Chapter 16 electronic health records

Hospital information system HIS

the comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hopital

Human - computer interface

the device used by humans to access and enter data into a computer system, such as a keyboard on a PC, personal digital assistant, voice recognition system, and so on

Point of care (POC)

the place or location where the physician administers services to the patient

Issues management

the process of resolving unexpected occurrences (e.g. late delivery of needed supplies or an uncorrected system problem)

Systemized Nomenclature of Medicine-Clinical Terms (SNOMED-CT)

a concept-based terminology consisting of more than 110,000 concepts with linkages to more than 180,000 terms with unique computer-readable codes

Encryption

the process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination

Retention schedule

time line for various records retention based on factors such as federal and state laws, statutes of limitations, age of patient, competency of patient, accreditation standards, AHIMA recommendations, and operational needs

Client/server architecture

computer architecture in which multiple computers (clients) are connected to other computers (servers) that store and distribute large amounts of shared data

Database management system (DBMS)

computer software that enables the user to create, modify, delete, and view the data in a database

Patient safety

condition of a patient being safe from harm or injury

Contextual

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

configuration, structure, and relationships of hardware (the machinery of the computer, including input/output devices, storage devices, etc.) in an info system

Eligibility verification

confirmation of insurance status

Proprietary vocabulary

controlled vocabulary that is formally approved by an organization such as a vendor that developed the vocabulary

Encoded

converted into code

Unintended consequence

An even that occurs when unexpected

Vocabulary standards

Common definition for med terms to encourage consistent descriptions of an individual's condition in the medical record

Thin client

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

Medication five right

Right drug; Right dose; Right route; Right time; Right patient

Point-of-Care charting

system whereby info is entered into the health record at the time and location of service

Computerized provider order entry (CPOE)

systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindications, or other clinical decision support

Electronic or enterprise report management (ERM)

systems that capture data from print files and other report-formatted digital documents, such as e-mail, e-fax, instant messages, web pages, digital dictation, and speech recognition and store them for subsequent viewing

barcode medication administration record (BC-MAR)

systems that identify the right patient and right drug to be given at the right time, in the right dose, and via the right route

Data conversion

task of moving data from one data structure to another, usually at the time of a new system install

Health information technology

technical aspect of processing health data and records, including classification and coding, abstracting, registry development, storage, and so on.

Computer output to laser disk/ enterprise report management (COLD/ERM)

technology that electronically stores documents and distributes them with fax, email, web, and traditional hard-copy print processes

Textual

term referring to the narrative nature of much of clinical documentation to date

Meaningful use

term used in the ARRA/HITECH legislation for providers to qualify for incentives for using EHR. 3 types of requirements for meaningful use: 1) use of certified EHR technology in a meaningful manner (e.g. electronic prescribing); 2) hat the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and 3) that, in using certified EHR technology, the provider submits information on clinical quality measures

Inter-operability

the ability, generally by adoption of standards, of systems to work together

Primary Care Physician (PCP)

1. physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan; 2. the physician who makes the initial diagnosis of a patient's medical condition

Transaction

1. units of work performed against a database management system that are treated in a coherent and reliable way independent of other transactions. A database transaction is atomic, consistent, isolated and durable. Examples of healthcare transactions include the entry of a medication order for a patient, the retrieval of a lab result for a patient, and the posting of temperature for a patient; 2. the individual events or activities that provide the basic input to the accounting process

Workflow

Any work process that must be handled by more than one person

Transactional database

Clinical data repository

Modular EHR

EHR product meets only one or more but not all of the requirements of a certified EHR

Web services architecture WSA

Emerging architecture that utilizes web-based tools to permit communication among different software applications

Workflow and process management

Ensures components work together to achieve their intended purpose

Clinical document architecture (CDA)

HL7 electronic exchange model for clinical documents (such as discharge summaries and progress notes)

Unstructured data

Non binary, human-readable data

Wireless on wheels WOWs

Notebook computers mounted on carts that can be moved through the facility by users

Uninterruptable power supply UPS

Source of power allows equipment or info systems to work when the power source is unavailable

Hybrid record

a health record that includes both paper and electronic elements

Health information exchange (HIE)

a plan in which health information is shared among providers

Electronic medication administration record (E-MAR)

a system designed to prevent medication errors by checking a patient's medication info against his/her barcoded wristband

ASTM international

a system of standards developed primarily for various EHR management processes

Electronic signature authentication (ESA)

a system that requires the author of a document to sign onto a patient record using a user ID and password, reviews the document to be signed, and indicates approval

Telehealth

a telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment

Standard vocabulary

a vocabulary that is accepted throughout the healthcare industry

Claims attachment

additional info that's submitted with a claim for healthcare services provided

Chart conversion

an EHR implementation activity in which data from the paper chart are converted into electronic format

Certification

an evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements

National health information infrastructure (NHII)

an infrastructure proposed by the National Committee of Vital and Health Statistics in 2002 that would be a set of technologies, standards, applications, systems, values, and laws that support all facets of provider healthcare, individual health, and public health

National Council for Prescription Drug Programs (NCPDP)

an organization that develops standards for exchanging prescription and payment info

Health information exchange organization (HIEO)

an organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards

Pharmacy information system

assists care providers in ordering, allocating, and administering medication; focuses on patient safety issues, especially medication errors and providing optimal patient care

Server failover

at least two if not more servers are performing the same processing on data simultaneously

Radio-frequency indentification (RFID)

automatic recognition technology that uses a device attached to an object to transmit data to a receiver and doesn't require direct contact

International health terminology standards development organization

company based in Denmark that is responsible for maintaining SNOMED International, a method for encoding data variables when physicians enter data into a history and physical exam template

Structured data

binary, computer-readable data

Institute of medicine (IOM)

branch of the National Academy of Sciences whose goal is to advance and distribute scientific knowledge with the mission of improving human health

Department of Health and Human Services (HHS)

cabinet-level federal agency that oversees all of the health- and human-services-related activities of the federal government and administers federal regulations

Clinical information system (CIS)

category of a healthcare info system that includes systems that directly support patient care

Clinical data repository (CDR)

central database that focuses on clinical information

Audit log

chronological set of computerized records that provides evidence of info system activity (log-ins and log-outs, file accesses) that is used to determine security violations

International classification of diseases, ninth revision, clinical modification (ICD-9-CM)

classification system used in the US to report morbidity and mortality information

RxNorm

clinical drug nomenclature developed by the Food and Drug Administration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms

National Drug Codes (NDC)

codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected otc products

Registry

collection of care info related to a specific disease, condition, or procedure that makes health record info available for analysis and comparison

Online analytical processing (OLAP)

data access architecture that allows the user to retrieve specific info from a large volume of data

Digital images

data provided in a computer-readable format

Drug knowledge database

database of info about drugs

Logical observations, identifiers, names and codes (LOINC)

database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research

Clinical data warehouse (CDW)

database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface

Meta-data

descriptive data that characterizes other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of info

Data dictionary

descriptive list of the data elements to be collected in an info system or database whose purpose is to ensure consistency of terminology

Remote patient monitoring device

device that enables a healthcare provider to monitor and treat from a remote locations

Continuity of care record (CCR)

documentation of care delivery from one healthcare experience to another

Personal health record (PHR)

e-record of health-related info on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual

Flat file

early form of database where data is stored in plain text file

Electronic health record (EHR)

electronic record of health-related info on an individual ... interoperable across more than one healthcare organization

Electronic medical record (EMR)

electronic record of health-related info on an individual ... within a single healthcare organization

Ancillary systems

electronic systems that generate clinical info (such as laboratory IS, radiology IS, pharmacy IS, etc...)

E-prescribing (e-RX)

enables prescriptions to be checked for drug contraindications and sent directly to a retail pharmacy of the patient's choosing

(BI) business intelligence

end product or goal of knowledge management

Remittance advice

explanation of payments (e.g. claim denials) made by third party payers

Data availability

extent to which health data are accessible whenever and where they're needed

Automated drug dispensing machines

system that makes drugs available for patient care

Health insurance portability and accountability act of 1996 (HIPAA)

federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information. The act limits exclusion for preexisting medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size of employer.

Natural language processing (NLP)

field of computer science and linguistics concerned with the interactions between computers and human (natural) languages that converts information from computer databases into readable human languages

Clinical messaging

function of electronically delivering data and automating the workflow around the management of clinical data

Consistent Federated model of HIE

health info exchange model where there is no centralized storage of patient data

Clinician

healthcare provider, including physicians and others who treat patients

Evidence-based medicine

healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies

Protocol

in healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in med research, rule or procedure to be followed in a clinical trial; in a computer network, a protocol is used to address and ensure delivery of data

Identity management

in the MPI, policies and procedures that manage patient identity, such as prohibiting the same record number for duplicate patients or duplicate records for one patient

Continuity of care document (CCD)

in the exchange of info w/ another provider and the patient, the CCD combines the content that physicians have agreed should be included in patient referrals w/ a means to format the data for e-transmission

Physician Quality Reporting System (PQRS)

incentive payment system for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries

Physician champion

individual who assist in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes

Claims data

info required to be reported on a healthcare claim for service reimbursement

Document imaging management system (DIMS)

info system that allowed a paper document to be scanned and displayed

Patient portal

info system that allows patient to login to obtain information, register and perform other functions

Nursing information system (NIS)

info system that assists in the planning and monitoring of overall patient care and documents the nursing care provided to a patient

Laboratory information system (LIS)

info system that collects, stores, and manages laboratory tests and their respective results. The LIS can speed up access to test results through improved efficiency from various locations, including anywhere in the hospital, the physician's office, or even the clinician's home

Billing system

info system that generates bill for healthcare services performed

Patient financial system (PFS)

info system that manages patient accounts

Coding and abstracting systems

info system used to assign code numbers and enter key info from the health record

Cloud computing

info systems that use the internet to access data

Closed-loop medication management

info systems used to provide patient safety when ordering and administering medications

Thick client

information system will full processing capabilities

Medical devices

instruments that collect or supply health info

Picture archiving and communications system (PACS)

integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images)

Claim

itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan either by the insured party or by the provider

Diagnostic studies

lab and other tests performed to help diagnose a patient

Results retrieval

lookup system that enables a user to access several different types of data from different source systems through a single application screen

Contraindication

med shouldn't be prescribed due to another med or condition

Speech dictation

method of collecting information in an information system through the spoken word

Redundant arrays of independent (or inexpensive) disks (RAID)

method of ensuring data security

Report cards

method used by managed care organizations (and other healthcare sectors) to report cost and quality of care provided

Federated model of (HIE)

model of health information exchange where there is not a centralized database of patient information

Disease management (DM)

more expansive view of care management in which patients with the highest risk of incurring high-cost interventions are targeted for standardizing and managing care throughout integrated delivery systems; program focused on preventing exacerbation of chronic diseases and on promoting healthier life styles for patients and clients with chronic diseases

Electronic funds transfer (EFT)

moving money electronically

E-visits

non-face-to-face interaction between patient and provider

Patient acuity staffing

number of nurses and other care provides is based on how sick the patient is

Database

organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications

Print file

output from a computer system that generates a file containing an image of information that can be printed

Health information technology for economic and clinical health (HITECH)

part of ARRA of 2009; includes requirements for standards development and for investment in health information technology infrastructure and strengthens federal privacy and security law; meant to increase the momentum of developing and implementing the EHR by 2014

National alliance for health information technology (NAHIT)

partnership of government and private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, and operating performance

Opt-in/Opt-out

patients' choices for having their data exchanged in the HIE

Template

pattern used in computer-based patient records to capture data in a structured manner

Hospitalist

physician employed by teaching hospitals to play the role that admitting physicians fulfill in hospitals that are not affiliated with medical training programs

Provider

physician, clinic, hospital, nursing home, or other healthcare entity (second party) that delivers healthcare services

International classification of diseases, 10th revision, clinical modification (ICD-10-CM)

planned replacement for ICD-9-CM, volumes 1 & 2, developed to contain more codes and allow greater specificity

Chief medical informatics officer (CMIO)

position typically held by a member of the medical staff and responsible for, among other things, leading EMR system implementation, engaging healthcare professionals in the system's development and use, and leading the group designated to serve as the central governance forum for establishing the healthcare organization's clinical IS prioritites

Controlled vocabulary

predefined set of terms and their meanings that may be used in structured data entry or natural language processing to represent expressions

National committee for quality assurance (NCQA)

private, not-for-profit accreditation organization whose mission is to evaluate and report on the quality of managed care organizations in the U.S.

Consent directive

process by which patients may opt in/out of having their data exchanged in the HIE

Clinical decision support (CDS)

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

Clinical documentation system

process in which individual data elemets are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts

Digital dictation

process in which vocal sounds are converted to bits and stored on computer for random access

Charge capture

process of collecting all services, procedures, and supplies provided during patient care

Authentication

process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature; proof of authorship that ensures, as much as possible, that log-ins and messages from a user originate from an authorized source

Configuration management

process of keeping a record of changes made in an EHR system as it's being customized to the organization's specifications

Prior authorization

process of obtaining approval from a healthcare insurance company before receiving healthcare services

Change control

process of performing an impact analysis and obtaining approval before modifications to the project scope are made

Medication reconciliation

process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to ICU

Patient-Centered Medical Home (PCMH)

program to provide comprehensive primary care that partners physicians with the patient and their family to allow better access to healthcare and improved outcomes

Practice guidelines

protocols of care that guide the clinical care process

Message format standards

protocols that help ensure data transmitted from one system to another remain comparable

Data exchange standards

protocols that help ensure that data transmitted from one system to another remain comparabl

Storage management

system used o manage the SAN, keep track of where data are stored, and move older data to less expensive, but still accessible, storage locations

Office of the National Coordinator (ONC) for Health Information Technology

provides leadership for the development and implementation of an interoperable health info technology infrastructure nationwide to improve healthcare quality and delivery

Nationwide health information network (NHIN)

provides the technology to support the national health information infrastructure

Results management

results retrieval technology that permits viewing of data by type and manipulation of several different types of data; results management systems

Identity matching algorithm

rules established in an information system that predicts the probability that two or more patients in the database are the same patient

Operating rules

rules that further explain the standards so their use is consistent across health plans

Process improvement

series of actions taken to identify, analyze, and improve existing processes

Migration path

series of steps required to move from one situation to another

Record locator service (RLS)

service that indicates where a given patient may have health information using probability equations

System

set of related and highly interdependent components that are operating for a particular purpose

Speech recognition

situation where speech is converted to text on a screen

Server redundancy

situation where two servers are duplicating effort

Practice management system (PMS)

software designed to help medical practices run more smoothly and efficiently

Chart deficiency system

software system designed to allow the HIM dept. to electronically track and manage documentation omissions from the health record

Storage management software

software used to manage the SAN, keep track of where data are stored, and move older data to less expensive, but still accessible, storage location

Clinical decision support system (CDSS)

special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions

Portals

special web pages that offer secure access and entry of data upon authorization of the owner of the page

Encoder

specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system

Multi - dimensional data base

specifically designed to handle data organized into a data structure with numerous dimensions

Digital imaging and communications and medicine (DICOM)

standard that promotes a digital image communications format and picture archive and communications systems for use with digital images

Electronic date interchange (EDI)

standard transmission format using strings of data for business info communicated among the computer systems of independent organizations

Data comparability

standardization of vocab 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

Core measures

standardized performance measure developed to improve the safety and quality of healthcare

Health level seven (HL7)

standards development organization accredited by the American National Standards Institute that addresses issues at the seventh, or application, level of healthcare systems interconnections

Storage area network (SAN)

storage devices organized into a network so that they can be accessible from any server in the network

Electronic document management system (EDMS)

storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents to be stored on optical disks

Relational database

stores data in predefined tables made up of rows and columns

Revenue cycle management (RCM)

supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue, with the goals of accelerated cash flow and lowered accounts receivable

Radiology information system (RIS)

system that collects, stores, and provides information on radiological tests such as ultrasound, magnetic resonance imaging, and positron emission tomography

Registration-Admission, Discharge, Transfer R-ADT

type of administrative info system that stores demographic info and performs functionality related to registration, admission, discharge, and transfer of patients within the organization

Hierarchical database

type of database that allows duplicate data

Electronic document/content management (ED/CM)

type of electronic document management system uses methods such as bar coding on the forms to identify specific content

Complete EHR

under meaningful use, EHR technology that has been developed to meet, at a minimum, all applicable certification criteria adopted by the Secretary of HHS

Release of information system

used when disclosing patient-identifiable info from the health record to another party

Pharmacy benefits manager (PBM)

vendor selected by the Bureau of Workers' Compensation to process outpatient medication bills submitted electronically

Data center

where the hardware and software for the electronic info systems are held

National Library of Medicine (NLM)

world's largest medical library and a branch of the National Institutes of Health

Interface

zone between different computer systems across which users want to pass information (e.g. a computer program written to exchange info between systems or the graphic display of an application program designed to make the program easier to use