LaTour Chapter 8
Privacy standards
Rules, conditions, or requirements developed to ensure the privacy of patient information
Accreditation Standards Committee X12
A committee of the American National Standards Institute that develops and maintains standards for the electronic exchange of business transactions
ORYX Initiative
A Joint Commission initiative that supports the integration of outcomes data and other performance measurement data into the accreditation process
Unique identification number
A combination of numbers or alphanumeric characters assigned to a particular patient
Uniform Hospital Discharge Data Set (UHDDS)
A core set of data elements adopted by the US Dept of Health, Education, and Welfare in 1974. Hospitals collect these on all discharges and all discharge abstract systems.
Data Elements for Emergency Department Systems (DEEDS)
A data set designed to support the uniform collection of information in hospital-based emergency departments.
Data dictionary
A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology
Data set
A list of recommended data elements with uniform definitions that are relevant for a particular use
Outpatient
A patient who receives ambulatory care services in a hospital-based clinic or department
Nomenclature
A recognized system of terms used in a science or art form that follows reestablished naming conventions.
Unified Medical Language System (MLS)
A set of files and software that brings together many health and biomedical vocabularies and standards to enable interoperability between computer systems. UMLS is used to enhance or develop applications, such as electronic health records, classification tools, dictionaries and language translators.
Outcomes and Assessment Information Set (OASIS)
A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs
ASTM Standard E1384-07
A standard that identifies the basic information to be included in electronic health records and requires the information to be organized into categories
Digital Imaging and Communications in Medicine (DICOM)
A standard that promotes a digital image communications format and picture archive and communications systems for use with digital images
Electronic data interchange
A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations
Extensible markup language (XML)
A standardized computer language that allows the interchange of data as structured text
Health Level Seven (HL7)
A standards development organization accredited by the American National Standards Institute that addresses issues at the application level of healthcare systems interconnections.
Prospective payment system (PPS)
A type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided.
Accreditation
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 reestablished written criteria. ALSO a determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards
National Institute for Standards and Technology
Agency of the US Dept. of Commerce founded in 1901 as the nation's first federal physical science research laboratory
ASTM (International)
American Society for Testing and Materials. A national organization whose purpose is to establish standards on materials, products, systems, and services
Data element
An individual fact or measurement that is the smallest unique subset of a database
Quality Data Model (QDM)
Clearly defines contents used in quality measures and clinical care. Intended to enable automation of structured data capture in EHRs, PHRs, and other clinical applications.
Structure and content standards
Common data elements and definitions of the data elements to be included in an electronic patient record
Vocabulary standards
Common definitions for medical terms to encourage consistent descriptions of an individual's condition in the health record
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.
Patient-identifiable data
Data in the health record that relates to a particular patient identified by name
Uniform Ambulatory Care Data Set (UACDS)
Data set developed by the NCVHS consisting of a minimum set of patient/client-specific data elements to be collected in ambulatory care settings
Centers for Medicare and Medicaid Services (CMS)
Division of Dept. of Health and Human Services that is responsible for developing healthcare policy in the US and for administering the Medicare program and federal portion of the Medicaid program. Was called the Health Care Financing Administration (HCFA) prior to 2001.
Minimum Data Set (MDS) Version 3.0
Document created when OBRA required CMS to develop an assessment instrument to standardize the collection of SNF patient data. The MDS is the minimum core of defined and categorized patient assessment data that serves as the basis for documentation and reimbursement in a SNF
Continuity of Care Document (CCD)
Document that is the result of bleeding the ASTM CCR standard content for referrals with the HL7 CDA standard for document construction. Widely used now in creating PHRs.
Continuity of Care Record (CCR)
Documentation of care delivery from one healthcare experience to another.
Bills of Mortality
Documents used in London during the 17th century to identify the most common causes of death
National Provider Identifier (NPI)
Eight-character alphanumeric identifier used to identify individual healthcare providers for Medicare billing purposes
Information
Factual data that have been collected, combined, analyzed, interpreted, and converted into a form that can be used for a specific purpose
National Center for Health Statistics (NCHS)
Federal agency responsible for collecting and disseminating information on health services utilization and the health status of the population in the US
Health Insurance Portability and Accountability Act (HIPAA)
Federal legislation enacted to provide continuity of health coverage, control healthcare fraud and abuse, reduce healthcare costs, and guarantee the security and privacy of health information.
Hospital discharge abstract system
Group of databases compiled from aggregate data on all patients discharged from a hospital
Healthcare information standards
Guidelines developed to standardize data throughout the healthcare industry.
Clinical Document Architecture (CDA)
HL7 electronic exchange model for clinical documents (like discharge summaries and progress notes).
Long-term care
Healthcare services provided in a non acute care setting to chronically ill, aged, disabled, or mentally handicapped individuals.
Standards development organization
Private or government agency involved in the development of healthcare informatics standards at a national or international level
Institute of Electrical and Electronics Engineers
National organization that develops standards for hospital system interface transactions, including links between critical care bedside instruments and clinical information systems.
International Organization for Standardization
Nongovernmental global organization established in 1987 that provides more than 17K quality standards for nearly every business, technology, and industry sector
Office of the National Coordinator of Health Information Technology
Office that provides leadership for the development and implementation of an interoperable health information technology infrastructure nationwide to improve healthcare quality and delivery
National Council for Prescription Drug Programs (NCPDP)
Organization that develops standards for exchanging prescription and payment information
Inpatient
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.
National Committee for Quality Assurance (NCQA)
Private, non-profit accreditation organization whose mission is to evaluate and report on the quality of managed care organizations in the US
Joint Commission
Private, non-profit organization that evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards. Used to be JCAHO. (on accreditation of healthcare organizations)
National Committee on Vital and Health Statistics (NCVHS)
Public policy advisory board that recommends policy to the National Center for Health Statistics and other federal health-related programs
Identifier standards
Recommended methods for assigning unique identifiers to individuals (patients and clinical providers), corporate providers, and healthcare vendors & suppliers
Standard
Scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured. A model or example established by authority, custom, or general consent. Rule established by an authority on a measure of quantity, weight, extent, value, or quality.
Healthcare Effective Data and Information Set (HEDIS)
Set of standard performance measures designed to provide purchasers and consumers of healthcare with the information they need for comparing the performance of managed healthcare plans.
Core data elements
Small set of data elements with standardized definitions that is often considered to be the core of data collection efforts.
Core measures
Standardized performance measures developed to improve the safety and quality of healthcare.
Transaction standards
Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another
Security standards
Statements that describe the processes and procedures meant to ensure that patient-identifiable health information remains confidential and protected from unauthorized disclosure, alteration, and destruction
Picture archiving and communication system (PACS)
System that digitizes medical images
Health Information Technology Policy Committee (HITPC)
The Health IT Policy Committee (HITPC) will make recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information. The American Recovery and Reinvestment Act of 2009 (ARRA) provides that the Health IT Policy Committee shall at least make recommendations on the areas in which standards, implementation specifications, and certifications criteria are needed in eight specific areas.
Standards and Interoperability Framework
The S&I Framework is one approach adopted by ONC's Office of Standards & Interoperability to fulfill its charge of enabling harmonized interoperability specifications to support national health outcomes and healthcare priorities, including Meaningful Use and the ongoing efforts to create better care, better population health and cost reduction through delvery improvements. The S&I Framework creates a forum - enabled by integrated functions, processes, and tools - where healthcare stakeholders can focus on solving real-world interoperability challenges.
Department of Health and Human Services
The cabinet-level federal agency that oversees all the health and human services-related activities of the federal government and administers federal regulations
Common Formats Version 1.1
The common definitions and reporting formats specified by AHRQ that allow healthcare providers to collect and submit standardized information regarding patient safety events. There are two general types: generic and event-specific.
Data
The dates, numbers, images, symbol, letters, and words and that represent basic facts and observations about people, processes, measurements, and conditions
Health information exchange (HIE)
The exchange of health information electronically between providers and others with the same level of interoperability, like labs and pharmacies.
American National Standards Institute (ANSI)
The organization that accredits all US standards development organizations to ensure that they are following due process in promulgating standards
American College of Radiology and the National Electrical Manufacturers Association
The original name of what is today called the DICOM standard. The ACR-NEMA standard was developed jointly by ACR (the American College of Radiology) and NEMA (the National Electrical Manufacturers Association). The ACR-NEMA standard was originally published in 1985, and an updated version, ACR-NEMA 2.0, was published in 1988. The goal of the standard was provide a vendor-independent set of rules for exchanging digital medical images. One limitation of ACR-NEMA was that it was defined for point-to-point connections only, rather than from use in a network environment. The third version of the standard, released in 1993, was renamed to DICOM (Digital Imaging and Communications in Medicine). DICOM 3.0 added network support, expanded object definitions (both image and non-image), and introduced conformance statements. The "3.0" was retained to reflect its heritage from ACR-NEMA.
Health Information Technology Standards Committee (HITSC)
This committee makes recommendations to the National Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information for purposes of adoption, consistent with the implementation of the Federal Health IT Strategic Plan and in accordance with policies developed by the HIT Policy Committee
Health Information Technology Expert Panel (HITEP)
This panel was formed by the National Quality Forum with support from AHRQ to create a better link between current quality measurement and EHR reporting capabilities.
Metadata registry
Used to store characteristics of data that are necessary to clearly describe, inventory, analyze, and classify data