RHIT
Complete EHR
2011 edition, Under meaningful use incentives, EHR technology that has been developed to meet, at a minimum, all mandatory 2011 Edition EHR certification criteria for either an ambulatory setting or inpatient setting (45 CFR 170.102)
Complete EHR
2014 edition, Under meaningful use incentives, EHR technology that has been developed to meet, at a minimum, all mandatory 2014 Edition EHR certification criteria for either an ambulatory setting or inpatient setting (45 CFR 170.102)
Demand bill
A bill generated and issued to the patient at the time of service or any other time outside the normal accounting cycle
Cross-sectional study
A biomedical research study in which both the exposure and the disease outcome are determined at the same time in each subject; See prevalence study
Double distribution
A budgeting concept in which overhead costs are allocated twice, taking into consideration that some overhead departments provide services to each other
Step-down allocation
A budgeting concept in which overhead costs are distributed once, beginning with the area that provides the least amount of non-revenue-producing services
Simultaneous equations method
A budgeting concept that distributes overhead costs through multiple iterations, allowing maximum distribution of interdepartmental costs among overhead departments
Uniform Ambulatory Care Data Set (UACDS)
A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient- or client-specific data elements to be collected in ambulatory care settings
Target system
A data set in which one is attempting to find equivalence or define the relationship
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; See also data warehouse
Data warehouse
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface; See clinical data warehouse; clinical repository
Call center
A central access point to healthcare services in which clinical decision-making algorithms generate a series of questions designed to help a nurse assess a caller's healthcare condition and direct the caller to the appropriate level of service
Clinical data repository (CDR)
A central database that focuses on clinical information
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
Corporate Integrity Agreement (CIA)
A compliance program imposed by the government, which involves substantial government oversight and outside expert involvement in the organization's compliance activities and is generally required as a condition of settling a fraud and abuse investigation
Common Object Request Broker Architecture (CORBA)
A component computer technology developed by a large consortium of vendors and users for handling objects over a network from various distributed platforms;
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
Assessment indicator code
A component of the code used for Medicare billing by long-term care facilities
Clinical abstract
A computerized file that summarizes patient demographics and other information, including reason for admission, diagnoses, procedures, physician information, and any additional information deemed pertinent by the facility
Certified health data analyst (CHDA®)
An AHIMA credential awarded to individuals who have demonstrated skills and expertise in health data analysis
X12
An ANSI-accredited group that defines EDI standards for many American industries, including healthcare insurance. Most of the electronic transaction standards mandated or proposed under HIPAA are X12 standards (The Accredited Standards Committee 2013)
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). The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from HL7, Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for Stage I Meaningful Use, and HITECH final rule. It is commonly referred to as Consolidate CDA or C-CDA (HL7 2013)
Digital Imaging and Communication in Medicine (DICOM)
An ISO standard that promotes a digital image communications format and picture archive and communications systems for use with digital images
Standard generalized markup language (SGML)
An International Standards Organization standard that establishes rules for identifying elements within a text document
Det Norske Veritas (DNV)
An independent international organization that began offering hospital accreditation services in the United States in 2008 (DNV 2013)
Certification authority (CA)
An independent licensing agency that vouches for a person's identity in encrypted electronic communications
Certification Commission for Healthcare Information Technology (CCHIT)
An independent, voluntary, private-sector initiative organized as a limited liability corporation that has been awarded a contract by the US Department of Health and Human Services (HHS) to develop, create prototypes for, and evaluate the certification criteria and inspection process for electronic health record products (EHRs) (CCHIT 2013)
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
Deemed status
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation (CMS 2013)
Court order
An official direction issued by a court judge and requiring or forbidding specific parties to perform specific actions
Systematized Nomenclature of Dentistry (SNODENT)
An official subset of SNOMED CT, it is a systemized nomenclature of dentistry containing dental diagnoses, signs, symptoms, and complaints (ADA 2013)
Database
An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications
Term neonate
Any neonate whose birth occurs from the beginning of the first day (267th day) of the 39th week through the end of the last day of the 42nd week (294th day), following onset of the last menstrual period
Data event
Any occurrence that generates new data or information, such as a diagnostic test
Claim attachment
Any of a variety of hardcopy or electronic forms needed to process a claim in addition to the claim itself, such as a copy of the emergency department note (CMS 2013)
Workers' Adjustment and Retraining Notification (WARN) Act
Federal legislation that requires employers to give employees a 60-day notice in advance of covered plant closings and covered mass layoffs (Public Law 100-379 1988)
Covered condition
In healthcare reimbursement, a health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay
Continuous data
In healthcare statistics, data that represent measurable quantities but are not restricted to certain specified values
Code
In information systems, software instructions that direct computers to perform a specified action; in healthcare, an alphanumeric representation of the terms in a clinical classification or vocabulary
Causation
In law, a relationship between the defendant's conduct and the harm that was suffered
Complaint
In litigation, a written legal statement from a plaintiff that initiates a civil lawsuit
Comprehensive outpatient program
In mental health or drug and alcohol treatment centers, an outpatient program for the prevention, diagnosis, and treatment of any illness, defect, or condition that prevents the individual from functioning in an optimal manner
Topology
In networking terms, the physical or logical arrangement of a network
Developing stage
In performance management, the stage during which opportunities for improving work processes or employee skills are identified
Day on leave of absence
A day occurring after the admission and prior to the discharge of a hospital inpatient when the patient is not present at the census-taking hour because he or she is on leave of absence from the healthcare facility
Coroner's case
A death that appears to be suspicious and requires action from the coroner to determine the cause of death
Structured decision
A decision made by following a formula or a step-by-step process
Unstructured decision
A decision that is made without following a prescribed method, formula, or pattern
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
Cherry picking
In reimbursement, the term given when payers target the enrollment of healthy patients to minimize healthcare costs
Confounding variable
In research an event or a factor that is outside a study but occurs concurrently with the study; Also called extraneous variable; secondary variable
Conclusion validity
In research, the extent to which the statistical conclusions about the relationships in the data are reasonable
Debt
Incurred when money is borrowed and must eventually be paid
Structure measures
Indicators that measure the attributes of the healthcare setting (for example, adequacy of equipment and supplies)
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
Complementary and alternative medicine (CAM)
A group of diverse medical and healthcare systems, practices, and products that are not considered to be part of conventional medicine
Community College Consortium
A group of identified community colleges within a geographical region whose goal is to educate health information technology professionals who will be responsible for facilitating the implementation of and support for an electronic healthcare system in the United States
Survey team
A group of individuals sent by an accrediting agency (usually the Joint Commission) to review a healthcare organization for accreditation purposes
Ad hoc committee
A group of individuals who join together to solve a particular task or problem
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
Storytelling
A group process technique in which group members create stories describing the plausible future state of the business environment
Commission for the Accreditation of Birth Centers
A group that surveys and accredits birth centers in the United States (CABC 2013)
Community Health Accreditation Program (CHAP)
A group that surveys and accredits home healthcare and hospice organizations (CHAP 2013)
C
A high-level programming language that enables programmers to write software instructions that can be translated into machine language to run on different types of computers
Backbone
A high-speed medium used as the main trunk in a computer network to transmit high volumes of traffic
Archival database
A historical copy of a database that is saved at a particular point in time. It is used to recover and restore the information in the database
Trauma center
A hospital that is specially staffed and equipped (usually with an air transport system) to handle trauma patients. They must meet specific criteria for trauma center designation
Cohort study
A study, followed over time, in which a group of subjects is identified as having one or more characteristics in common
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
Urban area
A metropolitan statistical area as defined by the Office of Management and Budget; See also core-based statistical area (CBSA)
Disaster planning
A plan for protecting electronic protected health information (ePHI) in the event of a disaster that limits or eliminates access to facilities and ePHI
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
Data backup plan
A plan that ensures the recovery of information that has been lost or becomes inaccessible
Unapproved abbreviations policy
A policy that defines the abbreviations that are unacceptable for use in the health record
Downtime procedure policy
A policy that focuses on sustaining business function during short interruptions that do not exceed the threshold that would be classified as disasters; Also called contingency plan
Alias policy
A policy that is implemented when resident confidentiality is required by the resident, family, or responsible party
Analysis of discharged health records policy
A policy that outlines steps to be taken to process discharged resident records
Census-reporting policy
A policy that outlines the process for census reporting and tracking
Subpoena policy
A policy that outlines the steps required to handle subpoenas and e-discovery requests
Chart-tracking/requests policy
A policy that outlines the way in which charts are signed out of the permanent files and how requests for records are handled
Chart order policy
A policy that provides a detailed listing of all documents and defines their order and section location within the health record
Chief knowledge officer (CKO)
A position that oversees the entire knowledge acquisition, storage, and dissemination process and that identifies subject matter experts to help capture and organize the organization's knowledge assets
Solo practice
A practice in which the physician is self-employed and legally the sole owner
Data field
A predefined area within a healthcare database in which the same type of information is usually recorded
Satellite clinic
A primary care facility, owned and operated by a hospital or other organization, which is located in an area convenient to patients or close to a specific patient population
X12N
A subcommittee of X12 that defines EDI standards for the insurance industry, including healthcare insurance (The Accredited Standards Committee 2013)
Workgroup on Electronic Data Interchange (WEDI)
A subgroup of Accreditation Standards Committee X12 that has been involved in developing electronic data interchange standards for billing transactions
Algorithmic translation
A process that involves the use of algorithms to translate or map clinical nomenclatures among each other or to map natural language to a clinical nomenclature or vice versa
Cost-benefit analysis
A process that uses quantitative techniques to evaluate and measure the benefit of providing products or services compared to the cost of providing them
Tracer methodology
A process the Joint Commission surveyors use during the on-site survey to analyze an organization's systems, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the sequence experienced by the patients; an evaluation that follows (traces) the hospital experiences of specific patients to assess the quality of patient care; part of the new Joint Commission survey processes (Joint Commission 2010)
Collective bargaining
A process through which a contract is negotiated that sets forth the relationship between the employees and the healthcare organization
Cost object
A product, process, department, or activity for which a healthcare organization wishes to estimate the cost
American Medical Informatics Association (AMIA)
A professional association for individuals, institutions, and corporations that promotes the development and use of medical informatics for patient care, teaching, research, and healthcare administration (AMIA 2013)
American Dental Association (ADA)
A professional dental association dedicated to the public's oral health, ethics, science, and professional advancement (ADA 2013)
Webmasters
Individuals who support web applications and the healthcare organization's intranet and Internet operations
Bloodborne pathogen
Infectious diseases such as HIV, hepatitis B, and hepatitis C that are transported through contact with infected body fluids such as blood, semen, and vomitus
Budget assumptions
Information about the overall organization's budget planning that sometimes includes an estimation of how revenues will increase or decrease and what limits will be placed on expenses
Claims data
Information required to be reported on a healthcare claim for service reimbursement
Thick client
Information system with full processing capabilities
Closed-loop medication management
Information systems used to provide patient safety when ordering and administering medications
Structured input (SI)
Information that has been organized to allow identification and separation of the context of the information from its content
Administrative information
Information used for administrative and healthcare operations purposes, such as billing and quality oversight
Demographic information
Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person
Web-based training
Instruction via the Internet that enables individuals to learn in a structure that is self-paced and self-directed while interacting and collaborating with other students and the instructor via a conferencing system
Workers' compensation
Insurance that employers are required to have to cover employees who get sick or injured on the job (CMS 2013)
Accreditation organization
A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations
Significant change in condition (SCIC) adjustment
A single episode payment under multiple home health resource groups, each prorated to the number of service days delivered
Adverse selection
A situation in which individuals who are sicker than the general population are attracted to a health insurance plan, with adverse effects on the plan's costs
Available for hospital autopsy
A situation in which the required conditions have been met to allow an autopsy to be performed on a hospital patient who has died
Secondary source
A summary of an original work, such as an encyclopedia
Clinical research
A specialized area of research that primarily investigates the efficacy of preventive, diagnostic, and therapeutic procedures; Also called medical research
Transcriptionist
A specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports
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
Claims scrubber software
A type of computer program at a healthcare facility that checks the claim elements for accuracy and agreement before the claims are submitted
Server
A type of computer that makes it possible to share information resources across a network of client computers
Stealth virus
A type of computer virus that attempts to hide itself by concealing its presence in infected files
Unique user identifier
A unique identifier assigned to all authorized users of the health record and used to track users and log-in procedures
Unrestricted question
A type of question that allows free-form responses; Also called open-ended question
Split percentage payment
A type of reimbursement in which payments are made for each episode period, and home health agencies receive two payments to make up the total permissible reimbursement for the episode
Causal relationship
A type of relationship in which one factor results in a change in another factor (cause and effect)
Conclusive research
A type of research performed in order to come to some sort of conclusion or help in decision making; includes descriptive research and causal research
Descriptive research
A type of research that determines and reports the current status of topics and subjects
Basic research
A type of research that focuses on the development and refinement of theories
Applied research
A type of research that focuses on the use of scientific theories to improve actual practice, as in medical research applied to the treatment of patients
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 chart
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
Shareware
A type of software that can be tried before being purchased
Severity of illness (SI or 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
Wireless technology
A type of technology that uses wireless networks and wireless devices to access and transmit data in real time
System testing
A type of testing performed by an independent organization to identify problems in information systems
Splitter vocabulary
A type of vocabulary that permits storage of each concept in a sample narrative. SNOMED is an example
Supplement
Under ICD-10-PCS, a root operation that involves putting in or on biological or synthetic material that physically reinforces or augments the function of a portion of a body part (CMS 2013)
Division
Under ICD-10-PCS, a root procedure that involves cutting into a body part without draining fluids or gases from the body part in order to separate or transect the body part (CMS 2013)
Data center
Where the hardware and software for the electronic information systems are held
Clinical guidelines/protocols
With clinical care plans and clinical pathways, a predetermined method of performing healthcare for a specific disease or other clinical situation based on clinical evidence that the method provides high-quality, cost-effective healthcare; Also called treatment guidelines/protocols
WORM technology
Write once, read many. The use of this technology prevents the user from altering what is stored, but the data can be viewed as many times as necessary
Autopsy report
Written documentation of the findings from a postmortem pathological examination
Statutory law
Written law established by federal and state legislatures; Also called legislative law
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
Androgynous leadership
Leadership in which cultural stereotyped masculine and feminine styles are integrated into a more effective hybrid style
Consumer-directed (driven) healthcare plan (CDHP)
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
Sanctions
Penalties or other methods of enforcement used to provide incentives for compliance with laws or rules and regulations such as the HIPAA Privacy and Security Rules and related policies and procedures of the covered entity; sanctions should be uniform across organizations (45 CFR 164.308 2013)
Team group dynamics
Models of team development uniformly define four stages of progression in team group dynamics, cautious affiliation, competitiveness, harmonious cohesiveness, and collaborative teamwork
Utilization manager (UM)
Person that evaluates patient care, ensuring neither underutilization nor overutilization of resources
Author
Person(s) who is (are) responsible and accountable for the health information creation, content, accuracy, and completeness for each documented event or health record entry
Capital assets
Physical assets with an estimated useful life of more than one year; See fixed assets; property, plant, and equipment (PPE)
Standing orders
Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure
Data navigator
Part of the information system development team. The person in this role would specialize in the development of the graphical user interface used to capture and navigate through the EHR and other systems
Third-party payment
Payments for healthcare services made by an insurance company or health agency on behalf of the insured
UNII Codes
See Established Name for Active Ingredients and FDA Unique Ingredient Identifier Codes
CEN
See European Committee for Standardization
VoIP
See Internet protocol technology
Voiceover IP (VoIP)
See Internet protocol technology
SEC
See Securities and Exchange Commission
SNODENT
See Systematized Nomenclature of Dentistry
SNOMED CT
See Systemized Nomenclature of Medicine Clinical Terminology
UMLS Knowledge Source Server (UMLSKS)
See UMLS Terminology Services
UMLS
See Unified Medical Language System
UACDS
See Uniform Ambulatory Care Data Set
UB-04
See Uniform Bill-04
UHDDS
See Uniform Hospital Discharge Data Set
URL
See Uniform Resource Locator
UMDNS
See Universal Medical Device Nomenclature System
WEDI
See Workgroup on Electronic Data Interchange
AIS
See abbreviated injury scale
ADL
See activities of daily living
ACGs
See adjusted clinical groups
Ambulatory care group (ACG)
See adjusted clinical groups
AHPB
See adjusted historic payment base
ALJ
See administrative law judge
ASO contract
See administrative services only contract
ADT
See admission-discharge-transfer
ABN
See advance beneficiary notice
Waiver
See advance beneficiary notice
AMA
See against medical advice; American Medical Association
AP-DRGs
See all patient diagnosis-related groups
ADS
See alternative delivery system
APC
See ambulatory payment classification
APC group
See ambulatory payment classification group
APC relative weight
See ambulatory payment classification relative weight
ASC services
See ambulatory surgical center (ASC) services
ASP
See application service provider
AR
See attributable risk
ACH
See automated clearinghouse
APR
See average payment rate
Bed complement
See bed count
Budget calendar
See budget cycle
BI
See business intelligence
BPR
See business process reengineering
CY
See calendar year
CMI
See case-mix index
CA
See certificate authority
CON
See certificate of need
CCS-P
See certified coding specialist-physician-based
CHDA
See certified health data analyst
CHP
See certified in healthcare privacy
CHPS
See certified in healthcare privacy and security
CMT
See certified medical transcriptionist
CNM
See certified nurse-midwife
CPHIMS
See certified professional in health information management systems
CDM
See charge description master
Charge description master (CDM)
See chargemaster
CC
See chief complaint
CISO
See chief information security officer
CITO
See chief information technology officer
CKO
See chief knowledge officer
CNO
See chief nursing officer
CSO
See chief security officer
CWW
See clinic without walls
CDW
See clinical data warehouse
CDS
See clinical decision support
CDIP
See clinical document improvement practitioner
Treatment guidelines/protocols
See clinical guidelines/protocols
CPG
See clinical practice guideline
CRG
See clinical risk group
Case law
See common law
CAM
See complementary and alternative medicine; component alignment model
COLD/ERM
See computer output to laser disk/enterprise report management
CTI
See computer-telephone integration
Clinical provider order entry
See computerized provider order entry
Extraneous variable
See confounding variable
Secondary variable
See confounding variable
CDHP
See consumer-directed (driven) healthcare plan
CME
See continuing medical education
CQI
See continuous quality improvement
Continuous improvement
See continuous quality improvement
CF
See conversion factor; national conversation factor
CBSA
See core-based statistical area
COLA
See cost-of-living adjustment
CE
See covered entity
CVO
See credential verification organization
CAH
See critical access hospital
CRM
See customer relationship management
Data entry
See data input
DML
See data manipulation language
Central data repository
See data repository
DWMS
See data warehouse management system
DBMS
See database management system
DSS
See decision support system
Strategic decision support system
See decision support system (DSS)
Demographic data
See demographic information
DRP
See disaster recovery plan
DSH
See disproportionate share hospital
DME
See durable medical equipment
DMERC
See durable medical equipment regional carrier
DPOA
See durable power of attorney
DPOA HCD
See durable power of attorney for healthcare decisions
Computer-based health record
See electronic health record
Computer-based patient record
See electronic health record
XML
See extensible markup language
Table of allowances
See fee schedule
Clinic without walls (CWW)
See group practice without walls
Criterion
See indicator
Vertically integrated plan/system
See integrated provider organization
Vertical dyad linkage
See leader-member exchange
Catastrophic coverage
See major medical insurance
Attrition
See mortality
Dichotomous data
See nominal level data
Distribution-free technique
See nonparametric technique
Stay outliers
See outlier
Direct relationship
See positive relationship
Surgical death rate
See postoperative death rate
Summary list
See problem list
Billing audit
See quantitative audit
Sound data
See real audio data
Severity of illness adjustment
See risk adjustment
Scatter chart
See scatter diagram
Scattergram
See scatter plot
SNF
See semantic normal form; skilled nursing facility
SI
See severity of illness
SOI
See severity of illness
SCIC adjustment
See significant change in condition adjustment
Clinic referral
See source of admission
Court/law enforcement referral
See source of admission
SLMBs
See specified low-income Medicare beneficiaries
SLP
See speech-language therapy
SGML
See standard generalized markup language
STPs
See standard treatment protocols
Statement of operations
See statement of revenue and expenses
Statement of fund balance
See statement of stockholder's equity
SAN
See storage area network
SQL
See structured query language
Closed-ended question
See structured question
Subpoena ad testificandum
See subpoena
SMI
See supplemental medical insurance (Medicare Part B)
Boot-record infectors
See system infectors
Clinical systems analyst
See systems analyst
SDLC
See systems development life cycle
TC
See technical component
Telestaffing
See telecommuting
TANF
See temporary assistance for needy families
TPA
See third-party administrator
Turnkey system
See turnkey product
UML
See unified modeling language
UPS
See uninterruptable power supply
UPIN
See unique physician identification number
Signal tracing data
See vector graphic data
Web browser-based (or web native) architectures
See web browser-based systems
WAN
See wide-area network
WLAN
See wireless local-area network
Business process management technology
See workflow technology
Bridge technology
Technology such as document imaging or clinical messaging that provides some, but not all, of the benefits of an EHR
Automated forms processing technology
Technology that allows users to electronically enter data into online digital forms and electronically extract data from online digital forms for data collection or manipulation; Also called e-forms technology
Workflow technology
Technology that automatically routes electronic documents into electronic in-baskets of its department staff for disposition decisions
Computer output to laser disk/enterprise report management (COLD/ERM)
Technology that electronically stores documents and distributes them with fax, e-mail, web, and traditional hard-copy print processes
Speech recognition technology
Technology that translates speech to text
Synergy
The interaction of parts to produce a greater outcome than would be obtained by the parts acting separately
American Psychiatric Association
The international professional association of psychiatrists and related medical specialists that works to ensure humane care and effective treatment for all persons with mental disorders, including mental retardation and substance-related disorders (American Psychiatric Association 2013)
Technical interoperability
The interoperability achieved through application of message format standards
Simulation and inventory modeling
The key components of a plan that are computer simulated for testing and experimentation so that optimal operational procedures can be found
Transformational leadership
The leadership of a visionary who strives to change an organization
Destruction of records
The act of breaking down the components of a health record into pieces that can no longer be recognized as parts of the original record
Charge entry
The act of entering ICD-9-CM, CPT, or HCPCS codes into a computerized billing system for services provided during a patient visit or procedure. In the EHR, this process occurs automatically
Testing
The act of performing an examination or evaluation
Verification
The act of proving or disproving the subject matter or documents in question or comparing an activity, a process, or a product with the corresponding requirements or specifications
Charge reconciliation
The act of reviewing charges entered for claims submission by the charge entry process. Ensures that all services, procedures, and supplies are available and pass to the claim form
Selection
The act or process of choosing
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
Tacit knowledge
The actions, experiences, ideals, values, and emotions of an individual that tend to be highly personal and difficult to communicate (for example, corporate culture, organizational politics, and professional experience)
Cash
The actual money that has been received and is readily available to pay debts; a short-term (current) asset account that represents currency and bank account balances; See current asset
Change management
The formal process of introducing change, getting it adopted, and diffusing it throughout the organization
Systems
The foundations of caregiving, which include buildings (environmental services), equipment (technical services), professional staff (human resources), and appropriate policies (administrative)
Clinical messaging
The function of electronically delivering data and automating the workflow around the management of clinical data
Authenticity
The genuineness of a record, that it is what it purports to be; information is authentic if proven to be immune from tampering and corruption
Batch processing
The grouping of computer tasks to be run at one time; common in mainframe systems where the user did not interact with the computer in real time but, instead, data were often processed at night and produced time-delayed output
Due process of law
The guarantee provided under the Constitution and the Bill of Rights that laws will be reasonable and not arbitrary and allows for challenges to a law's content and substance
Class
The higher-level abstraction of an object that defines its properties and operations
Supreme Court
The highest court in the US legal system; hears cases from the US Courts of Appeals and the highest state courts when federal statutes, treaties, or the US Constitution is involved
Years of schooling
The highest grade of schooling completed by the enrollee or patient
Conceptual data model
The highest level of data model, representing the highest level of abstraction, independent of hardware and software
Comprehensive Drug Abuse Prevention and Control Act of 1970
The legislation that controls the use of narcotics, depressants, stimulants, and hallucinogens; Also called Controlled Substances Act
Subrogation
The means by which an insurance company recovers moneys from a third party; that amount paid to or on behalf of an insurer, usually sought in respect to a loss (for example, an accident or injury)
Scalable
The measure of a system to grow relative to various measures of size, speed, number of users, volume of data, and so on
American Association of Medical Record Librarians (AAMRL)
The name adopted by the Association of Record Librarians of North America in 1944; precursor of the American Health Information Management Association
American Nurses Association (ANA)
The national professional membership association of nurses that works for the improvement of health standards and the availability of healthcare services, fosters high professional standards for the nursing profession, and advances the economic and general welfare of nurses
Bed count
The number of inpatient beds set up and staffed for use on a given day; Also called bed complement
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
Crude birth rate
The number of live births divided by the population at risk
Sample size
The number of subjects needed in a study to represent a population
Absolute frequency
The number of times that a score of value occurs in a data set
Charge code
The numerical identification of a service or supply that links the item to a particular department within the charge description master
Dual option
The offering of health maintenance organization coverage as well as indemnity insurance by the same carrier
Superbill
The office form used for physician office billing that is initiated by the physician and states the diagnoses and other information for each patient encounter
AHA Coding Clinic for HCPCS
The official coding advice resource for coding information on HCPCS CPT codes for hospital providers and certain HCPCS level II codes for hospitals, physicians, and other healthcare professionals (AHA 2013)
Code of Federal Regulations (CFR)
The official collection of legislative and regulatory guidelines mandated by final rules published in the Federal Register (CMS 2013)
Source of truth
The official source of information that will be used for legal purposes for a particular request for information
Append
The operation that results in adding information to documentation already in existence
Association of American Medical Colleges (AAMC)
The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians
Baseline
The original estimates for a project's schedule, work, and cost
Authorship
The origination or creation of recorded information attributed to a specific individual or entity acting at a particular time
Data governance (DG)
The overall management of the availability, usability, integrity, and security of the data employed in an organization or enterprise (Data Governance Institute)
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 storage
The physical location and maintenance of data
Attending physician
The physician primarily responsible for the care and treatment of a patient
Bill drop
The point at which a bill is completed and electronically or manually sent to the payer
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
Coding
The process of assigning numeric or alphanumeric representations to clinical documentation
Debt financing
The process of borrowing money at a cost in the form of interest
Data cleaning
The process of checking internal consistency and duplication as well as identifying outliers and missing data; Also called data cleansing; data scrubbing
Text processing
The process of converting narrative text into structured data for computer processing; Also called computer processing of natural language
Transcription
The process of deciphering and typing medical dictation
Delivery
The process of delivering a live-born infant or dead fetus (and placenta) by manual, instrumental, or surgical means
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
Data modeling
The process of determining the users' information needs and identifying relationships among the data
Utilization review (UR)
The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria at time frames specified in the organization's utilization management plan
Deductive reasoning
The process of developing conclusions based on generalizations
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
Text mining
The process of extracting and then quantifying and filtering free-text data
Compression algorithm
The process or program for reducing data to reduce the space needed for transmission and storage
Version control
The process whereby a healthcare facility ensures that only the most current version of a patient's health record is available for viewing, updating, and so forth
American Congress of Obstetricians and Gynecologists (ACOG)
The professional association of medical doctors specializing in obstetrics and gynecology
American Osteopathic Association (AOA)
The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals (AOA 2013)
American Health Information Management Association (AHIMA)
The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, advocacy, certification, and educational services
American Psychological Association (APA)
The professional organization that aims to advance psychology as a science and profession and promotes health, education, and human welfare (APA 2013)
Storming
The second of four steps that occur when creating a functional team, this occurs when individual team members examine their role within the group
System design
The second phase of the systems development life cycle
Design phase
The second phase of the systems development life cycle during which all options in selecting a new information system are considered
Chief nursing officer (CNO)
The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services
Chief information officer (CIO)
The senior manager responsible for the overall management of information resources in an organization
Critical path or critical pathway
The sequence of tasks that determine the project finish date;
Decentralization
The shift of decision-making authority and responsibility to lower levels of the organization
Uniform Bill-04 (UB-04)
The single standardized Medicare form for standardized uniform billing, implemented in 2007 for hospital inpatients and outpatients; this form will also be used by the major third-party payers and most hospitals (CMS 2013)
Assignment of benefits
The transfer of one's interest or policy benefits to another party; typically the payment of medical benefits directly to a provider of care
Attending physician identification
The unique national identification number assigned to the clinician of record at discharge who is responsible for the inpatient discharge summary (NCVHS 1996)
State
Under HITECH, each of the several States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands (Public Law 111-5)
all patient refined diagnosis-related groups
APR-DRGs
advanced practice registered nurse
APRN
assessment reference date
ARD
Accredited Standards Committee; ambulatory surgery center
ASC
Deposition
A method of gathering information to be used in a litigation process
Discus monitoring form
See Antipsychotic Dyskinesia Identification System
AHDI
See Association for Healthcare Documentation Integrity
AAMC
See Association of American Medical Colleges
ACDIS
See Association of Clinical Documentation Improvement Specialists
ARLNA
See Association of Record Librarians of North America
APS
See Attending Physician Statement
BBA of 1997
See Balanced Budget Act of 1997
BC/BS Service Benefit Plan
See Blue Cross and Blue Shield Federal Employee Program (FEP)
BI-RADS
See Breast Imaging Reporting and Data System Atlas
CDER Manual
See Center for Drug Evaluation and Research
CDC
See Centers for Disease Control and Prevention
CCHIT
See Certification Commission on Healthcare Information Technology
CISSP
See Certified Information Systems Security Professional
CRNA
See Certified Registered Nurse Anesthetist
CWLA
See Child Welfare League of America
CHIP
See Children's Health Insurance Program
CMP
See Civil Monetary Penalties Act
CHAMPUS
See Civilian Health and Medical Program-Uniformed Services; See also TRICARE
CHAMPVA
See Civilian Health and Medical Program-Veterans Administration
CCC
See Clinical Care Classification
CCOW
See Clinical Context Object Workgroup
CDA
See Clinical Document Architecture
CLIA
See Clinical Laboratory Improvement Amendments
SPL
See Clinical Special Product Label
CTV3
See Clinical Terms, Version 3
CFR
See Code of Federal Regulations
CAP
See College of American Pathologists; corrective action plan
CHIME
See College of Healthcare Information Management Executives
CAHIIM
See Commission on Accreditation of Health Informatics and Information Management Education
CoP
See Communities of Practice
CHAP
See Community Health Accreditation Program
CHI
See Consolidated Health Informatics
COBRA
See Consolidated Omnibus Budget Reconciliation Act of 1986
CCD
See Continuity of Care Document
CIA
See Corporate Integrity Agreement
CCI
See Correct Coding Initiative
CAQH
See Council for Affordable Quality Healthcare
COA
See Council on Accreditation
DSM-IV-TR
See Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, Text Revision
DICOM
See Digital Imaging and Communication in Medicine
Work breakdown structure
A hierarchical structure that decomposes project activities into levels of detail
Chart tracking
A process that identifies the current location of a paper record or information
Chart
1. (noun) The health record of a patient 2. (verb) To document information about a patient in a health record
Audit trail
1. A chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations 2. A record that shows who has accessed a computer system, when it was accessed, and what operations were performed; See also audit log
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
Digital
1. A data transmission type based on data that have been binary encoded 2. A term that refers to the data or information represented in an encoded, computer-readable format
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 (CMS 2013)
Corporate compliance program
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; See also external review
Closed record
1. A health record that has been closed following analysis to ensure all documentation components are met, for example, signatures and dictated reports 2. Documentation or a note that has been closed due to system requirements or after a defined period of time
Burden of proof
1. A legal term that obligates an individual to prove or disprove a fact 2. Under HITECH, a covered entity or business associate, as applicable, shall have the burden of demonstrating that all notifications were made as required by this subpart or that the use or disclosure did not constitute a breach, as defined at 164.402 (45 CFR 164.414 2009)
Contract
1. A legally enforceable agreement 2. An agreement between a union and an employer that spells out details of the relationship of management and the employees
Continuous quality improvement (CQI)
1. A management philosophy that emphasizes the importance of knowing and meeting customer expectations, reducing variation within processes, and relying on data to build knowledge for process improvement 2. A component of total quality management (TQM) that emphasizes ongoing performance assessment and improvement planning
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])
Automated clearinghouse (ACH)
An electronic network for the processing of financial transactions
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])
Business associate
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 2. As amended by HITECH, with respect to a covered entity, a person who creates, receives, maintains, or transmits PHI for a function or activity regulated by HIPAA, including claims processing or administration, data analysis, processing or administration, utilization review, quality assurance, patient safety activities, billing, benefit management, practice management, and repricing or provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services (45 CFR 160.103 2013)
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 (CMS 2013)
Autoauthentication
1. A procedure that allows dictated reports to be considered automatically signed unless the health information management department is notified of needed revisions within a certain time limit 2. A process by which the failure of an author to review and affirmatively either approve or disapprove an entry within a specified time period results in authentication
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 2. The next stage in the litigation process after a court has rendered a verdict; must be based on alleged errors or disputes of law rather than errors of fact
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 an 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) 4. As amended by HITECH at section 160.103, a rule, condition, or requirement, (1) describing the following information for products, systems, services, or practices, (i) classification of components; (ii) specification of materials, performance, or operations; or (iii) delineation of procedures; or (2) with respect to the privacy of protected health information (45 CFR 160.103 2013)
Token
1. A session token is a unique identifier which is generated and sent from a server to a software client to identify an interactive session, and which the client usually stores as an HTTP cookie 2. A security token is usually a physical device that an authorized user of computer services is given to aid in authentication
Computer virus
1. A software program that attacks computer systems with the intention of damaging or destroying files 2. Intentional computer tampering programs that may include file infectors, system or boot-record infectors, and macro viruses
Source system
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)
Structure
1. A term from Donabedian's model of quality assessment that assesses an organization's ability to provide services in terms of both the physical building and equipment and the people providing the healthcare services 2. The foundations of caregiving, which include buildings, equipment, technologies, professional staff, and appropriate policies
Budget neutral
1. A term typically applied to the federal government budget when a new project or proposal neither costs additional money nor saves money 2. Financial protections to ensure that overall reimbursement under the Ambulatory Payment Classification (APC) system is not greater than it would have been had the system not been in effect
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
Compiler
1. A type of software that looks at an entire high-level program before translating it into machine language 2. A third-generation programming language
Diagnosis-related groups (DRGs)
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 (CMS 2013)
Service
1. An act performed by a person on behalf of another person 2. The means by which a defendant is notified of a lawsuit
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 (CMS 2013)
Data element
1. An individual fact or measurement that is the smallest unique subset of a database 2. Under HIPAA, the smallest named unit of information in a transaction (45 CFR 162.103 2012)
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. When a covered entity obtains or receives a valid authorization for its use or disclosure of protected health information, such use or disclosure must be consistent with the authorization (45 CFR 164.508 2013); See also valid authorization
Attributes
1. Data elements within an entity that become the column or field names when the entity relationship diagram is implemented as a relational database 2. Properties or characteristics of concepts; used in SNOMED CT to characterize and define concepts
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 2. A recovery plan in the event of a power failure, disaster, or other emergency that limits or eliminates access to facilities and electronic protected personal health information (ePHI); See also business continuity plan
Critical access hospitals (CAHs)
1. Hospitals that are excluded from the outpatient prospective payment system because they are paid under a reasonable cost-based system as required under section 1834(g) of the Social Security Act 2. Under HITECH incentives, a facility that has been certified as a critical access hospital under section 1820(e) of the Act and for which Medicare payment is made under section 1814(l) of the Act for inpatient services and under section 1834(g) of the Act for outpatient services (42 CFR 495.4 2012)
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
Control
1. One of the four management functions in which performance is monitored in accordance with organizational policies and procedures 2. Under ICD-10-PCS, a root operation that involves stopping, or attempting to stop, postprocedural bleeding (CMS 2013)
Catastrophic expense limit
1. Specific amount, in a certain time frame such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan 2. The highest amount of money a Medicare patient will have to pay out of pocket during a certain period of time for certain covered charges (CMS 2013); See maximum out-of-pocket cost; stop-loss benefit
Availability
1. The accessibility for continuous use of data 2. Under HIPAA, the property that data or information is accessible and useable upon demand by an authorized person (45 CFR 164.304 2013)
De-identify
1. The act of removing from a health record or data set any information that could be used to identify the individual to whom the data apply in order to protect his or her confidentiality 2. To remove the names of the principal investigator (PI), co-investigators, and affiliated organizations to allow reviewers to maintain objectivity
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 (CMS 2013)
Cost
1. The amount of financial resources consumed in the provision of healthcare services 2. The dollar amount of a service provided by a facility
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; Also called data quality
Carrier
1. The insurance company; the insurer that sold the policy and administers the benefits 2. A private company that has a contract with Medicare to pay Medicare Part B bills (CMS 2013)
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; 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
Collection
1. The part of the billing process in which payment for services performed is obtained 2. In AHIMA's data quality management model, it is the process by which data elements are accumulated
Threat
1. The potential for exploitation of a vulnerability 2. Potential danger to a computer, network, or data
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 prespecified set of requirements
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
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 2. Proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source 3. As amended by HITECH, means the corroboration that a person is the one claimed (45 CFR 164.304 2013)
Triage
1. The sorting of, and allocation of treatment to, patients 2. An early assessment that determines the urgency and priority for care and the appropriate source of care
Default
1. The status to which a computer application reverts in the absence of alternative instructions 2. Pertains to an attribute, value, or option that is assumed when none is explicitly specified
Timeliness
1. The time between the occurrence of an event and the availability of data about the event. Timeliness is related to the use of the data. 2. The completion of a health record within timelines established by legal and accreditation standards and by organizational policy and medical staff bylaws
CMS-1500
1. The universal insurance claim form developed and approved by the AMA and CMS that physicians use to bill Medicare, Medicaid, and private insurers for professional services provided 2. A Medicare uniform professional claim form (CMS 2013)
Technology push
1. The view of information technology as being able to push organizations into new business areas 2. Technology where certain data are pushed or delivered to a particular computer
Transfer
1. Under ICD-10-PCS, a root operation that involves moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part (CMS 2013) 2. The movement of a patient from one treatment service or location to another 3. Discharge of a patient from a hospital and readmission to postacute-care or another acute-care hospital on the same day
Transplantation
1. Under ICD-10-PCS, a root operation that involves putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and function of all or a portion of a similar body part 2. A surgical procedure that involves removing a functional organ from either a deceased or living donor and implanting it in a patient needing a functional organ to replace a nonfunctional organ (CMS 2013)
Descriptor
1. Wording that represents the official definition of an item or service that can be billed using a particular code. 2. Under HIPAA, the text defining a code (45 CFR 162.103 2012) 3. Under Medicare, the text defining a code in a code set (CMS 2013)
Activity-based budget
A budget based on activities or projects rather than on functions or departments
Zone program integrity contractor (ZPIC)
A CMS program that replaces the Medicare Program Safeguard Contractors (PSCs). Are responsible for detection and prevention of fraud, waste, and abuse across all Medicare claim types by performing medical reviews, data analysis, and auditing
Clinical Special Product Label (SPL)
A LOINC standard that provides information found in the approved FDA drug label or package insert in a computer-readable format for use in electronic prescribing and decision support
Specified low-income Medicare beneficiaries (SLMBs)
A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly incomes, and limited resources (usually less than 120 percent of the federal poverty level) (CMS 2013)
CMS-1450
A Medicare uniform institutional claim form (CMS 2013)
Team facilitator
A PI team role primarily responsible for ensuring that an effective performance improvement process occurs by serving as advisor and consultant to the PI team, remaining a neutral, nonvoting member
Column/field
A basic fact within a table, such as LAST_NAME, FIRST_NAME, and date of birth
Transitional nonfacility relative value unit
A blend of charge-based relative value units and resource-based relative expense for services provided in a practice setting other than a facility, for example, a physician's office or freestanding clinic
Contract law
A branch of law based on common law that deals with written or oral agreements that are enforceable through the legal system
Criminal law
A branch of law that addresses crimes that are wrongful acts against public health, safety, and welfare, usually punishable by imprisonment or fine
Statistics
A branch of mathematics concerned with collecting, organizing, summarizing, and analyzing data
Court of Appeals
A branch of the federal court system that has the power to hear appeals on the final judgments of district courts
Behavioral healthcare
A broad array of psychiatric services provided in acute, long-term, and ambulatory care settings; includes treatment of mental disorders, chemical dependency, mental retardation, and developmental disabilities, as well as cognitive rehabilitation services
Care path
A care-planning tool similar to a clinical practice guideline that has a multidisciplinary focus emphasizing the coordination of clinical services; Also called clinical algorithm; See also clinical pathway; critical path or critical pathway
Cost inlier
A case in which the cost of treatment falls within the established cost boundaries of the assigned ambulatory patient group payment
All patient diagnosis-related groups (AP-DRGs)
A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes
Designated standards maintenance organizations (DSMO)
A category of organization established under HIPAA to maintain the electronic transaction standards (45 CFR 162.910 2009)
Certified medical transcriptionist (CMT)
A certification that is granted upon successfully passing the Association of Healthcare Documentation Integrity (AHDI) certification examination for medical transcriptionists with generally at least two years of experience (AHDI 2013b)
Variable
A characteristic or property that may take on different values
Compensable factor
A characteristic used to compare the worth of jobs (for example, skill, effort, responsibility, and working conditions)
Audit log
A chronological record of electronic system(s) activities that enables the reconstruction, review, and examination of the sequence of events surrounding or leading to each event or transaction from its beginning to end. Includes who performed what event and when it occurred
Adjusted clinical groups (ACGs)
A classification system developed by John Hopkins University that groups individuals according to resource requirements and reflects the clinical severity differences among the specific groups; formerly called ambulatory care groups (IASIST 2013)
Classification
A clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings, provides for the proper use of clinical words as names or symbols, and facilitates mapping standardized terms to broader classifications for administrative, regulatory, oversight, and fiscal requirements
Value set
A collection of concepts drawn from one or more vocabulary code systems and grouped together for a specific purpose
Data cube
A collection of one or more tables of data, assembled in a fashion that allows for dynamic analysis to be conducted on the joins, intersections, and overall integration of these predefined tables stored within a data warehouse
Wikis
A collection of webpages that together form a collaborative website
Computer telephony
A combination of computer and telephone technologies that allows people to use a telephone handset to access information stored in a computer system or to use computer technology to place calls within the public telephone network
Unique identification number
A combination of numbers or alphanumeric characters assigned to a particular patient
Subpoena
A command to appear at a certain time and place to give testimony on a certain matter; Also called subpoena ad testificandum
Accredited Standards Committee X12 (ASC X12)
A committee accredited by ANSI responsible for the development and maintenance of EDI standards for many industries. .. responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms
Unified modeling language (UML)
A common data-modeling notation used in conjunction with object-oriented database design
Control group
A comparison study group whose members do not undergo the treatment under study
Breast Imaging Reporting and Data System Atlas (BI-RADS®)
A comprehensive guide providing standardized breast imaging terminology, and a report organization, assessment structure, and a classification system for mammography, ultrasound, and MRI of the breast (ACR 2013)
Artificial neural network (ANN)
A computational technique based on artificial intelligence and machine learning in which the structure and operation are inspired by the properties and operation of the human brain
Turnkey product
A computer application that may be purchased from a vendor and installed without modification or further development by the user organization
Client/server architecture
A computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amounts of shared data
Wide-area network (WAN)
A computer network that connects devices across a large geographical area
DRG grouper
A computer program that assigns inpatient cases to diagnosis-related groups and determines the Medicare reimbursement rate
Assembler
A computer program that translates assembly-language instructions into machine language
Virus
A computer program, typically hidden, that attaches itself to other programs and has the ability to replicate and cause various forms of harm to the data
Zip
A computer utility that combines two or more files into one and reduces the size of the file
Thin client
A computer with processing capability but no persistent storage (disk memory) that relies on data and applications on the host it accesses to be able to process data
Web appliance
A computer without secondary storage capability that is designed to connect to a network
Decision support system (DSS)
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
Service Level Agreement (SLA)
A contract between a customer and a service provider that records the common understanding about service priorities, responsibilities, guarantees, and other terms, especially related to availability, serviceability, performance, operation, or other attributes of the service like billing and penalties in the case of violation of the SLA
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
Uniform Hospital Discharge Data Set (UHDDS)
A core set of data elements adopted by the US Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems
Strategy
A course of action designed to produce a desired (business) outcome
Default judgment
A court ruling against a defendant in a lawsuit who fails to answer a summons for a court appearance
Applications and data criticality analysis
A covered entity's formal assessment of the sensitivity, vulnerabilities, and security of its programs and the information it generates, receives, manipulates, stores, and transmits
Smart card
A credit-card-sized piece of plastic embedded with a computer chip that stores information and incorporates security features
Template-based entry
A cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient
ACR-NEMA
See American College of Radiology-National Electrical Manufacturers Association
Disposition
A description of the patient's status at discharge
Database model
A description of the structure to be used to organize data in a healthcare-related database such as an electronic health record
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 research
A design of research that determines the existence and degree of relationships among factors
Trojan horse
A destructive piece of programming code hidden in another piece of programming code (such as a macro or e-mail message) that looks harmless
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; See clinical protocol
Discrete variable
A dichotomous or nominal variable whose values are placed into categories
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
Documentation paradigm
A disease-specific format developed by the individual provider for the purpose of establishing standard clinical documentation forms
Center for Drug Evaluation and Research (CDER)
A division of the Federal Drug Administration which performs public health tasks by making sure safe and effective drugs are available to improve health in the United States (FDA 2013)
Therapeutic privilege
A doctrine that has historically allowed physicians to withhold information from patients in limited circumstances
Charitable immunity
A doctrine that shielded hospitals (as well as other institutions) from liability for negligence because of the belief that donors would not make contributions to hospitals if they thought their donation would be used to litigate claims combined with concern that a few lawsuits could bankrupt a hospital
AHIC
See American Health Information Community
Certificate of destruction
A document that constitutes proof that a health record was destroyed and that includes the method of destruction, the signature of the person responsible for destruction, and inclusive dates for destruction
Statement of work (SOW)
A document that defines the scope and goals of a specific project; Also called project charter
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
Communications plan
A documented approach to identifying the media and schedule for sharing information with affected parties
Trigger
A documented response that alerts a skilled nursing facility resident assessment instrument assessor to the fact that further research is needed to clarify an assessment
Clinical domain
A domain that captures significant indicators of clinical needs from several OASIS items, including patient history and sensory, integumentary, respiratory, elimination, neurological, emotional, and behavioral status
Shadow Record
A duplicate record kept for the convenience of the provider or facility; it usually is an exact duplicate of the original health record and should not contain documentation that is not in the original record
Severity weight (SW)
A factor developed by 3M to indicate relative severity within every level in APR-DRGs and used to improve comparisons in profiling by severity-adjusted raw statistics
Consolidated billing/bundling
A feature of the prospective payment system established by the Balanced Budget Act of 1997 for home health services provided to Medicare beneficiaries that requires the home health provider that developed the patient's plan of care to assume Medicare billing responsibility for all of the home health services the patient receives to carry out the plan
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 (CDC 2013)
Court of Claims
A federal or state court in which legal actions against the government are brought
Blue Cross and Blue Shield Federal Employee Program (FEP)
A federal program that offers a fee-for-service plan with preferred provider organizations and a point-of-service product; Also called BC/BS Service Benefit Plan
Temporary assistance for needy families (TANF)
A federal program that provides states with grants to be spent on time-limited cash assistance for low-income families, generally limiting a family's lifetime cash welfare benefits to a maximum of five years and permitting states to impose other requirements; replaced the Aid to Families with Dependent Children program
Secondary care
A general term for healthcare services provided by a specialist at the request of the primary care physician
Discipline
A field of study characterized by a knowledge base and perspective that is different from other fields of study
Bioethics
A field of study that applies ethical principles to decisions that affect the lives of humans, such as whether to approve or deny access to health information
Archive file
A file in a collection of files reserved for later research or verification for the purposes of security, legal processes, or backup
Break-even analysis
A financial analysis technique for determining the level of sales at which total revenues equal total costs, beyond which revenues become profits
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)
Statement of revenue and expenses
A financial statement showing how much the organization makes or loses during a given reporting period; Also called earnings report; income statement; profit and loss statement; statement of operations
Durable medical equipment regional carrier (DMERC)
A fiscal intermediary designated to process claims for durable medical equipment (CMS 2013)
Cash budget
A forecast of needs for available funds throughout the year
SOAPIER
A form of charting narrative notes that requires subjective, objective, assessment, plan, intervention, evaluation, and revision in the note structure
Wired equivalent privacy (WEP)
A form of encryption used to authenticate the sender and receiver of messages over networks, particularly when the Internet is involved in the data transmission; should provide authentication (both sender and recipient are known to each other), data security (safe from interception), and data nonrepudiation (data that were sent have arrived unchanged)
Undercoding
A form of incomplete documentation that results when diagnoses or procedures that should be coded are not assigned
Stop-loss insurance
A form of reinsurance that provides protection for medical expenses above a certain limit
Credential
A formal agreement granting an individual permission to practice in a profession, usually conferred by a national professional organization dedicated to a specific area of healthcare practice; or the accordance of permission by a healthcare organization to a licensed, independent practitioner (physician, nurse practitioner, or other professional) to practice in a specific area of specialty within that organization. Usually requires an applicant to pass an examination to obtain the credential initially and then to participate in continuing education activities to maintain the credential thereafter
Bureaucracy
A formal organizational structure based on a rigid hierarchy of decision making and inflexible rules and procedures
Capital budget process
A four-stage process organizations follow to determine what capital projects to include in the budget
Structured query language (SQL)
A fourth-generation computer language that includes both DDL and DML components and is used to create and manipulate relational databases
Clinical repository
A frequently updated database that provides users with direct access to detailed patient-level data as well as the ability to drill down into historical views of administrative, clinical, and financial data; Also called data warehouse
AMIA
See American Medical Informatics Association
Clinical service
A general term used to indicate a unit of medical staff responsibility (such as cardiology), a unit of inpatient beds (such as general medicine), or even a group of discharged patients with related diseases or treatment (such as orthopedic)
Double-entry accounting
A generally accepted method for recording accounting transactions in which debits are posted in the column on the left and credits are posted in the column on the right
American Society for Quality (ASQ)
A global community whose members are passionate about quality, quality control tools, and total quality management to make improvements in the world (ASQ 2013)
State Health Information Exchange Cooperative Agreement Program
A grant program that supports states or state designated entities (SDEs) in establishing HIE services among healthcare providers and hospitals in their regions
Scatter diagram
A graph that visually displays the linear relationships among factors
Storyboard
A graphic display tool used to communicate the details of performance improvement activities; a type of poster that includes text and graphics to describe and illustrate the activities of a PI project
Security pyramid
A graphic representation of security measures in which each depends on the one below it
Bar chart
A graphic technique used to display frequency distributions of nominal or ordinal data that fall into categories; Also called bar graph
Affinity diagram
A graphic tool used to organize and prioritize ideas after a brainstorming session
Cafeteria plan
A health plan that allows employees to choose among two or more benefits
Straight numeric filing system
A health record filing system in which health records are arranged in ascending numerical order
Serial filing system
A health record identification system in which a patient receives sequential unique numerical identifiers for each encounter with, or admission to, a healthcare facility
Unit numbering system
A health record identification system in which the patient receives a unique medical record number at the time of the first encounter that is used for all subsequent encounters
Center of Excellence
A healthcare facility selected to provide specific services based on criteria such as experience, outcomes, efficiency, and effectiveness. Tertiary and academic medical centers are often designated as centers of excellence for one or more services such as organ transplantation
Storage and retrieval
A healthcare facility's method for safely and securely maintaining and archiving individual patient health records for future reference
Ambulatory care center (ACC)
A healthcare provider or facility that offers preventive, diagnostic, therapeutic, and rehabilitative services to individuals not classified as inpatients or residents
American Accreditation Healthcare Commission/URAC
A healthcare quality improvement organization that offers managed care organizations, as well as other organizations, accreditation to validate quality healthcare, and provides education and measurement programs
Confidence interval
A healthcare statistic that is calculated from the standard error of the mean, it is an estimate of the true limits within which the true population mean lies; the range of values that may reasonably contain the true population mean
Unity of command
A human resources principle that assumes that each employee reports to only one specific management position
Alternative hypothesis
A hypothesis that states that there is an association between independent and dependent variables
Target population
A large group of individuals who are the focus of a study
Contingency model of leadership
A leadership theory based on the idea that the success of task- or relationship-oriented leadership depends on leader-member relationships, task structure, and position power
Audioconferencing
A learning technique in which participants in different locations can learn together via telephone lines while listening to a presenter and looking at handouts or books
Admission agreement
A legal contract signed by the resident that specifies the long-term care facility's responsibilities and fees for providing healthcare and other services
AMRA
See American Medical Record Association
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
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
Accession registry
A list of cases in a cancer registry in the order in which they were entered
ANSI
See American National Standards Institute
Data set
A list of recommended data elements with uniform definitions that are relevant for a particular use
Statement
A list of unpaid invoices; sometimes a cumulative list of all transactions between purchaser and vendor during a specific time period
Vocabulary standards
A list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field; See controlled vocabulary
Buildings
A long-term (fixed) asset account that represents the physical structures owned by the organization; See fixed assets
Data reliability
A measure of consistency of data items based on their reproducibility and an estimation of their error of measurement
Total quality management (TQM)
A management philosophy that includes all activities in which the needs of the customer and the organization are satisfied in the most efficient manner by using employee potentials and continuous improvement
Acceptance theory of authority
A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions
Theory X and Y
A management theory developed by McGregor that describes pessimistic and optimistic assumptions about people and their work potential
Concordance
A mapping term meaning agreement
Discordance
A mapping term meaning disagreement
Work distribution chart
A matrix that depicts the work being done in a particular workgroup in terms of specific tasks and activities, time spent on tasks, and the employees performing the tasks
Dependent variable
A measurable variable in a research study that depends on an independent variable
ANA
See American Nurses Association
Attributable risk (AR)
A measure of the impact of a disease on a population (for example, measuring additional risk of illness as a result of exposure to a risk factor)
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
Semantic differential scale
A measure that records a group's perception of a product, organization, or program through bipolar adjectives on a seven point continuum, resulting in a profile
Code on Dental Procedures and Nomenclature (CDT)
A medical code set of dental procedures, maintained and copyrighted by the ADA, used for consistency and specificity when reporting dental procedures (ADA 2013)
College of American Pathologists (CAP)
A medical specialty organization of board-certified pathologists that owns and holds the copyright to SNOMED CT® (CAP 2013)
Clinical drug
A medicine provided to a patient for treatment purposes in a variety of forms (such as pill, liquid); it has a clinical drug name, which includes the routed generic, the strength, and dose form
College of Healthcare Information Management Executives (CHIME)
A membership association serving chief information officers through professional development and advocacy (CHIME 2013)
APTA
See American Physical Therapy Association
Tactic
A method for accomplishing an end
Data display
A method for presenting or viewing data
Direct observation
A method in which the researchers conduct the observation themselves, spending time in the environment they are observing and recording observations
Cash accounting
A method of accounting that is used most frequently in a sole proprietorship or a small business environment that recognizes income and expense transactions when cash is received or cash is paid out
Constructive confrontation
A method of approaching conflict in which both parties meet with an objective third party to explore perceptions and feelings
Case definition
A method of determining criteria for cases that should be included in a registry
Barcoding technology
A method of encoding data that consists of parallel arrangements of dark elements, referred to as bars, and light elements, referred to as spaces, and interpreting the data for automatic identification and data collection purposes
Voice recognition technology
A method of encoding speech signals that do not require speaker pauses (but uses pauses when they are present) and of interpreting at least some of the signals' content as words or the intent of the speaker; Also called continuous speech recognition; continuous speech technology
Self-reported health status
A method of measuring health status in which a person rates his or her own general health, for example, by using a five category classification, excellent, very good, good, fair, or poor
360-degree evaluation
A method of performance evaluation in which the supervisors, peers, and other staff who interact with the employee contribute information
Secondary analysis
A method of research involving analysis of the original work of another person or organization
Content analysis
A method of research that provides a systematic and objective analysis of communication effectiveness, such as the analysis performed on tests
Survey
A method of self-report research in which the individuals themselves are the source of the data
Train-the-trainer
A method of training certain individuals who, in turn, will be responsible for training others on a task or skill
Staging system
A method used in cancer registers to identify specific and separate different stages or aspects of the disease
Simple payback method
A method used to justify a proposed capital expenditure where the asset cost is divided by the net annual income of the asset to determine how long it will take for the asset to "pay back" what it cost the organization
Systems development life cycle (SDLC)
A model used to represent the ongoing process of developing (or purchasing) information systems
Snowflake schema
A modification of the star schema in which the dimension tables are further divided to reduce data redundancy. Used in data warehouses
Service bonus
A monetary reward given to long-term staff in recognition of their skills and commitment to the organization
Claim status codes
A national administrative code set, identified in X12 277 Claims Status Notification transactions, that identifies the status of healthcare claims (CMS 2013)
Claim adjustment reason codes
A national administrative code set, used in X12 835 and X12 837 Claim Payment and Remittance Advice and Claims Transactions, that identifies the reasons for any differences or adjustments between the original provider charge for a claim or service and the payer's payment for it (CMS 2013)
American Association of Preferred Provider Organizations (AAPPO)
A national association composed of PPOs and affiliate organizations, which advocates for consumer awareness of their healthcare benefits and advocates for greater access, choice, and flexibility (AAPPO 2013)
Conversion factor
A national dollar amount that Congress designates to convert relative value units to dollars; updated annually
Correct Coding Initiative (CCI)
A national initiative designed to improve the accuracy of Part B claims processed by Medicare carriers (CMS 2013)
Semantic Data Model (SDM)
A natural application modeling mechanism that can capture and express the structure of an application environment; LOINC is an example of a semantic data model
Collaborative Stage Data Set
A new standardized neoplasm-staging system developed by the American Joint Commission on Cancer
Well newborn
A newborn born at term, under sterile conditions, with no diseases, conditions, disorders, syndromes, injuries, malformations, or defects diagnosed, and no operations other than routine circumcisions performed
Training and development model
A nine-step plan designed to help the health information manager or human resources department identify the training needs of an employee group
Council for Affordable Quality Healthcare (CAQH)
A not-for-profit alliance of health plans and trade associations, aims to simplify healthcare administration through industry initiatives that promote quality interactions, reduce costs, facilitate exchange, and encourage data integration. (CAQH 2013)
Advance beneficiary notice (ABN)
A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or supplier, and Medicare does not pay for it, then you probably do not have to pay for it (CMS 2013)
Accession number
A number assigned to each case as it is entered in a cancer registry
Ambulatory payment classification (APC) relative weight
A number reflecting the expected resource consumption of cases associated with each APC, relative to the average of all APCs, that is used in determining payment under the Medicare hospital outpatient prospective payment system (OPPS)
Computer key
A number unique to a specific individual for purposes of authentication
Concept Unique Identifier (CUI)
A numeric identifier in RxNorm that designates the same concept, no matter the form of the name or the table where it is located; also represents an opaque identifier found in the UMLS Metathesaurus
APA
See American Psychiatric Association; American Psychological Association
Transaction and Code Sets Standards
A part of the HIPAA administrative simplification rule designed to standardize transactions performed by covered entities. If a covered entity conducts one of the adopted transactions defined by HHS, they must use the adopted standard, either ASC X12 or NCPDP (for certain pharmacy transactions) (CMS 2013)
Corporate Code of Conduct
A part of the compliance plan that expresses the organization's commitment to ethical behavior
Short-stay patient
A patient admitted to the hospital for an intended stay of less than 24 hours and who is considered an outpatient and not included in inpatient hospital census statistics
Structured analysis
A pattern identification analysis performed for a specific task
Template
A pattern used in computer-based patient records to capture data in a structured manner
Skilled nursing facility prospective payment system (SNF PPS)
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
Team recorder/scribe
A performance improvement team role responsible for maintaining the records of a team's work during meetings, including any documentation required by the organization
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
Continued-stay utilization review
A periodic review conducted during a hospital stay to determine whether the patient continues to need acute care services
Trainee
A person who is learning a task or skill
Standard risk
A person who, according to an insured's underwriting standards, is entitled to purchase insurance without paying an extra premium or incurring special restrictions
Any and all records
A phrase frequently used by attorneys in the discovery phase of a legal proceeding. Subpoena-based requests containing this phrase may create a situation where the record custodian or provider's legal counsel can work to limit the records disclosed to those defined by a particular healthcare entity's legal health record. Typically, this is only during a subpoena phase, unless the information is legally privileged or similarly protected; the discovery phase of litigation probably can be used to request any and all relevant materials
Disability
A physical or mental condition that either temporarily or permanently renders a person unable to do the work for which he or she is qualified and educated
Vision
A picture of the desired future that sets a direction and rationale for change
Cookie
A piece of information passed from a web server to the user's web browser that is accessible only to the server/domain that sent it and is retrieved automatically through a program called an intelligent agent whenever the server's web page is visited; used to store passwords and ordering information and to set preferences and bookmarks
Statute
A piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor or the president
Data Encryption Standard (DES)
A private key encryption algorithm adopted as the federal standard which uses the same private key to both encrypt and decrypt binary coded information
Standards development organization (SDO)
A private or government agency involved in the development of healthcare informatics standards at a national or international level
Conflict management
A problem-solving technique that focuses on working with individuals to find a mutually acceptable solution
Task analysis
A procedure for determining the specific duties and skills required of a job
Separate procedure
A procedure that is commonly part of another, more complex procedure, but which may be performed independently or be otherwise unrelated to the procedure
Significant procedure
A procedure that is surgical in nature or carries a procedural or an anesthetic risk or requires specialized training
Arbitration
A proceeding in which disputes are submitted to a third party or a panel of experts outside the judicial trial system
Consent directive
A process by which patients may opt in or opt out of having their data exchanged in the HIE
Discharge utilization review
A process for assessing a patient's readiness to leave the hospital
Steerage
A process in which an insurer provides financial incentive or discounted rates to a healthcare facility to obtain a flow of patients they would not otherwise receive
Scope creep
A process in which the scope of a project grows while the project is in process, virtually guaranteeing that it will be over budget and behind schedule
Scientific inquiry
A process that comprises making predictions, collecting and analyzing evidence, testing alternative theories, and choosing the best theory
Compliance plan
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
Accreditation Association for Ambulatory Health Care (AAAHC)
A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single-specialty and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers (AAAHC 2013)
Unified Medical Language System
A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies (NLM 2013)
Business continuity plan
A program that incorporates policies and procedures for continuing business operations during a computer system shutdown; Also called contingency plan; disaster planning
Browser
A program that provides a way to view and read documents available on the World Wide Web
Voluntary Disclosure Program
A program unveiled in 1998 by OIG that encourages healthcare providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs
Tunneling protocol
A protocol that ensures that data passing over a virtual private network are secure and operates as an outer envelope to an envelope with its enclosure
Coding Clinic for HCPCS
A publication issued quarterly by the American Hospital Association and approved by the Centers for Medicare and Medicaid Services to give coding advice and direction for HCPCS code assignment (AHA 2013)
Semicolon
A punctuation mark [;] placed after a procedure description within a CPT code set to avoid repeating common information
Critical performance measures
A quantitative tool used to assess the importance of clinical, financial, and utilization aspects in relation to a healthcare provider's outcomes
Blended rate
A rate assigned to hospitals by the CMS based on cost of living, location, and services provided
Acid-test ratio
A ratio in which the sum of cash plus short-term investments plus net current receivables is divided by total current liabilities
Cost justification
A rationale developed to support competing requests for limited resources
Business record
A record that is made and kept in the usual course of business, at or near the time of the event recorded
Scales of measurement
A reference standard for data collection and classification; See categorical data; interval-level data; nominal-level data; ordinal-level data; ratio-level data
Stimulus
See American Recovery and Reinvestment Act of 2009
Certified Registered Nurse Anesthetist (CRNA)
A registered nurse who has completed additional training in anesthesia and provides anesthesia for a wide variety of surgical cases
Traditional fee-for-service (FFS) 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)
Cost report
A report required from providers on an annual basis in order for the Medicare program to make a proper determination of amounts payable to providers under its provisions; analyzes the direct and indirect costs of providing care to Medicare patients
Balance sheet
A report that shows the total dollar amounts in accounts, expressed in accounting equation format, at a specific point in time
Causal-comparative research
A research design that resembles experimental research but lacks random assignment to a group and manipulation of treatment; Also called quasi experimental design
Clinical pertinence review
A review of medical records performed to assess the quality of information using criteria determined by the healthcare organization; includes quantitative and qualitative components
Admission utilization review
A review of planned services (intensity of service) or a patient's condition (severity of illness) to determine whether care must be delivered in an acute care setting
Closed-record review
A review of records after a patient has been discharged from the organization or treatment has been terminated
Concurrent analysis
A review of the health record while the patient is still hospitalized or under treatment
Transfer record
A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility; Also called a referral form
Critic
A role in organizational innovation in which an idea is challenged, compared to stringent criteria, and tested against reality
Data resource manager
A role that ensures that the organization's information systems meet the needs of people who provide and manage patient services
Common rule
A rule of medical ethics concerning human research and testing governed by the Institutional Review Boards
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
Control chart
A run chart with lines on it called control limits that provides information to help predict the future outcome of a process with a high degree of accuracy; shows variation in key processes over time
Convenience sampling
A sampling technique where the selection of units from the population is based on easy availability or accessibility
Assembly language
A second-generation computer programming language that uses simple phrases rather than the complex series of switches used in machine language
Sensitivity label
A security level associated with the content of the information
User-based access
A security mechanism used to grant users of a system access based on identity
Automatic log-off
A security procedure that ends a computer session after a predetermined period of inactivity
Application programming interface (API)
A set of definitions of the ways in which one piece of computer software communicates with another or a programmer makes requests of the operating system or another application; operates outside the realm of the direct user interface
Data Elements for Emergency Department Systems (DEEDS)
A set of guidelines developed by the National Center for Injury Prevention and Control data set designed to support the uniform collection of information in hospital-based emergency departments
Coding formalization principles
A set of principles referring to the transition of coding from analysis of records to a process that involves data analysis using more sophisticated tools (for example, algorithmic translation, concept representation, or vocabulary or reimbursement mapping)
Category I Vaccine codes
A set of procedures or services codes maintained by the AMA. In recognition of the public health interest in vaccine products, these codes are approved for early release by the CPT Editorial Panel. The panel has agreed that new vaccine product codes could be published prior to FDA approval. These codes are indicated with the (. Once approved by the FDA, the symbol will be removed (AMA 2013)
Business process
A set of related policies and procedures that are performed step by step to accomplish a business-related function
Clinical terminology
A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement; See also nomenclature
Test statistics
A set of statistical techniques that examines the psychometric properties of measurement instruments
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
Terminology
A set of terms representing the system of concepts of a particular subject field; a clinical terminology provides the proper use of clinical words as names or symbols
Atlas System
A severity-of-illness system commonly used in the United States and Canada
Vision statement
A short description of an organization's ideal future state
Values statement
A short description that communicates an organization's social and cultural belief system
Visit
A single encounter with a healthcare professional that includes all of the services supplied during the encounter
Security threat
A situation that has the potential to damage a healthcare organization's information system
Screen prototype
A sketch of the user interface of each screen that is anticipated in a project
Core data elements/core content
A small set of data elements with standardized definitions often considered to be the core of data collection efforts
Utility program
A software program that supports, enhances, or expands existing programs in a computer system, such as virus checking, data recovery, backup, and data compression
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
Worm
A special type of computer virus, usually transferred from computer to computer via e-mail, that can replicate itself and use memory but cannot attach itself to other programs
Data definition language (DDL)
A special type of software used to create the tables within a relational database, the most common of which is structured query language
Data manipulation language (DML)
A special type of software used to retrieve, update, and edit data in a relational database, of which the most common is structured query language
Succession planning
A specific type of promotional plan in which senior-level position openings are anticipated and candidates are identified from within the organization; the candidates are given training through formal education, job rotation, and mentoring so that they can eventually assume these positions
Device driver
A specific type of software that is made to interact with hardware devices, such as the printer driver that ensures that the computer directs printing instructions appropriate to the type of printer to which it is connected
Data element domain
A specification (list or range) of the valid, allowable values that can be assigned for each data element in a data set
Domain
A sphere or field of activity and influence
Universal Medical Device Nomenclature System™ (UMDNS)
A standard international nomenclature and computer coding system for medical devices, developed by ECRI (ECRI Institute 2013)
Arden syntax
A standard language for encoding medical knowledge representation for use in clinical decision support systems
Certificate of need (CON)
A state-directed program that requires healthcare facilities to submit detailed plans and justifications for the purchase of new equipment, new buildings, or new service offerings that cost in excess of a certain amount
Statement of stockholder's equity
A statement detailing the reasons for changes in each stockholder's equity accounts; Also called statement of fund balance
Statement of retained earnings
A statement expressing the change in retained earnings from the beginning of the balance sheet period to the end
Code of ethics
A statement of ethical principles regarding business practices and professional behavior
Secondary diagnosis
A statement of those conditions coexisting during a hospital episode that affect the treatment received or the length of stay
Documentation guideline
A statement that indicates what health information must be recorded to substantiate use of a particular CPT code
Central tendency
A statistical term referring to the center of the distribution; an average or middle value
Disk mirroring
A storage technique which mirrors data from a primary drive to a secondary in the event of a drive failure
Tactical plan
A strategic plan at the level of divisions and departments
Balanced scorecard (BSC) methodology
A strategic planning tool that identifies performance measures related to strategic goals
Decision tree
A structured data-mining technique based on a set of rules useful for predicting and classifying information and making decisions
Single-blinded study
A study design in which (typically) the investigator but not the subject knows the identity of the treatment and control groups
Case-control study
A study that investigates the development of disease by amassing volumes of data about factors in the lives of persons with the disease (cases) and persons without the disease; See also retrospective study
Sequence diagram
A systems analysis tool for documenting the interaction between an actor and the information system
Benchmarking survey
A survey in which a healthcare facility compares elements of its operation with those of similar healthcare facilities
Census survey
A survey that collects data from all the members of a population
Database life cycle (DBLC)
A system consisting of several phases that represent the useful life of a database, including initial study, design, implementation, testing and evaluation, operation, and maintenance and evaluation
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
Charting by exception
A system of health record documentation in which progress notes focus on abnormal events and describe any interventions that were ordered and the patient's response; Also called focus charting
Terminal-digit filing system
A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement
Source-oriented health record format
A system of health record organization in which information is arranged according to the patient care department that provided the care
Secure messaging system
A system that eliminates the security concerns that surround e-mail, but retains the benefits of proactive, traceable, and personalized messaging; Also called secure notification delivery system
Theory
A systematic organization of knowledge that predicts or explains the behavior or events
Use case diagram
A systems analysis technique used to document a software project from a user's perspective
Access control grid
A tabular representation of the levels of authorization granted to users of a computer system's information and resources
Deliverable
A tangible output produced by the completion of project tasks
Successor
A task in a dependency relationship between two tasks that is dependent on the predecessor task
Data type
A technical category of data (text, numbers, currency, date, memo, and link data) that a field in a database can contain
Affinity grouping
A technique for organizing similar ideas together in natural groupings
Use case
A technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements
Use case analysis
A technique to determine how users will interact with a system. Uses the designed future (to-be) process and describes how a user will interact with the system to complete process steps and how the system will behave from the user perspective
Community-acquired infection
An infectious disease contracted as the result of exposure before or after a patient's period of hospitalization
Coalition building
A technique used to manage the political dimensions of change within an organization by building the support of groups for change
Workflow analysis
A technique used to study the flow of operations for automation; Also called operations analysis
Workaround
A temporary alternate process created as a substitute for an undesirable process to achieve a desired outcome until a more permanent solution is found
Univariate
A term referring to the involvement of one variable
Textual
A term referring to the narrative nature of much of clinical documentation to date
Assessment locking
A term that refers to the Centers for Medicare and Medicaid Services' requirement that long-term care facilities must encode Minimum Data Set assessments in a computerized file and edit the data items for compliance with data specifications
Scope of work
A term used in project management. A document that sets forth requirements for performance of work to achieve the project objectives
Scope
A term used in project management. A scope is a detailed statement that outlines and describes all work necessary to complete a project
Cross-functional
A term used to describe an entity or activity that involves more than one healthcare department, service area, or discipline
Terminal
A term used to describe the hardware in a mainframe computer system by which data may be entered or retrieved
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
Adverse action
A term used when an organization chooses to take action against an individual practitioner's clinical privileges or membership; Also called licensure disciplinary action
Cipher text
A text message that has been encrypted, or converted into code, to make it unreadable in order to conceal its meaning
Scalar chain
A theory in the chain of command in which everyone is included and authority and responsibility flow downward from the top of the organization
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
Clinical pathway
A tool designed to coordinate multidisciplinary care planning for specific diagnoses and treatments; See also critical path
SPECIALIST Lexicon
A tool that supplies the lexical information needed for the SPECIALIST natural language processing (NLP) system
Complete master census
A total census for a facility showing the names and locations of patients present in the hospital at a particular point in time
Blended learning
A training strategy that uses a combination of techniques—such as lecture, web-based training, or programmed text—to appeal to a variety of learning styles and maximize the advantages of each training method
Simulation
A training technique for experimenting with real-world situations by means of a computerized model that represents the actual situation
Cyclical staffing
A transitional staffing solution wherein workers are brought in for specific projects or to cover in busy times
Blitz team
A type of PI team that constructs relatively simple and quick "fixes" to improve work processes without going through the complete PI cycle
Concurrent coding
A type of coding that takes place while the patient is still in the hospital and receiving care
Broadband
A type of communications medium that can transmit multiple channels of data simultaneously
artificial neural network
ANN
American Occupational Therapy Association
AOTA
Strategic decision making
A type of decision making that is usually limited to individuals, such as boards of directors, chief executive officers, and top-level executives, who make decisions about the healthcare organization's strategic direction
Tactical decision making
A type of decision making that usually affects departments or business units (and sometimes policies and procedures) and includes short- and medium-range plans, schedules, and budgets
Contracted discount rate
A type of fee-for-service reimbursement in which the third-party payer has negotiated a reduced ("discounted") fee for its covered parties
Bus
A type of hardware that controls the flow of commands between the central processor and other components
Staff model health maintenance organization
A type of health maintenance that employs physicians to provide healthcare services to subscribers; See also closed panel
Structured data entry
A type of healthcare data documentation about an individual using a controlled vocabulary rather than narrative text; Also called discrete data
At risk contract
A type of managed care contract that provides a set fee for the care a patient is expected to receive throughout the life of the contract. Should the actual costs exceed the agreed upon contract fee, the patient continues to receive care through the end of the contract
Cache memory
A type of memory located on the central processing unit (CPU) that can also be on a part of the processor
Simulation observation
A type of nonparticipant observation in which researchers stage events rather than allowing them to happen naturally
Concept
A unique unit of knowledge or thought created by a unique combination of characteristics
Uniform Resource Locator (URL)
A unique website address that will take the web browser directly to the document located on a web page
Dual core (vendor strategy)
A vendor strategy in which one vendor primarily supplies the financial and administrative applications and another vendor primarily supplies the clinical applications
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
Sole proprietorship
A venture with one owner in which all profits are considered the owner's personal income
Stem and leaf plot
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 the ones digit of the number, and the other digits form the "stem"
Star schema
A visual method of expressing a multidimensional data structure in a relational database
Scatter plot
A visual representation of data points on an interval or ratio level used to depict relationships between two variables; Also called scatter diagram; scattergram
Strategy map
A visual representation of the cause-and-effect relationships among the components of an organization's strategy
Standard vocabulary
A vocabulary that is accepted throughout the healthcare industry
Algorithm
A way of solving a mathematical problem within a limited number of steps that often requires repetition of the step
Communities of Practice (CoP)
A web-based electronic network for communication among members of the American Health Information Management Association
Web portal technology
A website entryway serving as a starting point to access, find, and deliver information and including a broad array of resources and services, such as e-mail, forums, and search engines
Data mart
A well-organized, user-centered, searchable database system that usually draws information from a data warehouse to meet the specific needs of users
application programming interface
API
adverse patient occurrences
APO
Wireless local-area network (WLAN)
A wireless local-area network that uses radio waves as the carrier
Diagnosis
A word or phrase used by a physician to identify a disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care
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
Universal protocol
A written checklist developed by the Joint Commission to prevent errors that can occur when physicians perform the wrong procedure, for example
Certificate of coverage
A written description of benefits included in a health plan and required by state law
Subpoena 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
Corrective action plan (CAP)
A written plan of action to be taken in response to identified issues or citations from an accrediting or licensing body
American Association of Medical Record Librarians
AAMRL
American Academy of Professional Coders
AAPC
activity-based costing
ABC
adverse drug reaction
ADR
American Hospital Association
AHA
Certified in healthcare privacy and security (CHPS®)
AHIMA credential that recognizes advanced competency in designing, implementing, and administering comprehensive privacy and security protection programs in all types of healthcare organizations; requires successful completion of the CHPS exam sponsored by AHIMA
Body of Knowledge (BoK)
AHIMA's collected resources, knowledge, and expertise within and related to health information management
American Society for Testing and Materials Committee E31 (ASTM E31) Healthcare Informatics
ASTM Committee E31 on Healthcare Informatics develops standards related to the architecture, content, storage, security, confidentiality, functionality, and communication of information used within healthcare and healthcare decision-making, including patient-specific information and knowledge (ASTM 2013)
asynchronous transfer mode
ATM
Sensitivity
Ability to detect a characteristic when the characteristic exists; See also specificity
Specificity
Ability to detect the absence of a characteristic when the characteristic is absent; See also sensitivity
Assessment completion date
According to the Centers for Medicare and Medicaid Services' instructions, the date by which a Minimum Data Set for Long-Term Care must be completed; that is, within 14 days of admission to a long-term care facility
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 (Joint Commission 2013)
Comprehensive Accreditation Manual for Hospitals (CAMH)
Accreditation manual published by the Joint Commission
ASC X12
Accredited Standards Committee, Electronic Data Interchange; See Accredited Standards Committee X12
Data ownership
Acknowledgement by all persons involved with creating and applying data and the quality for which they are responsible
ADFM
Active duty family member; a designation used under TRICARE
Continuing medical education (CME)
Activities such as accredited sponsorship, nonaccredited sponsorship, medical teaching, and publications that advance medical care and other learning experiences, proof of which is required for a physician to maintain certification
Derived attribute
An attribute whose value is based on the value of other attributes (for example, current date minus date of birth yields the derived attribute age)
Cost outlier adjustment
Additional reimbursement for certain high-cost home care cases based on the loss-sharing ratio of costs in excess of a threshold amount for each home health resource group
Consumer Coalition for Health Privacy
Affiliated with the Health Privacy Project, this organization was created to educate and empower healthcare consumers on privacy issues at the various levels of government and consists of patients and consumer advocacy organizations (Consumer Coalition for Health Privacy 2013)
Attorney in fact
Agent authorized by an individual to make certain decisions, such as healthcare determinations, according to a directive written by the individual
Withhold pool
Aggregate amount withheld from all providers' capitation payments as an amount to cover expenditures in excess of targets
Deficiency analysis
An audit process designed to ensure that all services billed have been documented in the health record
Total billed charges
All charges for procedures and services rendered to a patient during a hospitalization or encounter
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
Data comprehensiveness
All required data items are included. Ensures that the entire scope of the data is collected with intentional limitations documented
Cost-of-living adjustment (COLA)
Alteration that reflects a change in the consumer price index (CPI), which measures purchasing power between time periods; the CPI is based on a market basket of goods and services that a typical consumer buys
ACOG
American Congress of Obstetrics and Gynecology
ADA re:dental
American Dental Association
ADA re:disabilities
Americans with Disabilities Act
Clinical document improvement practitioner (CDIP®)
An AHIMA credential awarded to individuals who have achieved specialized skills in clinical documentation improvement
Context-based access control
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
Code edit
An accuracy checkpoint in the claims-processing software, such as female procedures done only on female patients
SOAP
An acronym for a component of the problem-oriented medical record that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans
Civil proceeding (action)
An action brought to enforce, redress, or protect private rights or to protect a private right or compel a civil remedy in a dispute between private parties (in general, all types of actions other than criminal proceedings)
Tort
An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm
Cost driver
An activity that affects or causes costs
Direct medical education costs
An add-on to the ambulatory payment classification amount to compensate for costs associated with outpatient direct medical education of interns and residents
Bivariate
An adjective meaning the involvement of two variables
Baseline adjustment for volume and intensity of service
An adjustment to the conversion factor needed to fulfill the statutory budget neutrality requirement
Urgent admission
An admission in which the patient requires immediate attention for care and treatment of a physical or psychiatric problem. Generally, the patient is admitted to the first available, suitable accommodation
Digital certificate
An electronic document that establishes a person's online identity
Assignment
An agreement between a physician and CMS whereby a physician or supplier agrees to accept the Medicare-approved amount as payment in full for services or supplies provided under Part B. Medicare pays the physician or supplier 80 percent of the approved amount after the annual $100 deductible has been met; the beneficiary pays the remaining 20 percent (CMS 2013)
Administrative services only (ASO) contract
An agreement between an employer and an insurance organization to administer the employer's self-insured health plan
Work distribution analysis
An analysis used to determine whether a department's current work assignments and job content are appropriate
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 (AAAM 2008)
Web-enabled technology
An application that was originally written for a client or server or mainframe environment that is rewritten to be accessed through a web browser
Value-based leadership
An approach that emphasizes values, ethics, and stewardship as central to effective leadership
Web services architecture (WSA)
An architecture that utilizes web-based tools to permit communication among different software applications
Applied artificial intelligence
An area of computer science that deals with algorithms and computer systems that exhibit the characteristics commonly associated with human intelligence
Council on Certification
An arm of AHIMA that today fulfills the role of the Board of Registration, a certification board instituted in 1933 to provide a baseline by which to measure qualified medical record librarians
Variance analysis
An assessment of a department's financial transactions to identify differences between the budget amount and the actual amount of a line item
Child Welfare League of America (CWLA)
An association of public and private nonprofit agencies and organizations across the United States and Canada devoted to improving life for abused, neglected, and otherwise vulnerable children and young people and their families
Court-ordered warrant (bench warrant)
An authorization issued by a court for the attachment or arrest of a person either in the case of contempt or where an indictment has been found or to bring in a witness who does not obey a subpoena
Business case
An economic argument, or justification, usually for a capital expenditure
Activity-based costing (ABC)
An economic model that traces the costs or resources necessary for a product or customer
American Standard Code for Information Interchange (ASCII)
An electronic code that converts English characters to numbers, with each letter assigned a specific number. Computers utilize this code to represent text fields, which in turn allows systems to transfer data from one computer to another
Digital signature
An electronic signature that binds a message to a particular individual and can be used by the receiver to authenticate the identity of the sender
Completeness
An element of a legally defensible health record; the health record is not complete until all its parts are assembled and the appropriate documents are authenticated according to medical staff bylaws
Data administrator
An emerging role responsible for managing the less technical aspects of data, including data quality and security
Sheltered employment
An employment category provided in a special industry or workshop for the physically, mentally, emotionally, or developmentally handicapped
Virtual private network (VPN)
An encrypted tunnel through the Internet that enables secure transmission of data (CMS 2013)
C Plus Plus
An enhancement made to the original C programming language that includes classes, templates, operator overloading, and exception handling, among other improvements. C++ and C are highly compatible
Contract service
An entity that provides certain agreed-upon services for the facility, such as transcription, coding, or copying
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; codes of ethics published by professional associations or societies; regulations for accreditation published by accreditation agencies; usual and common practice of equivalent clinicians or organizations in a geographical region
Concurrent utilization review
An evaluation of the medical necessity, quality, and cost-effectiveness of a hospital admission and ongoing patient care at or during the time that services are rendered
Voluntary review
An examination of an organization's structures and processes conducted at the request of a healthcare facility seeking accreditation from a reviewing agency
Data quality review
An examination of health records to determine the level of coding accuracy and to identify areas of coding problems
Waiver of privilege
An exception to physician-patient privilege that occurs when a party claims damages for a mental or physical injury; the party thereby waives his or her right to confidentiality to the extent that it is necessary to determine whether the mental or physical injury is due to another cause
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
Clinical Context Object Workgroup (CCOW)
An implementation standard protocol developed by HL7 to allow clinical applications to share information at the point of care (HL7 2011b)
Delinquent health record
An incomplete record not finished or made complete within the time frame determined by the medical staff of the facility
Shift differential
An increased wage paid to employees who work less desirable shifts, such as evenings, nights, or weekends
Commission on Accreditation of Health Informatics and Information Management Education (CAHIIM)
An independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality accreditation standards for health informatics and health information management educational programs (CAHIIM 2013)
Commission on Certification for Health Informatics and Information Management (CCHIIM)
An independent body within AHIMA that establishes and enforces standards for the certification and certification maintenance of health informatics and information management professionals
Dual eligible
An individual covered by both Medicare and Medicaid
Accountable Care Organization (ACO) Participant
An individual or group of ACO provider(s)/supplier(s) that is identified by a Medicare-enrolled TIN, that alone or together with one or more other ACO participants comprise(s) an ACO, and that is included on the list of ACO participants that is required under 425.204(c)(5) (42 CFR 425.20 2011)
Boarder
An individual such as a parent, caregiver, or other family member who receives lodging at a healthcare facility but is not a patient
Certified Tumor Registrar
An individual who has achieved specialized skills in the cancer registry
Competent adult
An individual who has reached the age of majority and is mentally and physically competent to tend to his or her own affairs; may consent to treatment and may authorize the access or disclosure of his/her health information
Champion
An individual within an organization who believes in an innovation or change and promotes the idea by building financial and political support
Stakeholder
An individual within the company who has an interest in, or is affected by, the results of a project
Vulnerability
An inherent weakness or absence of a safeguard that could be exploited by a threat
Agenda for Change
An initiative undertaken by the Joint Commission that focused on changing the emphasis of the accreditation process from structure to outcomes
Day outlier
An inpatient hospital stay that is exceptionally long when compared with other cases in the same diagnosis-related group
Summons
An instrument used to begin a civil action or special proceeding and is a means of acquiring jurisdiction over a party
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
System catalog
An integrated data dictionary (which is a component of a database management system) that generally contains information on data tables and relationships in addition to data definitions
Computer-telephone integration (CTI)
An integration of computer technology and public telephone services that allows people to access common computer functions such as database queries via telephone handsets or interactive voice technology
Systems theory
An interdisciplinary field of study that analyzes and describes how any group of objects work together to produce a result
American Society for Testing and Materials (ASTM) International
An international organization whose purpose is to establish standards on materials, products, systems, and services (ASTM 2013)
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, and medical rehabilitation programs and accredits such programs on the basis of its standards (CARF International 2013)
Council on Accreditation (COA)
An international, independent, not-for-profit, child and family service and behavioral healthcare accrediting organization. Founded in 1977 by the Child Welfare League of America and Family Service America (COA 2013)
Behavioral description interview
An interview format that requires applicants to give specific examples of how they have performed a specific procedure or handled a specific problem in the past
Structured interview
An interview format that uses a set of standardized questions that are asked of all applicants
Cause-and-effect diagram
An investigational technique that facilitates the identification of the various factors that contribute to a problem; See also fishbone diagram
Transition
An ongoing plan used in establishing and maintaining the Medicare fee schedule
Web services
An open, standardized way of integrating disparate, web browser-based and other applications
Data repository
An open-structure database that is not dedicated to the software of any particular vendor or data supplier, in which data from diverse sources are stored so that an integrated, multidisciplinary view of the data can be achieved; Also called central data repository; when related specifically to healthcare data, a clinical data repository
Stop order
An order given that calls for the discontinuation of medications unless the physician gives a specific order to continue the medication; this method prevents patients from receiving drugs for a longer period of time than is necessary
Ambulatory Care Quality Alliance
An organization consisting of a broad base of healthcare professionals who work collaboratively to improve healthcare quality and patient safety through performance measurement, data aggregation, and reporting in the ambulatory care setting
American National Standards Institute (ANSI)
An organization that governs standards in many aspects of public and private business; developer of the Health Information Technology Standards Panel (ANSI 2013)
Corporation
An organization that may have one or many owners in which profits may be held or distributed as dividends (income paid to the owners)
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities
American Correctional Association (ACA)
An organization that provides education, training, correctional certification, and accreditation for correctional healthcare organizations
Accreditation Commission for Health Care (ACHC)
An organization that provides quality standards and accreditation programs for home health and other healthcare organizations (ACHC 2013)
Credential verification organization (CVO)
An organization that verifies healthcare professionals' background, licensing, and schooling, and tracks continuing education and other performance measures
Conversion strategy
An organization's plan for changing from a paper-based health record to an electronic health record
Appreciative inquiry
An organizational development technique in which successful practices are identified and expanded throughout the organization
Data audit
An organizational procedure for monitoring the quality of data by analyzing reports for anomalies, inaccuracies, and missing data
Surgery
An umbrella term referring to the procedures of incision, excision, amputation, introduction, endoscopy, suture, and manipulation
Special-cause variation
An unusual source of variation that occurs outside a process but affects it
Contra-account
Any account set up to adjust the historical value of a balance sheet account (for example, cumulative depreciation is a contra-account to an equipment [fixed-asset] account)
Boarder baby
Any infant who remains in the nursery after the mother's discharge for any reason
Unsupervised learning
Any learning technique that has as its purpose to group or cluster items, objects, or individuals
Clinical documentation
Any manual or electronic notation (or recording) made by a physician or other healthcare clinician related to a patient's medical condition or treatment
ARRA
See American Recovery and Reinvestment Act of 2009 (ARRA)
Whole number
Any of the set of nonnegative integers. It cannot be a fraction, decimal, percentage, or negative number
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
Carve-outs
Applicable services that are cut out of the contract and paid at a different rate
Authorization documentation
As amended by HITECH, a covered entity must document and retain any signed authorization under section 164.508 as required at 164.530(j) (45 CFR 164.508 2013)
Belmont Report
As a result of the National Research Act, Public Law 93-348, the Department of Health and Human Services was commissioned to create a statement of ethical principles in the use of human subjects in research. The report summarizes the findings of the Commission as the result of its deliberation (HHS 1979)
Designated record set
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; (ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals (2) For purposes of this paragraph, the term means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity (45 CFR 164.501 2013)
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 in connection with a transaction covered by this subchapter (45 CFR 160.103 2013)
Chain of trust
As amended by HITECH, a Security Rule that states a covered entity may permit a business associate to create, receive, maintain, or transmit electronic protected health information on the covered entity's behalf only if the covered entity obtains satisfactory assurances that the business associate will appropriately safeguard the information (45 CFR 164.308 2013)
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. The contract may not authorize the business associate to use or further disclose the information in a manner that would violate the requirements of HIPAA, and requires termination of the contract if the covered entity or business associate are aware of noncompliant activities of the other (45 CFR 164.504 2013)
Authorization required—Sale of protected health information
As amended by HITECH, a covered entity must obtain an authorization for any disclosure of protected health information which is a sale of protected health information (45 CFR 164.508 2013)
Authorization required—Marketing
As amended by HITECH, a covered entity must obtain an authorization for any use or disclosure of protected health information for marketing, except if the communication is in the form of, A) A face to face communication made by a covered entity to an individual; or (B) A promotional gift of nominal value provided by the covered entity. (ii) If the marketing involves financial remuneration to the covered entity from a third party, the authorization must state that such remuneration is involved (45 CFR 164.508 2013)
Authorization required—Psychotherapy notes
As amended by HITECH, a covered entity must obtain an authorization for any use or disclosure of psychotherapy notes, except, (i) To carry out the following treatment, payment, or health care operations, (A) Use by the originator of the psychotherapy notes for treatment; (B) Use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or (C) Use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and (ii) A use or disclosure that is required by section 164.502, permitted by section 164.512 (45 CFR 164.508 2013)
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 (45 CFR 164.404 2013)
Confidential Communication
As amended by HITECH, a covered health care provider must permit individuals to request and must accommodate reasonable requests by individuals to receive communications of protected health information from the covered health care provider by alternative means or at alternative locations. (ii) A health plan must permit individuals to request and must accommodate reasonable requests by individuals to receive communications of protected health information from the health plan by alternative means or at alternative locations, if the individual clearly states that the disclosure of all or part of that information could endanger the individual (45 CFR 164.522 2013)
Subcontractor
As amended by HITECH, a person to whom a business associate delegates a function, activity, or service, other than in the capacity of a member of the workforce of such business associate (45 CFR 160.103 2013)
Direct treatment relationship
As amended by HITECH, a treatment relationship between an individual and a health care provider that is not an indirect treatment relationship (45 CFR 164.501 2013)
Termination of access
As amended by HITECH, an administrative safeguard under the Security Rule that states a covered entity must implement procedures for terminating access to electronic protected health information when the employment of a workforce member ends (45 CFR 164.308 2013)
Correctional institution
As amended by HITECH, any penal or correctional facility, jail, reformatory, detention center, work farm, halfway house, or residential community program center operated by, or under contract to, the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, for the confinement or rehabilitation of persons charged with or convicted of a criminal offense or other persons held in lawful custody. Other persons held in lawful custody includes juvenile offenders, adjudicated delinquent, aliens detained awaiting deportation, persons committed to mental institutions through the criminal justice system, witnesses, or others awaiting charges or trial (45 CFR 164.501 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; (2) adopt standard identifiers for health plans, health care providers, employers, and individuals for use on standard transactions; and (3) adopt standards to protect the security and privacy of personally identifiable health information (45 CFR Parts 160, 162, and 164 2013)
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 (45 CFR 160.103 2013)
Authorization copy
As amended by HITECH, if a covered entity seeks an authorization from an individual for a use or disclosure of protected health information, the covered entity must provide the individual with a copy of the signed authorization (45 CFR 164.508 2013)
Covered functions
As amended by HITECH, those functions of a covered entity the performance of which makes the entity a health plan, health care provider, or health care clearinghouse (45 CFR 164.103 2009)
Small health plan
As amended by HITECH, means a health plan with annual receipts of $5 million or less (45 CFR 160.103 2013)
Unsecured personal health information (PHI)
As amended by HITECH, protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the secretary in the guidance issued under section 13402(h)(2) of Public Law 111-05 (45 CFR 164.402 2013)
Act
As amended by HITECH, refers to the Social Security Act (45 CFR 160.103 2013)
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 (45 CFR 164.304 2013)
Addressable standards
As amended by HITECH, the implementation specifications of the HIPAA Security Rule that are designated "addressable" rather than "required"; to be in compliance with the rule, the covered entity must implement the specification as written, implement an alternative, or document that the risk for which the addressable implementation specification was provided either does not exist in the organization, or exists with a negligible probability of occurrence (45 CFR 164.306 2013)
Treatment
As amended by HITECH, the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another (45 CFR 164.501 2013)
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. It includes the following types of information transmissions, (1) Health care claims or equivalent encounter information; (2) Health care payment and remittance advice; (3) Coordination of benefits; (4) Health care claim status; (5) Enrollment and disenrollment in a health plan; (6) Eligibility for a health plan; (7) Health plan premium payments; (8) Referral certification and authorization; (9) First report of injury; (10) Health claims attachments; (11) Health care electronic funds transfers (EFT) and remittance advice; (12) Other transactions that the secretary may prescribe by regulation (45 CFR 160.103 2013)
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 (45 CFR 160.103 2013)
Data aggregation
As amended by HITECH, with respect to protected health information created or received by a business associate in its capacity as the business associate of a covered entity, the combining of such protected health information by the business associate with the protected health information received by the business associate in its capacity as a business associate of another covered entity, to permit data analyses that relate to the health care operations of the respective covered entities (45 CFR 164.501 2013)
Countersignature
Authentication by a second provider that signifies review and evaluation of the actions and documentation, including authentication, of a first provider
Civil Monetary Penalties Act (CMP)
Authorizes the imposition of substantial civil money penalties against an entity that engages in activities including, but not limited to (1) knowingly presenting or causing to be presented a claim for services not provided as claimed or which is otherwise false or fraudulent in any way; (2) knowingly giving or causing to be given false or misleading information reasonably expected to influence the decision to discharge a patient; (3) offering or giving remuneration to any beneficiary of a federal health care program likely to influence the receipt of reimbursable items or services; (4) arranging for reimbursable services with an entity which is excluded from participation from a federal health care programs; (5) knowingly or willfully soliciting or receiving remuneration for a referral of a federal health care program beneficiary; or (6) using a payment intended for a federal health care program beneficiary for another use (42 CFR 1003.100 2004)
ASHRM
See American Society for Healthcare Risk Management
ASQ
See American Society for Quality
back-end speech recognition
BESR
Ambulatory payment classification group (APC group)
Basic unit of the ambulatory payment classification (APC) system. Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided. APC groups are based on HCPCS/CPT codes. A single visit can result in multiple APC groups. APC groups consist of five types of service, significant procedures, surgical services, medical visits, ancillary services, and partial hospitalization. The APC group was formerly known as the ambulatory visit group (AVG) and ambulatory patient group (APG)
Document image data
Bitmapped images based on data created and stored on analog paper or photographic film
Scorecards
Reports of outcomes measures to help leaders know what they have accomplished; Also called dashboards
Data Elements for Emergency Department Systems
DEEDS
Comprehensive Accreditation Manual for Hospitals
CAMH
Commission on Accreditation of Rehabilitation Facilities
CARF
Continuity of care record
CCR
clinical data repository
CDR
Certified Guidance Document
CGD
community health dimension
CHD
clinical information system
CIS
Data Encryption Standard
DES
Detailed
DET
data governance
DG
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. It incorporates clinical process-of-care measures as well as measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey on how patients view their care experiences
Common Object Request Broker Architecture
CORBA
Category III codes
CPT codes that contain a temporary set of codes for emerging technologies, services, and procedures (AMA 2013)
Category II codes
CPT codes that describe clinical components that may be typically included in evaluation and management services or other clinical services and, therefore, do not have a relative value associated with them. May also describe results from clinical laboratory or radiology tests and other procedures, identified to address patient safety practices, or services reflecting compliance with state or federal law. The use of these codes is optional (AMA 2013)
Computed tomography
CT
Concept Unique Identifier
CUI
Clinical risk group (CRG)
Capitated prospective payment system that predicts future healthcare expenditures for populations
Tertiary care
Care centered on the provision of highly specialized and technologically advanced diagnostic and therapeutic services in inpatient and outpatient hospital settings
CTS
Carpal tunnel syndrome
Current assets
Cash and other assets that typically will be converted to cash within one year
disease management
DM
Certified Information Systems Security Professional (CISSP)
Certification sponsored by the International Information Systems Security Certification Consortium (ISC2); it is a generic security certification and therefore is not healthcare specific (ISC2 2013)
Structured question
Close-ended question, which is used more for self-assessments, web-based or e-mailed surveys, or mailed and faxed surveys; Also called closed-ended question
Data-based DSS
Decision support system that focuses on providing access to the various data sources within the organization through one system
Topography
Code that describes the site of origin of the neoplasm and uses the same three- and four-character categories as in the neoplasm section of the second chapter of ICD-10. Description of a part of the body
Administrative data
Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance
Unlisted procedure codes
Codes available in each section of CPT to describe procedures that have no specific procedure code assigned because the procedure is new or unusual
Temporary National Codes
Codes established by insurers when a code is needed before the next January 1 annual update for permanent national codes; these codes are independent of the permanent national codes
ABC Codes
Codes that consist of five-character, alphabetic strings that identify services, remedies, or supplies. Codes are followed by a two-character code modifier, which identifies the practitioner type who delivered the care (Alternative Link 2009)
Concept permanence
Codes that represent the concept in a controlled medical terminology are not reused; therefore meanings do not change
Standing committees
Committees that are put in place to oversee ongoing and cross-functional issues (examples include the medical staff committee, a quality improvement committee, or an infection control committee)
Structure and content standards
Common data elements and definitions of the data elements to be included in an electronic patient record
CWF
Common working file
Circuit switching
Communications technology that establishes a connection between callers in a telephone network using a dedicated circuit path
Component state associations (CSAs)
Component state associations are part of the volunteer structure of AHIMA and are organized in every state, the District of Columbia, and the Commonwealth of Puerto Rico. The purpose of each Component State Association shall be to promote the mission and purpose of AHIMA in its state
System infectors
Computer viruses that infect the system areas of diskettes or the hard drive of a computer; See boot-record infectors
Worker immaturity-maturity
Concept borrowed from Chris Argyris, who suggested that job and psychological maturity also influences leadership style; job maturity refers to how much work-related ability, knowledge, experience, and skill a person has; psychological maturity refers to willingness, confidence, commitment, and motivation related to work
Span of control
Concept of classical organization theory that suggests managers are capable of supervising only a limited number of employees
Data timeliness
Concept of data quality that involves whether the data is up-to-date and available within a useful time frame. Timeliness is determined by how the data are being used and their context
Concept orientation
Concepts in a controlled medical terminology are based on meanings, not words
Self-efficacy
Confidence in one's personal capabilities to do a job. The belief in one's capacity to organize and carry out a course of action to manage a situation
Authenticate
Confirm by signing
Detective controls
Controls that are put in place to find errors that may have been made during a process; for example, routine coding quality audits and registration audits
Third opinion
Cost containment measure to prevent unnecessary tests, treatments, medical devices, or surgical procedures
Unit labor cost
Cost determined by dividing the total annual compensation by total annual productivity
Base year
Cost reporting period upon which a rate is based
Coinsurance
Cost sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met; the percentage may vary by type or site of service
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
Uncontrollable costs
Costs over which department managers have little or no influence
Appellate court
Courts that hear appeals on final judgments of the state trial courts or federal trial courts
Certified professional coder-hospital (CPC-H)
Credential sponsored by the American Academy of Professional Coders that certifies hospital-based coders (AAPC 2013)
Diffusion S curve
Curve that shows that each of the adopter categories engages innovation at a different time and a different acceptance rate
database life cycle
DBLC
data definition language
DDL
Secondary data source
Data derived from the primary patient record, such as an index or a database
Data accessibility
Data items that are easily obtainable and legal to access with strong protections and controls built into the process
Bitmapped data
Data made up of pixels displayed on a horizontal and vertical grid or matrix
Analog
Data or information that is not represented in an encoded, computer-readable format
Vital statistics
Data related to births, deaths, marriages, and fetal deaths
Coded data
Data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed, and compared
Discrete data
Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values
Data precision
Data values should be just large enough to support the application or process
Beacon Community Cooperative Agreement Program
Demonstrates how health IT investments and MU of EHR advance the vision of patient-centered care, while achieving the three-part aim of better health, better care, at lower cost. The ONC is providing $250 million over three years to 17 selected communities throughout the United States that have already made inroads in the development of secure, private, and accurate systems of EHR adoption and health information exchange (ONC 2013)
Compliance officer
Designated individual who monitors the compliance process at a healthcare facility
Certification standards
Detailed compulsory requirements for participation in Medicare and Medicaid programs
Barcode-enabled devices
Devices used throughout healthcare facilities that are designed to use barcodes for increased accuracy; See also barcoding technology
Vector graphic data
Digital data that have been captured as points and are connected by lines (a series of point coordinates) or areas (shapes bounded by lines); Also called signal tracing data
Checksum
Digits or bits summed according to arbitrary rules and used to verify the integrity of numerical data
Six Sigma
Disciplined and data-driven methodology for getting rid of defects in any process
Continuous variables
Discrete variables measured with sufficient precision
Direct method of cost allocation
Distributes the cost of overhead departments solely to the revenue-producing areas
Work products
Documents produced during the completion of a task that may be a component of, or contribute to, a project deliverable
Deficiency assignment
Each facility must develop its own procedures for quantitative analysis and responsibility for completion of the record must be assigned to each responsible provider; the deficiencies, or parts of the record needing completion or signature, are entered into the HIS or on paper worksheets attached to the incomplete, or deficient, health record
Byte
Eight bits treated as a single unit by a computer to represent a character
Computerized provider order entry (CPOE)
Electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically. These systems usually contain error prevention software that provides the user with prompts that warn against the possibility of drug interaction, allergy, or overdose and other relevant information
Disease management (DM)
Emphasizes the provider-patient relationship in the development and execution of the plan of care, prevention strategies using evidence-based guidelines to limit complications and exacerbations, and evaluation based on outcomes that support improved overall health
Standards and Interoperability (S and I) Framework
Empowers healthcare stakeholders to establish standards, specifications and other implementation guidance that facilitate effective healthcare information exchange. The S and I Framework creates a forum, enabled by integrated functions, processes, and tools, where healthcare stakeholders can focus on solving real world interoperability challenges (S and I Framework 2013)
American College of Surgeons 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 (ACS 2013)
Clinical Laboratory Improvement Amendments (CLIA)
Established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test is (Public Law 90-174 1967)
Blood and blood component usage review
Evaluation of how blood and blood components are used using the Joint Commission guidelines
Surgical review
Evaluation of operative and other procedures, invasive and noninvasive, using the Joint Commission guidelines
Authenticated evidence
Evidence that appears to be relevant and has been shown to have a baseline authenticity or trustworthiness
Cost outlier
Exceptionally high costs associated with inpatient care when compared with other cases in the same diagnosis-related group
Case-mix group (CMG) relative weights
Factors that account for the variance in cost per discharge and resource utilization among case-mix groups (42 CFR 412 2008)
Uniformed Services Employment and Reemployment Rights Act (1994)
Federal legislation that prohibits discrimination against individuals because of their service in the uniformed services (Public Law 103-353)
ASTM E31
See American Society for Testing and Materials Committee E31—Healthcare Informatics
Block grant
Fixed amount of money given or allocated for a specific purpose, such as a transfer of governmental funds to cover health services
Diagnostic criteria
For each mental disorder listed in the DSM-IV, a type of list is provided that indicates what symptoms must be present as well as those symptoms that must not be present in order for a patient to meet the qualifications for a particular mental diagnosis (DMS 2013)
Cutover
In disaster planning, the transition process when switching from the alternative recovery site back to the original location or to a new location
Association of Clinical Documentation Improvement Specialists (ACDIS)
Formed in 2007 as a community in which clinical documentation improvement professionals could communicate resources and strategies to implement successful programs and achieve professional growth (ACDIS 2013)
Association for Healthcare Documentation Integrity (AHDI)
Formerly the American Association for Medical Transcription (AAMT), this association has a model curriculum for formal educational programs that includes the study of medical terminology, anatomy and physiology, medical science, operative procedures, instruments, supplies, laboratory values, reference use and research techniques, and English grammar
Categorical data
Four types of data (nominal, ordinal, interval, and ratio) that represent values or observations that can be sorted into a category; See scales of measurement
Add-on codes
In CPT coding, these codes are referred to as additional or supplemental procedures. They are indicated with a "+" symbol and are to be reported in addition to the primary procedure code. They are not to be reported as standalone codes and are exempt from use of the -51 modifier (AMA 2013)
Virtuoso teams
Group of experts brought together to address an issue or situation
Adult day care
Group or individual therapeutic services provided during the daytime hours to persons outside their homes; usually provided for individuals with geriatric or psychiatric illnesses
User groups
Groups composed of users of a particular computer system
Cost centers
Groups of activities for which costs are specified together for management purposes
Consistent federated model (of HIE)
Health information exchange model where there is no centralized storage of patient data
Transfusion record
Health record documentation that includes information on the type and amount of blood products a patient received, the source of the blood products, and the patient's reaction to them
Disproportionate share hospital (DSH)
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
Benefit
Healthcare service for which the healthcare insurance company will pay; See covered service (expense)
Statistical inference
Helps to make inference or guess about a larger group of data by drawing conclusions from a small group of data
Teaching hospital
Hospital engaged in an approved graduate medical education residency program in medicine, osteopathy, dentistry, or podiatry
Ambulatory payment classification (APC)
Hospital outpatient prospective payment system (OPPS). The classification is a resource-based reimbursement system
Sole-community hospital
Hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other hospitals (as determined by the Secretary of the HHS), is the sole source of patient hospital services reasonably available to individuals in a geographical area who are entitled to benefits
Swing beds
Hospital-based acute care beds that may be used flexibly to serve as acute or skilled nursing care
Short-stay outlier
Hospitalization that is five-sixths of the geometric length of stay for the long-term care diagnosis related group (LTC-DRG)
Chief information security officer (CISO)
IT leadership role responsible for overseeing the development, implementation, and enforcement of a healthcare organization's security program; role has grown as a direct result of the HIPAA security regulations
Chief information technology officer (CITO)
IT leadership role that guides an organization's decisions related to technical architecture and evaluates the latest technology developments and their applicability or potential use in the organization
American Society for Testing and Materials Standard E1384 ASTM E1384 - 07(2013) Standard Practice for Content and Structure of the Electronic Health Record (EHR)
Identifies the basic information to be included in electronic health records and requires the information to be organized into categories
Crisis management plan
In disaster planning, a plan that defines the processes and controls that will be followed until the operations are fully restored
Brackets
In ICD-10-CM punctuation are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. In the Alphabetic Index brackets are used to identify manifestation codes (CDC 2013)
Colons
In ICD-10-CM what punctuation symbol is used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category (CDC 2013)
Description
In a controlled medical vocabulary, a description is the combination of a concept and a term
Counterclaim
In a court of law, a countersuit
Data normalization
In a relational database, it is the process of organizing data to minimize redundancy
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
Credits
In accounting, or the revenue cycle, the amounts on the right side of a journal entry
Avoiding
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
Cold site
In disaster planning, a basic facility with adequate space and infrastructure (electrical power, telecommunications) to support the organization's information systems
Corrective controls
Internal controls designed to fix problems that have been discovered, frequently as a result of detective controls
Chart reviews
Internal studies and external reviews including billing audits
Continuity of care record (CCR) ASTM E2369
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. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care (ASTM 2013)
Strategic goals
Long-term objectives set by an organization to improve its operations
Discoverability
Limitations on the ability of parties to discover pretrial information held by another
Benefit level
Limits to healthcare coverage benefits as the result of a contract between a person and his or her health plan
Sample frame
List of subjects from which the sample is drawn
Crosswalks
Lists of translating codes from one system to another
Standards development organization maps
Maps created or adopted by a standards development organization or in cooperation between organizations
Scale
Measure with progressive categories, such as size, amount, importance, rank, or agreement
Certification/recertification
Medicare requirement for the physician's official recognition of skilled nursing care needs for the resident
Contraindication
Medication should not be prescribed due to another medication or condition
Certificate holder
Member of a group for which an employer or association has purchased group healthcare insurance; See also insured; member; policyholder; subscriber
Branding communications
Messages sent to increase awareness of, and to enhance the image of, a product in the marketplace
Speech dictation
Method of collecting information in an information system through spoken word
Community (-based premium) rating
Method of determining healthcare insurance premium rates by geographic area (community) rather than by age, health status, or company size, which increases the size of the risk pool resulting in increased costs to younger, healthier individuals who are, in effect, subsidizing older or less healthy individuals
Self-insured plan
Method of insurance in which the employer or other association itself administers the health insurance benefits for its employees or their dependents, thereby assuming the risks for the costs of healthcare for the group (CMS 2013)
Systematic literature review
Methodical approach to literature review that reduces the possibility of bias; characterized by explicit search criteria to identify literature, and inclusion and exclusion criteria to select articles and information sources, and evaluation against consistent methodological standards; See integrative review; meta-analysis
Unallocated reserves
Monies that have not been assigned a specific use
Standard normal distribution
Most of the values in a set of data are close to the "average" and relatively few values tend to one extreme or the other, creating a bell-shaped curve; See also normal distribution
Semantic interoperability
Mutual understanding of the meaning of data exchanged between information systems
Standardized payment
National base amount in the inpatient rehabilitation facility prospective payment system (IRF PPS). This amount is multiplied with the relative weight of the case-mix group to calculate the unadjusted payment; published annually in the Federal Register
Wireless wide-area network (WWAN)
Network that uses mobile telecommunication cellular network technologies to connect computers across a large area
Unstructured data
Nonbinary, human-readable data
ASTM
See American Society for Testing and Materials International
Custodial care
Nonskilled personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of bed or chair, moving round, and using the bathroom (CMS 2013)
Wireless on wheels (WOWs)
Notebook computers mounted on carts that can be moved through the facility by users
Decimal
Numbered or proceeding by tens; based on the number 10; expressed in or utilizing a decimal system, especially with a decimal point
Standardized mortality ratio
Observed mortality rate divided by the expected mortality rate
Synchronous
Occurring at the same time
ASCII
See American Standard Code for Information Interchange
Community Health Dimension (CHD)
One aspect of a national health information network infrastructure that acknowledges the importance of population-based health data and resources that are necessary to improve public health
Descriptive text
One component of the DSM, text that describes mental disorders under the following headings, Diagnostic Features; Subtypes and Specifiers; Recording Procedures; Associated Features and Disorders; Specific Culture, Age, and Gender Features; Prevalence, Course, Familial Pattern, and Differential Diagnosis (APA 2013)
Bed count day
One inpatient bed, set up and staffed for use in a 24-hour time period
Conceptual skills
One of the three managerial skill categories that includes intellectual tasks and abilities such as planning, deciding, and problem solving
Technical skills
One of the three managerial skill categories, related to knowledge of the technical aspects of the business
Surgical operation
One or more surgical procedures performed at one time for one patient via a common approach or for a common purpose
Bylaws
Operating documents that describe the rules and regulations under which a healthcare organization operates; See also rules and regulations
Association of Record Librarians of North America (ARLNA)
Organization formed 10 years after the beginning of the hospital standardization movement whose original objective was to elevate the standards of clinical recordkeeping in hospitals, dispensaries, and other healthcare facilities; precursor of the American Health Information Management Association
Coordinated care plans
Organized patient care plans that meet the standards set forth in the law for managed care plans (for example, health maintenance organizations, provider-sponsored organizations, and preferred provider organizations)
AQA Alliance
Originally known as the Ambulatory Care Quality Alliance. a large voluntary multi-stakeholder collaborative of physicians and other clinicians, consumers, purchasers, health plans, and others who strive to meet its responsibilities in an effective, efficient, public and transparent manner
Dashboards
Reports of process measures to help leaders follow progress to assist with strategic planning; Also called scorecards
Withhold
Portion of providers' capitated payments that managed care organizations deduct and hold in order to create an incentive for efficient or reduced utilization of healthcare services; Also called physician contingency reserve
Software engineers
Positions that combine aspects of systems analysis and programming; they analyze users' needs and design, test, and develop software to meet those needs
Creditable coverage
Prior healthcare coverage that is taken into account to determine the allowable length of preexisting condition exclusion periods (for individuals entering group health plan coverage)
Bugs
Problems in software that prevent the smooth application of a function
Telephone callback procedures
Procedures used primarily when employees have access to an organization's health information systems from a remote location that verify whether the caller's number is authorized and prevent access when it is not
Systems analysis
Process of studying organizational operations and determining information systems requirements for a given application
Secondary research
Processing data that has already been collected by another party
Telemedicine
Professional services given to a patient through an interactive telecommunications system by a practitioner at a distant site (CMS 2013); Also called telehealth
Strategic communications
Programs created to advance specific organizational goals such as promoting a new center or service, establishing a new program, or positioning the organization as a center of excellence in a specific discipline such as cardiology or oncology
Trait approach
Proposes that leaders possess a collection of traits or qualities that distinguish them from nonleaders
Data exchange standards
Protocols that help ensure that data transmitted from one system to another remain comparable
Standard treatment protocols (STPs)
Protocols that identify the specific service units necessary to produce a given product (patient)
Balanced Budget Act (BBA) 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)
Structure indicators
Quality indicators that measure the attributes of an organizational setting, such as number and qualifications of staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures
ACHE
See American College of Healthcare Executives
Base (payment) rate
Rate per discharge for operating and capital-related components for an acute care hospital
Wage index
Ratio that represents the relationship between the average wages in a healthcare setting's geographic area and the national average for that healthcare setting. Wage indexes are adjusted annually and published in the Federal Register
Cancer registry
Records maintained by many states for the purpose of tracking the incidence (new cases) of cancer; Also called tumor registry
Credited coverage
Reduction of waiting period for pre-existing condition based on previous creditable coverage
Workforce trends
Referring to changes that will likely take place in the workforce in the future
Transactional leadership
Refers to the role of the manager who strives to create an efficient workplace by balancing task accomplishment with interpersonal satisfaction
Uniform Bill-92 (UB-92)
Replaced by the UB-04 in 2007; it was a Medicare form for standardized uniform billing (CMS 2013)
UMLS Terminology Services (UTS)
Replaced the UMLS Knowledge Source Server (UMLSKS) in December 2010. A tool that provides access to the Knowledge Sources and other related resources via the Internet
Survey tools
Research instruments that are used to gather data and information from respondents in a uniform manner through the administration of a predefined and structured set of questions and possible responses
Comparative effectiveness research (CER)
Research that generates and synthesizes evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition, or to improve the delivery of care
Direct costs
Resources expended that can be identified as pertaining to specific goods and services (for example, medications pertain to specific patients)
Variable costs
Resources expended that vary with the activity of the organization, for example, medication expenses vary with patient volume
Analysis
Review of health record for proper documentation and adherence to regulatory and accreditation standards
Civilian Health and Medical Program—Uniformed Services (CHAMPUS)
Run by the Department of Defense, provided medical care to active duty members of the military, military retirees, and their eligible dependents. This program is now called TRICARE (CMS 2013)
standard cost profile
SCP
Semantic Data Model
SDM
standards development organization
SDO
severity weight
SW
Application controls
Security strategies, such as password management, included in application software and computer programs
ASTM E1384
See ASTM E1384 - 07(2013) Standard Practice for Content and Structure of the Electronic Health Record (EHR)
AIMS
See Abnormal Involuntary Movement Scale
AAAHC
See Accreditation Association for Ambulatory Health Care
AHRQ
See Agency for Healthcare Research and Quality
AHIP
See America's Health Insurance Plans
AAAASF
See American Association for Accreditation of Ambulatory Surgery Facilities
AAHP
See American Association of Health Plans
AAPPO
See American Association of Preferred Provider Organizations
Components
Self-contained miniapplications that are an outgrowth of object-oriented computer programming and provide an easy way to expand, modernize, or customize large-scale applications because they are reusable and less prone to bugs
Data silos
Separate repositories of data that do not communicate with each other
Charity care
Services for which healthcare organizations did not expect payment because they had previously determined the patients' or clients' inability to pay
Aberrancy
Services in medicine that deviate from what is typical in comparison to the national norm
Transfusion reactions
Signs, symptoms, or conditions suffered by a patient as the result of the administration of an incompatible transfusion
Allied health professionals performance review
Similar to the review for nursing staff, other allied health professionals, licensed and unlicensed, must provide evidence of maintenance of credentials and the ability to appropriately follow delineated procedure in their area of expertise in the healthcare organization
Server redundancy
Situation where two servers are duplicating effort
Cultural competence
Skilled in awareness, understanding, and acceptance of beliefs and values of the people of groups other than one's own
Uninterruptable power supply (UPS)
Source of power that allows equipment or information systems to work when the power source is unavailable
APC grouper
Software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter
Code editor
Software that evaluates the clinical consistency and completeness of health record information and identifies potential errors that could affect accurate prospective payment group assignment
Stop-loss benefit
Specific amount, in a certain time frame such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan; See catastrophic expense limit; maximum out-of-pocket cost
Clinical protocol
Specific instructions for performing clinical procedures established by authoritative bodies, such as medical staff committees, and intended to be applied literally and universally; See also clinical practice guidelines
Back-end speech recognition (BESR)
Specific use of SRT in an environment where the recognition process occurs after the completion of dictation by sending voice files through a server
Core measure/core measure set
Standardized performance measures developed to improve the safety and quality of healthcare (for example, core measures are used in the Joint Commission's ORYX initiative)
Conditions for Coverage
Standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid (CMS 2013); See also Conditions of Participation
Tort laws
State legislation that applies to civil cases dealing with wrongful conduct or injuries
Core-based statistical area (CBSA)
Statistical geographic entity consisting of the county or counties associated with at least one core (urbanized area or urban cluster) of at least 10,000 in population, plus adjacent counties having a high degree of social and economic integration with the core as measured through commuting ties with the counties containing the core. Metropolitan and micropolitan statistical areas are two components of CBSAs (US Census Bureau 2010)
Storage area network (SAN)
Storage devices organized into a network so that they can be accessible from any server in the network
Scenarios
Stories describing the current and feasible future states of the business environment
Time and motion studies
Studies in which complex tasks are broken down into their component motions to determine inefficiencies and to develop improvements
Staffing analysis
Study performed to determine the most efficient and cost-effective staff mix
Automated drug dispensing machines
System that makes drugs available for patient care
Barcode medication administration record (BC-MAR)
System that uses barcoding technology for positive patient identification and drug information
Web browser-based systems
Systems and applications written in one or more web programming languages; Also called web browser-based (or web native) architectures
Shared systems
Systems developed by data-processing companies in the 1960s and 1970s to address the computing needs of healthcare organizations that could not afford, or chose not to purchase, their own mainframe computing systems
Web content management systems
Systems in which information placed on a website can be labeled and tracked so that it can be easily located, modified, and reused
Cybernetic systems
Systems that have standards, controls, and feedback mechanisms built in to them
Closed systems
Systems that operate in a self-contained environment
TCP/IP transmission control protocol/Internet protocol
TCP/IP
Tax Equity and Fiscal Responsibility Act of 1982
TEFRA
Web 3.0
Technologists are beginning to discuss the concept of Web/Health 3.0, and while the definitions vary widely, it will likely focus on expanding the participatory and collaborative nature of social networks that defined Web 2.0 to include more real-time video and 3D elements; other commentators argue that Web 3.0 will adopt Semantic web standards, thereby allowing computers to read and generate content similar to humans
Computers on wheels (COWs)
Term affectionately used to refer to notebook computers mounted on carts and moved with the users
Best practice
Term used to refer to services that have been deemed effective and efficient with certain groups of clients
Stress testing
Testing performed toward the end of EHR implementation to ensure that the actual number, or load, of transactions that would be performed during peak hours can be performed
Case-mix groups (CMGs)
The 97 function-related groups into which inpatient rehabilitation facility discharges are classified on the basis of the patient's level of impairment, age, comorbidities, functional ability, and other factors
AHIMA Standards of Ethical Coding
The American Health Information Management Association's principles of professional conduct for coding professionals involved in diagnostic or procedural coding or other health record data abstraction
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
Supplemental medical insurance (SMI)
The Medicare program that pays for a portion of the costs of physicians' services, outpatient hospital services, and other related medical and health services for voluntarily insured and disabled individuals (CMS 2013)
Acute-care prospective payment system
The Medicare reimbursement methodology system referred to as the inpatient prospective payment system (IPPS). Hospital providers subject to the IPPS utilize the Medicare severity diagnosis-related groups (MS-DRGs) classification system, which determines payment rates (CMS 2012)
Attestation
The act of applying an electronic signature to the content showing authorship and legal responsibility for a particular unit of information
Security officer or chief security officer
The Security Rule mandates an individual to be in charge of the security program for the covered entity. HIPAA calls this individual a security official; however this position is frequently called chief security officer (CSO) by the covered entities. This person is responsible for overseeing privacy policies and procedures and managing the organization's information security program
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 (WHO 2013)
Unified messaging
The ability for an individual to receive or retrieve various forms of messaging at a single access point, including voice, e-mail, fax, and text messages
Construct validity
The ability of an instrument to measure hypothetical, nonobservable traits
Skill
The ability, education, experience, and training required to perform a job task
Statement of changes in net assets
The accounting statement that explains the differences in net assets from period to period on the balance sheet
Data warehousing
The acquisition of all the business data and information from potentially multiple, cross-platform sources, such as legacy databases, departmental databases, and online transaction-based databases, and then the warehouse storage of all the data in one consistent format used to analyze data for decision-making purposes
Conditions of Participation
The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services (CMS 2013); See also Conditions for Coverage
Data standard
The agreed-upon specifications for the values acceptable for specific data fields; See also data content standard
Average payment rate (APR)
The amount of money the Centers for Medicare and Medicaid could pay a health maintenance organization for services rendered to Medicare recipients under a risk contract
Simple random sampling
The process of selecting units from a population so that each one has exactly the same chance of being included in the sample
Debit
The amount on the left side of an account entry that represents an increase in an expense or liability account or a decrease in a revenue or asset account
Business process reengineering (BPR)
The analysis and design of the workflow within and between organizations
Ancillary service visit
The appearance of an outpatient in a unit of a hospital or outpatient facility to receive services, tests, or procedures; ordinarily not counted as an encounter for healthcare services
Staffing structure
The arrangement of staff positions within an organization
Shift rotation
The assignment of employees to different periods of service to provide coverage, as needed
Arithmetic mean length of stay (AMLOS)
The average length of stay for all patients
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
Sixty-day episode payment
The basic unit of payment under the home health prospective payment system that covers a beneficiary for 60 days regardless of the number of days furnished unless the beneficiary elects to transfer, has a significant change in condition, or is discharged and then returns to the same agency within the 60-day episode
Accounting period
The entire process of identifying and recording a transaction and ultimately reporting it as part of an organization's financial statement
Stillbirth
The birth of a fetus, regardless of gestational age, that shows no evidence of life (such as heartbeats or respirations) after complete expulsion or extraction from the mother during childbirth
Constitutional law
The body of law that deals with the amount and types of power and authority that governments are given
Central processing unit
The brain of a computer, or the circuits that make the electrical parts function
Civil law
The branch of law involving court actions among private parties, corporations, government bodies, or other organizations, typically for the recovery of private rights with compensation usually being monetary
Accounting entity
The business structure, including the activities and records to be maintained for the preparation of an individual organization's financial statements
Backward compatibility
The capability of a software or hardware product to work with earlier versions of itself
Critical care
The care of critically ill patients in a medical emergency requiring the constant attention of the physician
Data management
The combined practices of HIM, IT, and HI that affect how data and documentation combine to create a single business record for an organization
Budget cycle
The complete process of financial planning, operations, and control for a fiscal year; overlaps multiple fiscal years; Also called budget calendar
Conceptual framework of accounting
The concept that the benefits of financial data should exceed the cost of obtaining them and that the data must be understandable, relevant, reliable, and comparable
Dead on arrival (DOA)
The condition of a patient who arrives at a healthcare facility with no signs of life and who was pronounced dead by a physician
Contextual
The condition of depending on the parts of a written or spoken statement that precede or follow a specified word or phrase and can influence its meaning or effect
Architecture
The configuration, structure, and relationships of hardware (the machinery of the computer including input/output devices, storage devices, and so on) in an information system
Three-dimensional imaging
The construction of pictures generated from computer data in three dimensions
Cost-sharing
The cost for medical care that patients pay for themselves, like a copayment, coinsurance, or deductible (CMS 2013)
System build (or configuration)
The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system
Significance level
The criterion used for rejecting the null hypothesis; a preestablished cutoff that determines whether the null hypothesis is rejected; the alpha level
Debt service
The current obligations of an organization to repay loans
Cross-training
The training to learn a job other than the employee's primary responsibility
Assessment final completion date
The date (within 32 days of the assessment's final completion date) on which the Centers for Medicare and Medicaid requires Minimum Data Set for Long-Term Care assessments to be electronically submitted to the facility's state Minimum Data Set for Long-Term Care database
Assessment reference date (ARD)
The date that sets the designated end point of resident observation for all staff participating in the assessment
Data
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions
Direct obstetric death
The death of a woman resulting from obstetric complications of the pregnancy state, labor, or puerperium; from interventions, omissions, or treatment; or from a chain of events resulting from any of the events listed
Certainty factor
The defined certainty percentage rate with which an occurrence must present itself to satisfy quality standards
Differentiation
The degree to which a tumor resembles the normal tissue from which it arose
Transparency
The degree to which individual patients are made aware of how their personal health information is or has been dispersed to secondary medical databases
Temporary budget variance
The difference between the budgeted and actual amounts of a line item that is expected to reverse itself in a subsequent period; the timing difference between the budget and the actual event
Contractual allowance
The difference between what is charged by the healthcare provider and what is paid by the managed care company or other payer; Also called contractual adjustment
Against medical advice (AMA)
The discharge status of patients who leave a hospital prior to the recommended discharge date given by the physician
Variability
The dispersion of a set of measures around the population mean
Cost allocation
The distribution of costs
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 (DRP)
The document that defines the resources, actions, tasks, and data required to manage the businesses recovery process in the event of a business interruption
Charges
The dollar amounts actually billed by healthcare facilities for specific services or supplies and owed by patients
Consolidated Health Informatics (CHI) initiative
The effort to achieve CHI through federal agencies spearheaded by the Office of National Coordinator for Health Information Technology
Work
The effort, usually described in hours, needed to complete a task
Board of directors
The elected or appointed group of officials who bear ultimate responsibility for the successful operation of a healthcare organization; Also called board of governors; board of trustees
Beneficiary-elected transfer
The elective transfer of a patient from one home health agency to another during a 60-day episode
Virtualization
The emulation of one or more computers within a software platform that enables one physical computer to share resources across other computers
Business intelligence (BI)
The end product or goal of knowledge management
Days in accounts receivable
The ending accounts receivable balance divided by an average day's revenues
Clinical practice standards
The established criteria against which the decisions and actions of healthcare practitioners and other representatives of healthcare organizations are assessed in accordance with state and federal laws, regulations, and guidelines; the codes of ethics published by professional associations or societies; the criteria for accreditation published by accreditation agencies; or the usual and common practice of similar clinicians or organizations in a geographical region
Valuation
The estimated market value of a project, an object, a merger, and so on
Correlation
The existence and degree of relationships among factors
Content validity
The extent to which an instrument's items represent the content that the instrument is intended to measure
Data currency
The extent to which data are up-to-date; a datum value is up-to-date if it is current for a specific point in time. It is outdated if it was current at some preceding time yet incorrect at a later time
Data validity
The extent to which data have been verified to be accurate
Data availability
The extent to which healthcare data are accessible whenever and wherever they are needed
Data relevancy
The extent to which healthcare-related data are useful for the purposes for which they were collected
Data confidentiality
The extent to which personal health information is kept private
Data consistency
The extent to which the healthcare data are reliable and the same across applications
Corporate negligence
The failure of an organization to exercise the degree of care considered reasonable under the circumstances that resulted in an unintended injury to another party
Age Discrimination in Employment Act (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)
Securities and Exchange Commission (SEC)
The federal agency that regulates all public and some private transactions involving the ownership and debt of organizations (SEC 2013)
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 (CHAMPVA 2013)
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
Unfreezing
The first stage of Lewin's change process in which people are presented with disconcerting information to motivate them to change
Data structure
The form in which data are stored, as in a file, a database, a data repository, and so on
Civil Rights Act 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)
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
The federal legislation that modified Medicare's retrospective reimbursement system for inpatient hospital stays by requiring implementation of diagnosis-related groups and the acute care prospective payment system (Public Law 97-248 1982)
Social Security Act of 1935
The federal legislation that originally established the Social Security program as well as unemployment compensation and support for mothers and children; amended in 1965 to create the Medicare and Medicaid programs (Ch 531, 49 Stat. 620 1935)
Security Rule
The federal regulations created to implement the security requirements of HIPAA
Customary fee
The fee normally charged by physicians of the same specialty in the same geo-
Biotechnology
The field devoted to applying the techniques of biochemistry, cellular biology, biophysics, and molecular biology to addressing practical issues related to human beings, agriculture, and the environment
System maintenance and evaluation
The final phase of the systems development life cycle
System planning and analysis
The first phase of the systems development life cycle
Analysis phase
The first phase of the systems development life cycle during which the scope of the project is defined, project goals are identified, current systems are evaluated, and user needs are identified
X-axis
The horizontal axis on a graph where the independent variables are noted
Skewness
The horizontal stretching of a frequency distribution to one side or the other so that one tail is longer than the other, creating a negative or positive skew
Assets
The human, financial, and physical resources of an organization
Ancillary packaging
The inclusion of routinely performed support services in the reimbursement classification of a healthcare procedure or service
Disaster recovery coordinator
The individual authorized and responsible for implementing and coordinating IS disaster recovery operations
Database administrator
The individual responsible for the technical aspects of designing and managing databases
Compliance program guidance
The information provided by the Office of the Inspector General of the Department of Health and Human Services to help healthcare organizations develop internal controls that promote adherence to applicable federal and state guidelines
Data granularity
The level of detail at which the attributes and values of healthcare data are defined
Bit
The level of voltage (low or high) in a computer that provides the binary states of 0 and 1 that computers use to represent characters
Vertical structure
The levels and relationships among positions in an organizational hierarchy
Staff authority
The lines of reporting in the organizational chart in which the position advises or makes recommendations
Computerized internal fee schedule
The listing of the codes and associated fees maintained in the practice's computer system, along with the additional data fields necessary for completing the CMS-1500 claim form
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
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 court of general jurisdiction, which hears more serious criminal cases or civil cases that involve large amounts of money
Content and records management
The management of digital and analog records using computer equipment and software. It encompasses two related organization-wide roles, content management and records management
Communications
The manner in which various individual computer systems are connected (for example, telephone lines, microwave, satellite)
Average daily census
The mean number of hospital inpatients present in the hospital each day for a given period of time
Semantics
The meaning of a word or term; sometimes refers to comparable meaning, usually achieved through a standard vocabulary
Audit controls
The mechanisms that record and examine activity in information systems
Clinician/physician web portals
The media for providing physician/clinician access to the provider organization's multiple sources of data from any network-connected device
Average record delinquency rate
The monthly average number of discharges divided by the monthly average number of delinquent records
Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT)
The most comprehensive, multilingual clinical healthcare terminology in the world. SNOMED CT contributes to the improvement of patient care by underpinning the development of electronic health records that record clinical information in ways that enable meaning-based retrieval (IHTSDO 2013)
Transmission control protocol/Internet protocol (TCP/IP)
The multifaceted protocol suite, or open standard not owned by or proprietary to any company, on which the Internet runs
American Medical Record Association (AMRA)
The name adopted by the American Association of Medical Record Librarians in 1970; precursor of the American Health Information Management Association
American Medical Association (AMA)
The national professional membership organization for physicians that distributes scientific information to its members and the public, informs members of legislation related to health and medicine, and represents the medical profession's interests in national legislative matters; maintains and publishes the CPT coding system (AMA 2013)
American College of Healthcare Executives (ACHE)
The national professional organization of healthcare administrators that provides certification services for its members and promotes excellence in the field (ACHE 2013)
American Physical Therapy Association (APTA)
The national professional organization whose goal is to foster advancements in physical therapy practice, research, and education (APTA 2013)
America's Health Insurance Plans (AHIP)
The national trade association representing the health insurance industry. It's members provide health and supplemental benefits to more than 200 million Americans through employer-sponsored coverage, the individual insurance market, and public programs such as Medicare and Medicaid.
American Hospital Association (AHA)
The national trade organization that provides education, conducts research, and represents the hospital industry's interests in national legislative matters; membership includes individual healthcare organizations as well as individual healthcare professionals working in specialized areas of hospitals, such as risk management; one of the four Cooperating Parties on policy development for the use of ICD-9-CM (AHA 2013)
American Occupational Therapy Association
The nationally recognized professional association of more than 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy
Unfavorable variance
The negative difference between the budgeted amount and the actual amount of a line item, where actual revenue is less than budget or where actual expenses exceed budget
Shared Visions—New Pathways
The new accreditation process implemented by the Joint Commission in January 2004 and designed to focus on systems critical to the safety and quality of patient care, treatment, and services
Consolidated Health Informatics (CHI)
The notion of adopting existing health information interoperability standards throughout all federal agencies
Scope of command
The number and type of employees who report to a specific management position in a defined organizational structure
Bed capacity
The number of beds that a facility has been designed and constructed to house
Cash conversion cycle
The period that refers to expenditures needed to provide services to patients through the reimbursement or collection of fees for those provided services
Secondary storage
The permanent storage of data and programs on disks or tapes
Custodian of health records
The person designated as responsible for the operational functions of the development and maintenance of the health record and who may certify through affidavit or testimony the normal business practices used to create and maintain the record
Clinical data manager
The person responsible for managing the data collected during the research project, developing data standards, conducting clinical coding for specific data elements, determining the best database to house the data, choosing appropriate software systems to analyze the data, and conducting data entry and data analysis; includes various responsibilities according to the research study protocol
Source of admission
The point from which a patient enters a healthcare organization, including physician referral, clinic referral, health maintenance organization referral, transfer from a hospital, transfer from a skilled nursing facility, transfer from another healthcare facility, emergency department referral, court or law enforcement referral, and delivery of newborns
Benefits realization
The point in time when the organization believes all end users are trained, the system has gone live, and there has been some period of time to get acclimated and adopt as much of the process changes and functionality as possible
Dividends
The portion of an organization's profit that is distributed to its investors
Technical component (TC)
The portion of radiological and other procedures that is facility based or nonphysician based (for example, radiology films, equipment, overhead, endoscopic suites, and so on)
Autopsy
The postmortem examinations of the organs and tissues of a body to determine the cause of death or pathological conditions
Clustering
The practice of coding/charging one or two middle levels of service codes exclusively, under the philosophy that some will be higher, some lower, and the charges will average out over an extended period
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
Consolidation
The process by which the ambulatory patient group classification system determines whether separate payment is appropriate when a patient is assigned multiple significant procedure groups
Clinical quality assessment
The process for determining whether the services provided to patients meet predetermined standards of care
Semantic normal form (SNF)
The preferred term for clinical drugs in RxNorm
Discovery process
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
Average wholesale price (AWP)
The price commonly used when negotiating pharmacy contracts
Taxonomy
The principles of a classification system, such as data classification, and the study of the general principles of scientific classification
Statistical significance
The probability that an observed difference is due to chance
Scanning
The process by which a document is read into an optical imaging system
Data collection
The process by which data are gathered
Work schedules
The process by which facility managers ensure that each department has adequate personnel to properly complete all assigned tasks
Clinical data analytics
The process by which health information is captured, reviewed, and used to measure quality
Delegation
The process by which managers distribute work to others along with the authority to make decisions and take action
Association rule analysis (rule induction)
The process of extracting useful if/then rules from data based on statistical significance; See also rule induction
Vocational rehabilitation
The process of facilitating an individual in the choice of or return to a suitable vocation, assisting the patient to obtain training for vocation, preparing an individual to cope emotionally, psychologically, and physically with changing circumstances in life (CMS 2013)
Clinical analytics
The process of gathering and examining data in order to help gain greater insight about patients
Socialization
The process of influencing the behavior and attitudes of a new employee to adapt positively to the work environment
Configuration management
The process of keeping a record of changes made in an EHR system as it is being customized to the organization's specifications; Also called change control
Data security
The process of keeping data, both in transit and at rest, safe from unauthorized access, alteration, or destruction
Spaced training
The process of learning a task in sections separated by time
Backup
The process of maintaining a copy of all software and data for use in the case that the primary source becomes compromised
Data retrieval
The process of obtaining data from a healthcare database
Team building
The process of organizing and acquainting a team and building skills for dealing with later team processes
Biofeedback
The process of providing visual or auditory evidence to a person on the status of an autonomic body function (such as the sounding of a tone when blood pressure is at a desirable level) so that he or she learns to exert control over the function
Data capture
The process of recording healthcare-related data in a health record system or clinical database
Degaussing
The process of removing or rearranging the magnetic field of a disk in order to render the data unrecoverable
Backscanning
The process of scanning past medical records into the system so that there is an existing database of patient information, making the system valuable to the user from the first day of implementation
Systematic sampling
The process of selecting a sample of subjects for a study by drawing every nth unit on a list
Cluster sampling
The process of selecting subjects for a sample from each cluster within a population (for example, a family, school, or community)
Stratified random sampling
The process of selecting the same percentages of subjects for a study sample as they exist in the subgroups (strata) of the population
American Society for Healthcare Risk Management (ASHRM)
The professional society for healthcare risk management professionals that is affiliated with the American Hospital Association and provides educational tools and networking opportunities for its members
Accounting rate of return
The projected annual cash inflows, minus any applicable depreciation, divided by the initial investment
Bed occupancy ratio
The proportion of beds occupied, defined as the ratio of inpatient service days to bed count days during a specified period of time
Death rate
The proportion of inpatient hospitalizations that end in death
Cancer mortality rate
The proportion of patients that die from cancer
Autopsy rate
The proportion or percentage of deaths in a healthcare organization that are followed by the performance of autopsy
American Recovery and Reinvestment Act of 2009 (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. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases
Sample size calculation
The qualitative and quantitative procedures to determine an appropriate sample size
Bandwidth
The range of frequencies a device or communication medium is capable of carrying
Continuum of care
The range of healthcare services provided to patients, from routine ambulatory care to intensive acute care; the emphasis is on treating individual patients at the level of care required by their course of treatment with the assurance of communication between caregivers
Cost of capital
The rate of return required to undertake a project
Cesarean section rate
The ratio of all cesarean sections to the total number of deliveries, including cesarean sections, during a specified period of time
Anesthesia death rate
The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time
Bounded rationality
The recognition that decision making is often based on limited time and information about a problem and that many situations are complex and rapidly changing
Dependency
The relationship between two tasks in a project plan
Data quality
The reliability and effectiveness of data for its intended uses in operations, decision making, and planning; See also data integrity
Anesthesia report
The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure
Consultation
The response by one healthcare professional to another healthcare professional's request to provide recommendations or opinions regarding the care of a particular patient or resident
Data stewardship
The responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing, or otherwise making use of personal 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
Divestiture
The result of a parent company selling a portion of the company to an outside party for cash or other assets
Zero balance
The result of writing off the balance of an account, which closes off the account and ends the days in accounts receivable
Authority
The right to make decisions and take actions necessary to carry out assigned tasks
Actor
The role a user plays in a system
Syntax
The rules and conventions that one needs to know or follow in order to validly record information, or interpret previously recorded information, for a specific purpose. Such rules and conventions may be either explicit or implicit (CMS 2013)
Team norms
The rules, both explicit and implied, that determine both acceptable and unacceptable behavior for a group
American College of Surgeons (ACS)
The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice (ACS 2013)
Common-cause variation
The source of variation in a process that is inherent within the process
Bill hold period
The span of time during which a bill is suspended in the billing system awaiting late charges, diagnosis or procedure codes, insurance verification, or other required information
Cost accounting
The specialty branch of accounting that deals with quantifying the resources expended to provide the goods and services offered by the organization to its customers, clients, or patients
Care plan
The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care; serves as the primary source for ongoing documentation of the resident's care, condition, and needs
Data definition
The specific meaning of a healthcare-related data element
Data comparability
The standardization of vocabulary such that the meaning of a single term is the same each time the term is used in order to produce consistency in information derived from the data
Attending Physician Statement (APS)
The standardized insurance claim form created in 1958 by the Health Insurance Association of America and the American Medical Association; See also COMB-1 form
Solvency
The state of being able to pay all debts
Task
The step to be performed in order to complete a project or part of a project
Ten-step monitoring and evaluation process
The systematic and ongoing collection, organization, and evaluation of data related to indicator development promoted by the Joint Commission in the mid-1980s
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
Data conversion
The task of moving data from one data structure to another, usually at the time of a new system installation
Decile
The tenth equal part of a distribution
Advanced practice registered nurse (APRN)
The term being increasingly used by legislative and governing bodies to describe the collection of registered nurses that practice in the extended role beyond the normal role of basic registered nursing
Unit testing
The testing step in EHR implementation that ensures that each data element is captured, recorded, and processed appropriately within a given application
System implementation
The third phase of the systems development life cycle
Waiting period
The time between when a patient signs up with an insurance company and when the coverage starts (CMS 2013)
Charge ticket
The tool used to collect data for the billing process; Also called billing slip; charge slip; encounter form; fee slip; fee ticket; route slip; route tag; superbill
Current ratio
The total current assets divided by total current liabilities
Debt ratio
The total liabilities divided by the total assets
Crude death 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
Therapy threshold
The total number of therapy visits (10) for an episode of care in the Medicare system
Telesurgery
The use of robotics to perform surgery. This allows surgery to be performed on a patient in a different location
Telematics
The use of telecommunications and networks to share information among a patient and healthcare providers located in different locations or sites
Collateral
The value of specific assets that are used to guarantee the purchase of material goods
Y-axis
The vertical axis on a graph that displays frequency
Work division
The way in which tasks are handled within an organization
Benefits period
The way that Medicare measures the use of hospital and skilled nursing facility services. A benefit period begins the day a patient goes to a hospital or skilled nursing facility. The benefit period ends when the patient has not received any hospital care (or skilled care in an SNF) for 60 days in a row. There is no limit to the number of benefit periods a patient can have (CMS 2013)
Birth weight
The weight of a neonate (expressed to the nearest gram) determined immediately after delivery or as soon thereafter as feasible
Adjusted historic payment base (AHPB)
The weighted average prevailing charge for a physician service applied in a locality for 1991 and adjusted to reflect payments for services with charges below the prevailing charge levels and other payment limits; determined without regard to physician specialty and reviewed and updated yearly since 1992
Work and data flow analyst
The work and data flow analyst must be able to study the flow of data into the system and its associated processes and look for ways to improve it, using data flow diagrams and other tools to document the various flows of data within the facility
Date of encounter (outpatient and physician services)
The year, month, and day of an encounter, visit, or other healthcare encounter
Date of procedure (inpatient)
The year, month, and day of each significant procedure
Drug Listing Act of 1972
This act amended the Federal Food, Drug, and Cosmetic Act so that drug establishments that are engaged in the manufacturing, preparation, propagation, compounding, or processing of a drug are required to register their establishments and list all of their commercially marketed drug products with the Food and Drug Administration (FDA) (Public Law 92-387 1972)
Speech-language therapy (SLP)
Treatment to regain and strengthen speech skills (CMS 2013)
Civil Rights Act
Title VII (1964), The federal legislation that prohibits discrimination in employment on the basis of race, religion, color, sex, or national origin (Public Law 88-352 1964)
Benefit cap
Total dollar amount that a healthcare insurance company will pay for covered healthcare services during a specified period, such as a year or lifetime
Common Formats Version 1.1
Tracking system used to report patient safety events
Trauma registry software
Tracks patients with traumatic injuries from the initial trauma treatment to death
Awareness training
Training designed to help individuals understand and respond to information technology concerns
Clinical Care Classification System Version 2.5 (CCC)
Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings (Sabacare 2013)
Closed panel
Type of health maintenance organization that provides hospitalization and physicians' services through its own staff and facilities; beneficiaries are allowed to use only those specified facilities and physicians or dentists who accept the plan or organization's conditions of membership and reimbursement; See group model health maintenance organization; staff model health maintenance organization
Case-based payment
Type of prospective payment method in which the third-party payer reimburses the provider a fixed, preestablished payment for each case
Translational research
Type of research that converts new knowledge, mechanisms, and techniques generated by advances in basic science research into new approaches for prevention, diagnosis, and treatment of disease
Zero-based budgets
Types of budgets in which each budget cycle poses the opportunity to continue or discontinue services based on available resources so that every department or activity must be justified and prioritized annually to effectively allocate resources
usual, customary, and reasonable
UCR
UMLS Terminology Services
UTS
Certified Guidance Document (CGD)
Under ARRA, the purpose is to explain the factors ONC will use to determine whether or not to recommend to the Secretary of HHS a body as a Recommended Certification Body (RCB). The CGD will serve as a guide for ONC as it evaluates applications for RCB status and seeks to provide all of the information a body would need to apply for and obtain such status (2 CFR 176 2009)
Common ownership
Under HIPAA, Subpart A of this section, exists if an entity or entities possess an ownership or equity interest of five (5) percent or more in another entity (45 CFR 164.103 2009)
Valid authorization
Under HIPAA, a valid authorization under section 164.508 must contain at least the following elements, (i) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion; (ii) The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure; (iii) The name or other specific identification of the person(s), or the class of persons, to whom the covered entity may make the requested use or disclosure; (iv) A description of each purpose of the requested use or disclosure; (v) An expiration date or an expiration event that relates to the individual or the purpose of the use or disclose; (vi) Signature of the individual and the date. If the authorization is signed by a personal representative of the individual, a description of such representative's authority to act for the individual must also be provided (45 CFR 164.508 2013)
Amendment Request
Under HIPAA, an amendment of protected health information, an individual has the right to have a covered entity amend protected health information or a record about the individual in a designated record set for as long as the protected health information is maintained in the designated record set (45 CFR 164.526 2001)
Compound authorization
Under HIPAA, an authorization for use or disclosure of protected health information may not be combined with any other document to create a compound authorization, except as follows, (i) an authorization for the use of disclosure of protected health information for a research study may be combined with any other type of written permission for the same or another research study; (ii) an authorization for a use or disclosure of psychotherapy notes may only be combined with another authorization for a use or disclosure of psychotherapy notes; (iii) when a covered entity has conditioned the provision of treatment, payment, enrollment in the health plan, or eligibility for benefits under this section on the provision of one of the authorizations (45 CFR 164.508 2013)
Defective authorization
Under HIPAA, an authorization is not valid, if the document submitted has any of the following defects, (i) The expiration date has passed or the expiration event is known by the covered entity to have occurred; (ii) The authorization has not been filled out completely, with respect to an element described in section 164.508(c); (iii) The authorization is known by the covered entity to have been revoked; (iv) The authorization violates any paragraph in 164.508; (v) Any information in the authorization is known by the covered entity to be false (45 CFR 164.508 2013)
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 and to manage the conduct of the covered entity's or business associate's workforce in relation to the protection of that information (45 CFR 164.304 2013)
Common control
Under HIPAA, exists if an entity has the power, directly or indirectly, to significantly influence or direct the actions or policies of another entity (45 CFR 164.103 2009)
Code Set
Under HIPAA, means any set of codes used to encoded data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This set includes the codes and the descriptors of the codes (45 CFR 162.103 2012)
Covered professional services
Under HITECH incentives, specific to the Medicare program, are those services furnished by an eligible provider, which is based on services defined in the Medicare fee schedule (42 CFR 495.100 2012)
Common MU data set
Under HITECH incentives, the following data expressed, where indicated, according to the specified standard(s), (1) Patient Name, (2) Sex, (3) Date of birth, (4) Race—the standard specified in 170.207(f), (5) Ethnicity—the standard specified in 170.207(f), (6) Preferred language—the standard specified in 170.207(g); (7) Smoking status—the standard specified in 170.207(h); (8) Problems—at a minimum, the version of the standard specified in 170.207(a)(3), (9) Medications—at a minimum, the version of the standard specified in 170.207(d)(2), (10) Medication allergies—at a minimum, the version of the standard specified in 170.207(d) (2), (11) Laboratory test(s)—at a minimum, the version of the standard specified in 170.207(c)(2), (12) Laboratory value(s)/results(s), (13) Vital signs—height, weight, blood pressure, BMI, (14) Care plan field(s), including goals and instructions, (15) Procedures—(i) At a minimum, the version of the standard specified in 170.207(a)(3) or 170.207(b)(2), (ii) Optional. The standard specified at 170.207(b)(3), (iii) Optional. The standard specified at 170.207(b)(4), (16) Care team member(s) (45 CFR 170.102 2012)
Certified EHR Technology
Under HITECH, (1) For any federal fiscal year (FY) or calendar year (CY) up to and including 2013, (i) A complete EHR that meets the requirements included in the definition of a qualified EHR and has been tested and certified in accordance with the certification program established by the national coordinator as having met all applicable certification criteria adopted by the secretary for the 2011 edition EHR certification criteria or the equivalent 2014 edition EHR certification criteria; or (ii) A combination of EHR modules in which each constituent EHR module of the combination has been tested and certified in accordance with the certification program established by the national coordinator as having met all applicable certification criteria adopted by the secretary for the 2011 edition EHR certification criteria or the equivalent 2014 edition EHR certification criteria, and the resultant combination also meets the requirements included in the definition of a qualified EHR; or (iii) EHR technology that satisfies the definition for FY and CY 2014 and subsequent years specified in paragraph (2); (2) For FY and CY 2014 and subsequent years, the following, EHR technology certified under the ONC HIT Certification Program to the 2014 edition EHR certification criteria that has, (i) The capabilities required to meet the base EHR definition; and (ii) All other capabilities that are necessary to meet the objectives and associated measures under 42 CFR 495.6 and successfully report the clinical quality measures selected by CMS in the form and manner specified by CMS (or the states, as applicable) for the stage of meaningful use that an eligible professional, eligible hospital, or critical access hospital seeks to achieve (45 CFR 170.102 2012)
Base EHR
Under HITECH, an electronic record of health-related information on an individual that, Includes patient demographic and clinical health information, such as medical history and problem lists; (2) Has the capacity, (i) To provide clinical decision support; (ii) To support physician order entry; (iii) To capture and query information relevant to health care quality; (iv) To exchange electronic health information with, and integrate such information from other sources; (v) To protect the confidentiality, integrity, and availability of health information stored and exchanged; and (3) Has been certified to the certification criteria adopted by the Secretary at, 170.314(a)(1), (3), and (5) through (8); (b)(1), (2), and (7); (c)(1) through (3); (d)(1) through (8). (4) Has been certified to the certification criteria at 170.314(c)(1) and (2), (i) For no fewer than 9 clinical quality measures covering at least 3 domains from the set selected by CMS for eligible professionals, including at least 6 clinical quality measures from the recommended core set identified by CMS; or (ii) For no fewer than 16 clinical quality measures covering at least 3 domains from the set selected by CMS for eligible hospitals and critical access hospitals (45 CFR 170.102 2012)
Certification criteria
Under HITECH, criteria set of guidelines (1) to establish that health information technology meets applicable standards and implementation specifications adopted by the secretary or (2) that are used to test and certify that health information technology includes required capabilities (45 CFR 170.102 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 (45 CFR 164.402 2013)
Contrary
Under HITECH, when used to compare a provision of state law to a standard, requirement, or implementation specification adopted under this subchapter means, 1) A covered entity or business associate would find it impossible to comply with both the state and federal requirements; or (2) The provisions of state law stands as an obstacle to the accomplishment and execution of the full purposes and objectives of part C of title XI of the Act, section 264 of Public Law 104-191, or sections 13400-13424 of Public Law 111-5, as applicable (45 CFR 260.202 2013)
Breach of security
Under HITECH, with respect to unsecured PHR, identifiable health information of an individual in a PHR, acquisition of such information without the authorization of the individual. Unauthorized acquisition will be presumed to include unauthorized access to unsecured PHR identifiable health information unless the vendor of personal health records, PHR related entity, or third party service provider that experienced the breach has reliable evidence showing that there has not been, or could not reasonably have been, unauthorized acquisition of such information (16 CFR 318.2, as stated in Public Law 111-5 2009)
Default codes
Under ICD-10-CM a code listed next to a main term in the Alphabetic Index is referred to as a what code? The code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition (CDC 2013)
Bypass
Under ICD-10-PCS, a root operation that involves altering the route of passage of the contents of a tubular body part (CMS 2013)
Detachment
Under ICD-10-PCS, a root operation that involves cutting off all or part of the upper or lower extremities (CMS 2013)
Dilation
Under ICD-10-PCS, a root operation that involves expanding an orifice or the lumen of a tubular body part (CMS 2013)
Alteration
Under ICD-10-PCS, a root operation that involves modifying the natural anatomic structure of a body part without affecting the function of the body part (CMS 2013)
Destruction
Under ICD-10-PCS, a root operation that involves physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent (CMS 2013)
Change
Under ICD-10-PCS, a root procedure that involves taking out or off a device from a body part and putting back an identical or similar devices in or on the same body part without cutting or puncturing the skin or a mucous membrane (CMS 2013)
Ambulatory surgery center or 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
Common law
Unwritten law originating from court decisions where no applicable statute exists; See case law; judge-made law
Dictation system
Used by physicians and transcription staff to dictate various medical reports such as the operative report, history and physical, and the discharge summary
Audit reduction tool
Used to review the audit trail and compare it to facility-specific criteria and eliminate routine entries such as the periodic backups
Automated code assignment
Uses data that have been entered into a computer to automatically assign codes; uses natural language processing (NLP) technology—algorithmic (rules-based) or statistical—to read the data contained in a CPR
value-based purchasing
VBP
Telecommunications
Voice and data communications
web services architecture
WSA
Blogs
Web logs that provide a web page where users can post text, images, and links to other websites
Data entity
a discrete form of data, such as a number or a word
Correction
addendum, and appending health records policy, A policy that outlines how corrections, addenda, or appendages are made in a health record
Data mapping
allows for connections between two systems. This connection allows for data initially captured for one purpose to be translated and used for another purpose. One system in a map is identified as the source while the other is the target. 2. Process by which two distinct data models are created and a link between these models is defined. 3. A process used in data warehousing by which different data models are linked to each other using a defined set of methods to characterize the data in a specific definition. This definition can be any atomic unit, such as a unit of metadata or any other semantic. This data linking follows a set of standards, which depends on the domain value of the data model used. Data mapping serves as the initial step in data integration
Usual
customary, and reasonable (UCR), 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
Discharged
no final bill (DNFB) report, A report that includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete
Subjective
objective, assessment, plan (SOAP), Documentation method that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans
American Academy of Professional Coders (AAPC)
other than ahima who else provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations (AAPC 2013)
Customary
prevailing and reasonable (CPR) charge payment method, Type of retrospective fee-for-service payment method used by Medicare until 1992 to determine payment amounts for physician services, in which the third-party payer pays for fees that are customary, prevailing, and reasonable
virtual private network
vpn