HOSA: HI
Six Sigma uses
(D)MAIC
What precent of physician practices reported screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence? Hospitals?
16%, 24%
The First stage of Healthcare in the US ranged from
1776 to 1900
Second stage of healthcare in US ranged from
1900 to WWI
Assosiation of Record Librarians constituted the first effort at an association beyond the local level focusing on the study and evaluation of standards for clinical records around
1912
ACS created the Hospital Standardized Program serving as the genesis for accrediation movement of the 20th century in
1918
Association of Record Librarians of North America (ARLNA) was formed in
1928
ARLNA Changed name to the American Association of Medical Record Libraries (AAMRL) in
1938
State health departments came into existence in
1945
AAMRL changed name to the American Medical Record Association (AMRA) in
1970
AHA's "Patient's Bill of Rights" was created in the
1970s
The notion of what might become the PHR was envisioned in. . .
1973
The term medical informatics was first used in. . .
1974
Fourth stage of Healthcare in the US ranged from
1980 to Present
US congress created the Malcolm Baldrige National Quality Award leading to the creation of a new public-private partnership in
1987
The Human Genome Project started in; ended in. . .
1988; 2003
AMRA changed to the American Health Information Management Association (AHIMA)
1991
the Medicare Patient Safety Monitoring System was created in
2001
Home health data went public with the Home Health Quality Initiative (HHQI) in
2003
The Global Trigger Tool (GTT) was developed in
2003
The Health Information Technology for Clinical and Economic Health (HITECH) Act was created in. . .
2008
The professional association with a central role in the development of health information management profession is
AHIMA
Four common approaches to developing standards
Ad hoc: group agree to informal specifications De facto: single vendor controls industry Government mandate: government agency creates standard and mandates its use Consensus: interested parties work in an open process
Nature of Contract
An offer (by the pt requesting tx) has been accepted (by the healthcare provider to render tx)
First voluntary health agency in US was
Anti-Tuberculosis Society of Philadelphia founded in 1892
Meaningful use was introduced in three phases:
Capture PHI electronically in a structured format Encourage use of HIT to promote continuous quality improvement at the point of care and the exchange of information Promote improvements in quality, safety, and efficiency to improve patient outcomes
Benefits of PHR in different perspectives
Consumers, patients, and caregivers: supports healthcare and wellness Healthcare providers: potential to improve the care that is delivered Payers: there is the potential for improved customer service Employers: potential for imrpoved employee productivity Society: potential for strengthening health promotion and disease prevention
Three significant concepts of SA are
Context, content, and users
First medical teatise addressing the connection between workers' health and the environmennt was
De Morbis Artifican Diatriba in 1700
Metadata
Described data's origin, the institution or geographic region from where it came, and where it might be accessed on the internet; unseen information in common files
Levels of Data Analytics:
Descriptive: what happened? Diagnostic: why did it happen? Predictive: what will happen? Prescriptive: how can we make it happen?
The governmental branch with the greatest day-to-day influence in healthcare is the
Executive branch
XML
Extensible Markup language; works well with raw data, allowing it to be treated in a familiar fashion to words on HTML
one of the most successful efforts in moving the concept of patient rights from and ethical basis to legal basis is the
Federal Patient Self-Determination Act (FPSD)
Releases
Future improvements that provide routine maintenance, patches, or fixes to existing functionality
3 main types of managed care arrangements in the US
HMOs, IPAs, PPOs
Structured data is often found in. . .
History and physicals, progress notes, reports, and discharge summaries
HTML
Hypertext markup language; a programming language that allows for the display of information in a similar format on different operating systems and system hardware
the stages of development of a standard include
Identification, conceptualization, discussion, specification, early implementation, conformance, certification
ARRA qualifies EHRs as an electronic record of health-related information on an individual that it
Includes patient demographic and clinical health information, such as medical history and problem lists Has the capacity to: Provide clinical decision support Support physician order entry Capture and query information relevant to health care quality Exchange electronic health information with, and integrate such information from other sources
Explosion in the number and type of allied health professionals can be contributed to:
Innovations in technology Rise of the hospital as central institution in the health care delivery system Medical and surgical specialization Increased health insurance coverage
IOM's summary of the problems with paper medical records in 1990s include. . .
It can only be used by a single person at one time, often disorganized, may be incomplete, easily lost, harder to share with other providers, provides a lack of security
Origin of the definition of informatics is attributed to either. . .
Karl Steinuch of Germany in 1957 or Phillipe Dreyfus of France in 1962
Knowledge access
Knowledge is not directly executed or processed but resides on a centralized knowledge server from which it can be retrieved for display to users
Ordinances
Laws arising from the actions of municipal bodies such as boards of aldermen or city councils
Statuory Law
Laws created by the legislative branches of federal and state governments
Government branches play a role in healthcare:
Legislative branch functions to enact laws, determining the need for new laws and changes in existing laws Executive branch functions to enforce and administer the laws; organized on a departmental basis Judicial branch functions to interpret the law through the adjudication and resolution of disputes
Benefits of EHR
Multiple users can access it at the same time Ability for multiple views of that data Better communication Possible re-uses of clinical data Data can be used for applying data science and analytics, measuring and improving the quality of care, population and public health users, facilitating clinical research
Surgical assistant (SA)
PAs furthered specialized to help the surgeon during operative procedures
The AHA's "Patient's Bill of Rights" is currently referred to as the
Patient Care Partnership
Moore's law
Prediction made by Gordon Moore in 1965 that the number of components on an integrated circuit would double roughly every 2 years
1996, HIPAA was designed with several goals:
Provide insurance portability Promote the use of MSAs Decrease the costs of healthcare administration by simplifying insurance processes Combat waste, fraud, and abuse
Data
Raw material collected and stared
HIM's 3 levels of practice are. . .
Registered Health Information (RHIA), Registered Health Information Technologist (RHIT), and Certified Coding Specialist (CCS)
ARLNA Made a certification exam resulting in the granting of the
Registered Record Librarian (RRL) Credential
Functional Interoperability
Sending messages between computers in a format or structure that can be interpreted at the level of data fields
Semantic Interoperability
Sending messages between computers that cannot only be interpreted but understood and used in an intelligent manner
For EHR data to be put in a cloud-based store to allow patients to enter anytime there needs to be three components:
Standard data elements Standard data receipt for each clinical encounter with the push of the encounter into the patient's data store A contract that sets the rules for access and control of such a system
What system is a state-of-the-art EHR that has transformed healthcare in the US Veteran's Health Administration?
The Veteran's Health information Systems and Technology Architecture (VistA)
What are the 4 elements of clinical data?
The patient (name), the attribute (vitals, etc.), value of the attribute (#), and the time of observation
Three types of voluntary health agencies include
Those concerned with specific diseases Those concerned with special organs or structures of the body Those concerned with society as a whole or specific groups of people or issues
HIPAA Statues:
Title I: Health Care Access, Portability, and Renewability Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform Title III: Tax-Related Health Provisions Title IV: Application and Enforcement of Group Health Plan Requirements Title V: Revenue Offsets
Big Data consists of. . .
Volume, Velocity, Variety, Variability
Third stage in healthcare for the US ranged from
WWII to 1980
Communities of practice
Web-based program managed by the AHIMA that provides a virtual network for members who share common interests
Areas where HIE needs to be addressed include:
Workflow, funding, Complex Legal and Regulatory Environment, usability
Professional Association
a body of people with specialized learning who exert mental, rather than manual, labor and organize for a common purpose or objective
Law
a body of rules of action or conduct prescribed by a controlling authority that has binding legal force
Network
a collection of computers connected together by way of cables or wireless links so that they can exchange data with one another
Categorical imperative
a command derived from a principle that does not allow exceptions
Independent Practice Associations (IPAs)
a community-based group of independent practitioners who contract to provide care for prepaid, enrolled individuals
Internet Service Provider (ISP)
a company that provides Internet services and sells access to the Internet
Mainframe
a computer containing powerful central processing unit that controls the activity of the dummy monitor
Systems architecture (SA)
a conceptual model that fundamentally designs and organizes the components of a system, explains the component relationships to each other and to the outside environment, and establishes the principle governing a system's design and evolution
Nominal data
a data set that classifies values but does not require a logical ordering to those values
Interval data
a data set that is both ordered and constant but contains no natural zero as a point of reference
Ordinal data
a data set that is ordered, though the differences between the values are not important
OpenNotes
a decade old program made in an effort to allow patients to read the notes that clinicians write in their records
Intentional Infliction of Emotional Distress (IIED)
a defendant's conduct that is so extreme and outrageous that it causes the plaintiff to experience severe emotional distress and the defendant engaged in the conduct with the intent to cause emotional distress
Disk Drive
a device that reads and writes data from a rotating disk
Affinity diagram
a diagram that organizes information into a visual pattern to show the relationship between factors in a problem
Electronically stored information
a distinct category of information that includes e-mails, web pages, word processing files, and databases stored in the memory of computers, optical discs, flash memory, and backup media
systems-orientated architecture
a distributed model for building and managing enterprise-level software by relying on discrete services to reach across a network of applications
Post-test probability
a function of what the probability was before we obtained the test (pre-test/prior probability) and then the result of the test
byte
a group of eight bits used to measure memory size and transfer speed
Accountable Care Organization (ACO)
a group of providers and suppliers of services that work together to coordinate care for the patients who receive Medicare health benefits
Public Health
a healthcare discipline dealing with the community at large, focused on protecting and improving community health by organized community effort and preventive delivery of medical, social, and sanitary services
Rights
a just claim or entitlement, whether based on law, ethics, or morality, that other are obligated to respect
Preemption
a legal doctrine that states that certain matter are of such a national nature that federal laws preempt, or take precedence over, state and local laws
Nominal group technique
a list of ideas is labeled alphabetically and then prioritized by determining which ideas have the highest degree of importance or should be considered first
Health savings accounts (HSAs)
a means of allowing individuals who buy high deductible insurance coverage to save money for out-of-pocket costs in tax-free accounts
Tracer methodology
a means of tracing the delivery of a patient's care through the health record as a way to analyze the healthcare provider's care, treatment, or service to the patient
Health Insurance Exchange (HIX)
a mechanism that creates a marketplace for consumers to compare insurance offerings according to common rules and to purchase a plan that best fits their needs
Data Dashboard
a method developed to present a variety of data in a single display in an easy to read format
Health Systems Science (HSS)
a new science for medicine, different from basic and clinical science
Health maintenance organizations (HMOs)
a prepaid, organized system for providing comprehensive health care services within a geographic area to all persons under contract, emphasizing preventive medicine
Quality Improvement Model
a problem or process is chosen for study, data are collected to measure the problem or process, data are assessed, and a method for improvement is developed
Failure to warn (Failure to protect)
a psychotherapist's failure to take steps to protect and innocent third party from a dangerous patient
Key performance indicators (KPIs)
a quantifiable measure used to evaluate the health of an organization, a particular department within an organization, or even a particular business process in meeting objectives for performance
Root Cause Analysis
a reactive process performed by a safety team that attempts to discover the prior casual events that gave rise to a observed safety even
Application Programming Interfaces (API)
a set of definitions and protocols for building and integrating application software without the calling function/application knowing how the data source is structured or implemented in the remote application
Contemporary KA
a shared process involving a clinical subject matter expert (SME) and a knowledge engineer
Low agreement
a substantial amount of error in the number of triggers and which triggers are detected
Computer-based Patient Record Institute (CPRI)
a system that integrates data from multiple sources, captures data at the point of care, and support health care providers in their division making
Assault
a threat that does not involve physical contact
Registry
a type of data source with a more limited collection focusing on one or a small number of diseases and all data pertinent to that disease
Internet
a worldwide network of smaller networks
Interoperability
ability of two or more systems or components to exchange informations and use that information that has been exchanges (Institute for Electronic and Electrical Engineers [IEEE], 1990)
Ethical Concepts
abstract ideas or thoughts that deal with ethics
Ethical Acts
actions that can be judged as proper or acceptable behavior based on some standard of right and wrong
Involuntary commitments
admissions that occur against a patient's will
De-identifiable data
all individually identifiable information is removed
Hardware
all of the physical electronic components of a computer system
Addressable controls
also required but can be compensated if the addressable control is not available to the covered entity
Computer Science
an academic discipline that focuses on the scientific aspects of computing and IT
Infobutton manager
an analog of an inference engine in a production rule or procedural system, aware of what knowledge sources are available, determining where they are applicable, and formulating the links to human-readable knowledge that are displayed in that context
Data Analytics
an application of data science; the extensive use of data, statistical and quantitative analysis, explanatory and predictive models, and fact-based management to drive decisions and actions
tethered PHR
an extension of the healthcare provider's EHR
optometrist
an individual who diagnoses and provides selective eye treatment
allied health professional
an individual who has graduated from an educational program in a science relating to health care and shares the responsibility for the delivery of healthcare services to the patient with clinicians
Podiatrist
an individual with specialized education and training who is concerned with diagnosing, treating, and preventing abnormal foot conditions
Extranet
an intranet system that allows selected external users limited access to the private networks
Standalone PHR
an isolated application, typically on a website or mobile device
Health Record
an ordered set of documents or collection of data which contains a complete and accurate description of the patient's history, condition, diagnostic, and therapeutic treatment, and the results of treatment
Home health agency
an organization that provides nursing and other professional and technical services to patients at their places of residence
Breach
an unauthorized acquisition, access, or use of PHI
Management information systems
another field underlying IT is usually taught in business schools
Missed care
any aspect of required care that is omitted either in part of in whole, or delayed
Near Miss Event
any event that could have had an adverse patient consequence but did not, and was indistinguishable from a full-fledged adverse event in all but outcome
Evidence-based practice (EBP)
application of EBM in patient care
Text mining
application of data mining techniques to unstructured textual data
Data visualization
application of visual methods to tell the story about the data
Layered Approach
architectural components are separated into layers making it easier to customize and update different versions of interfaces, workflows, and events without altering others not involved in a customization or update
Diagnosis codes are
assigned to patients at different stages of care and permit a disease index or database to be generated
Social engineering
attempt to get the end user to do something they would not do normally, allowing the actor to access their system
Four concepts directly relate to content of the health record:
authorship, authentication, timeliness, and completeness
Comparative justice
balancing the competing interests of individuals and groups against one another, with no independent standard used to make this comparison
Pareto chart
bar graph used to identify and separate major and minor problems
Administrative data
basic identification and financial data routinely collected from every patients
Permanent medical data consists of
blood group, gender, and allergies
Digital Health
broad term for digital, IT-related, aspects of health and healthcare
Interventions
can include any type of health or healthcare activity, including drug therapy, diet therapy, surgery, alternative medicine, etc
Secondary care
care provided by a specialist, often at request of the primary care physician
Deliquent record
caused by failure to complete the records or make corrections timely
Nonintentional torts
civil wrongs committed by persons who lack intent to do something wrong
intentional torts
civil wrongs committed by persons with the intent to do something wrong
Aspects of patients rights formed in the
code of ethics in the 1950s
Clinical data
collected and maintained data the relate to the patients's health and course of treatment and care
Health care Information Systems
collection of facts and data used to provide specific meaningful information support and improve health services management
Deeming authority
compliance with the requirement sand standards of accrediting organizations may substitute for compliance with the federal government's Medicare Conditions of Participation for Hospital published by the CMS
International health agencies
composed of governmental and nongovernmental entities that transcend national borders to perform public work in health care
Informatics encompasses:
computer programming, database management, mathematical modeling, statistics, and research design
Expert Systems
computer programs designed to mimic human expertise
Artificial intelligence (AI)
computer science focused on developing information systems and algorithms capable of performing tasks associated with human intelligence
Personal Computer (PC)
computer that contains a central processing unit
Servers
computers that provide shared services to other computers on a network
Qualitative Analysis
concentrates on the quality of the record content and not the quality of the medical care rendered to the patient
Quantitative Analysis
concentrates on what forms or data should be present in, but are missing from, the health record
Etiquette
concerned with how human being relate to one another under certain circumstances
Criminal law
conduct the government has declared injurious to the public order with specific punishments identified for violations
3 pillars of information security:
confidentiality, integrity, availability
Private law
conflicts between private parties
Public Law
conflicts between the government and private parties or between two or more branches of government
Metropolitan area network (MAN)
connects an array of computers across a campus or city, employing wireless infrastructure or optical fiber connections to link between sites
Wide area network (WAN)
connects computers that are widely separated geographically (cities, countries, or continents)
physician-oriented
consisted of observations made mainly by the physician about the pt
Preferred Provider Organization (PPO)
consists of a network of participating hospitals, physicians, medical groups, and other providers who contract with a sponsor (insurance company or employer) to provide services to those enrolled
Medical staff coordinator
coordinates all efforts related to procuring written documentation of a physician's qualifications to provide clinical services
Certified Coding Specialist (CCS)
credential designed for those individuals who hold a broader and deeper coding knowledge and work in hospital inpatient and outpatient settings
Concurrent Data collection
data can be gathered at the time they entered through the use of modern interface and transmission standards
Data Warehouses
databases that aggregate information and make it easier to query and generate reports; import data from EHR and other sources such as financial and administrative data
Healthcare facilities typically collect seven broad categories of patient data:
dates, counts, test results, diagnoses, procedures, treatment outcomes, and assessments
Computer-based provider order entry (CPOE) systems
decision support is provided at the time of clinician order creation in order to maximize the impact of decision making
Community Mental Health Care
delivery system posited that the least restrictive alternative was the best alternative for the mentally ill patient who could control their behavior and cooperate with treatment plans
Certified in Healthcare Privacy and Security (CHPS)
denotes mastery level of competency in health care privacy and security management
Health Information department
department responsible for managing appropriate use of and access to patient specific health information
Privacy Officer
develops and implements policies and procedures relating to the HIPAA Privacy Rule and serves as the covered entitiy's point of contact to receive complains while also disseminating information about the entity's privacy practices
Security Officer
develops and implements policies and procedures relating to the HIPAA Security Rule and is held accountable for a covered entity's security procedures
Modem
device that allows a computer to transfer information over a telephone line
Health Information Department Director
directs the administrative functions of the health information department and may be a RHIT or RHIA
Data errors can be made in the
documentation process, the abstracting process, the coding process, the indexing and registry process, and the interpreting process
Logical reasoning
drawing on the fund of knowledge of what findings occur in diseases and how likely they are in a given patient
Computer-based patient record (CPR)
earlier terms for the EHR
Structured Data (discrete data)
elements usually are organized into some sort of regularized form.
Managed care
enrolled population will receive health care services through either a prepayment or discounted fee-for-services arrangement
Certified Coding Associate (CCA)
entry-level coding individuals who have coding training but lack significant job experience
differential diagnosis
enumerate all of the diagnostic possibilities and estimate their relative likelihood in a given pt
Privacy Rule
establishes the concept of PHI, protecting the information relating to the past, present, or future physical or mental health of an individual, the provision of healthcare to an individuals, or the payment for provision fo healthcare to an individual
Security Rule
establishes the concept of protecting the confidentiality, integrity, and availability of electronically formatted PHI created, received, maintained, or transmitted by a covered entity
Deontology (formalism or duty orientation)
ethical decision making is based on moral rules and unchanging principles that are derived from reason and can be applied universally
Corporate negligence
failure of a hospital, entrusted with the task of providing accommodations necessary to carry out its purpose, to follow the established standard of conduct to which it should conform
fidelity
faithfulness, loyalty, and devotion to one's obligations or duties
Information retrieval
field devoted to searching knowledge-based information
Caption
fixed amount per person is paid for healthcare services regardless of the quantity or nature of the rendered services
Medical Library Science
focus on published data and how it is catalogued, abstracted, and retrieved by groups and individuals
HIA
focuses on managing health record systems and ensuring compliance with external and internal standards relating to the privacy and security of health records and the information contained within those records
HIT
focuses on organizing and managing health records for completeness, accuracy, and proper entry of data, using computer applications to improve patient care and control health costs
Knowledge representation (KR)
focuses on the format of the knowledge that enables the computer to have knowledge directly executed or at least interpreted
Concurrent Activities (Parallel activities)
follow arrows to document their paths
Integrated health record
follows a strict chronological order for organization
Deep learning (DL)
form of ML associated with the use of neural networks that have deep layers requiring substantial processing
Peripheral
form of computer hardware that is added to a host computer to expand its capabilities
Versions
future improvements that provide new functionality
Ambulatory health care
given to patients who are not confined to an institutional bed as inpatients at the time care is rendered
Information
gives meaning and organization of data
Gantt charts
graphic representations that show the time relationships in a project
ethics committee
groups formed within an organization to establish new and evaluate existing ethics codes and corporate policies and to address ethical issues that arise in the workplace
Veracity
habitual truthfulness and honesty
complentary and alternative medicine (CAM)
healing system, practice, or product that falls outside of what is considered conventional medicine employed together with conventional medicine
Component state association (CSA)
health information management association located in every state to provide leadership, networking, and professional education opportunities at the state level for AHIMA members
Leading causes of hospitalization or for extending the length of stay include
heart attack and heart failure
Consumer advocate
helps consumers understand the meaning and use of their PHI
number needed to treat (NNT)
how many people must be treated or have the intervention for one individual to benefit
Minimum Standards document
identified the standards deemed essential to proper care and treatment of hospital patients; produced by the ASC
Cause-and-effect diagram (Fishbone or Ishikawa diagram)
identifies major categories of factors that influence and effect and the sub-factors within each of those categories
Tumor registrar
identifies, collects, and maintains information about benign and malignant tumors that are initially diagnosed or treated by an organization
Limited data set
include health information and dates
Evidence-based medicine (EBM)
includes a set of tools and a disciplined approach to inform clinical decision making, yet applies the best research evidence mainly to patient care
Covered entities
includes health plans, healthcare clearinghouses, and healthcare providers who transmit standard transactions in electronic form
Autonomy
independence, self-determination, or freedom
chiropractor
individual with specialized education and training who treats the body's structural and neurological systems
SDOH data is available at 2 levels:
individual-level data and population-level data
Protected Health Information (PHI)
individually identifiable health information
Certified Coding Specialist-Physician Based (CCS-P)
individuals demonstrate through an examination expertise in physician-based settings
Business Associates
individuals or organizations doing business with covered entities that are involved in the use or disclosure of PHI
Scribes
individuals who enter data for physicians
Clinical Document Improvement Practitioner (CDIP)
individuals who specialize in capturing the documentation necessary to fully communicate the patient's health status and condition
Certified Health Data Analyst (CHDA)
individuals with expertise in health data analysis
Clinical informatics
informatics applied in healthcare settings
Imaging informatics
informatics with a focus on imaging, including the use of systems to store and retrieve images across all types if informatics
History and Physical
initial assessment by a clinician
Denial of Service (DoS)
intended to stop traffic from reaching a certain website or destination through flooding that site with bogus requests so legitimate traffic cannot get through
Judicial decisions (common law)
interpret relevant constitutional provisions, federal or state statues, regulations, and previous court decisions
mHealth
involved the use of mobile devices for health
Observation Activity
involves the use of the quality monitoring cycle PDSA to recognize patterns and trends
Virtual Private Network (VPN)
is a WAN that connects private subscribers together using the public internet as the transport medium while ensuring through encryption technology that the private subscribers' traffic is not readable by the internet at large
Executive orders
issues by the chief executive at either the federal or state level and are used to interpret or implement a provision of a constitution or law
Wisdom
knowing how to apply knowledge
inference engines
knowledge and the computer application or system that processes the knowledge are separate, allowing the knowledge base to be maintained as scientific and clinical evidence evolve without having to alter the application that processes this knowledge
Res ipsa loquitur
latin for "The thing speaks for itself;" applies in situations where the defendant had exclusive control over the thing that caused harm to the patient and the harm itself could only have occured through negligence
Respondent superior (vicarious liability)
liability of a superior for the acts of a subordinate or servant acting within the scope of his authority
Shoulder surfing
look over the victim's should and views restricted information or copies down their password
Continuum of care
matching an individual's ongoing needs with the appropriate level and type of medical, psychological, health, or social care or service within an organization or across multiple organizations
Hazard ratio
measure of relative risk, but accounts for time and survival
Placebos
medically inert substances that are used as a control in testing the effectiveness of another, medicated substance
Speed of CPU is measured in
megahertz (MHz)
Authorship
method of identifying the healthcare provider who made an entry in the record
Overlaid record
more than one patient is mapped to the same record
duplicate records
more than one record exists for a patient
Quaternary care
most complex level of medical and surgical care available
Code of ethics
most significant features of professional associations; written lists of a profession's values and standards of conduct
Voluntary Health Agencies
nongovernmental organizations created to perform public work in health care through private means
Precision Medicine
notion of diagnosis and treatment of a patient being more precise
Largest health care profession in the US is
nurses
Nurse Practitioner (NP)
nursing specialist possessing an expanded scope of practice compared to a RN and can serve independently of physicians in some states to treat and diagnose patients
intranet
operates as a private network that is accessible only within one organization
Professional practice experience (practicums or externships)
opportunities that provide a student with nonpaid, on-the-job experience prior to graduation
CD-ROM (compact disk read-only memory) disk
optical storage medium that uses the same technology as music compact disks and can store vast amounts of information
Philanthropic Foundations
organizations designed to distribute donated funds in an effort to better humankind
Source-oriented health record
organized according to the source or department that provided the data
problem-oriented
organized by a focus on specific pt problems
time-oriented
organized chronologically
Department-oriented
organized into sections (notes, lab reports)
Problem-oriented health record
organizes data according to the patient's problems in order of importance
Civil law
part of the law that does not include criminal law, focusing on private rights and remedies
Variable medical data consists of
patient history, physical exam, drug prescriptions, lab results, images, and biological signals
The AHIMA's revised code of ethics reflects their core values:
patient's right to privacy, and incorporates changes in technology, healthcare, and association management, and lessons learned from recent code violations and inquires
Fee-for-services
payment is made for each service provided
informed presence bias
people in the EHR whose data may be different from those who have not received care at that healthcare system or perhaps gotten no care at all
Utility programs
performs simple operations on files created by other programs
Application Program
performs tasks on behalf of the end sure
Business record exception
permits admission of health records into evidence if the record was made and kept as part of the normal course of business, was made at or near the time of matter recorded, and made by a person within the business with knowledge of the events appearing in the record
Individual-level data
pertain directly to the patient in front of the provider and can be used to flag patients who may need referral to community-based social services
Population-level data
pertain to an area in which a given patient lives
Battery
physical contact involving injury or offense
Physical Safeguards
physical security measures taken to protect information
Generalists
physicians who conduct a wide or unlimited practice to include comprehensive care of an individual or family
Administrative Safeguards
policy or procedures used to provide security and governance to privacy and security
Enforce health laws and regulations and put a concern on
policy, planning, legislation, financial support, research, and evaluation
Pareto Principle
posits that for many events, 20 percent of problems pose 80 percent of the impact
Completeness
possessing all parts or elements necessary to be considered whole or entire
Merit
potential for benefit after the initial investment of limited resources
Regulations
prescribed courses of action that arise from law, principle, or custom
Confidentiality
prevents the unauthorized disclosure of data
Clinical privileges
privileges based on criteria generally derived from national standards; at discipline specific; and relate to the type of clinical privileges requested by the physician
Asynchonously (back end)
process dictations for later editing
Data wrangling
process if taking raw data and processing it into formats that are suitable for things like analytics, learning, visualization, and so forth
Knowledge Acquisition (KA)
process in CDS by which clinical, scientific, administractice, or other classes of expert knowledge ore identified and structured so that they can be applied against data in the computer to generate support for decision making
Inferencing
process of applying the knowledge to data to produce CDS
Fellow of the American Health Information Management Association (FAHIMA)
professionals who posses at minumum a graduate degree, 10 years of full-time professional experience, 10 years of continuous membership, and evidence of sustained and substantial professional achievement
Adult day care services
programs targeted to elderly persons during the daytime hours that offer health and social services
WHO was created to
promote international standarization of drugs, vaccines, and other biologic agents provide epidemic and statistical service sponsor health research develop international quarantine measures prepare and distribute publications provide technical and program-planning assistance to participating nations
E-prescribing
promotes patient care and contains costs due to the reduced margin of error in the delivery of care (elimination of illegible handwriting) and provides an automated means to track usage, costs, and inventory
Utilitarianism (consequentialism)
proposed that everyone should make choices that promote the greatest balance of good over harm for everyone else
Block grants
provide designated amounts of funding to individual states, which then divide where and how to spend the monies provided
Query/Find Information
provider queries for information about a pt using HIE functionality in their EHR system or a third-party application
CDS employing knowledge access
provides a link between a user of an EHR system and a knowledge source
Knowledge
provides understanding and applicability to new situations
Constitutional law
provisions found in the Constitution, considered superior or supreme above laws arising from other sources
ISDN
public digital data network intended to supplant traditional telephone systems
telehealth
pursuit of health when separated by time and/or distance
inferrential statistics
reaching conclusions baked upon data from a sample, where patterns in the data are modeled so that randomness and uncertainty in observations are addressed
Morals
recognized principles or fundamental standards of right conduct that an individual internalizes
Double Effect Principle
recognizes that ethical choices may result in untoward outcome
Information technology (IT)
refers to computers and related technology
Health information technology (HIT or Health IT)
refers to the health-related application of IT
Translational research
research aimed to accelerate research findings into clinical practice
Comparative effectiveness research (CER)
research that compares one or more diagnostic or treatment options to evaluate effectiveness, safety or outcomes
Frequency polygon
resembles a histogram except that is takes a line form rather than a bar form
Data analysts
responsible for analyzing records and data quantitatively and qualitatively
Document and Repository Manager
responsible for ensuring long-term data integrity and access through the development of retention policies and procedures, determination of appropriate media for data and record storage, and maintenance of data control inventories
Central processing unit (CPUs)
responsible for executing programs, performing calculations, and moving data between memory and long-term storage media
To Err Is Human, Building a Safter Health System, 2000, focused on
safety and quality of care, claimed that almost 100,000 hospital deaths were caused by medical errors
Integrated PHR
separate application with the ability to import data from one or more provider EHRS
Medicaid
serves pregnant women, parents with dependent children who have no way to pay for healthcare, low-income families, the elderly needing long-term care, and the disabled population
Medicare
serves those over 65 years of age and those under the age of 65 with certain disabilities or end-stage renal disease
World Wide Web (WWW)
set of technology standards that enables the publishing of multimedia documents to be read by anyone with access to the internet made available in the early 1990s
Respite care
short-term care provided during the day or overnight to patients as a way to temporarily relieve the home caregiver
Quality circles
small groups of workers who perform similar work that meet regularly to analyze and solve work-related problems and to recommend solutions to management
tertiary care
specialized medical and surgical care provided for complex or unusual medical problems
Aggregate Data Collection
specific data are combined into larger grouping that can be used to describe a bigger concept; patients will not be identifiable
Procedural formalism
statements represented by the formalism can be directly executed by the computer
Declarative formalism
structured using a controlled syntax, serving as an input to a system that would use them in conjunction with other instructions or applications in order to apply the knowledge to clinical data
Systematic reviews (evidence reports)
studies that bring all evidence on some treatment or test together so that a big picture can be obtained
Epidemiology
study of the cause and distribution of diseases
SOAP stands for. . .
subjective, objective, assessment, plan
Legal Health record
subset of the business record, generated at or by the health care provider or organization, that addresses the patient's episode of care that was delivered by the provider or organization that may be released to third parties in response to legal process
Health record content includes
sufficient information to identify the patient clearly, to justify the diagnosis and treatment, and to document the result accurately
Three elements incorporated in Ledley and Lusted 1959 paper. . .
symbolic logic, probabilities, and value theory
electronic laboratory reporting (ELR) and Electronic Case Reporting (eCR) both use
syntactic and semantic standards to report details about a patient's infection and treatment ot agencies so they can perform their statutory role in tracking disease and ensuring patients recieve treatment
Availability
system and network accessibility, focuses on power loss or network connectivity outages
Ethical theories
systematic statements or plans of principles used to deal with ethical dilemmas
continuous quality improvement
systematic, team-based approach to process and performance improvement
Clinical Practice Guidelines (CPGs)
systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances
Practice management system
systems handle the non-clinical functions of medical practice such as scheduling, billing, and eligibility verification
Ransomware
target an individual or organization through a social engineering attack and get the victim to install malicious software then used to perform reconnaissance on the network to identify vulnerabilities, escalate privileges, and distribute ransomware code to other area
Technical Safeguards
technical tools implemented to protect data
Patient Safety: Achieving a New Standard for Care, 2004, asserted
that in order to prevent errors and to learn from the errors that do occur, a new healthcare delivery system was needed
First Institute of Medicine (IOM) on an informatics topic was. . .
the Computer-Based Patient Record published in 1991
Mental health
the ability to cope with and adjust to the recurrent stresses of living in an acceptable way
Basic Interoperability
the ability to transmit and receive data from one computer to another successfully
Absolute risk reduction (ARR) or Risk difference
the absolute difference of risk between the experimental and control groups
Absolute measures
the absolute risk for the control and experimental groups
Medical transcription
the act of transcribing prerecorded dictation to create medical reports, correspondence, and other administrative material
Authentication
the act or process of ensuring the entity in the record for both accuracy and authorship
Registration
the actions of a nongovernmental entity to recognize those individuals who meet specified standards
Public Health Informatics
the application of informatics in areas of public health, including surveillance, reporting, and health promotion
Bioinformatics
the application of informatics in cellular and molecular biology, often with a focus on genomics
Key Capabilities of an Electronic Health Record System, 2003, discussed
the basic functions of EHR, database management, and data standards
Fringe benefits
the benefits were supplemental to the wage and salary offered to the employee
Defense in Depth
the building of several layers of security controls around data
Primary Care
the care provided by the HCP at the initial point of contact and in the coordination of all aspects of the patient's health care
Cause-and-effect diagrams examines
the categories of the 4 Ms (methods/manpower/materials/machinery) or the 4 Ps (policies/procedures/people/plant)
Information systems
the collection of components (facts or data) that work in concert to achieve a common objective
Clinical Data
the collection of observations about a patient
Values
the concepts that give meaning to an individual's life and serve as the framework for decision making
Information Governance
the coordinated framework and approach designed to satisfy operational needs and information compliance requirements, manage information risks, and optimize information value
Administrative Law
the decisions and regulations issues by government agencies that are charges with interpreting statutory law
Outsourcing
the delegation of non-care operations from internal production of a business to an external entity that specializes in an operation
Mobile Diagnostic Services (MDS)
the delivery of portable diagnostic examinations
Discovery
the devices or tools used by one side to obtain facts and information about the case from the other side
Biomedical and health informatics (BMHI) or Health Informatics
the discipline focused on the use of information, aided by technology, to improve individual health, healthcare, public health, and research in biomedicine and health
Health information management (HIM)
the discipline historically focused on management of medical records with 3 main levels of practice
Health Information Exchange (HIE)
the electronic transfer of patient-level health related data or information across diverse and often competing organizations across the health ecosystem
Send Information
the end-user actively transmits information to another user or information system
Recieve Information
the end-user or information system passively receives a document or data from another user or information system
Timeliness
the entry of data in the record within a suitable time period
Health information exchange (HIE)
the exchange of health information across traditional business and other boundaries
Breach of Contract
the failure of the parties to a contract to perform according to the contract's terms
Distributive Justice
the fair distribution of burdens and benefits using an independent standard
Consumer health informatics
the field devoted to the informatics from a consumer view, often with a focus on mobile health
Ethics
the formal study of moral choices that conform to standards of conduct
Bylaws
the framework used to identify the roles and responsibilities of the board and its members
Clinical Decision support (CDS)
the functionality that addresses challenges such as knowledge acquisition, computable knowledge management, knowledge sharing, knowledge representation, and standards for doing so and the structuring of data that facilitates automated, computer-based application of knowledge to generate decision aids, tools, and interventions that can help improve decision-making and thereby clinical and process outcomes
Record retention policies
the general principles determining the length of time that health records must be maintained by the healthcare provider
Three main groups share responsibility for healthcare organization's compliance with the requirements:
the health care provider, the health information management (HIM) professional, and the organization's health record committee
Paternalism
the healthcare professional acted in the role of a father to his children, deciding what was best for the patient's welfare without first being required to consult with the patients
Mental Illness
the inability to cope effectively with the recurrent stresses of living
Charge Description Master (CDM)
the linking of procedures to charges using current procedural terminology code to be tracked using a computerized program
Hospice care
the management of symptoms for patients considered terminally ill, with a life expectancy of less than six months if their disease follows its normal course
pallative care
the management of symptoms for patients with serious illness at any stage
Health Information
the meaningful data relating to the past, present, or future health of an individual that is created or received in any form or medium by a HCP, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse
Six Sigma
the measurement of quality to a level of near perfection or without defects
Odds ratio (OR)
the odds of having one of the undesired outcomes or events versus not having it
Code of Federal Regulations (CFR)
the official publication of general and permanent rules and regulations of the federal government
Total Quality Management
the organization-wide approach to quality improvement
Data provenance
the origin and trustworthiness of data
Electronic health record (EHR)
the patient's health record in digital form
Personal Health Record (PHR)
the personally controlled health record
Retrospective data collection
the poccess of converting the paper record into a computerized abstract of the same would be performed after a patient was discharged
Organizational
the policies and considerations covering governance, social, legal, and organizational concerns used to facilitate the secure, seamless, and timely communication and use of data both within and between organizations, entities, and individuals
Pattern recognition
the presentation of the patient is matched up against the different possible diagnoses and the best fitting pattern is usually the diagnosis that is pursued
Rules
the principals established by authorities, prescribing or directing certain action or forbearance from action
Odds
the probability of an event occurring divided by the probability of an event not occurring
Accreditation
the process by which an external entity reviews an organization or program of study to determine if the organization or program meets certain predetermined standards
Utilization review
the process of comparing preestablished criteria against the health care provided to the patient to determine whether that care is necessary
Best Interest Standard
the process of determining what is the best interest of an individual when the individual cannot make such a decision on their own
Cold feed process
the process of having one computer application directly deposit data elements into a specialized data collection system
Data mining
the processing and modeling of data to discover previously unknown patterns or relationships
telemedicine
the provision of healthcare when participants separated by time and/or distance
Benefince
the quality of kindness, mercy, and charity
confidence interval (CI)
the range of values indicated the true value
relative risk (RR) or risk ratio
the rate of risk relative to the control
Patients rights
the recognition that a patient is the one who is entitled to determine the extent to which the patient will receive or forgo care and treatment
Designated record set (DSR)
the record maintained by the covered entity to make decisions about individuals
A general recognition that a patient possesses certain health care rights emerged simultaneously with 2 developments:
the rise of the consumer culture and movement away from paternalism in health care
control event rate (CER)
the risk of the event from the control intervention
experimental event rate (EER)
the risk of the event from the experimental intervention
Relative measures
the risk relative to the control group
information and communications technology (ICT)
the same as IT with emphasis on telecommunications
Data science
the science of learning from data; studies the methods involved in the analysis and processing of data and proposes technology to improve methods in an evidence-based manner
Benchmarking
the structured process of comparing outcomes or work practices generated by one group or organization against those of an acknowledged superior performer as a means of improving performance
Occupational Health
the subspeciality of healthcare focused on anticipating, evaluating, and controlling the environmental factors arising in or from the workplace that result in injury, illness, impairment, or otherwise affect the well-being
Information Systems Life Cycle
the succession of stages of an information system Include design and development, implementation and testing, operating and maintenance, and obsolescence
Brute Force Attack
the threat actor will attempt to throw random credentials at an application login page to see if they can gain access
Integrity
the trustworthiness and permanence of data, an insurance that the lab results or personal medical history of a patient is not modifiable by unauthorized entities or corrupted by a poorly designed process
breach of confidentiality
the unauthorized, acquisition, access, use, or disclosure of PHI which compromises the security of privacy of such information
Medical abandonment
the unilateral severing, by the physician, of the physician-patient relationship without giving the patient reasonable notice at a time when there is a necessity for continuing care
Value-added concept
the unique contribution of an activity is measured by the difference between the original component materials and the finished work product
Machine Learning (ML)
the use of computers to learn from patterns in data
Clinical research informatics
the use of informatics to facilitate clinical research with increasing emphasis on translational research
Health 2.0
the use of social media software and its ability to promote collaboration between patients, their caregivers, medical professionals, and other stakeholders in health care settings
Cloud computing
the virtualization of servers, software, data access, and storage resources
Splotation
the wrongful destruction or material alteration of evidence or the failure to preserve property or data for another's use as evidence
Hacktivists
these individuals or groups who do not have direct access to the organizarion's electronic resources
Quality Assurance (QA)
those actions taken to establish, protect, promote, and improve the quality of healthcare
Threat actors
those with malicious intent in securing information
A data dashboard can
track, analyze, and display key performance indicators (KPI), metrics, and other data points
PERT (Program Evaluation and Review Techniques)
tracks activities according to a time sequence, showing the interdependence of activities
DSL
transmists all data as digital signals but does not require access to television connections, used traditional telephone wiring
Problem-oriented medical record
type of record where all entriest are grouped under specific problems (SOAP)
Knowledge reuse
unit of knowledge implemented for one purpose is employed for another
Bit
unit of measure for computer storage; a single digit representing either the number 1 or 0
Knowledge transfer
units of knowledge formatted to directly interpretable or executable by the computer are moved from the place where they were first composed or implemented to another system or organization
Progress notes
update of progress by primary, consulting, and ancillary providers
eHealth
use of ICT for health
Business intelligence
use of data to obtain timely and valuable insights into business and clinical data
Synchronously (front end)
used by clinician.
Bayes' Theorem
used explicitly for calculating the post-test probability of a medical diagnosis
Tailgating
uses someone else's access to a restricted area by following closely behind the individual
Meaningful use
using certified EHRs in a way that allows for electronic exchange of health information to improve quality of care and to submit information on clinical quality measures
e-Discovery
when discovery seeks information stored electronically in any medium
Simple regression or univariate regression
when only one variable can be explained but data on the outcome variable are unknown or unavailable
Central Knowledge Server
yields chunks of marked-up knowledge via knowledge access for display by technologies such as infobuttons, KR facilitates knowledge sharing, including knowledge transfer and knowledge reuse
