RHIT Exam Prep
Data mapping
1. 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
Equivalence
1. Describes the relationship between the source and target and informs users how close or distant the two systems are. 2. A map's degree of equivalence affects its utility and reliability
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
Enterprise information management (EIM)
1. Ensuring the value of information assets, requiring an organization-wide perspective of information management functions; it calls for explicit structures, policies, processes, technology, and controls 2. The infrastructure and processes to ensure the information is trustworthy and actionable
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)
Heuristics
1. Rules for map development 2. A method or set of rules for solving problems other than by algorithm
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
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)
Delete
1. To eliminate by blotting out, cutting out, or erasing 2. To remove or eliminate, as to erase data from a field or to eliminate a record from a file; a method of erasing data
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)
Buildings
A long-term (fixed) asset account that represents the physical structures owned by the organization; See fixed assets
College of Healthcare Information Management Executives (CHIME)
A membership association serving chief information officers through professional development and advocacy (CHIME 2013)
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 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
Alias
A name added to, or substituted for, the proper name of a person; an assumed name
Hospital newborn inpatient
A patient born in the hospital at the beginning of the current inpatient hospitalization
History and physical documentation requirements policy
A policy that specifies the detail required in the history and physical examination done by the physician or physician extender
Ethernet
A popular protocol (format) for transmitting data in local-area networks
Intranet
A private information network that is similar to the Internet and whose servers are located inside a firewall or security barrier so that the general public cannot gain access to information housed within the network
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
American Dental Association (ADA)
A professional dental association dedicated to the public's oral health, ethics, science, and professional advancement (ADA 2013)
Health science librarian
A professional librarian who manages a medical library
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
Fetal death rate
A proportion that compares the number of intermediate or late fetal deaths to the total number of live births and intermediate or late fetal deaths during the same period of time
Institute for Healthcare Improvement (IHI)
A quality and safety improvement group partnering with patients and healthcare professionals to promote safe and effective healthcare (IHI 2013)
Incident report
A quality or performance management tool used to collect data and information about potentially compensable events (events that may result in death or serious injury); See also occurrence report
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
Cost justification
A rationale developed to support competing requests for limited resources
Discounting
A reduction from the full rate of payment. This can be the result of a fee for service contract, multiple procedures, or due to third party payer guidelines
Downsizing
A reengineering strategy to reduce the cost of labor and streamline the organization by laying off portions of the workforce
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 settin
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
Critic
A role in organizational innovation in which an idea is challenged, compared to stringent criteria, and tested against reality
Inventor
A role in organizational innovation that requires idea generation
Convenience sampling
A sampling technique where the selection of units from the population is based on easy availability or accessibility
Felony
A serious crime such as murder, larceny, rape, or assault for which punishment is usually severe
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)
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
Core data elements/core content
A small set of data elements with standardized definitions often considered to be the core of data collection efforts
Flash drive
A small, portable storage device with multi-gigabyte capacity that connects to a computer via a universal serial bus (USB) connection; also known by several other names, such as jump drive, thumb drive, and others
Alert
A software-generated warning that is based on a set of clinical rules built in to a healthcare information system
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
Clinical research
A specialized area of research that primarily investigates the efficacy of preventive, diagnostic, and therapeutic procedures; Also called medical research
Health Information Standards Board (HISB)
A subgroup of the American National Standards Institute that acts as an umbrella organization for groups interested in developing healthcare computer messaging standards
Alphabetic filing system
A system of health record identification and storage that uses the patient's last name as the first component of identification and his or her first name and middle name or initial for further definition
Integrated health record format
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
Hierarchical system
A system structured with broad groupings that can be further subdivided into more narrowly defined groups or detailed entities
Coalition building
A technique used to manage the political dimensions of change within an organization by building the support of groups for change
Bus
A type of hardware that controls the flow of commands between the central processor and other components
Causal relationship
A type of relationship in which one factor results in a change in another factor (cause and effect)
Computer-based training
A type of training that is delivered partially or completely using a computer
Hospital-affiliated ambulatory surgery center
An ambulatory surgery center that is owned and operated by a hospital but is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, record keeping, and financial and accounting systems
Executive sponsor
An individual who helps a team leader keep the team on track and sometimes ensures that the team obtains the organizational support required to accomplish its goal
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)
Data content standard
Clear guidelines for the acceptable values for specified data fields. These standards make it possible to exchange health information using electronic networks
Concept permanence
Codes that represent the concept in a controlled medical terminology are not reused; therefore meanings do not change
Circuit switching
Communications technology that establishes a connection between callers in a telephone network using a dedicated circuit path
Internal data
Data from within the facility that include administrative and clinical data
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
Continuous variables
Discrete variables measured with sufficient precision
Hiring
Engaging the services of an individual in return for compensation
Health maintenance organization (HMO)
Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: (1) an organized healthcare delivery system to a geographic area, (2) a set of basic and supplemental health maintenance and treatment services, (3) voluntarily enrolled members, and (4) predetermined fixed, periodic prepayments for members' coverage
FAHIMA
Fellow of the American Health Information Management Association; See Fellowship Program
Block grant
Fixed amount of money given or allocated for a specific purpose, such as a transfer of governmental funds to cover health services
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
Claims data
Information required to be reported on a healthcare claim for service reimbursement
Billing system
Information system that generates a bill for healthcare services performed
Coding and abstracting systems
Information system used to assign code numbers and enter key information from the health record
Information assets
Information that has value for an organization
Androgynous leadership
Leadership in which cultural stereotyped masculine and feminine styles are integrated into a more effective hybrid style
Base (payment) rate
Rate per discharge for operating and capital-related components for an acute care hospital
Grantee
Recipient of a research grant, who is responsible for carrying out the research with little or no direct involvement from the granting agency
Cancer registry
Records maintained by many states for the purpose of tracking the incidence (new cases) of cancer; Also called tumor registry
Accounts payable (A/P)
Records of the payments owed by an organization to other entities
Credited coverage
Reduction of waiting period for pre-existing condition based on previous creditable coverage
Format
Refers to the organization of information in the health record; there are many possible formats, and most facilities use a combination of formats
Application controls
Security strategies, such as password management, included in application software and computer programs
BPR
See business process reengineering
Boot-record infectors
See system infectors
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
Automated drug dispensing machines
System that makes drugs available for patient care
Equal Employment Opportunity Act
The 1972 amendment to the Civil Rights Act of 1964 prohibiting discrimination in the workplace on the basis of age, gender, race, color, religion, sex, or national origin (Public Law 92-261 1972)
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
Generalizability
The ability to apply research results, data, or observations to groups not originally under study
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
Discrimination
The act of treating one entity differently from another
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
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
Generic device group
The actual nomenclature or naming level by which a product or a group of similar products can be classified in the Global Medical Dictionary Nomenclature using a selected generic descriptor and its unique code
Forming
The first of four steps in assembling a functional team
Assets
The human, financial, and physical resources of an organization
Gross death rate
The number of inpatient deaths that occurred during a given time period divided by the total number of inpatient discharges, including deaths, for the same time period
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
Census
The number of inpatients present in a healthcare facility at any given time
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
History and physical (H and P)
The pertinent information about the patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems
Data storage
The physical location and maintenance of data
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
Information capture
The process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device generated information that is gathered and computed about a patient as part of healthcare
Degaussing
The process of removing or rearranging the magnetic field of a disk in order to render the data unrecoverable
Biomedical research
The process of systematically investigating subjects related to the functioning of the human body
Empiricism
The quality of being based on observed and validated evidence
Bandwidth
The range of frequencies a device or communication medium is capable of carrying
Cost of capital
The rate of return required to undertake a project
Decentralization
The shift of decision-making authority and responsibility to lower levels of the organization
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)
Hospital-based eligible providers (EPs)
Under HITECH, unless it meets the requirement of 495.5 of this part, a hospital-based EP means an EP who furnishes 90 percent or more of his or her covered professional services in sites of service identified by the codes used in the HIPAA standard transaction as an inpatient hospital or emergency room setting in the year preceding the payment year, or in the case of a payment adjustment year, in either of the two years before such payment adjustment year (42 CFR 495.4 2012)
Food and drug interactions
Unexpected conditions that result from the physiologic incompatibility of therapeutic drugs and food consumed by a patient
International Classification for Nursing Practice (ICNP®)
Unified nursing language system into which existing terminologies can be cross-mapped (ICNP 2013)
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
Data entity
a discrete form of data, such as a number or a word
ADL
activities of daily living
E/M
evaluation and management
Consultation rate
The total number of hospital inpatients receiving consultations for a given period divided by the total number of discharges and deaths for the same period
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
Disenrollment
A process of termination of coverage of a plan member
Chart tracking
A process that identifies the current location of a paper record or information
Clinical Documentation Improvement Plan
A program in which specialists concurrently review health records for incomplete documentation, prompting clinical staff to clarify ambiguity which allows coders to assign more concise disease classification codes
Central tendency
A statistical term referring to the center of the distribution; an average or middle value
Geometric mean length of stay (GMLOS)
A statistically adjusted value of all cases of a given Medicare severity diagnosis-related group (MS-DRG), allowing for the outliers, transfer cases, and negative outlier cases that would normally skew that data; used to compute hospital reimbursement for transfer cases
Federal Anti-Kickback Statute
A statute that establishes criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit or receive remuneration in order to induce business for which payment may be made under any federal healthcare program
Disk mirroring
A storage technique which mirrors data from a primary drive to a secondary in the event of a drive failure
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
Focused study
A study in which a researcher orally questions and conducts discussions with members of a group
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
Feasibility study
A study that looks at factors affecting an issue's ability to generate the necessary cash flows to meet principal and interest requirements
Graphical user interface (GUI)
A style of computer interface in which typed commands are replaced by images that represent tasks (for example, small pictures [icons] that represent the tasks, functions, and programs performed by a software program)
Discharge summary
A summary of the resident's stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility
E code (external cause of injury code)
A supplementary ICD-9-CM classification used to identify the external causes of injuries, poisonings, and adverse effects of pharmaceuticals
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
Infection control
A system for the prevention of communicable diseases that concentrates on protecting healthcare workers and patients against exposure to disease-causing organisms and promotes compliance with applicable legal requirements through early identification of potential sources of contamination and implementation of policies and procedures that limit the spread of disease
Healthcare provider cost report information system (HCRIS)
A system of Medicare cost report files containing information on provider characteristics, utilization data, and cost and charge data by cost center
Extranet
A system of connections of private Internet networks outside an organization's firewall that uses Internet technology to enable collaborative applications among enterprises
Internet protocol (IP) telephony
A type of communications technology that allows people to initiate real-time calls through the Internet instead of the public telephone system; See voiceover IP (VoIP)
Interpreter
A type of communications technology that converts high-level language statements into machine language one at a time
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
Group model health maintenance organization
A type of health plan in which an HMO contracts with an independent multispecialty physician group to provide medical services to members of the plan
Fixed costs
Resources expended that do not vary with the activity of the organization (for example, mortgage expense does not vary with patient volume)
Analysis
Review of health record for proper documentation and adherence to regulatory and accreditation standards
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
Best practice
Term used to refer to services that have been deemed effective and efficient with certain groups of clients
Fit for purpose
Testing that ensures the map meets the needs for which it was created
Honesty (integrity) tests
Tests designed to evaluate an individual's honesty using a series of hypothetical questions
Data
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions
Infant death
The death of a live-born infant at any time from the moment of birth to the end of the first year of life (364 days, 23 hours, 59 minutes from the moment of birth)
Fetal death
The death of a product of human conception before its complete expulsion or extraction from the mother regardless of the duration of the pregnancy; See stillbirth
Gross autopsy rate
The number of inpatient autopsies conducted during a given time period divided by the total number of inpatient deaths for the same time period
Inpatient daily census
The number of inpatients present at census-taking time each day, plus any inpatients who were both admitted and discharged after the previous day's census-taking time
Autopsy rate
The proportion or percentage of deaths in a healthcare organization that are followed by the performance of autopsy
Grievance procedures
The steps employees may follow to seek resolution of disagreements with management on job-related issues
Histology
The study of microscopic structure of tissue
Future value
The total dollar amount of an investment at a later point in time, including any earned or implied interest
Hospital autopsy rate
The total number of autopsies performed by a hospital pathologist for a given time period divided by the number of deaths of hospital patients (inpatients and outpatients) whose bodies were available for autopsy for the same time period
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
e-commerce
The use of the Internet and its derived technologies to integrate all aspects of business-to-business and business-to-consumer activities, processes, and communications
Collateral
The value of specific assets that are used to guarantee the purchase of material goods
Generally accepted auditing standards (GAAS)
The way in which organizations record and report financial transactions so that financial information is consistent between organizations
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
Incremental budgeting
A budgeting approach in which the financial database of the past is increased by a given percentage and adjustments are made for anticipated changes, with an added inflation factor
Double distribution
A budgeting concept in which overhead costs are allocated twice, taking into consideration that some overhead departments provide services to each other
European Committee for Standardization
A business facilitator in Europe, removing trade barriers for European industry and consumers; through its services it provides a platform for the development of European Standards and other technical specifications (FEANTSA 2013)
Clean claim
A completed insurance claim form that contains all the required information (without any missing information) so that it can be processed and paid promptly
Factor comparison method
A complex quantitative method of job evaluation that combines elements of both the ranking and point methods
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; the subset of standards for healthcare covered in CORBAmed
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
Hybrid online analytical processing (HOLAP)
A data access methodology that is coupled tightly with the architecture of the database management system to allow the user to perform business analyses
Certified coding specialist—physician-based (CCS-P®)
An AHIMA credential awarded to individuals who have demonstrated coding expertise in physician-based settings, such as group practices, by passing a certification examination
Certified coding specialist (CCS®)
An AHIMA credential awarded to individuals who have demonstrated skill in classifying medical data from patient records, generally in the hospital setting, by passing a certification examination
Chart conversion
An EHR implementation activity in which data from the paper chart are converted into electronic form
Health IT Policy Committee
An HHS advisory committee that recommends the policy framework for the development and adoption of a nationwide health information infrastructure (ONC 2013)
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)
Certification authority (CA)
An independent licensing agency that vouches for a person's identity in encrypted electronic communications
Index
An organized (usually alphabetical) list of specific data that serves to guide, indicate, or otherwise facilitate reference to the data
Enabling technologies
Any newly developed equipment that facilitates data gathering or information processing not possible previously
Data event
Any occurrence that generates new data or information, such as a diagnostic test
Ad hoc committee
A group of individuals who join together to solve a particular task or problem
backbone
A high-speed medium used as the main trunk in a computer network to transmit high volumes of traffic
Hospital outpatient
A hospital patient who receives services in one or more of a hospital's facilities when he or she is not currently an inpatient or a home care patient
Cohort study
A study, followed over time, in which a group of subjects is identified as having one or more characteristics in common
Budget
A plan that converts the organization's goals and objectives into targets for revenue and spending
Emergency mode operation plan
A plan that defines the processes and controls that will be followed until the operations are fully restored; Also called crisis management plan
Data backup plan
A plan that ensures the recovery of information that has been lost or becomes inaccessible
Alias policy
A policy that is implemented when resident confidentiality is required by the resident, family, or responsible party
Account
A subdivision of assets, liabilities, and equities in an organization's financial management system
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
Collective bargaining
A process through which a contract is negotiated that sets forth the relationship between the employees and the healthcare organization
Intensive review
A process undertaken when an incident occurs that requires the review of medical record or other data elements to determine if process problems exist and if an ongoing performance measure should be established to monitor process stability
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)
Informaticians
Individuals in a field of study (informatics) that focuses on the use of technology to improve access to, and utilization of, information
Active membership
Individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics are eligible for active membership. Active members in good standing shall be entitled to all membership privileges including the right to vote
Human subjects
Individuals whose physiologic or behavioral characteristics and responses are the object of study in a research program
Iatrogenic
Induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures
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
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
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
Indirect medical education (IME) adjustment
Percentage increase in Medicare reimbursement to offset the costs of medical education that a teaching hospital incurs
Guarantor
Person who is responsible for paying the bill or guarantees payment for healthcare services; adult patients are often their own guarantors, but parents guarantee payments for the healthcare costs of their children
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
Genetic algorithms
Optimization techniques that can be used to improve other data-mining algorithms so that they derive the best model for a given set of data
Fraud
The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s) (CMS 2013)
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)
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
Copy/Paste Functionality
The act of copying text within the electronic health record, copying of text from an outside document and pasting it into the EHR or pasting it to a new location with the record, in which the original text is not removed from the record
Examination
The act of evaluating the body to determine the presence or absence of disease
Health record ownership
The generally accepted principle that individual health records are maintained and owned by the healthcare organization that creates them but that patients have certain rights of control over the release of patient-identifiable (confidential) information
Information management
The generation, collection, organization, validation, analysis, storage, and integration of data as well as the dissemination, communication, presentation, utilization, transmission, and safeguarding of the information
Elective admission
The formal acceptance by a healthcare organization of a patient whose condition or surgical procedure permits adequate time to schedule the availability of a suitable accommodation
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
Gatekeeper
The healthcare provider or entity responsible for determining the healthcare services a patient or client may access (CMS 2013)
Coding professional
The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements
Class
The higher-level abstraction of an object that defines its properties and operations
Conceptual data model
The highest level of data model, representing the highest level of abstraction, independent of hardware and software
Evidence
The means by which the facts of a case are proved or disproved
Bed count or Bed complement
The number of inpatient beds set up and staffed for use on a given day
Hospital death rate
The number of inpatient deaths for a given period of time divided by the total number of live discharges and deaths for the same time period
Crude birth rate
The number of live births divided by the population at risk
Absolute frequency
The number of times that a score of value occurs in a data set
Dual option
The offering of health maintenance organization coverage as well as indemnity insurance by the same carrier
Claims processing
The process of accumulating claims for services, submitting claims for reimbursement, and ensuring that claims are satisfied
Final signature
The process of applying the responsible provider's electronic signature to documentation. Once applied, the documentation is considered complete
Coding
The process of assigning numeric or alphanumeric representations to clinical documentation
Forms automation
The process of automating a paper form in a database so that the form can be printed from multiple locations throughout the organization and included within the health record
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
Compression algorithm
The process or program for reducing data to reduce the space needed for transmission and storage
Chief nursing officer (CNO)
The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services
Chief executive officer (CEO)
The senior manager appointed by a governing board to direct an organization's overall long-term strategic management
Chief financial officer (CFO)
The senior manager responsible for the fiscal management of an organization
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;
Duplicate medical record number
The situation in which a single patient is associated with more than one medical record number
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
General ledger (G/L) key
The two- or three-digit number in the chargemaster that assigns each item to a particular section of the general ledger in a healthcare facility's accounting section
Implied consent
The type of permission that is inferred when a patient voluntarily submits to treatment
Infrastructure
The underlying framework and features of an information system
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)
Admission and readmissions processing policy
A policy that provides the guidelines that are required when a resident is admitted or readmitted to the facility
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
Action plan
A set of initiatives that are to be undertaken to achieve a performance improvement goal
Administrative management theory
A subdivision of classical management theory that emphasizes the total organization rather than the individual worker and delineates the major management functions
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
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)
Agenda for Change
An initiative undertaken by the Joint Commission that focused on changing the emphasis of the accreditation process from structure to outcomes
Administrative data
Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance
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)
Abuse
Describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced (CMS 2011)
Affiliated covered entity
Legally separate covered entities, affiliated by common ownership or control; for purposes of the Privacy Rule, these legally separate entities may refer to themselves as a single covered entity
Acute care
Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and treat an injury or a short-term illness
Adult learning
Self-directed inquiry aided by the resources of an instructor, colleagues/fellow students, and educational materials
Aberrancy
Services in medicine that deviate from what is typical in comparison to the national norm
Abbreviations
Shortened forms of words or phrases; in healthcare, when there is more than one meaning for an approved abbreviation, only one meaning should be used or the context in which the abbreviation is to be used should be identified
Adjustment
The process of writing off an unpaid balance on a patient account to make the account balance
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)
Consistent federated model (of HIE)
Health information exchange model where there is no centralized storage of patient data
Health information management (HIM) department
Healthcare facility department responsible for the management and safeguarding of information in paper and electronic form
Evidence-based medicine
Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies
Description
In a controlled medical vocabulary, a description is the combination of a concept and a term
Developing stage
In performance management, the stage during which opportunities for improving work processes or employee skills are identified
Health services research
Research conducted on the subject of healthcare delivery that examines organizational structures and systems as well as the effectiveness and efficiency of healthcare services
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)
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
Inventory control
The balance between purchasing and storing the supplies needed and not wasting money or space should the requirements for that supply change or the space available for storage be limited
Great person theory
The belief that some people have natural (innate) leadership skills
Department of Health and Human Services (HHS)
The cabinet-level federal agency, and principal agency for protecting the health of all Americans and providing essential human services, especially for those who are at least able to help themselves (HHS 2013)
Interoperability
The capability of different information systems and software applications to communicate and exchange data
Critical care
The care of critically ill patients in a medical emergency requiring the constant attention of the physician
Human resources
The employees of an organization
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
Health information exchange (HIE)
The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies
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
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
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
Duplicate billing
The practice of submitting more than one claim for the same item or service
Information technology (IT)
1. Computer technology (hardware and software) combined with telecommunications technology (data, image, and voice networks); often used interchangeably with information system (IS) 2. A term that encompasses most forms of technology used to create, store, exchange, and use electronic information
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
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
Health record
1. Information relating to the physical or mental health or condition of an individual, as made by or on behalf of a health professional in connection with the care ascribed that individual 2. A medical record, health record, or medical chart that is a systematic documentation of a patient's medical history and care
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)
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)
Firewall
A computer system or a combination of systems that provides a security barrier or supports an access control policy between two networks or between a network and any other traffic outside the network
Integrated services digital network (ISDN)
A computer system that transmits voice, data, and signaling digitally and with significantly increased bandwidth compared to traditional T-1 lines
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
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
Informatic
A field of study that focuses on the use of technology to improve access to, and utilization of, information
Hospital
A healthcare entity that has an organized medical staff and permanent facilities that include inpatient beds and continuous medical or nursing services and that provides diagnostic and therapeutic services for patients as well as overnight accommodations and nutritional services
Clinician
A healthcare provider, including physicians and others who treat patients
American Association of Preferred Provider Organization (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)
Blue Cross and Blue Shield Association
A national federation of 38 independent, community-based, and locally operated Blue Cross and Blue Shield companies. The Association owns and manages the Blue Cross and Blue Shield trademarks and names in more than 170 countries and territories around the world (BCBS 2013)
House staff
A physician in training who is continuing his or her medical education in a residency program, working with specialists to obtain higher-level skills and experience treating patients
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
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
Electronic medication administration record (EMAR)
A system designed to prevent medication errors by checking a patient's medication information against his or her bar-coded wristband
Incentive pay
A system of bonuses and rewards based on employee productivity; often used in transcription areas of healthcare facilities
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
Case study
A type of nonparticipant observation in which researchers investigate one person, one group, or one institution in depth
Health systems agency (HSA)
A type of organization called for by the Health Planning and Resources Development Act Amendment of 1979 to have broad representation of healthcare providers and consumers on governing boards and committees (Public Law 96-79 1979)
Interview survey
A type of research instrument with which the members of the population being studied are asked questions and respond orally
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
Concept
A unique unit of knowledge or thought created by a unique combination of characteristics
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
External validity
An attribute of a study's design that allows its findings to be applied to other groups
Internal validity
An attribute of a study's design that contributes to the accuracy of its findings
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 certificate
An electronic document that establishes a person's online identity
Automated clearinghouse (ACH)
An electronic network for the processing of financial transactions
Data administrator
An emerging role responsible for managing the less technical aspects of data, including data quality and security
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)
House of Delegates
An important component of the volunteer structure of the American Health Information Management Association that conducts the official business of the organization and functions as its legislative body
Document review
An in-depth study performed by accreditation surveyors of an organization's policies and procedures, administrative records, human resources records, performance improvement documentation, and other similar documents, as well as a review of closed patient records
Delinquent health record
An incomplete record not finished or made complete within the time frame determined by the medical staff of the facility
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
Federal Trade Commission (FTC)
An independent federal agency tasked with dealing with two areas of economics in the United States: consumer protection and issues having to do with competition in business (FTC 2013)
Financial Accounting Standards Board (FASB)
An independent organization that sets accounting standards for businesses in the private sector
American Correctional Association (ACA)
An organization that provides education, training, correctional certification, and accreditation for correctional healthcare organizations (ACA 2013)
Data audit
An organizational procedure for monitoring the quality of data by analyzing reports for anomalies, inaccuracies, and missing data
Attorney-client privilege
An understanding that protects communication between client and attorney
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)
Document
Any analog or digital, formatted, and preserved "container" of data or information
Fiscal year
Any consecutive 12-month period an organization uses as its accounting period
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
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])
Consent
1. A patient's acknowledgement that he or she understands a proposed intervention, including that intervention's risks, benefits, and alternatives 2. The document signed by the patient that indicates agreement that protected health information (PHI) can be disclosed
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)
Insurance
1. A purchased contract (policy) according to which the purchaser (insured) is protected from loss by the insurer's agreeing to reimburse for such loss 2. Reduction of a person's (insured's) exposure to risk by having another party (insurer) assume the risk
Interrupted stay case
1. A rehabilitation stay interrupted by a single admission to an acute care hospital 2. Discharge in which the patient was discharged from the inpatient rehabilitation facility and returned within three calendar days
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
Accounts receivable (A/R)
1. Records of the payments owed to the organization by outside entities such as third-party payers and patients 2. Department in a healthcare facility that manages the accounts owed to the facility by customers who have received services but whose payment is made at a later date
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
Clinical trial
1. The final stages of a long and careful research process that tests new types of medical care to see if they are safe (CMS 2013) 2. Experimental study in which an intervention or treatment is given to one group in a clinical setting and the outcomes compared with a control group that did not have the intervention or treatment or that had a different intervention or treatment
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)
Column/field
A basic fact within a table, such as LAST_NAME, FIRST_NAME, and date of birth
Halo effect
A bias that occurs when someone allows certain information to influence a decision disproportionately
Data analysis
A body of methods that help to describe facts, detect patterns, develop explanations, and test hypotheses. It is used in all the sciences. It is used in business, in administration, and in policy (Levine and Roos 2002)
Administrative law
A body of rules and regulations developed by various administrative entities empowered by Congress; falls under the umbrella of public law
Information theory
A branch of applied mathematics and electrical engineering and involves the quantification of information
Contract law
A branch of law based on common law that deals with written or oral agreements that are enforceable through the legal system
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
Intrahospital transfer
A change in medical care unit, medical staff unit, or responsible physician during hospitalization
Compensable factor
A characteristic used to compare the worth of jobs (for example, skill, effort, responsibility, and working conditions)
History of present illness (HPI)
A chronological description of the development of the patient's present illness from the first sign or symptom or from the previous encounter to the present
Intentional tort
A circumstance where a healthcare provider purposely commits a wrongful act that results in injury
ICD-9-CM
A classification system used in the United States to report morbidity and mortality information; See International Classification of Diseases, Ninth Revision, Clinical Modification
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
Controlled medical terminology
A coded vocabulary of medical concepts and expressions used in healthcare
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)
Incidence rate
A computation that compares the number of new cases of a specific disease for a given time period to the population at risk for the disease during the same time period
Extreme immaturity
A condition referring to a newborn with a birth weight of fewer than 1,000 grams or gestation of fewer than 28 completed weeks
Edit
A condition that must be satisfied before a computer system can accept data
Acknowledgement
A form that provides a mechanism for the resident to recognize receipt of important information
Default judgment
A court ruling against a defendant in a lawsuit who fails to answer a summons for a court appearance
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
Evaluation research
A design of research that examines the effectiveness of policies, programs, or organizations
Discrete variable
A dichotomous or nominal variable whose values are placed into categories
Facility directory
A directory of patients being treated in a healthcare facility
Ergonomics
A discipline of functional design associated with the employee in relationship to his or her work environment, including equipment, workstation, and office furniture adaptation to accommodate the employee's unique physical requirements so as to facilitate efficacy of work functions
Communicable disease
A disease that can be transmitted from an infected person, animal, or inanimate reservoir to a susceptible person or host by either direct or indirect contact
Documentation paradigm
A disease-specific format developed by the individual provider for the purpose of establishing standard clinical documentation forms
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
Communications plan
A documented approach to identifying the media and schedule for sharing information with affected parties
Hot site
A duplicate of the organization's critical systems stored in a remote location
Department of a provider
A facility, organization, or physician's office that is either created or acquired by a main provider for the purpose of furnishing healthcare services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of the ambulatory payment classification final rule
Court of Claims
A federal or state court in which legal actions against the government are brought
Cash budget
A forecast of needs for available funds throughout the year
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
Interview
A formal meeting, often between a job applicant and a potential employer
Grievance
A formal, written description of a complaint or disagreement
Cafeteria plan
A health plan that allows employees to choose among two or more benefits
Individual provider
A health professional who delivers or is professionally responsible for delivering services to a patient, is exercising independent judgment in the care of the patient, and is not under the immediate supervision of another healthcare professional
Active record
A health record of an individual who is a currently hospitalized inpatient or an outpatient
Inpatient psychiatric facility (IPF)
A healthcare facility that offers psychiatric medical care on an inpatient basis
Alternative hypothesis
A hypothesis that states that there is an association between independent and dependent variables
Foreign key
A key attribute used to link a column or data point in one table to the column or data point in another table
Addendum
A late entry added to a health record to provide additional information in conjunction with a previous entry. The late entry should be timely and bear the current date and reason for the additional information being added to the health record
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
Data set
A list of recommended data elements with uniform definitions that are relevant for a particular use
Interview guide
A list of written questions to be asked during an interview
Formulary
A listing of drugs, classified by therapeutic category or disease class; in some health plans, providers are limited to prescribing only drugs listed on the plan's formulary. The selection of items to be included in the formulary is based on objective evaluations of their relative therapeutic merits, safety, and cost
Equipment
A long-term (fixed) asset account representing depreciable items owned by the organization that have value over multiple fiscal years (for example, the historical cost of a CT scanner is recorded in an equipment account); See fixed assets
Acceptance theory of authority
A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions
Concordance
A mapping term meaning agreement
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)
Deposition
A method of gathering information to be used in a litigation process
Failure Mode Effect and Criticality Assessment (FMECA)
A methodology for determining the cause of sentinel events
Hay method of job evaluation
A modification of the point method of job evaluation that numerically measures the levels of three major compensable factors: know-how, problem-solving ability, and accountability; Also called Hay Guide Chart/Profile Method of Job Evaluation
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)
Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV)
A nomenclature developed by the American Psychiatric Association to standardize the diagnostic process for patients with psychiatric disorders, which includes codes that correspond to ICD-9-CM codes; most recent version is fourth edition (text revision), or DSM-IV-TR, published in 2000 (APA 2013)
Health Privacy Project
A nonprofit organization whose mission is to raise public awareness of the importance of ensuring health privacy in order to improve healthcare access and quality
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)
Accession Number
A number assigned to each case as it is entered in a cancer registry
Corporate Code of Conduct
A part of the compliance plan that expresses the organization's commitment to ethical behavior
Brand name
A patent for a new drug that gives its manufacturer the exclusive right to market the drug for a specific period of time under a brand name
Capitated patient
A patient enrolled in a managed care program that pays a fixed monthly payment to the patient's identified primary care provider
Clinic outpatient
A patient who is admitted to a clinical service of a clinic or hospital for diagnosis or treatment on an ambulatory basis
eHealth initiative
A private organization which involves many groups working on the improvement of health information technology and health information exchange (eHealth Initiative 2013)
Conflict management
A problem-solving technique that focuses on working with individuals to find a mutually acceptable solution
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
Inductive reasoning
A process of creating conclusions based on a limited number of observations
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)
General Equivalence Mappings (GEMs)
A program created to facilitate the translation between ICD-9-CM and ICD-10-CM/PCS (CMS 2010)
Information security program
A program that includes all activities of an organization related to information security, including policies, standards, training, technical and procedural controls, risk assessment, auditing and monitoring, and assigned responsibility for management of the program
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
Exploratory research
A research design used because a problem has not been clearly defined or its scope is unclear
Historical research
A research design used to investigate past events
Hawthorne effect
A research study that found that novelty, attention, and interpersonal relations have a motivating effect on performance
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
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
Assembly language
A second-generation computer programming language that uses simple phrases rather than the complex series of switches used in machine language
ICNP Catalogues
A set of precoordinated statements being developed by the International Council of Nurses that will consist of subsets of nursing diagnoses, interventions, and outcomes for a specific area of practice
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
Entity relationship diagram (ERD)
A specific type of data modeling used in conceptual data modeling and the logical-level modeling of relational databases
Abnormal involuntary Movement Scale (AIMS)
A standardized form that can be used in facilities to document involuntary movements
Health
A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
Emergency preparedness
A state of readiness to react to an emergency situation
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
Explanation of benefits (EOB)
A statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by a health plan. See payer remittance report
Code of ethics
A statement of ethical principles regarding business practices and professional behavior
Hypothesis
A statement that describes a research question in measurable terms
Factor analysis
A statistical technique in which a large number of variables are summarized and reduced to a smaller number based on similar relationships among those variables
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
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
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
Hedge
A transaction that reduces the risk of an investment
Healthcare information system (HIS)
A transactional system used in healthcare organizations (for example, patient admitting, accounting, and receivables); See hospital information system
Excludes 2
A type 2 Excludes note represents "not included here." An Excludes 2 note indicates that the condition excluded is not a part of the condition represented by the code, but a patient may have both conditions at the same time (CDC 2013)
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
Interval data
A type of data that represents observations that can be measured on an evenly distributed scale beginning at a point other than true zero
Home Assessment Validation and Entry (HAVEN)
A type of data-entry software used to collect Outcome and Assessment Information Set (OASIS) data and then transmit them to state databases; imports and exports data in standard OASIS record format, maintains agency/patient/employee information, enforces data integrity through rigorous edit checks, and provides comprehensive online help. HAVEN is used in the home health prospective payment system (HHPPS)
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
Assisted living
A type of freestanding long-term care facility where residents receive necessary medical services but retain a degree of independence
Communities of Practice (CoP)
A web-based electronic network for communication among members of the American Health Information Management Association
HIM Career Map
A web-based interactive and visual representation of the job titles and roles that make up the scope of HIM and the career pathways associated with them (AHIMA 2013)
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
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
American Society for Testing and Materials Committee E31 (ASTM E31)
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)
Hospital newborn bassinet
Accommodations including incubators and isolettes in the newborn nursery with supporting services (such as food, laundry, and housekeeping) for hospital newborn inpatients
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
Geographic adjustment factor (GAF)
Adjustment to the national standardized Medicare fee schedule relative value components used to account for differences in the cost of practicing medicine in different geographic areas of the country
Deficiency analysis
An audit process designed to ensure that all services billed have been documented in the health record
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)
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
Compensation
All direct and indirect pay, including wages, mandatory benefits, and benefits such as medical insurance, life insurance, child care, elder care, retirement plans, and longevity pay
Generally accepted accounting principles (GAAP)
An accepted set of accounting principles or standards, and recognized procedures central to financial accounting and reporting
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
Employee Retirement Income Security Act of 1974 (ERISA)
An act that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans (Public Law 93-406 1974)
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)
Institutional Review Board (IRB)
An administrative body that provides review, oversight, guidance, and approval for research projects carried out by employees serving as researchers, regardless of the location of the research (such as a university or private research agency); responsible for protecting the rights and welfare of the human subjects involved in the research. IRB oversight is mandatory for federally funded research projects
Health Resources and Services Administration (HRSA)
An agency of the US Department of Health and Human Services and the primary federal agency for improving access to healthcare services for people who are uninsured, isolated, or medically vulnerable. Comprising six bureaus and ten offices, HRSA provides leadership and financial support to healthcare providers in every state and US territory. HRSA grantees provide healthcare to uninsured people, people living with HIV/AIDS, pregnant women, mothers, and children. They train health professionals and improve systems of care in rural communities (HRSA 2013)
Administrative services only (ASO) contract
An agreement between an employer and an insurance organization to administer the employer's self-insured health plan
Hierarchy
An authoritarian organizational structure in which each member is assigned a specific rank that reflects his or her level of decision-making authority within the organization
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
Interactive voice response
An automated call handler that can be configured to automatically dial a log of callers and deliver appointment reminders, lab results, and other information when a person answers the phone
Hospital Standardization Program
An early 20th-century survey mechanism instituted by the American College of Surgeons and aimed at identifying quality-of-care problems and improving patient care; precursor to the survey program offered by the Joint Commission
Innovator
An early adopter of change who is eager to experiment with new ways of doing things
Business case
An economic argument, or justification, usually for a capital expenditure
Electronic health record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization; Also called computer-based health record; computer-based patient record
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
Helsinki Agreement
An ethical code established in 1964 by the 18th World Medical Assembly to guide researchers beyond the Nuremberg Code; differentiates between clinical or therapeutic research and nonclinical research and addresses problems with those who are legally incompetent and who need "proxy" representation
Chief operating officer (COO)
An executive-level role responsible at a high level for day-to-day operations of an organization
Item description
An explanation of a service or supply listed in the chargemaster
Geographic practice cost index (GPCI)
An index developed by the Centers for Medicare and Medicaid Services to measure the differences in resource costs among fee schedule areas compared to the national average in the three components of the relative value unit (RVU): physician work, practice expenses, and malpractice coverage; separate GPCIs exist for each element of the RVU and are used to adjust the RVUs, which are national averages, to reflect local costs
Enterprise master patient index (EMPI)
An index that provides access to multiple repositories of information from overlapping patient populations that are maintained in separate systems and databases
Indicator measurement system
An indicator-based monitoring system developed by the Joint Commission for accredited organizations and meant to provide hospitals with information on their performance
Expert witness
An individual called to testify in a case based on their expertise in a certain subject
High-risk pool
An insurance plan (often a state healthcare insurance plan) that covers unhealthy or medically uninsurable people whose healthcare costs will be higher than average and whose utilization of healthcare services will be higher than average. Also the term for the small group of unhealthy individuals who have the high probability of incurring many healthcare services at high costs
Hospice
An interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families (CMS 2013)
Internet
An international network of computer servers that provides individual users with communications channels and access to software and information repositories worldwide
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)
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
Cause-and-effect diagram
An investigational technique that facilitates the identification of the various factors that contribute to a problem; See also fishbone diagram
Hippocratic oath
An oath created by ancient Greeks to embody a code of medical ethics
Health insurance query for home health agencies (HIQH)
An online transaction system that provides information on home health and hospice episodes for specific Medicare beneficiaries
Independent practice organization (IPO) or association (IPA)
An open-panel health maintenance organization that provides contract healthcare services to subscribers through independent physicians who treat patients in their own offices; the HMO reimburses the IPA on a capitated basis; the IPA may reimburse the physicians on a fee-for-service or a capitated basis; Also called foundation model; individual practice association model
Do not resuscitate (DNR)
An order written by the treating physician stating that in the event the patient suffers cardiac or pulmonary arrest, cardiopulmonary resuscitation should not be attempted
Fiscal intermediary (FI)
An organization that contracts with the Centers for Medicare and Medicaid Services to serve as the financial agent between providers and the federal government in the local administration of Medicare Part A or Part B claims; usually, but not necessarily, an insurance company (CMS 2013)
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)
Insurer
An organization that pays healthcare expenses on behalf of its enrollees; See third-party payer
American Association of Accreditation of Ambulatory Surgery Facilities
An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities (AAAASF 2013)
General interview guide
An outline or checklist of issues that the researcher can use for interviews that are a bit more structured than the informal conversational interview, often used with very long interviews that are audiotaped so the researcher has time to focus on the interview process
Injury Severity Score (ISS)
An overall severity measurement maintained in the trauma registry and calculated from the abbreviated injury scores for the three most severe injuries of each patient (Trauma Org 2013)
Employer-based self-insurance
An umbrella term used to describe health plans that are funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees' medical expenses and retain control over the funds but bear the risk of paying claims greater than their estimates
Discharge diagnosis
Any one of the diagnoses recorded after all the data accumulated during the course of a patient's hospitalization or other circumscribed episode of medical care have been studied
Diversity
Any perceived difference among people, such as age, functional specialty, profession, sexual orientation, geographic origin, lifestyle, or tenure with the organization or position
Interim period
Any period that represents less than an entire fiscal year
Carve-outs
Applicable services that are cut out of the contract and paid at a different rate
Genetic services
As amended by HITECH, (1) a genetic test; (2) genetic counseling (including obtaining, interpreting, or assessing genetic information); or (3) genetic education (45 CFR 160.103 2013)
Implementation specifications
As amended by HITECH, specific requirements or instructions for implementing a privacy or security standard (45 CFR 170.102 2012)
Health information service provider (HSP)
As described by the US HHS Office of the National Coordinator for Health Information Technology (ONC), a vendor that supplies the data integration and connectivity services for a health information organization
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)
Document image data
Bitmapped images based on data created and stored on analog paper or photographic film
Abstract
Brief summary of the major parts of a research study
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)
Clinical risk group (CRG)
Capitated prospective payment system that predicts future healthcare expenditures for populations
Current assets
Cash and other assets that typically will be converted to cash within one year
Highly sensitive health information
Certain types of patient information that require special handling in regard to access, requests, uses, and disclosures due to the nature of the information
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)
Employment-at-will
Concept that employees can be fired at any time and for almost any reason based on the idea that employees can quit at any time and for any reason
Authenticate
Confirm by signing
Granular
Consisting of small components or details
Enterprisewide content management (ECM)
Consists of a cluster of technologies that manage the enterprise's unstructured intellectual substance of its documents and records, such as symbol, image, video, and audio data
Certified professional coder-hospital (CPC-H)
Credential sponsored by the American Academy of Professional Coders that certifies hospital-based coders (AAPC 2013)
Discrete data
Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values
Competencies
Demonstrated skills that a worker should perform at a high level
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)
Inventory
Goods on hand and available to sell, presumably within a year (a business cycle)
Investor-owned hospital chain
Group of for-profit healthcare facilities owned by stockholders
Benefit
Healthcare service for which the healthcare insurance company will pay; See covered service (expense)
Ambulatory payment classification (APC)
Hospital outpatient prospective payment system (OPPS). The classification is a resource-based reimbursement system
Exclusive provider organization (EPO)
Hybrid managed care organization that provides benefits to subscribers only when healthcare services are performed by network providers; sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organizations
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
Brackets
In ICD-10-CM brackets 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 colons: are 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)
Fully Specified Name
In SNOMED CT, the unique text assigned to a concept that completely describes that concept
Counterclaim
In a court of law, a countersuit
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)
Information technology governance (ITG)
Is led by the CIO; it is the process to ensure the effective evaluation, selection, prioritization, and funding of competing IT investments. ITG oversee the implementation and extracts (measurable) business benefits
Health Information Technology for Economic and Clinical Health Act (HITECH)
Legislation created to promote the adoption and meaningful use of health information technology in the United States. Subtitle D of the Act provides for additional privacy and security requirements that will develop and support electronic health information, facilitate information exchange, and strengthen monetary penalties. Signed into law on February 17, 2009, as part of ARRA (Public Law 111-5 2009)
False Claims Act
Legislation passed during the Civil War, amended in 1986, that prohibits contractors from making a false claim to a governmental program; used to reinforce the prevention of healthcare fraud and abuse (Public Law 99-562 1986)
Forward map
Mapping that proceeds from a newer code set to an older code set (CMS 2010)
Government recognized maps
Maps developed by a standards development organization or other authorized source; however, with government recognition these maps move from a voluntary standard to a government standard. Examples of this type of map are the ICD-9-CM to
Hierarchy of needs
Maslow's theory that suggested that human needs are organized hierarchically from basic physiological requirements to creative motivations; See Maslow's Hierarchy of Needs
Durable medical equipment (DME)
Medical equipment designed for long-term use in the home, including eyeglasses, hearing aids, surgical appliances and supplies, orthotics and prostheses, and bulk and cylinder oxygen (CMS 2013); Also called home medical equipment (HME)
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
Impairment group code (IGC)
Multidigit code that represents the primary reason for a patient's admission to an inpatient rehabilitation facility
E-visits
Non-face-to-face interaction between patient and provider
Acquisition
One healthcare entity purchase of another healthcare entity in order to acquire control of all of its assets
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
International Federation of Health Information Management (IFHIM)
Organization that supports national associations and health record professionals to improve health records and systems; IFHIM was established in 1968 under the name IFHRO, International Federation of Health Record Organizations, as a forum to bring national organizations together
Healthcare provider organizations
Organizations that include but are not limited to, physician offices, clinics, outpatient facilities, freestanding surgical centers, hospitals, regional health centers, and enterprise-wide health systems
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)
Internal controls
Policies and procedures designed to protect an organization's assets and to reduce the exposure to the risk of loss due to error or malfeasance
Failed/missed appointment policy
Policy that tracks appointments that are canceled or missed. A failed/missed appointment policy should state the required documentation of information concerning the missed appointment
Accreditation standards
Preestablished statements of the criteria against which the performance of participating healthcare organizations will be assessed during a voluntary accreditation
Incomplete record processes
Processes including deficiency analysis and chart completion practices
Data exchange standards
Protocols that help ensure that data transmitted from one system to another remain comparable
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)
Health informatics and information management (HIIM)
Refers to the individuals responsible for managing healthcare data and information in paper or electronic form and controlling its collection, access, use, exchange, and protection through the application of health information technology
Global package
Refers to the payment policy of bundling payment for the various services associated with a surgery into a single payment covering professional services for preoperative care, the surgery itself, and postoperative care
Cognitive
Related to mental abilities, such as talking, memory, and problem solving
Harvard relative value scale study
Research conducted at Harvard University by William Hsiao and Peter Braun on establishing the appropriate relative values for physician services
Health savings accounts (HSAs)
Savings accounts designed to help people save for future medical and retiree health costs on a tax-fee basis; part of the 2003 Medicare bill; Also called medical savings accounts
Health informatics
Scientific discipline that is concerned with the cognitive, information-processing, and communication tasks of healthcare practice, education, and research, including the information science and technology to support these tasks
Equity
Securities that are shared in the ownership of the organization
Charity care
Services for which healthcare organizations did not expect payment because they had previously determined the patients' or clients' inability to pay
Health data analyst
Someone who uses application skills to manage, analyze, interpret, and transform health data into accurate, consistent, and timely information
Cultural competence
Skilled in awareness, understanding, and acceptance of beliefs and values of the people of groups other than one's own
Incentive
Something that stimulates or encourages an individual to work harder
APC group
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
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
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)
Epidemiological studies
Studies that are concerned with finding the causes and effects of diseases and conditions
Historical-prospective study
Study design used when existing data sources can be used to identify characteristics pertaining to the study groups; groups followed over time, usually from the time data are first collected to the present or into the future, to examine their outcomes
Barcode medication administration record (BC-MAR)
System that uses barcoding technology for positive patient identification and drug information
Electronic record 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 stores them for subsequent viewing; Also called computer output to laser disk (COLD) technology
Cybernetic systems
Systems that have standards, controls, and feedback mechanisms built in to them
Closed systems
Systems that operate in a self-contained environment
Computers on wheels (COWs)
Term affectionately used to refer to notebook computers mounted on carts and moved with the users
Ability (achievement) tests
Tests used to assess the skills an individual already possesses; Also called performance tests
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
American Academy of Professional Coders (AAPC)
The American Academy of Professional Coders provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations (AAPC 2013)
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
Centers for Medicare and Medicaid Services (CMS)
The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid. Historically, CMS has maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set (CMS 2013)
ISO 9000
The ISO 9000 family addresses various aspects of quality management and contains some of ISO's best known standards. The standards provide guidance and tools for companies and organizations who want to ensure that their products and services consistently meet customers' requirements, and that quality is consistently improved (ISO 2013)
Construct validity
The ability of an instrument to measure hypothetical, nonobservable traits
Attestation
The act of applying an electronic signature to the content showing authorship and legal responsibility for a particular unit of information
Harassment
The act of bothering or annoying someone repeatedly
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
Depreciation
The allocation of the dollar cost of a capital asset over its expected life
Dollars in accounts receivable
The amount of money owed a healthcare facility when claims are pending
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
Duration
The amount of time, usually measured in days, for a task to be completed
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
e-HIM
The application of technology to managing health information
Front-end processes
The billing processes associated with preregistration, prebooking, scheduling, and registration activities that collect patient demographic and insurance information, perform verification of patient insurance, and determine medical necessity
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
Home health prospective payment system (HHPPS)
The case mix reimbursement system developed by the Centers for Medicare and Medicaid Services in 2008, to cover home health services, including therapy visits and different resource costs provided to Medicare beneficiaries (CMS 2013)
Expectations
The characteristics that customers want to be evident in a healthcare product, service, or outcome
International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)
The coding classification system that will replace ICD-9-CM, Volume 3, on October 1, 2014. ICD-10-PCS has 16 sections and contains significantly more procedure codes than ICD-9-CM, providing the ability to code procedures with a greater level of specificity (CMS 2013)
Cost-sharing
The cost for medical care that patients pay for themselves, like a copayment, coinsurance, or deductible (CMS 2013)
Interest
The cost of borrowing money; payment to creditors for using money on credit
Ethnic group
The cultural group with which the patient identifies by means of either recorded family data or personal preference
Debt service
The current obligations of an organization to repay loans
Date of service (DOS)
The date a test, procedure, or service was rendered
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
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
Encounter
The face-to-face contact between a patient and a provider who has primary responsibility for assessing and treating the condition of the patient at a given contact and exercises independent judgment in the care of the patient
Independent variables
The factors in experimental research that researchers manipulate directly
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
Government Accounting Standards Board (GASB)
The federal agency that sets the accounting standards to be followed by government entities
Customary fee
The fee normally charged by physicians of the same specialty in the same geo-
Data granularity
The level of detail at which the attributes and values of healthcare data are defined
Hardware
The machines and media used in an information system
Financial accounting
The mechanism that organizations use to fully comprehend and communicate their financial activities
Audit controls
The mechanisms that record and examine activity in information systems
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)
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
Chief complaint
The principal problem a patient reports to a healthcare provider
Industry standard
The procedures or criteria that have been recognized as acceptable practices by peer professional, credentialing, or accrediting organizations
Clinical Documentation Improvement (CDI)
The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes
Clinical analytics
The process of gathering and examining data in order to help gain greater insight about patients
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 (ASHRM 2013)
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
Hospital autopsy rate, adjusted
The proportion of deaths of hospital patients following which the bodies were available for autopsy and hospital autopsies were performed; See available for hospital autopsy
Bad debt
The receivables of an organization that are uncollectible
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
Authority
The right to make decisions and take actions necessary to carry out assigned tasks
Actor
The role a user plays in a system
Data analytics
The science of examining raw data with the purpose of drawing conclusions about that information. It includes data mining, machine language, development of models, and statistical measurements. Analytics can be descriptive, predictive, or prescriptive
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
Assessment
The systematic collection and review of information pertaining to an individual who wants to receive healthcare services or enter a healthcare setting
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
For-profit organization
The tax status assigned to business entities that are owned by one or more individuals or organizations and that earn revenues in excess of expenditures that are subsequently paid out to the owners or stockholders
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
Inpatient discharge
The termination of hospitalization through the formal release of an inpatient from a hospital; See also discharge status
Implementation phase
The third phase of the systems development life cycle during which a comprehensive plan is developed and instituted to ensure that the new information system is effectively implemented within the organization
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
Gross patient service revenues
The total amount the healthcare organization earns in full for its services
Current ratio
The total current assets divided by total current liabilities
Debt ratio
The total liabilities divided by the total assets
International Organization for Standardization (ISO)
The world's largest developer of voluntary International Standards. International Standards give state of the art specifications for products, services, and good practice, helping to make industry more efficient and effective. Developed through global consensus, they help to break down barriers to international trade (ISO 2013)
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
Discharge date (inpatient)
The year, month, and day that an inpatient was formally released from the hospital and room, board, and continuous nursing services were terminated
Date of birth
The year, month, and day when an individual was born
Interface
The zone between different computer systems across which users want to pass information (for example, a computer program written to exchange information between systems or the graphic display of an application program designed to make the program easier to use)
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)
Accidents/Incidents
Those mishaps, misfortunes, mistakes, events, or occurrences that can happen during the normal daily routines and activities in the long-term care setting
Health information technology extension program
To assist healthcare providers to adopt, implement, and effectively use certified EHR technology that allows for the electronic exchange and use of health information, the Secretary, acting through the Office of the National Coordinator, shall establish a health information technology extension program to provide health information technology assistance services to be carried out through the Department of Health and Human Services
Forecast
To calculate or predict some future event or condition through study and analysis of available pertinent data
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
Indemnity health insurance
Traditional, fee-for-service healthcare plan in which the policyholder pays a monthly premium and a percentage of the usual, customary, and reasonable healthcare costs and the patient can select the provider
Awareness training
Training designed to help individuals understand and respond to information technology concerns
Continuing education
Training that enables employees to remain current with advancing knowledge in their profession
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)
Anatomical modifiers
Two-digit CPT codes that provide information about the exact body location of procedures, such as -LT, Left side, and -TA, Left great toe
Implied contract
Type of agreement between physician and patient that is created by actions
Inspection
Under ICD-10-PCS, a root procedure that involves visually or manually exploring a body part (CMS 2013)
Face sheet
Usually the first page of the health record, which contains patient identification, demographics, date of admission, insurance coverage or payment source, referral information, hospital stay dates, physician information, and discharge information, as well as the name of the responsible party, emergency and additional contacts, and the resident's diagnoses
Inpatient rehabilitation facility PPS (IRFPPS)
Utilizes the patient assessment instrument to assign patients to case-mix groups according to their clinical situation and resource requirements (CMS 2013)
Homogeneity
Variance in measurements or scores of the sample. Less variance, or greater homogeneity, in the measurements or scores of the sample results in narrower confidence intervals (CIs); greater variance and heterogeneity result in wider CIs
Eligibility verification
Verification that determines if a patient's health plan will provide reimbursement for services to be performed, and sometimes prior-authorization management systems where a health plan requires review and approval of a procedure (or referral) prior to performing the service
Coefficient of determination
r2. r2 measures how much of the variation in one variable is explained by the second variable
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)
Affinity diagram
A graphic tool used to organize and prioritize ideas after a brainstorming session
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)
Access Report
Report that provides a list of individuals who accessed patient information during a given period
Chart
1. (noun) The health record of a patient 2. (verb) To document information about a patient in a health record
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])
Episode of care
1. A period of relatively continuous medical care performed by healthcare professionals in relation to a particular clinical problem or situation 2. One or more healthcare services given by a provider during a specific period of relatively continuous care in relation to a particular health or medical problem or situation 3. In home health, all home care services and nonroutine medical supplies delivered to a patient during a 60-day period; the episode of care is the unit of payment under the home health prospective payment system (HHPPS)
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)
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
Experimental research
1. A research design used to establish cause and effect 2. A controlled investigation in which subjects are assigned randomly to groups that experience carefully controlled interventions that are manipulated by the experimenter according to a strict protocol; Also called experimental study
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
Inferential statistics
1. Statistics that are used to make inferences from a smaller group of data to a large one 2. A set of statistical techniques that allows researchers to make generalizations about a population's characteristics (parameters) on the basis of a sample's characteristics
Hold harmless
1. Status in which one party does not hold the other party responsible 2. A term used to refer to the financial protections that ensure that cancer hospitals recoup all losses due to the differences in their ambulatory payment classification payments and the pre-APC payments for Medicare outpatient services
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
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
Accountability
1. The state of being liable for a specific activity 2. All information is attributable to its source (person or device)
Contract coder
A coder who is hired as an independent contractor on a temporary basis to assist with coding backlog
Allied health professional
A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)
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)
Hospitalist
A doctor who primarily takes care of patients when they are in the hospital. This doctor will take over your care from your primary doctor when you are in the hospital, keep your primary doctor informed about your progress, and will return you to the care of your primary doctor when you leave the hospital (CMS 2013)
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
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
Family numbering
A filing system, sometimes used in clinic settings, in which an entire family is assigned one number
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)
Durable medical equipment regional carrier (DMERC)
A fiscal intermediary designated to process claims for durable medical equipment (CMS 2013)
Employee self-logging
A form of self-reporting in which the employees simply track their tasks, volume of work units, and hours worked
Distance learning
A learning delivery mode in which the instructor, the classroom, and the students are not all present in the same location and at the same time
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 boo
Employment contract
A legal and binding agreement of terms related to an individual's work, such as hours, pay, or benefits
Intellectual property
A legal term that refers to creative thoughts that, when they generate a unique solution to a problem, may take on value and thus can become a commodity
Advance directive
A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences
Intelligent prompting
A means in tables and forms for displaying only clinically relevant items
Dependent variable
A measurable variable in a research study that depends on an independent variable
Interrater reliability
A measure of a research instrument's consistency in data collection when used by different abstractors
Intrarater reliability
A measure of a research instrument's reliability in which the same person repeating the test will get reasonably similar findings
Data reliability
A measure of consistency of data items based on their reproducibility and an estimation of their error of measurement
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
Exit conference
A meeting that closes a site visit during which the surveyors representing an accrediting organization summarize their findings and explain any deficiencies that have been identified
Garnishment
A method of collecting a monetary award in which a certain percentage of the defendant's wages are routinely set aside and paid to the plaintiff toward full satisfaction of the judgment
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
Conversion factor
A national dollar amount that Congress designates to convert relative value units to dollars; updated annually
Flat fee systems
A predefined amount paid for a unit of service
Domain
A sphere or field of activity and influence
Fixed budget
A type of budget based on expected capacity with no consideration of potential variations
Hospital identification
A unique institutional number within a data collection system
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 (DICOM 2013)
Cost driver
An activity that affects or causes costs
Indicator
An activity, event, occurrence, or outcome that is to be monitored and evaluated under the Joint Commission standard in order to determine whether those aspects conform to standards; commonly relates to the structure, process, or outcome of an important aspect of care; Also called a criterion 2. A measure used to determine an organization's performance over time
Inpatient admission
An acute care facility's formal acceptance of a patient who is to be provided with room, board, and continuous nursing service in an area of the facility where patients generally stay at least overnight
Bivariate
An adjective meaning the involvement of two variables
Discharge analysis
An analysis of the health record at or following discharge
Dual eligible
An individual covered by both Medicare and Medicaid
Boarder
An individual such as a parent, caregiver, or other family member who receives lodging at a healthcare facility but is not a patient
Credential verification organization (CVO)
An organization that verifies healthcare professionals' background, licensing, and schooling, and tracks continuing education and other performance measures
Concept orientation
Concepts in a controlled medical terminology are based on meanings, not words
Facility specific index
Databases established by healthcare facilities to meet their individual, specific needs for customer care or other reporting requirements. These indexes make it possible to retrieve health records in a variety of ways including by disease, physician, operation, or other data element. Prior to computerization in healthcare, these indexes were kept on cards. Today, most are compiled from databases routinely developed by the facility
Explicit knowledge
Documents, databases, and other types of recorded and documented information
Blood and blood component usage review
Evaluation of how blood and blood components are used using the Joint Commission guidelines
Infection review
Evaluation of the risk of infection among patients and healthcare providers, looking for, preventing, and controlling the risk
Aftercare
Healthcare services that are provided to a patient after a period of hospitalization or rehabilitation and are administered with the objective of improving or restoring health to the degree that aftercare is no longer needed
Artificial intelligence (AI)
High-level information technologies used in developing machines that imitate human qualities such as learning and reasoning
American Society for Testing and Material Standard E1384 (ASTM E1384)
Identifies the basic information to be included in electronic health records and requires the information to be organized into categories (ASTM 2013)
Fair and Accurate Credit Transaction Act (FACTA)
Law passed in 2003 that contains provisions and requirements to reduce identity theft (Public Law 108-159 2003)
Initiating structure
Leaders in this group were more task-focused and centered on giving direction, setting goals and limits, and planning and scheduling activities
Consent to treatment
Legal permission given by a patient or a patient's legal representative to a healthcare provider that allows the provider to administer care and treatment or to perform surgery or other medical procedures
Discoverability
Limitations on the ability of parties to discover pretrial information held by another
Home health (HH)
Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services (CMS 2013); Also called home care
Integrity constraints
Limits placed on the data that may be entered into a database
Benefit level
Limits to healthcare coverage benefits as the result of a contract between a person and his or her health plan
Crosswalks
Lists of translating codes from one system to another
Hospital within hospital (HwH)
Long-term care hospital physically located within another hospital
Federated model (of HIE)
Model of health information exchange where there is not a centralized database of patient information
Interpersonal skills
One of the three managerial skill categories that includes skills in communicating and relating effectively to others
Birth certificate
Paperwork that must be filed for every live birth regardless of where it occurred
Bugs
Problems in software that prevent the smooth application of a function
Identifier standards
Recommended methods for assigning unique identifiers to individuals (patients and clinical providers), corporate providers, and healthcare vendors and suppliers
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
Information governance (IG)
The accountability framework and decision rights to achieve enterprise information management (EIM). IG is the responsibility of executive leadership for developing and driving the IG strategy throughout the organization. IG encompasses both data governance (DG) and information technology governance (ITG)
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
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
Active listening
The application of effective verbal communication skills as evidenced by the listener's restatement of what the speaker said
Clinical privileges
The authorization granted by a healthcare organization's governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits
Federal poverty level (FPL)
The income qualification threshold established by the federal government for certain government entitlement programs
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
Discharge planning
The process of coordinating the activities related to the release of a patient when inpatient hospital care is no longer needed
Delivery
The process of delivering a live-born infant or dead fetus (and placenta) by manual, instrumental, or surgical means
Insurance certification
The process of determining that the patient has insurance coverage for the treatment that is planned or expected
Data modeling
The process of determining the users' information needs and identifying relationships among the data
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
Computer-assisted coding (CAC)
The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes
Association rule analysis (rule induction)
The process of extracting useful if/then rules from data based on statistical significance; See also rule induction
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
Cesarean section rate
The ratio of all cesarean sections to the total number of deliveries, including cesarean sections, during a specified period of time
Inpatient bed occupancy rate
The total number of inpatient service days for a given time period divided by the total number of inpatient bed count days for the same time period; Also called percentage of occupancy
Eighty-five/fifteen (85/15) rule
The total quality management assumption that 85 percent of the problems that occur are related to faults in the system rather than to worker performance
Cross-training
The training to learn a job other than the employee's primary responsibility
Discharge transfer
The transfer of an inpatient to another healthcare institution at the time of discharge
Birth weight
The weight of a neonate (expressed to the nearest gram) determined immediately after delivery or as soon thereafter as feasible
Calendar year (CY)
Twelve-month period (year) that begins January 1 and ends December 31
Hierarchical database
Type of database that allows duplicate data
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
Intuition
Unconscious decision making based on extensive experience in similar situations
Hybrid entity
Under HITECH, a single legal entity (1) that is a covered; (2) whose business activities include both covered and non-covered functions; and (3) that designates health care components in accordance with paragraph 164.105 (45 CFR 164.103 2009)
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)
Extraction
Under ICD-10-PCS, a root operation that involves pulling or stripping out or off all or a portion of a body part by the use of force (CMS 2013)
Insertion
Under ICD-10-PCS, a root operation that involves putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of the body part (CMS 2013)
Extirpation
Under ICD-10-PCS, a root operation that involves taking or cutting out solid matter from a body part (CMS 2013)
Drainage
Under ICD-10-PCS, a root operation that involves taking or letting out fluids or gases from 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)
Denial
When a bill has been returned unpaid for any of several reasons (for example, sending the bill to the wrong insurance company, patient not having current coverage, inaccurate coding, lack of medical necessity, and so on)
Electronic prescribing (e-Rx)
When a prescription is written from the personal digital assistant and an electronic fax or an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy's information system
Data center
Where the hardware and software for the electronic information systems are held
International Medical Informatics Association (IMIA)
Worldwide not-for-profit organization that promotes medical informatics in healthcare and biomedical research (IMIA 2013)
Audit trial
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
Intervention
1. A clinical manipulation, treatment, or therapy 2. A generic term used by researchers to mean an act of some kind
Direct method of cost allocation
Distributes the cost of overhead departments solely to the revenue-producing areas
Community Health Accreditation Program (CHAP)
A group that surveys and accredits home healthcare and hospice organizations (CHAP 2013)
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
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)
Integrity
1. The state of being whole or unimpaired 2. The ability of data to maintain its structure and attributes, including protection against modification or corruption during transmission, storage, or at rest. Maintenance of data integrity is a key aspect of data quality management and security
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
Emergency Medical Treatment and Active Labor Act (EMTALA)
A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat "patient dumping"—the transferring, discharging, or refusal to treat indigent emergency department patients because of their inability to pay (Public Law 99-272 1986)
Homeland Security Act
A 2002 act with the goal of preventing terrorist attacks in the United States while reducing the vulnerability of terrorism, minimizing its damages, and assisting in recovery from attacks in the United States. This act gives the government authorities the right to access health information needed to investigate and deter terrorism (Public Law 107-295 2002)
Zone program integrity contractor (ZPIC)
A CMS program that replaces the Medicare Program Safeguard Contractors (PSCs). ZPICs are responsible for detection and prevention of fraud, waste, and abuse across all Medicare claim types by performing medical reviews, data analysis, and auditing (CMS 2012)
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
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
Health Information Management and Systems Society (HIMSS)
A cause-based, not-for-profit organization exclusively focused on providing global leadership for the optimal use of IT and management systems for the betterment of healthcare
Integration testing
A form of testing during EHR implementation performed to ensure that the interfaces between applications and systems work
International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
A system used for classifying incidences of malignant disease (WHO 2013)
Hospital inpatient beds
Accommodations with supporting services (such as food, laundry, and housekeeping) for hospital inpatients, excluding those for the newborn nursery but including incubators and bassinets in nurseries for premature or sick newborn infants
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
Comprehensive Accreditation Manual for Hospitals (CAMH)
Accreditation manual published by the Joint Commission
Error
Act involving an unintentional deviation from truth or accuracy
Ethicist
An individual trained in the application of ethical theories and principles to problems that cannot be easily solved because of conflicting values, perspectives, and options for action
Beneficiary
An individual who is eligible for benefits from a health plan
Employer identification number (EIN)
As amended by HITECH, stands for the employer identification number assigned by the Internal Revenue Service, US Department of the Treasury. The EIN is the taxpayer identifying number of an individual or other entity (whether or not an employer) assigned under one of the following: (1) 26 U.S.C. 6011(b), which is the portion of the Internal Revenue Code dealing with identifying the taxpayer in tax returns and statements, or corresponding provisions of prior law, or (2) 26 U.S.C. 6109, which is the portion of the Internal Revenue Code dealing with identifying numbers in tax returns, statements, and other required documents (45 CFR 160.103 2013)
Disclosure
As amended by HITECH, the release, transfer, provision of access to, or divulging in any manner of information outside the entity holding the information (45 CFR 160.103 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)
Indirect treatment relationship
As amended by HITECH, under HIPAA, a relationship between an individual and a health care provider in which (1) the health care provider delivers health care to the individual based on the orders of another health care provider; and (2) the health care provider typically provides services or products, or reports the diagnosis or results associated with the health care, directly to another health care provider, who provides the services or products or reports to the individual (45 CFR 164.501 2013)
Documentation audits
Audits within the EHR that should look for completeness, timeliness, internal consistency, and other factors that have typically been evaluated in paper documentation
Countersignature
Authentication by a second provider that signifies review and evaluation of the actions and documentation, including authentication, of a first provider
Allowable charge
Average or maximum amount a third-party payer will reimburse providers for a service
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)
Hospital-acquired condition (HAC)
CMS identified eight hospital-acquired conditions (not present on admission) as "reasonably preventable," and hospitals will not receive additional payment for cases in which one of the eight selected conditions was not present on admission; the eight originally selected conditions include: foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infection, vascular catheter-associated infection, and surgical site infection—mediastinitis after coronary artery bypass graft; additional conditions were added in 2010 and remain in effect: surgical site infections following certain orthopedic procedures and bariatric surgery, manifestations of poor glycemic control, and deep vein thrombosis (DVT)/pulmonary embolism (PE) following certain orthopedic procedures (CMS 2013)
Category III codes
CPT codes that contain a temporary set of codes for emerging technologies, services, and procedures (AMA 2013)
Exploding charges
Charges for items that must be reported separately but are used together, such as interventional radiology imaging and injection procedures
Checksum
Cherry picking
International Classification on Functioning, Disability and Health (ICF)
Classification of health and health-related domains that describe body functions and structures, activities, and participation (WHO 2013)
Base year
Cost reporting period upon which a rate is based
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
Controllable costs
Costs that can be influenced by a department director or manager
Appellate court
Courts that hear appeals on final judgments of the state trial courts or federal trial courts
General jurisdiction
Courts that hear more serious criminal cases or civil cases that involve large amounts of money; may hear all matters of state law except for those cases that must be heard in courts of special jurisdiction
Certified professional coder (CPC)
Credential sponsored by the American Academy of Professional Coders that certifies physician coders (AAPC 2013)
Flat file
Early form of database where data is stored in plain text file
Byte
Eight bits treated as a single unit by a computer to represent a character
Intellectual capital
The combined knowledge of an organization's employees with respect to operations, processes, history, and culture
Empowerment
The condition of having the environment and resources to perform a job independently
Food and Drug Administration (FDA)
The federal agency responsible for controlling the sale and use of pharmaceuticals, biological products, medical devices, food, cosmetics, and products that emit radiation, including the licensing of medications for human use (FDA 2013); See Federal Food, Drug and Cosmetic Act
Indian Health Service (IHS)
The federal agency within the Department of Health and Human Services that is responsible for providing federal healthcare services to American Indians and Alaska natives (IHS 2013)
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
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)
Functionality training
Training focused specifically on the capabilities and features of the software; how to navigate through the application, how to enter data into different modules within the application, and such
Human readable format
Under HITECH, a format that enables a human to read and easily comprehend the information presented to him or her regardless of the method of presentation (45 CFR 170.102 2012)
EHR module
Under HITECH, means any service, component, or combination thereof that can meet the requirements of at least one certification criterion adopted by the Secretary (45 CFR 160.103 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 default 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)
Excludes 1
Under ICD-10-CM, a type 1 Excludes note is a pure excludes note. It means "not coded here." An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the note (CDC 2013)
Dilation
Under ICD-10-PCS, a rUnder ICD-10-PCS, a root operation that involves expanding an orifice or the lumen of a tubular body part (CMS 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)
Fragmentation
Under ICD-10-PCS, a root operation that involves breaking solid matter in a body part into pieces (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)
Excision
Under ICD-10-PCS, a root operation that involves cutting out or off, without replacement, a portion of a body part (CMS 2013)
Creation
Under ICD-10-PCS, a root operation that involves making a new genital structure that does not physically take the place of a body part. Used to code sex change operations in ICD-10-PCS (CMS 2013)
Chronic
Used when specifying a medical disease or illness of long duration
ADFM
Active duty family member; a designation used under TRICARE
Activity-based costing (ABC)
An economic model that traces the costs or resources necessary for a product or customer
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)
Accreditation Commission for Health Care (ACHC)
An organization that provides quality standards and accreditation programs for home health and other healthcare organizations (ACHC 2013)
Act
As amended by HITECH, refers to the Social Security Act (45 CFR 160.103 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)
Access control
1. A computer software program designed to prevent unauthorized use of an information resource 2. As amended by HITECH, a technical safeguard that requires a covered entity must in accordance with 164.306(a)(1) implement technical policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons or software programs that have been granted access rights as specified in 164.308(a)(4) (45 CFR 164.312 2003)
Accreditation
1. A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity's work against preestablished written criteria 2. A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards 3. The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency
Admission date
1. The date the patient was admitted for inpatient care, outpatient service, or start of care 2. In the inpatient hospital setting, the admission date is the hospital's formal acceptance of a patient who is to receive healthcare services while receiving room, board, and continuous nursing services (CMS 2013)
Accounting
1. The process of collecting, recording, and reporting an organization's financial data 2. A list of all disclosures made of a patient's health information
Abstracting
1. The process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome 2. The process of extracting elements of data from a source document or database and entering them into an automated system
Activity-based budget
A budget based on activities or projects rather than on functions or departments
Accounting of disclosures
1. Under HIPAA, a standard that states (1) An individual has a right to receive an accounting of disclosures of protected health information made by a covered entity in the six years prior to the date on which the accounting is requested, except for disclosures. To carry out treatment, payment, and health care operations as provided in 164.506; (ii) To individuals of protected health information about them as provided in 164.502; (iii) Incident to a use or disclosure otherwise permitted or required by this subpart, as provided in 164.502; (iv) Pursuant to an authorization as provided in 164.508; (v) For the facility's directory or to persons involved in the individual's care or other notification purposes as provided in 164.510; (vi) For national security or intelligence purposes as provided in 164.512(k)(2); (vii) To correctional institutions or law enforcement officials as provided in 164.512(k)(5); (viii) As part of a limited data set in accordance with 164.514(e); or (ix) That occurred prior to the compliance date for the covered entity (45 CFR 164.528 2002) 2. On May 31, 2011 a notice of proposed rule-making (NPRM) was issued that would modify the AOD standard. The purpose of these modifications is, in part, to implement the statutory requirement under the Health Information Technology for Economic and Clinical Health Act ("the HITECH Act" or "the Act") to require covered entities and business associates to account for disclosures of protected health information to carry out treatment, payment, and health care operations if such disclosures are through an electronic health record. Pursuant to both the HITECH Act and its more general authority under HIPAA, the department proposes to expand the accounting provision to provide individuals with the right to receive an access report indicating who has accessed electronic protected health information in a designated record set. Under its more general authority under HIPAA, the department also proposes changes to the existing accounting requirements to improve their workability and effectiveness (HHS 2011)
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
Add-on codes
In CPT coding, add-on codes are referred to as additional or supplemental procedures. Add-on codes are indicated with a "+" symbol and are to be reported in addition to the primary procedure code. Add-on codes are not to be reported as standalone codes and are exempt from use of the -51 modifier (AMA 2013)
Administrative information
Information used for administrative and healthcare operations purposes, such as billing and quality oversight
Action steps
Specific plans an organization intends to accomplish in the near future as an effort toward achieving its long-term strategic plan
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)
Activities of daily living (ADL)
The basic activities of self-care, including grooming, bathing, ambulating, toileting, and eating
Accounting enity
The business structure, including the activities and records to be maintained for the preparation of an individual organization's financial statements
Admitting diagnosis
The condition identified by the physician at the time of the patient's admission requiring hospitalization (CMS 20
Admissibility
The condition of being admitted into evidence in a court of law
Activity date or status
The element in the chargemaster that indicates the most recent activity of an item
Accounting peroid
The entire process of identifying and recording a transaction and ultimately reporting it as part of an organization's financial statement
Abortion
The expulsion or extraction of all (complete) or any part (incomplete) of the placenta or membranes, without an identifiable fetus or with a live-born infant or a stillborn infant weighing less than 500 grams
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
Acute-care hospital
Under HITECH specific to the Medicaid program, a health care facility (1) where the average length of patient stay is 25 days or fewer; and (2) with a CMS certification number (previously known as the Medicare provider number) that has the last four digits in the series 0001-0879 or 1300-1399 (42 CFR 495.302 2012)
Adverse drug reaction (ADR)
Unintended, undesirable, or unexpected effects of prescribed medications or of medication errors that require discontinuing a medication or modifying the dose, require initial or prolonged hospitalization, result in disability, require treatment with a prescription medication, result in cognitive deterioration or impairment, are life threatening, result in death, or result in congenital anomalies (Joint Commission 2011)
Curriculum
A prescribed course of study in an educational program
Data collection
The process by which data are gathered
Hybrid health record
A combination of paper and electronic records; a health record that includes both paper and electronic elements
Bar chart
A graphic technique used to display frequency distributions of nominal or ordinal data that fall into categories; Also called bar graph
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
Histogram
A graphic technique used to display the frequency distribution of continuous data (interval or ratio data) as either numbers or percentages in a series of bars
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)
Confidentiality
1. A legal and ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure 2. As amended by HITECH, the practice that data or information is not made available or disclosed to unauthorized persons or processes (45 CFR 164.304 2013)
Informed consent
1. A legal term referring to a patient's right to make his or her own treatment decisions based on the knowledge of the treatment to be administered or the procedure to be performed 2. An individual's voluntary agreement to participate in research or to undergo a diagnostic, therapeutic, or preventive medical procedure
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)
Actual charge
1. A physician's actual fee for service at the time an insurance claim is submitted to an insurance company, a government payer, or a health maintenance organization; may differ from the allowable charge 2. Amount provider actually bills a patient, which may differ from the allowable charge
Gap analysis
1. A review of the collected literature and data to assess whether gaps exist 2. Advice for those conducting the literature review on additional literature and data sources missed
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
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
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)
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)
Consent to use and disclose information
1. As amended by HITECH, a covered entity is permitted to use or disclose protected health information as follows: (i) To the individual; (ii) For treatment, payment, or health care operations as permitted by 164.506. (iii) Incident to a use to disclosure otherwise permitted or required by this subpart, provided that the covered entity has complied with the applicable requirements of 164.502, 164.514, and 164.530 with respect to such otherwise permitted or required use or disclosure; (iv) Except for uses and disclosures prohibited under 164.502, pursuant to and in compliance with a valid authorization (v) pursuant to an agreement under 164.510, and (vi) as permitted by and in compliance with this section. 2. As amended by HITECH, a business associate may use or disclose protected health information only as permitted or required by its business associate contract or other arrangement pursuant to 164.504 or as required by law (45 CFR 164.506 2013)
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
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
Grouper
1. Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes 2. A computer software program that automatically assigns prospective payment groups on the basis of clinical codes
Ancillary services
1. Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment 2. Professional healthcare services such as radiology, laboratory, or physical therapy
Access
1. The ability of a subject to view, change, or communicate with an object in a computer system 2. As amended by HITECH, the ability or means necessary to read, write, modify, or communicate data/information or otherwise use any system resource (45 CFR 164.304 2003)
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)
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
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
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
Hard coding
1. The process of attaching a CPT/HCPCS code to a procedure located on the facility's chargemaster so that the code will automatically be included on the patient's bill 2. Use of the charge description master to code repetitive services
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
Global Assessment of Functioning (GAF) Scale
A 100-point tool rating overall psychological, social, and occupational functioning of individuals, excluding physical and environmental impairment
Health Care Quality Improvement Act (HCQIA)
A 1986 act that requires facilities to report professional review actions on physicians, dentists, and other facility-based practitioners to the National Practitioner Data Bank (NPDB) (Public Law 99-660 1986)
CMS-1450
A Medicare uniform institutional claim form (CMS 2013)
Institute of Medicine (IOM)
A branch of the National Academy of Sciences whose goal is to advance and distribute scientific knowledge with the mission of improving human health (IOM 2013)
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
Group case study
A case study in which the interviews and observations are performed on a group of individuals instead of just one individual
Ethnicity
A category in the Uniform Hospital Discharge Data Set that describes a patient's cultural or racial background
Designated standards maintenance organizations (DSMO)
A category of organization established under HIPAA to maintain the electronic transaction standards (45 CFR 162.910 2009)
Bundled payments
A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness or over a specified time; a relatively continuous period in relation to a particular clinical problem or situation; they include multiple services and may include multiple providers of care; See also episode-of-care reimbursement
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
Help desk
A central access point to information system support services that attempts to resolve users' technical problems, sometimes with the use of decision-making algorithms, and tracks problems until their resolution
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
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)
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
Home health resource group (HHRG)
A classification system for the home health prospective payment system (HHPPS) derived from the data elements in the Outcome and Assessment Information Set (OASIS) with 80 home health episode rates established to support the prospective reimbursement of covered home care and rehabilitation services provided to Medicare beneficiaries during 60-day episodes of care; a six-character alphanumeric code is used to represent a severity level in three domains
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
A coding and classification system used in the United States to report diagnoses in all healthcare settings and inpatient procedures and services as well as morbidity and mortality information (CDC 2013)
Global Medical Device Nomenclature (GMDN)
A collection of internationally recognized terms used to accurately describe and catalog medical devices; in particular, the products used in the diagnosis, prevention, monitoring, treatment, or alleviation of disease or injury in humans
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
Impact analysis
A collective term used to refer to any study that determines the benefit of a proposed project, including cost-benefit analysis, return on investment, benefits realization study, or qualitative benefit study
Accredited Standards Committee X 12 (ASC x12)
A committee accredited by ANSI responsible for the development and maintenance of EDI standards for many industries. The ASC "X12N" is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms (Accredited Standards Committee 2013)
Functional status
A commonly used measure of a patient's mental and physical abilities to perform the activities of daily living
Hypertext transport protocol (HTTP)
A communications protocol that enables the use of hypertext linking
File transfer protocol (FTP)
A communications protocol that enables users to copy or move files between computer systems
Interactive voice technology (IVT)
A communications technology that enables an individual to use a telephone to access information from a computer
Internet service provider (ISP)
A company that provides connections to the Internet
Control group
A comparison study group whose members do not undergo the treatment under study
Fee schedule
A complete listing of fees used by health plans to pay doctors or other providers (CMS 2013)
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
Assessment indicator code
A component of the code used for Medicare billing by long-term care facilities
Current Procedural Terminology (CPT®)
A comprehensive, descriptive list of terms and associated numeric and alphanumeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and updated annually by the American Medical Association (AMA 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
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
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
Information kiosk
A computer station located within a healthcare facility that patients and families can use to access information
Inpatient Rehabilitation Validation and Entry (IRVEN)
A computerized data-entry system used by inpatient rehabilitation facilities (IRFs). Captures data for the IRF Patient Assessment Instrument (IRF PAI) and supports electronic submission of the IRF PAI. Also allows data import and export in the standard record format of the Centers for Medicare and Medicaid Services (CMS)
Health record analysis
A concurrent or ongoing review of health record content performed by caregivers or HIM professionals while the patient is still receiving inpatient services to ensure the quality of the services being provided and the completeness of the documentation being maintained; Also called health record review
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
Application 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
Health Integrity and Protection Data Bank
A database maintained by the federal government to provide information on fraud-and-abuse findings against US healthcare providers
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
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
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
Board certified
A designation given to a physician or other health professional who has passed an exam from a medical specialty board and is thereby certified to provide care within that specialty
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
Intermediate care facility
A facility that provides health-related care and services to individuals who do not require the degree of care or treatment that a hospital or a skilled nursing facility provides but who still require medical care and services because of their physical or mental condition
Healthcare Cost and Utilization Project (HCUP)
A family of databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by AHRQ. HCUP databases are derived from administrative data and contain encounter-level, clinical and nonclinical information including all-listed diagnoses and procedures, discharge status, patient demographics, and charges for all patients, regardless of payer (such as, Medicare, Medicaid, private insurance, uninsured), beginning in 1988 (HCUP 2013)
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)
Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) (HCERA)
A federal law enacted by Congress through reconciliation in order to make changes to the Patient Protection and Affordable Care Act. HCERA was signed into law by President Barack Obama on March 30, 2010 (Public Law 111-152 2010); Also called HR 4872
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
Affordable Care Act
A federal statute that was signed into law on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the act is the product of the healthcare reform agenda of the Democratic 111th Congress and the Obama administration (PPACA 2010); Also called Patient Protection and Affordable Care Act (PPACA)
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
Ethics
A field of study that deals with moral principles, theories, and values; in healthcare, a formal decision-making process for dealing with the competing perspectives and obligations of the people who have an interest in a common problem
Archive file
A file in a collection of files reserved for later research or verification for the purposes of security, legal processes, or backup
Health insurance prospective payment system (HIPPS) code
A five-character alphanumeric code used in the home health prospective payment system (HHPPS) and in the inpatient rehabilitation facility prospective payment system (IRFPPS). In the HHPPS, the HIPPS code is derived or computed from the home health resource group (HHRG); in the IRFPPS, the HIPPS code is derived from the case-mix group and comorbidity. Reimbursement weights for each HIPPS code correspond to the levels of care provided
Global payment
A form of reimbursement used for radiological and other procedures that combines the professional and technical components of the procedures and disperses payments as lump sums to be distributed between the physician and the healthcare facility
Intelligent document recognition (IDR) technology
A form of technology that automatically recognizes analog items, such as tangible materials or documents, or recognizes characters or symbols from analog items, enabling the identified data to be quickly, accurately, and automatically entered into digital systems
Interagency transfer form
A form that contains sufficient information about a patient to provide continuity of care during transfer or discharge
Bureaucracy
A formal organizational structure based on a rigid hierarchy of decision making and inflexible rules and procedures
Clinical vocabulary
A formally recognized list of preferred medical terms; Also called medical vocabulary
Capital budget process
A four-stage process organizations follow to determine what capital projects to include in the budget
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
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
Electronic signature
A generic, technology-neutral term for the various ways that an electronic record can be signed, such as a digitized image of a signature, a name typed at the end of an e-mail message by the sender, a biometric identifier, a secret code or PIN, or a digital signature
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)
Icon
A graphic symbol used to represent a critical event in a process flowchart
Flow chart
A graphic tool that uses standard symbols to visually display detailed information, including time and distance, of the sequential flow of work of an individual or a product as it progresses through a process
Gantt chart
A graphic tool used to plot tasks in project management that shows the duration of project tasks and overlapping tasks
Graph
A graphic tool used to show numerical data in a pictorial representation
Focus group
A group of approximately 6-12 subjects, usually experts in the particular area of study, brought together to discuss a specific topic using the focused interview method, usually with a moderator who is not on the research team
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
eHealth Exchange
A group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. Participating organizations mutually agree to support a common set of standards and specifications that enable the establishment of a secure, trusted, and interoperable connection among all participating Exchange organizations for the standardized flow of information (eHealth Exchange 2013)
Integrated healthcare network
A group of healthcare organizations that collectively provides a full range of coordinated healthcare services ranging from simple preventative care to complex surgical care
EHR collaborative
A group of healthcare professional and trade associations formed to support Health Level 7 (HL7), a healthcare standards development organization, in the development of a functional model for electronic health record systems
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
Cooperating parties for ICD-9-CM
A group of organizations (the American Health Information Management Association, the American Hospital Association, the Centers for Medicare and Medicaid Services, and the National Center for Health Statistics) that collaborates in the development and maintenance of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Experimental (study) group
A group of participants in which the exposure status of each participant is determined and the individuals are followed forward to determine the effects of the exposure
Brainstorming
A group problem-solving technique that involves the spontaneous contribution of ideas from all members of the group
Commission for the Accreditation of Birth Centers
A group that surveys and accredits birth centers in the United States (CABC 2013)
Extended care facility
A healthcare facility licensed by applicable state or local law to offer room and board, skilled nursing by a full-time registered nurse, intermediate care, or a combination of levels on a 24-hour basis over a long period of time
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
Inpatient long-term care hospital (LTCH)
A healthcare facility that has an average length of stay greater than 25 days, with patients classified into distinct diagnosis groups called
Inpatient rehabilitation facility (IRF)
A healthcare facility that specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self-care, and independence
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 of 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
Administrative law judge
A hearings officer who presides over appeal conflicts between providers of services, or beneficiaries, and Medicare contractors (5 USC 3501 2004)
Chain of command
A hierarchical reporting structure within an organization
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
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
Insured
A holder of a health insurance policy; See certificate holder; member; policyholder; subscriber
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
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
Drop-down menu
A list of options that appear below an item when clicked which a user selects to complete the computer entry; See also pick list
Discordance
A mapping term meaning disagreement
General ledger
A master list of individual revenue and expense accounts maintained by an organization
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)
Healthcare Common Procedure Coding System (HCPCS)
A medical code set that identifies healthcare procedures, equipment, and supplies for claim submission purposes. It has been selected for use in the HIPAA transactions. HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS Level II contains alphanumeric codes used to identify various items and services that are not included in the CPT medical code set. These are maintained by HCFA, the BCBSA, and the HIAA. HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes", and must have "W," "X," "Y," or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA-ZY range used for locally assigned procedure modifiers (CMS 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)
Gender rule
A method of determining which insurance company is the primary carrier for dependents when both parents carry insurance on them. The rule states that the insurance for the male of the household is considered primary
Birthday rule
A method of determining which insurance company is the primary carrier for dependents when both parents carry insurance on them. The rule states that the policyholder with the birthday earliest in the calendar year carries the primary policy for the dependents. If the policyholders are both born on the same day, the policy that has been in force the longest is the primary policy. Birth year has no relevance in this method
Intelligent character recognition (ICR) technology
A method of encoding handwritten, print, or cursive characters and of interpreting the characters as words or the intent of the writer; See gesture recognition technology
Ethnography
A method of observational research that investigates culture in naturalistic settings using both qualitative and quantitative approaches
Fee-for-service (FFS) reimbursement
A method of reimbursement through which providers retrospectively receive payment based on either billed charges for services provided or on annually updated fee schedules; Also called fee-for-service basis
Content analysis
A method of research that provides a systematic and objective analysis of communication effectiveness, such as the analysis performed on tests
Chronological order
A method of sequencing the health record according to time where the most recent document is found at the end of the health record
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)
Correct Coding Initiative (CCI)
A national initiative designed to improve the accuracy of Part B claims processed by Medicare carriers (CMS 2013)
Collaborative Stage Data Set
A new standardized neoplasm-staging system developed by the American Joint Commission on Cancer
Final note
A note becomes finalized either through attestation and system requirement or after a defined period of time, per organizational policies and procedures, applicable rules and regulations, and medical staff bylaws
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)
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
Case manager
A nurse, doctor, or social worker who arranges all services that are needed to give proper healthcare to a patient or group of patients (CMS 2013)
Controlled vocabulary
A predefined set of terms and their meanings that may be used in structured data entry or natural language processing to represent expressions
Adverse drug event
A patient injury resulting from a medication, either because of pharmacological reaction to a normal dose, or because of a preventable adverse reaction to a drug resulting from an error (Joint Commission 2011)
Established patient
A patient who has received professional services from the physician or another physician of the same specialty in the same practice group within the past three years
Emergency patient
A patient who is admitted to the emergency services department of a hospital for the diagnosis and treatment of a condition that requires immediate medical, dental, or allied health services in order to sustain life or to prevent critical consequences
Hospital inpatient
A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight
Hospital Outpatient Quality Reporting Program (Hospital OQR)
A pay for quality data reporting program implemented by the Centers for Medicare and Medicaid Services (CMS) for outpatient hospital services. The Hospital OQR Program was mandated by the Tax Relief and Health Care Act of 2006, which requires subsection (d) hospitals to submit data on measures on the quality of care furnished by hospitals in outpatient settings. Measures of quality may be of various types, including those of process, structure, outcome, and efficiency (CMS 2013)
Inpatient psychiatric facility PPS (IPFPPS)
A per diem prospective payment system that is based on 15 diagnosis-related groups, which became effective on January 1, 2005 (CMS 2013)
Fishbone diagram
A performance improvement tool used to identify or classify the root causes of a problem or condition and to display the root causes graphically; See also cause-and-effect diagram
Force-field analysis
A performance improvement tool used to identify specific drivers of, and barriers to, an organizational change so that positive factors can be reinforced and negative factors reduced
External review (audit)
A performance or quality review conducted by a third-party payer or consultant hired for the purpose; See audit
Continued-stay utilization review
A periodic review conducted during a hospital stay to determine whether the patient continues to need acute care services
Caregiver
A person who helps care for someone who is ill, disabled, or aged. Some are relatives or friends who volunteer their help. Some provide caregiving services for a fee (CMS 2013)
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
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
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
Correction, addendum, and appending health records policy
A policy that outlines how corrections, addenda, or appendages are made in a health record
Incomplete records policy
A policy that outlines how physicians are notified of records missing documentation or signatures
Analysis of discharged health records policy
A policy that outlines steps to be taken to process discharged resident records
Health record committee policy
A policy that outlines the goals of the committee, the audit tools used, the number of audits required and specific time frames for their completion, and the results-reporting mechanisms
Census-reporting policy
A policy that outlines the process for census reporting and tracking
Faxing policy
A policy that outlines the steps to take for faxing individually identifiable health information and business records and usually limits what information may be faxed
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
Hospital inpatient autopsy
A postmortem (after death) examination performed on the body of a patient who died during an inpatient hospitalization by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility
Hospital autopsy
A postmortem (after death) examination performed on the body of a person who has at some time been a hospital patient by a hospital pathologist or a physician of the medical staff who has been delegated the responsibility; See hospital inpatient autopsy
Durable power of attorney (DPOA)
A power of attorney that remains in effect even after the principal is incapacitated; some are drafted so that they only take effect when the principal becomes incapacitated (CMS 2013)
Data field
A predefined area within a healthcare database in which the same type of information is usually recorded
Home health agency (HHA)
A program or organization that provides a blend of home-based medical and social services to homebound patients and their families for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness, injury, or disability; these services include skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides
Health Care Quality Improvement Program (HCQIP)
A program that supports the mission of CMS to assure healthcare security for beneficiaries. The mission of HCQIP is to promote the quality, effectiveness, and efficiency of services to Medicare beneficiaries by strengthening the community of those committed to improving quality; monitoring and improving quality of care; communicating with beneficiaries and healthcare providers, practitioners, and plans to promote informed health choices; protecting beneficiaries from poor care; and strengthening the infrastructure (CMS 2013)
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)
Coding Clinic for ICD-9-CM
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 ICD-9-CM (AHA 2013)
Blended rate
A rate assigned to hospitals by the CMS based on cost of living, location, and services provided
Essential Medical Data Set (EMDS)
A recommended data set designed to create a health history for an individual patient treated in an emergency service
Business record
A record that is made and kept in the usual course of business, at or near the time of the event recorded
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
Facility-based registry
A registry that includes only cases from a particular type of healthcare facility, such as a hospital or clinic
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)
Facility quality indicator profile
A report based on the data gathered during the Minimum Data Set for Long-Term Care that indicates what proportion of the facility's residents have deficits in each area of assessment during the reporting period and, specifically, which residents have which deficits; the profile also provides data comparing the facility's current status with a preestablished comparison group
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
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
Balance sheet
A report that shows the total dollar amounts in accounts, expressed in accounting equation format, at a specific point in time
Claim
A request for payment for services, benefits, or costs by a hospital, physician or other provider that is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider
Data resource manager
A role that ensures that the organization's information systems meet the needs of people who provide and manage patient services
Clinical vocabulary manager
A role within an organization that manages classification systems and vocabularies for the organization
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
Automatic log-off
A security procedure that ends a computer session after a predetermined period of inactivity
Executive manager
A senior manager who oversees a broad functional area or group of departments or services, sets the organization's future direction, and monitors the organization's operations in those areas
Full-time equivalent (FTE)
A statistic representing the number of full-time employees as calculated by the reported number of hours worked by all employees, including part-time and temporary, during a specific time period
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
Financial indicators
A set of measures designed to routinely monitor the current financial status of a healthcare organization or of one of its constituent parts
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)
Health record security program
A set of processes and procedures designed to protect the data and information stored in a health record system from damage and unauthorized access
Business process
A set of related policies and procedures that are performed step by step to accomplish a business-related function
Healthcare Effectiveness Data and Information Set (HEDIS)
A set of standard performance measures that can give you information about the quality of a health plan. You can find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare and Medicaid Services (CMS) collects HEDIS data for Medicare plans (CMS 2013)
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
Atlas System
A severity-of-illness system commonly used in the United States and Canada
Goal
A specific description of the services or deliverable goods to be provided as the result of a business process
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
Capitation
A specified amount of money paid to a health plan or doctor. This is used to cover the cost of a health plan member's healthcare services for a certain length of time (CMS 2013)
Exclusion
A specified condition or circumstance listed in an insurance policy for which the policy will not provide benefits; Also called impairment rider
HL7 EHR Functional Model
A standard developed by HL7 that details the specifications for an electronic health record
Arden syntax
A standard language for encoding medical knowledge representation for use in clinical decision support systems
Electronic data interchange (EDI)
A standard transmission format using strings of data for business information communicated among the computer systems of independent organizations (CMS 2013)
Instrument
A standardized and uniform way to measure and collect data
Hypertext markup language (HTML)
A standardized computer language that allows the electronic transfer of information and communications among many different information systems
Extensible markup language (XML)
A standardized computer language that allows the interchange of data as structured text
Functional requirement
A statement that describes the processes a computer system should perform to derive the technical specifications, or desired behavior, of a system
Indemnification statement
A statement that exempts the signer from incurring liabilities or penalties
Documentation guideline
A statement that indicates what health information must be recorded to substantiate use of a particular CPT code
Income statement
A statement that summarizes an organization's revenue and expense accounts using totals accumulated during the fiscal year
Alphanumeric filing system
A system of health record identification and storage that uses a combination of alphabetic letters (usually the first two letters of the patient's last name) and numbers to identify individual records
Integrated delivery system (IDS)
A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care; See integrated provider organization
Electronic health record system (EHR-S)
A system that ensures the longitudinal collection of electronic health information for and about persons; enables immediate electronic access to person- and population-level information by authorized users; provides knowledge and decision support that enhances the quality, safety, and efficiency of patient care; and supports efficient processes for healthcare delivery
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
Environmental scanning
A systematic and continuous effort to search for important cues about how the world is changing outside and inside the organization
Frequency distribution
A table or graph that displays the number of times (frequency) a particular observation occurs
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
ER modeling
A term used in the context of information management and technology to describe a graphic technique used for the understanding and organization of data independent of actual implementation of a database
Function
A term used to describe an entity or activity that involves a single healthcare department, service area, or discipline
Cross-functional
A term used to describe an entity or activity that involves more than one healthcare department, service area, or discipline
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
Document control number (DCN)
A term used to refer to the number assigned to a claim when received for processing, facilitating ease of search on the part of the CMS
Cipher text
A text message that has been encrypted, or converted into code, to make it unreadable in order to conceal its meaning
Grounded theory
A theory about what is actually going on instead of what should go on
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
Environmental assessment
A thorough review of the internal and external conditions in which an organization operates
Clinical pathway
A tool designed to coordinate multidisciplinary care planning for specific diagnoses and treatments; See also critical path
Cyclical staffing
A transitional staffing solution wherein workers are brought in for specific projects or to cover in busy times
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
Flexible budget
A type of budget that is based on multiple levels of projected productivity (actual productivity triggers the levels to be used as the year progresses)
Internet browsers
A type of client software that facilitates communications among World Wide Web information servers
Double-blind study
A type of clinical trial conducted with strict procedures for randomization in which neither researcher nor subject knows whether the subject is in the control group or the experimental group
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
Alternative delivery system (ADS)
A type of healthcare delivery system in which health services are provided in settings such as skilled and intermediary facilities, hospice programs, nonacute outpatient programs, and home health programs, which are more cost-effective than in the inpatient setting
Focused interview
A type of interview used when the researcher wants to collect a more in-depth, heartier type of information not obtainable from closed-ended questions
Frequency polygon
A type of line graph that represents a frequency distribution
Group practice without walls (GPWW)
A type of managed care contract that allows physicians to maintain their own offices and share administrative services; Also called clinic without walls (CWW)
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
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
Intensity of service (IS or IOS)
A type of supportive documentation that reflects the diagnostic and therapeutic services for a specified level of care
Healthcare practitioner identification
A unique national identification number assigned to the healthcare practitioner of record for each encounter
Health record number
A unique numeric or alphanumeric identifier assigned to each patient's record upon admission to a healthcare facility
Facility identification
A unique universal identification number across data systems for a facility
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
False cost reports
A way of increasing Medicare payments inappropriately by submitting inaccurate financial reports
Algorithm
A way of solving a mathematical problem within a limited number of steps that often requires repetition of the step
Flex years
A work arrangement in which employees are paid over a 12-month period, but work less than 12 months
Flextime
A work schedule that gives employees some choice in the pattern of their work hours, usually around a core of midday hours
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
Certificate of coverage
A written description of benefits included in a health plan and required by state law
Hearsay
A written or oral statement made outside of court that is offered in court as evidence
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
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
Early adopters
Accounts for about 13.5 percent of the organization. The individuals in this group have a high degree of opinion leadership, and they are more localized than cosmopolitan and often look to the innovators for advice and information; these are the leaders and respected role models in the organization, and their adoption of an idea or practice does much to initiate change
Data ownership
Acknowledgement by all persons involved with creating and applying data and the quality for which they are responsible
Disciplinary action
Action taken to improve unsatisfactory work performance or behavior on the job
Group practice
An organization of physicians who share office space and administrative support services to achieve economies of scale; often a clinic or ambulatory care center
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
Attorney in fact
Agent authorized by an individual to make certain decisions, such as healthcare determinations, according to a directive written by the individual
Express contract
Agreement between physician and patient that is specifically articulated
Data comprehensiveness
All required data items are included. Ensures that the entire scope of the data is collected with intentional limitations documented
Hypothesis test
Allows the analyst to determine the likelihood that a hypothesis is true given the data present in the sample with a predetermined acceptable level of making an error
Facility charge
Allows the capture of an E/M charge that represents those resources not included with the CPT code for the clinic environment
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
Expenses
Amounts that are charged as costs by an organization to the current year's activities of operation
Certified coding associate (CCA®)
An AHIMA credential awarded to entry-level coders who have demonstrated skill in classifying medical data by passing a certification exam
Clinical document improvement practitioner (CDIP®)
An AHIMA credential awarded to individuals who have achieved specialized skills in clinical documentation improvement
Certified health data analyst (CHDA®)
An AHIMA credential awarded to individuals who have demonstrated skills and expertise in health data analysis
Health Information Technology Standards Committee
An HHS advisory committee that recommends standards, implementation specifications, and certification criteria for the electronic exchange and use of health information
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
Baseline adjustment for volume and intensity of service
An adjustment to the conversion factor needed to fulfill the statutory budget neutrality requirement
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)
Ground rules
An agreement concerning attendance, time management, participation, communication, decision making, documentation, room arrangements and cleanup, and so forth, that has been developed by PI team members at the initiation of the team's work
Career planning
Looking beyond simply getting a job to position oneself for more challenging and diverse work in the long term
Health information management (HIM)
An allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions
Grace period
An amount of time beyond a due date during which a payment may be made without incurring penalties; in healthcare, the specific time (usually 31 days) following the premium due date during which insurance remains in effect and a policyholder may pay the premium without penalty or loss of benefits
Fuzzy logic
An analytic technique used in data mining to handle imprecise concepts
Functional needs assessment
An assessment that describes the key capabilities or application requirements for achieving the benefits of the EHR as the organization has envisioned it
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 (CWLA 2013)
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)
Information system (IS)
An automated system that uses computer hardware and software to record, manipulate, store, recover, and disseminate data (that is, a system that receives and processes input and provides output); often used interchangeably with information technology (IT)
Healthcare claims and payment/advice transaction
An electronic transmission sent by a health plan to a provider's financial representative for the purpose of providing information about payments or payment processing and information about the transfer of funds
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
Float employee
An employee who is not assigned to a particular shift, function, or unit and who may fill in as needed in cases of standard employee absence or vacation
Full-time employee
An employee who works 40 hours per week, 80 hours per two-week period, or 8 hours per day
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
Freestanding facility
An entity that furnishes healthcare services to beneficiaries and is not integrated with any other entity as a main provider, a department of a provider, or a provider-based entity
Contract service
An entity that provides certain agreed-upon services for the facility, such as transcription, coding, or copying
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
Data quality review
An examination of health records to determine the level of coding accuracy and to identify areas of coding problems
All patients 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
Biometric identification system
An identification system that analyzes biological data about users, such as voiceprints, fingerprints, handprints, retinal scans, faceprints, and full-body scans
Det Norske Veritas (DNV)
An independent international organization that began offering hospital accreditation services in the United States in 2008 (DNV 2013)
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)
Hacker
An individual who bypasses a computer system's access control by taking advantage of system security weaknesses or by appropriating the password of an authorized user
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
Health information management (HIM) professional
An individual who has received professional training at the associate or baccalaureate degree level in the management of health data and information flow throughout healthcare delivery systems; formerly known as medical record technician or medical record administrator
Information technology (IT) professional
An individual who works with computer technology in the process of managing health information
Health Industry Business Communications Council (HIBCC®)
An industry-sponsored and supported nonprofit council, founded in 1983 to develop a standard for data transfer using uniform bar code labeling (HIBCC 2013)
Hospital-acquired infection
An infection occurring in a patient in a hospital or healthcare setting in whom the infection was not present or incubating at the time of admission, or the remainder of an infection acquired during a previous admission; See nosocomial infection
Community-acquired infection
An infectious disease contracted as the result of exposure before or after a patient's period of hospitalization
Executive dashboard
An information management system providing decision makers with regularly updated information on an organization's key strategic measures
Feeder system
An information system that operates independently but provides data to other systems such as an EHR; Also called source system
Day outlier
An inpatient hospital stay that is exceptionally long when compared with other cases in the same diagnosis-related group
Dependent
An insured's spouse and unmarried children, claimed on income tax. The maximum age of dependent children varies by policy. A common ceiling is 19 years of age, with continuation to age 26 provided the child is a full-time student at an accredited school, primarily dependent upon the covered employee for support and maintenance, and is unmarried. Some healthcare insurance policies also allow same-sex domestic partners to be listed as dependents
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
Healthcare Information Systems Steering Committee
An interdisciplinary team of healthcare professionals generally responsible for developing a strategic information system plan, prioritizing information system projects, and coordinating IS-related projects across the enterprise
Internal rate of return (IRR)
An interest rate that makes the net present value calculation equal zero
Customer
An internal or external recipient of services, products, or information
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)
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)
Incident
An occurrence in a medical facility that is inconsistent with accepted standards of care
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
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
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
Healthcare Information Technology Standards Panel (HITSP)
An organization developed under the auspices of the American National Standards Institute (ANSI) to deal with the many issues of privacy and security as the United States Nationwide Health Information Network develops (HITSP 2013)
Integrated provider organization (IPO)
An organization that manages the delivery of healthcare services provided by hospitals, physicians (employees of the IPO), and other healthcare organizations (for example, nursing facilities); See integrated delivery system
Health information organization (HIO)
An organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards
Information technology (IT) strategy
An organization's information technology goals, objectives, and strategic plans, which serve as a guide to the procurement of information systems within an organization
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
Database
An organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications
Hospital outpatient care unit
An organized unit of a hospital that provides facilities and medical services exclusively or primarily to patients who are generally ambulatory and who do not currently require or are not currently receiving services as an inpatient of the hospital
Boarder baby
Any infant who remains in the nursery after the mother's discharge for any reason
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
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)
Indirect standardization
Appropriate to use for risk adjustment when the risk variables are categorical and the rate or proportion for the variable of interest is available for the standard or reference group at the level of the risk categories, the expected outcome rate for each risk category is calculated based on the reference group and then weighted by the volume in each risk group at population to be compared to the standard
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 Belmont Report summarizes the findings of the Commission as the result of its deliberation (HHS 1979)
Electronic media
As amended by HITECH, (1) Electronic storage material on which data is or may be recorded electronically, including, for example, devices in computers (hard drives) and any removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital memory card; (2) Transmission media used to exchange information already in electronic storage media. Transmission media include, for example, the Internet, extranet or intranet, leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media if the information being exchanged did not exist in electronic form immediately before the transmission (45 CFR 160.103 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)
Flexibility of approach
As amended by HITECH, a condition under the Security Rule in which a covered entity can adopt security protection measures that are appropriate for its organization (45 CFR 164.306 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 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)
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)
Health care provider
As amended by HITECH, a provider of services (as defined in section 1861(u) of the Act, 42 U.S.C. 1395x(u)), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395x(s)), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business (45 CFR 160.103 2013)
Emergency access procedures
As amended by HITECH, a technical safeguard that provides access in an emergency situation to healthcare providers even if they do not normally have access to the information (45 CFR 164.312 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)
Health oversight agency
As amended by HITECH, an agency or authority of the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is authorized by law to oversee the health care system (whether public or private) or government programs in which health information is necessary to determine eligibility or compliance, or to enforce civil rights laws for which health information is relevant (45 CFR 164.501 2013)
Group health plan
As amended by HITECH, an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income and Security Act of 1974 (ERISA), 29 U.S.C. 1002(1)), including insured and self-insured plans, to the extent that the plan provides medical care (as defined in section 2791(a)(2) of the Public Health Service Act (PHS Act), 42 U.S.C. 300gg-91(a)(2)), including items and services paid for as medical care, to employees or their dependents directly or through insurance, reimbursement, or otherwise, that: has 50 or more participants (as defined in section 3(7) of ERISA, 29 U.S.C. 1002(7)); or (2) is administered by an entity other than the employer that established and maintains the plan (45 CFR 160.103 2013)
Health plan
As amended by HITECH, an individual or group plan that provides, or pays the cost of, medical care. Examples include, but are not limited to, a group health plan, an HMO, Part A or B of the Medicare program, Medicaid program, Indian health services, or Medicare Advantage program (45 CFR 160.103 2013)
Health information
As amended by HITECH, any information, including genetic information, whether oral or recorded in any form or medium, that: Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual (45 CFR 160.103 2013)
Health care operations
As amended by HITECH, any of the following activities of the covered entity (1) Conducting quality assessment and improvement activities; (2) Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, health plan performance, conducting training programs in which students; (3) Except as prohibited under 164.502(a)(5)(i), underwriting, enrollment, premium rating, and other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits; (4) Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs; (5) Business planning and development; and (6) Business management and general administrative activities of the entity (45 CFR 164.501 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)
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)
Individually identifiable health information
As amended by HITECH, information that is a subset of health information, including demographic information collected from an individual, and: (1) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (2) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (i) that identifies the individual; or (ii) with respect to which there is a reasonable basis to believe the information can be used to identify the individual (45 CFR 160.103 2013)
Health care clearinghouse
As amended by HITECH, means a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and "value-added" networks and switches, that does either of the following functions: (1) Processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction. (2) Receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard format or nonstandard data content for the receiving entity (45 CFR 160.103 2013)
Genetic testing
As amended by HITECH, means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, if the analysis detects genotypes, mutations, or chromosomal changes. Genetic testing does not include an analysis of proteins or metabolites that are directly related to a manifested disease, disorder, or pathological condition (45 CFR 160.103 2013)
Health care
As amended by HITECH, means care, services, or supplies related to the health of an individual. Health care includes, but is not limited to, the following: (1) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and (2) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription (45 CFR 160.103 2013)
Electronic Protected Health Information (ePHI)
As amended by HITECH, means information that comes within paragraphs (1)(i) or (1)(ii) of this definition of protected health information as specified in this section which is (1)(i) information transmitted by electronic media, and (1)(ii) information maintained in electronic media (45 CFR 160.103 2013)
Genetic information
As amended by HITECH, refers to health information pertaining to individual genetic tests, genetic tests of family members of the individual, manifestations of a disease in family members, including any fetus carried by the individual or family member who is a pregnant woman, and any embryo legally held by an individual or family member utilizing an assisted reproductive technology (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)
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)
International Classification of Primary Care (ICPC-2)
Classification used for coding the reasons of encounter, diagnoses, and interventions in an episode-of-care structure
ICD-9-CM Coordination and Maintenance Committee
Committee composed of representatives from NCHS and CMS that is responsible for maintaining the United States' clinical modification version of the International Classification of Diseases, Ninth Revision (ICD-9-CM) code sets; holds open meetings that serve as a public forum for discussing (but not making decisions about) proposed revisions to ICD-9-CM (CMS 2013)
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
Early majority
Compromises about 34 percent of the organization; although usually not leaders, the individuals in this group represent the backbone of the organization, are deliberate in thinking and acceptance of an idea, and serve as a natural bridge between early and late adopters
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
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
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
Certified professional in health information management systems (CPHIMS)
Credential (managed jointly by HIMSS, AHA Certification Center, and applied measurement professionals) that certifies knowledge of healthcare information and management systems and understanding of psychometrics (the science of measurement); requires baccalaureate or graduate degree plus associated experience
High-cost threshold
Criterion to assess whether technologies would be inadequately paid under the inpatient prospective payment system (IPPS): The sum of the geometric mean and the lesser of .75 of the national adjusted operating standardized payment amount (increased to reflect the difference between costs and charges) or .75 of one standard deviation of mean charges by diagnosis related group (DRG)
Evaluation and management (E/M) codes
Current Procedural Terminology codes that describe patient encounters with healthcare professionals for assessment counseling and other routine healthcare services (CMS 2010)
Diffusion S curve
Curve that shows that each of the adopter categories engages innovation at a different time and a different acceptance rate
External data
Data coming from outside the facility that can be used to compare the facility with other similar facilities
Inputs
Data entered into a hospital system (for example, the patient's knowledge of his or her condition, the admitting clerk's knowledge of the admission process, and the computer with its admitting template are all inputs for the hospital's admitting system)
Aggregate data
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed
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
Free-text data
Data that are narrative in nature
Coded data
Data that are translated into a standard nomenclature of classification so that they may be aggregated, analyzed, and compared
Data precision
Data values should be just large enough to support the application or process
Interval-level data
Data with a defined unit of measure, no true zero point, and equal intervals between successive values; See also ratio-level data
Data-based DSS
Decision support system that focuses on providing access to the various data sources within the organization through one system
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)
Health Information Technology Regional Extension Center (HITREC or REC)
Developed by the HITECH Act, these grants were designed to support and serve healthcare providers to help them quickly become adept and meaningful users of electronic health records (EHRs) (ONC 2013)
Health Information Technology Research Center (HITRC)
Developed by the HITECH Act, this center gathers information on effective practices and helps the RECs work with one another and with relevant stakeholders to identify and share best practices in EHR adoption, meaningful use, and provider support (ONC 2013)
Barcode-enabled devices
Devices used throughout healthcare facilities that are designed to use barcodes for increased accuracy; See also barcoding technology
Interrogatories
Discovery devices consisting of a set of written questions given to a party, witness, or other person who has information needed in a legal case
Federal Health Architecture (FHA)
E-Government Line of Business initiative managed by the Office of the National Coordinator for Health IT. FHA was formed to coordinate health IT activities among the more than 20 federal agencies that provide health and healthcare services to citizens (ONC 2013)
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
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
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)
Formative evaluation
Evaluations that measure or assess improvement in delivery methods with regard to technology used; quality of implementation of a new process or technology; information about the organizational placement of a given process; type of personnel involved in a program; or other important factors such as the procedures, source, and type of inputs
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
Evidence-based clinical practice guideline
Explicit statement that guides clinical decision making and has been systematically developed from scientific evidence and clinical expertise to answer clinical questions; systematic use of guidelines is termed evidence-based medicine
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)
Hospital inpatient quality reporting program
Formerly known as the Reporting Hospital Quality Data for Annual Payment Update Program, this program is intended to equip consumers with quality of care information to make more informed decisions about healthcare options. Developed as a part of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, it provided new requirements for quality reporting (CMS 2013)
Indirect costs
Resources expended that cannot be identified as pertaining to specific goods or services (for example, electricity is not allocable to a specific patient)
Debt
Incurred when money is borrowed and must eventually be paid
Health Research Extension Act (1985)
Federal legislation that established guidelines for the proper care of animals used in biomedical and behavioral research (Public Law 99-158 1985)
Americans with Disabilities Act (ADA) of 1990
Federal legislation which ensures equal opportunity for and elimination of discrimination against persons with disabilities (Public Law 110-325 2008)
Diagnostic criteria
For each mental disorder listed in the DSM-IV, a set of extensive diagnostic criteria are provided that indicate 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)
External customers
Individuals from outside the organization who receive products or services from within the organization
Association for Healthcare Documentation Integrity (AHDI)
Formerly the American Association for Medical Transcription (AAMT), the AHDI 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 (AHDI 2013)
Health Level 7 (HL7)
Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards-developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services (HL7 2013)
Elements of negligence
Four basic elements must be proven in a malpractice case: failure to use due care, breach of duty, damages, and causation
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
History types
Generally defined by E/M services as: problem-focused (chief complaint; brief history of present illness or problem); expanded problem-focused (chief complaint; brief history of present illness; problem-pertinent system review); detailed (chief complaint; extended history of present illness; extended system review; pertinent past, family, and social history); and comprehensive (chief complaint; extended history of present illness; complete system review; complete past, family, and social history)
Cost centers
Groups of activities for which costs are specified together for management purposes
Healthcare Data Organizations (HDOs)
Groups that maintain healthcare data bases in both the public and private sectors; they may be state owned or privately held; these groups use data to for reporting systems such as hospital discharge data and all-payer claims databases (APCDs)
Healthcare information standards
Guidelines developed to standardize data throughout the healthcare industry (for example, developing uniform terminologies and vocabularies)
Health record banking
Health record banking is a new concept that is making headlines. This PHR model would allow patients and healthcare providers to share information by making deposits of health information into a bank. The health record bank would have to protect the privacy and security of the health information
Intraoperative anesthesia record
Health record documentation that describes the entire surgical process from the time the operation began until the patient left the operating room
Interval note
Health record documentation that describes the patient's course between two closely related hospitalizations directed toward the treatment of the same complaint when a patient has been discharged and readmitted within 30 days
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
Independent practitioners
Individuals working as employees of an organization, in private practice, or through a physician group who provide healthcare services without supervision or direction
Interval history
If the history and physical have been completed within the 30 days prior to admission, there must be an updated entry in the medical record that documents an examination for any changes in the patient's condition since the original history and physical examination, and this entry must be included in the record within the first 24 hours of admission
Injury (harm)
In a negligence lawsuit, one of four elements, which may be economic (hospital expenses and loss of wages) and noneconomic (pain and suffering), that must be proved to be successful
Fund balance
In a not-for-profit setting, the entity's net assets or resources remaining after subtracting liabilities that are owed; in a for-profit organization, the owner's equity
Data normalization
In a relational database, it is the process of organizing data to minimize redundancy
Credits
In accounting, or the revenue cycle, the amounts on the right side of a journal entry
Hospital live birth
In an inpatient facility, the complete expulsion or extraction of a product of human conception from the mother, regardless of the duration of pregnancy, which, after such expulsion or extraction, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles
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
Crisis management plan
In disaster planning, a plan that defines the processes and controls that will be followed until the operations are fully restored
Controls
In disaster planning, the process or plans to mitigate and reduce potential risks
Cutover
In disaster planning, the transition process when switching from the alternative recovery site back to the original location or to a new location
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
Consumer
In healthcare, a patient, client, resident, or other recipient of healthcare services
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
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
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
Closed-loop medication management
Information systems used to provide patient safety when ordering and administering medications
Demographic information
Information used to identify an individual, such as name, address, gender, age, and other information linked to a specific person
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
Established Name for Active Ingredients and FDA Unique Ingredient Identifier (UNII) Codes
Interoperability standard for active ingredients in medications
Human Genome Nomenclature (HUGN)
Interoperability standard for exchanging information regarding the role of genes in biomedical research and healthcare
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
Editor
Logic (algorithms) within computer software that evaluates data. Medicare's Standard Claims Processing System (or PSC Supplemental Edit Software) and its Outpatient Code Editor (OCE) contain editors that select certain claims, evaluate, or compare information on the selected claims or other accessible source, and depending on the evaluation, take actions on the claims, such as pay in full, pay in part, or suspend for manual review; See code editor
Functional independence measure (FIM)
Measure used to evaluate the level of independence of patients in long-term acute-care (LTCH) settings where the focus of care is on extensive rehabilitation of the patient. FIM includes 18 items that are scored on a scale of 1 to 7, with 1 being the most dependent and 7 being the most independent. Total scores range between 18 and 126. FIM scores can be used as outcome measures by LTCHs
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
Grant
Monetary assistance provided to a facility, university, or individual who will then use this monetary assistance to fully carry out and complete an intended research study
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)
Group number
Number identifying the employer, association, or other entity that purchases healthcare insurance for the individual members of the group
Decimal
Numbered or proceeding by tens; based on the number 10; expressed in or utilizing a decimal system, especially with a decimal point
Diagnostic codes
Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries
Generic
Once a patent for a brand name expires, other manufacturers may copy the drug and release it under its pharmaceutical or "generic" name
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
Bylaws
Operating documents that describe the rules and regulations under which a healthcare organization operates; See also rules and regulations
Healthcare payer organizations
Organizations that include clearinghouses, the federal and state government, accountable care organizations (ACOs), insurance companies including self-insured organizations, medical billing companies, and medical banking
Federal Physician Self-Referral Statute (Stark)
Originally a part of the Omnibus Budget Reconciliation Act of 1989, it is a law that prohibits physicians from ordering designated health services for Medicare (and to some extent Medicaid) patients from entities with which the physician, or an immediate family member, has a financial relationship (Stark Law 2013)
Healthcare Facilities Accreditation Program (HFAP)
Originally created in 1945 to conduct an objective review of services provided by osteopathic hospitals, HFAP has maintained its deeming authority continuously since the inception of CMS in 1965 and meets or exceeds the standards required by CMS/Medicare to provide accreditation to all hospitals, ambulatory care/surgical facilities, mental health facilities, physical rehabilitation facilities, clinical laboratories and critical access hospitals. HFAP also provides certification reviews for Primary Stroke Centers (HFAP 2013)
AQA Alliance
Originally known as the Ambulatory Care Quality Alliance, the coalition is now known as the AQA alliance. The AQA is 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 (AQA Alliance 2013)
Health Information Technology Expert Panel (HITEP)
Panel charged to create a better link between current quality measurement and EHR reporting capabilities
Death certificate
Paperwork that must be completed when someone dies, as directed by state law; generally filled out by the funeral director or other person responsible for internment or cremation of remains and signed by the physician, who provides the cause of death
IS-A relationships
Parent-child relationships that link concepts within a hierarchy
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
Capital assets
Physical assets with an estimated useful life of more than one year; See fixed assets; property, plant, and equipment (PPE)
Ambulatory care
Preventive or corrective healthcare services provided on a nonresident basis in a provider's office, clinic setting, or hospital outpatient setting
Fee
Price assigned to a unit of medical or health service, such as a visit to a physician or a day in a hospital; may be unrelated to the actual cost of providing the service; See charge
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)
Coordination of benefits (COB)
Process for determining the respective responsibilities of two or more health plan that have some financial responsibility for a medical claim (CMS 2013)
Fellowship Program
Program of earned recognition for AHIMA members who have made significant and sustained contributions to the HIM profession through meritorious service, excellence in professional practice, education, and advancement of the profession through innovation and knowledge sharing
Expectancy theory of motivation
Proposes that one's efforts will result in the attainment of desired performance goals
e-Discovery
Refers to Amendments to Federal Rules of Civil Procedure and Uniform Rules Relating to Discovery of Electronically Stored Information; wherein audit trails, the source code of the program, metadata, and any other electronic information that is not typically considered the legal health record is subject to motion for compulsory discovery
Dashboards
Reports of process measures to help leaders follow progress to assist with strategic planning; Also called scorecards
Federal Rules of Evidence (FRE)
Rules established by the US Supreme Court guiding the introduction and use of evidence in federal court proceedings that are an important benchmark for state and other courts. FRE governs what and how electronic records may be used, and the roles of record custodianship
Federal Rules of Civil Procedure (FRCP)
Rules established by the US Supreme Court setting the "rules of the road" and procedures for federal court cases. FRCP include electronic records and continue to be very important as benchmarks in how these records can be used in courts, not only federal, but state and other courts as well (Public Law 97-462 1983)
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
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)
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
Interval scale
Situation where the intervals between adjacent scale values are equal with respect to the attributes being measured
Inference engine
Specialized computer software that tries to match conditions in rules to data elements in a repository (when a match is found, the engine executes the rule, which results in the occurrence of a specified action)
Exempt employees
Specific groups of employees who are identified as not being covered by some or all of the provisions of the Fair Labor Standards Act
Covered service (expense)
Specific healthcare charges that an insurer will consider for payment under the terms of a health insurance policy; See benefit
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
Financial counselors
Staff dedicated to helping patients and physicians determine sources of reimbursement for healthcare services; counselors are responsible for identifying and verifying the method of payment and debt resolution for services rendered to patients
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)
Functional independent assessment tool
Standardized tool to measure the severity of patients' impairments in rehabilitation settings. The tool captures characteristics that reflect the functional status of patients. Patients with lower scores on the tool have less independence and need more assistance than patients with higher scores
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
Good Samaritan statute
State law or statute that protects healthcare providers from liability for not obtaining informed consent before rendering care to adults or minors at the scene of an emergency or accident
Evidence of insurability
Statement or proof of a health status necessary to obtain healthcare insurance, especially private healthcare insurance
Health Maintenance Organization (HMO) Act
The 1973 federal legislation that outlined the requirements for federal qualifications of health maintenance organizations, consisting of legal and organizational structures, financial strength requirements, marketing provisions, and healthcare delivery (Public Law 93-222 1973)
Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, Text Revision (DSM-IV-TR)
The 2004 text revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, with updated clinical terms, but very few coding changes (APA 2013)
Federal Food, Drug and Cosmetic Act
The basic authority intended to ensure that foods are pure and wholesome, safe to eat, and produced under sanitary conditions; that drugs and devices are safe and effective for their intended uses; that cosmetics are safe and made from appropriate ingredients; and that all labeling and packaging is truthful, informative, and not deceptive (Public Law 92-387 1938)
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
Interventional radiology
The branch of medicine that diagnoses and treats a wide range of diseases using percutaneous or minimally invasive techniques under imaging guidance
Agency for Healthcare Research and Quality (AHRQ)
The branch of the US Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services (AHRQ 2013a)
Backward compatibility
The capability of a software or hardware product to work with earlier versions of itself
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
The coding classification system that will replace ICD-9-CM, Volumes 1 and 2, on October 1, 2014. ICD-10-CM is the United States' clinical modification of the WHO's ICD-10. ICD-10-CM has a total of 21 chapters and contains significantly more codes than ICD-9-CM, providing the ability to code with a greater level of specificity (CDC 2013)
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
Integration
The complex task of ensuring that all elements and platforms in an information system communicate and act as a uniform entity; or the combination of two or more benefit plans to prevent duplication of benefit payment
Hospital information system (HIS)
The comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital
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
Information life cycle
The cycle of gathering, recording, processing, storing, sharing, transmitting, retrieving, and deleting information
Federal Register
The daily publication of the US Government Printing Office that reports all changes in regulations and federally mandated standards, including HCPCS and ICD-9-CM codes (CMS 2013)
Financial data
The data collected for the purpose of managing the assets and expenses of a business (for example, a healthcare organization, a product line); in healthcare, data derived from the charge generation documentation associated with the activities of care and then aggregated by specific customer grouping for financial analysis
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
Eligibility date
The date on which a member of an insured group may apply for insurance
Assessment reference date (ARD)
The date that sets the designated end point of resident observation for all staff participating in the assessment
Intermediate fetal death
The death of a product of human conception before its complete expulsion or extraction from the mother that is 20 complete weeks of gestation (but less than 28 weeks) and weighs 501 to 1,000 grams
Early fetal death
The death of a product of human conception that is fewer than 20 weeks of gestation and 500 grams or less in weight before its complete expulsion or extraction from the mother
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
Indirect obstetric death
The death of a woman that resulted from a previously existing disease (or a disease that developed during pregnancy, labor, or the puerperium) that was not due to obstetric causes, although the physiologic effects of pregnancy were partially responsible for the death
Certainty factor
The defined certainty percentage rate with which an occurrence must present itself to satisfy quality standards
Efficacy
The degree to which a minimum of resources is used to obtain outcomes
Differentiation
The degree to which a tumor resembles the normal tissue from which it arose
Effectiveness
The degree to which stated outcomes are attained
Information integrity
The dependability or trustworthiness of information. It concerns more than data quality or data accuracy—it encompasses the entire framework in which information is recorded, processed, and used
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
Discharge status
The disposition of the patient at discharge (that is, left against medical advice, discharged to home, transferred to skilled nursing facility, or died)
Cost allocation
The distribution of costs
Employee record
The document in which an employee's information relating to job performance and so on is kept
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
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
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 accuracy
The extent to which data are free of identifiable errors
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
Accuracy
The extent to which information reflects the true, correct, and exact description of the care that was delivered with respect to both content and timing
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
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)
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)
Autopsy
The postmortem examinations of the organs and tissues of a body to determine the cause of death or pathological conditions
Freedom of Information Act (FOIA)
The federal law established in 1967, amended in 1986, that is applicable only to federal agencies, through which individuals can seek access to information without the authorization of the person to whom the information applies (Public Law 99-570 1986)
Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)
The federal law requiring every hospital that participates in Medicare and has an emergency room to treat any patient in an emergency condition or active labor, whether or not the patient is covered by Medicare and regardless of the patient's ability to pay; COBRA also requires employers to provide continuation benefits to specified workers and families who have been terminated but previously had healthcare insurance benefits (Public Law 99-272 1986)
Hill-Burton Act
The federal legislation enacted in 1946, amended in 1949, as the Hospital Survey and Construction Act to authorize grants for states to construct new hospitals and, later, to modernize old ones (Ch. 722. 63 1949)
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The 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; limits exclusion for pre-existing 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; requires covered entities (most healthcare providers and organizations) to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifiers in HIPAA transactions (Public Law 104-191 1996); Also called the Kassebaum-Kennedy Law
Family and Medical Leave Act of 1993 (FMLA)
The federal legislation that allows full-time employees time off from work (up to 12 weeks) to care for themselves or their family members with the assurance of an equivalent position upon return to work (Public Law 103-3 1993)
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)
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)
Equal Pay Act of 1963 (EPA)
The federal legislation that requires equal pay for men and women who perform substantially the same work (Public Law 88-38 1963)
Fair Labor Standards Act of 1938 (FLSA)
The federal legislation that sets the minimum wage and overtime payment regulations (52 Stat. 1060 1938)
Emergency Maternal and Infant Care Program (EMIC)
The federal medical program that provides obstetrical and infant care to dependents of active duty military personnel in the four lowest pay grades
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
Exit interview
The final meeting an employee has with his or her employer before leaving the organization
End product
The final result(s) of healthcare services in terms of the patient's expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing
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
Blue Cross and Blue Shield (BC/BS)
The first prepaid healthcare plans in the United States; Blue Shield plans traditionally cover hospital care and Blue Cross plans cover physicians' services
Data structure
The form in which data are stored, as in a file, a database, a data repository, and so on
Dumping
The illegal practice of transferring uninsured and indigent patients who need emergency services from one hospital to another (usually public) hospital solely to avoid the cost of providing uncompensated services. EMTALA, passed in 1986 and implemented in 1990, contains provisions intended to curtail this practice
Cancer mortality rate
The proportion of patients that die from cancer
Histocompatibility
The immunologic similarity between an organ donor and a transplant recipient
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
Duty to warn
The legal obligation of a health professional to disclose information to warn an intended victim when a patient threatens to harm an individually identifiable victim and the psychiatrist or mental health provider believes that the patient is likely to harm the individual
Federal Employees' Compensation Act (FECA) 1966
The legislation enacted in 1916, amended in 1966 to mandate workers' compensation for civilian federal employees, whose coverage includes lost wages, medical expenses, and survivors' benefits (Public Law 89-488 1966)
Examination types
The levels of E/M services define four types of examination: problem-focused (an examination that is limited to the affected body area or organ system); expanded problem-focused (an examination of the affected body area or organ system and other symptomatic or related organ systems); detailed (an extended examination of the affected body area[s] and other symptomatic or related organ systems); and comprehensive (a complete single-system specialty examination or a general multisystem examination) (CMS 2010)
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
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 length of stay (ALOS)
The mean length of stay for hospital inpatients discharged during a given period of time; Also called average duration of hospitalization
Average daily census
The mean number of hospital inpatients present in the hospital each day for a given period of time
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
Emergency and trauma care
The medical-surgical care provided to individuals whose injuries or illnesses require urgent care to address conditions that could be life threatening or disabling if not treated immediately
Average record delinquency rate
The monthly average number of discharges divided by the monthly average number of delinquent records
International Classification of Diseases, Tenth Revision (ICD-10)
The most recent revision of the disease classification system developed and used by the WHO to track morbidity and mortality information worldwide (WHO 2013)
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 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
Admission-discharge-transfer (ADT)
The name given to software systems used in healthcare facilities that register and track patients from admission through discharge including transfers; usually interfaced with other systems used throughout a facility such as an electronic health record or lab information system
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 (ANA 2013)
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 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. AHIP'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. AHIP advocates for public policies that expand access to affordable healthcare coverage to all Americans through a competitive marketplace that fosters choice, quality, and innovation (AHIP 2013)
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, Inc (AOTA)
The nationally recognized professional association of more than 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy (AOTA 2013)
Health record entry
The notation made in a patient's legal health record, whether paper or electronic, by the responsible healthcare practitioner to document an event or observation associated with healthcare services provided to the patient
Consolidated Health Informatics (CHI)
The notion of adopting existing health information interoperability standards throughout all federal agencies
Fetal autopsy rate
The number of autopsies performed on intermediate and late fetal deaths for a given time period divided by the total number of intermediate and late fetal deaths for the same time period
Bed capacity
The number of beds that a facility has been designed and constructed to house
Install base
The number of clients for which a vendor has installed a system, as opposed to the number of clients for which a vendor is in the process of selling a system
Infant mortality rate
The number of deaths of individuals under one year of age during a given time period divided by the number of live births reported for the same time period
Hospital-acquired infection rate
The number of hospital-acquired infections for a given time period divided by the total number of inpatient discharges for the same time period
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)
CPT Assistant
The official publication of the American Medical Association that addresses CPT coding issues
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 (AAMC 2013)
Baseline
The original estimates for a project's schedule, work, and cost
Historical cost
The original resources expended by an organization to acquire an asset; considered the more objective measurement for financial reporting purposes
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)
Hospital insurance (Medicare Part A)
The part of Medicare insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare (CMS 2013)
Auditing
The performance of internal or external reviews (audits) to identify variations from established baselines (for example, review of outpatient coding as compared with CMS outpatient coding guidelines)
Hospitalization
The period during an individual's life when he or she is a patient in a single hospital without interruption except by possible intervening leaves of absence
Eligibility period
The period of time following the eligibility date (usually 31 days) during which a member of an insured group may apply for insurance without evidence of insurability
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
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
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
Chief of staff
The physician designated as leader of a healthcare organization's medical staff
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
Discharge
The point at which an individual's active involvement with an organization or program ends, and the organization or program no longer maintains active responsibility for the care of the individual. In ambulatory or office-based settings, where episodes of care occur even though the organization continues to maintain active responsibility for the care of the individuals, discharge is the point at which an encounter or episode of care (that is, an office or clinic visit for the purpose of diagnostic evaluation or testing, procedures, treatment, therapy, or management) ends
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
Favorable variance
The positive difference between the budgeted amount and the actual amount of a line item, that is, when actual revenue exceeds budget or actual expenses are less than budget
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
Aging of accounts
The practice of counting the days, generally in 30-day increments, from the time a bill was sent to the payer to the current day
Document imaging
The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed
Group therapy
The practice of one therapist providing the same therapeutic services to everyone in the group, in which residents may benefit by observing other residents in the group performing the same activity
Healthcare data analytics
The practice of using data to make business decisions in healthcare
Employee orientation
The process in which employees are introduced to an organization and a new job
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
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
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
Career development
The process of progressing within one's profession or occupation
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
Accrue
The process of recording known transactions in the appropriate time period before cash payments/receipts are expected or due
Ethical decision making
The process of requiring everyone to consider the perspectives of others, even when they do not agree with them
Credentialing
The process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services
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
Cluster sampling
The process of selecting subjects for a sample from each cluster within a population (for example, a family, school, or community)
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
American College of Obstetricians and Gynecologist (ACOG)
The professional association of medical doctors specializing in obstetrics and gynecology (ACOG 2013)
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)
Adjusted hospital autopsy rate
The proportion of hospital autopsies performed following the deaths of patients whose bodies are available for autopsy
Death rate
The proportion of inpatient hospitalizations that end in death
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 (ARRA 2009); Also called Recovery Act; Stimulus
Infection rate
The ratio of all infections to the number of discharges, including deaths
Anesthesia death rate
The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time
Feasibility
The realistic likelihood of an evaluation's success given the available time, resources, and expertise
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
Documentation
The recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers
Hospital Outpatient Prospective Payment System (HOPPS)
The reimbursement system created by the Balanced Budget Act of 1997 for hospital outpatient services rendered to Medicare beneficiaries; maintained by the Centers for Medicare and Medicaid Services (CMS 2013)
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
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)
Design phase
The second phase of the systems development life cycle during which all options in selecting a new information system are considered
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
Expressed consent
The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services
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
Heterogeneity
The state or fact of containing various components
Customer service training
Training that focuses on creating a true customer orientation within the work environment
In-service education
Training that teaches employees specific skills required to maintain or improve performance, usually internal to an 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
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
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)
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)
Code Set Maintaining Organization
Under HIPAA, an organization that creates and maintains the code sets adopted by the secretary for use in the transactions for which standards are adopted in this part (45 CFR 162.103 2012)
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. A code 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)
Children's hospital
Under HITECH specific to the Medicaid program, a separately certified children's hospital, either freestanding or hospital-within-hospital that (1) Has a CMS certification number (CCN), previously known as the Medicare provider number, that has the last 4 digits in the series 3300-3399; or (2) Does not have a CCN but has been provided an alternative number by CMS for purposes of enrollment in the Medicaid EHR Incentive Program as a children's hospital and; (3) Predominantly treats individuals under 21 years of age (42 CFR 495.302 2012)
Ambulatory surgery center
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
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)
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
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)
Financial renumeration
Under HITECH, direct or indirect payment from or on behalf of a third party whose product or service is being described. Direct or indirect payment does not include any payment for treatment of an individual (45 CFR 164.501 2013)
EHR reporting period
Under HITECH, except with respect to payment adjustment years, refers to the initial continuous 90-day period within the calendar year an eligible hospital or provider demonstrates meaningful use of a certified EHR technology. Subsequent reporting years are full calendar years in which the provider demonstrates meaningful use of a certified EHR technology (42 CFR 495.4 2012)
Health information technology (HIT)
Under HITECH, hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information (Public Law 111-5 2009)
Enterprise integration
Under HITECH, means the electronic linkage of health care providers, health plans, the government, and other interested parties, to enable the electronic exchange and use of health information among all the components in the health care infrastructure in accordance with applicable law, and such term includes related application protocols and other related standards (Public Law 111-5 2009)
Eligible hospital
Under HITECH, specific to the Medicare program, a hospital subject to the prospective payment system specified in 412.1(a)(1) of this chapter, excluding those hospitals specified in 412.23 and 412.25 (42 CFR 495.100 2012)
Eligible professional (EP)
Under HITECH, specific to the Medicare program, means a physician as defined in section 1861(r) of the Act, which includes, with certain limitations, all of the following types of professionals: 1) a doctor of medicine or osteopathy, (2) a doctor of dental surgery or medicine, (3) a doctor of podiatric medicine, (4) a doctor of optometry, (5) a chiropractor (45 CFR 495.100 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)
EHR Certification Criteria, 2011 Edition
Under HITECH, the certification criteria at 45 CFR 170.302, 170.304, and 170.306 (45 CFR 170.102 2012)
EHR Certification Criteria, 2014 Edition
Under HITECH, the certification criteria at 45 CFR 170.314 (45 CFR 170.102 2012)
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)
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)
Fusion
Under ICD-10-PCS, a root procedure that involves joining together portions of an articular body part rendering the articular body part immobile (CMS 2013)
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
Blogs
Web logs that provide a web page where users can post text, images, and links to other websites
Alert fatigue
When an excessive number of alerts are used in an information system, users get tired of looking at the alerts and may ignore them
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
Autopsy report
Written documentation of the findings from a postmortem pathological examination
