terms may be presented together for documentation purposes.

Natural language

one's everyday speaking tongue, which is very expressive and requires no change in how you think when using it in documentation

Reference Terminology Model

refers to a set of terms based upon evidence-based research; some of the potential uses for this model include facilitating the documentation of nursing problems (diagnosis) and actions (interventions) in electronic information systems

invisible/deep Web

sites not reachable by traditional search tools

Visible/surface web

sites reachable by the traditional search engines

Interface terminology

terminology that allows the exchange of computer clinical information with the user

Interdisciplinary terminology

terminology that can be used across disciplines in healthcare; the ANA recognizes three interdisciplinary terminologies: the Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT); Logical Observations: Identifiers, Names, Codes (LOINC); and the Alternative Billing Codes (ABC).

Health numeracy

the ability of a consumer to interpret and act on numerical information to make effective health decisions

Health literacy

the ability to obtain and understand health information for decision making; it includes the capacity to understand instructions on prescription drug bottles, appointments slips, medical education brochures doctor's directions, consent forms, and the ability to negotiate complex healthcare systems.

Accessibility

the design of a resource, such as a website, that allows individuals with disabilities the ability to access the resource; the resource design should allow for use of screen readers for persons with limited eyesight as well as for those who are hearing disabled.

Security

the measures implemented to prevent unauthorized users access to the personal health information of patients.

Privacy

the right of patients to control what happens to their personal health information.

Classify

to groups terms so that they can be analyzed beyond the individual term.

Integrated

uniting separate entities into a whole.

Support group

use a variety of online forums, for example, patient portals, social networking websites, message boards, e-mail lists, chat rooms, or any combination of these.

Usability

websites should meet certain criteria to make them useable for their audience, including considering location of drop-down menus, the amount of information on the screen, the font size, the amount of instructions for finding videos, and navigation issues; the site needs to be compliant with the American Disability Act usability principles.

Reference terminology

works behind the scenes, taking a documentation term and giving it a code related to concepts at a higher level to allow a broader analysis.