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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"

Registry

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

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"

Union

"A collective bargaining unit that represents groups of employees and is authorized to negotiate with employers on the employees' behalf in matters related to compensation, health, and safety"

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"

President's Information Technology Advisory Committee (PITAC)

"A committee that advises the federal administration on information technology, including EHR interoperability issues"

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"

Nursing facility

"A comprehensive term for long-term care facilities that provide nursing care and related services on a 24-hour basis for residents requiring medical, nursing, or rehabilitative care"

Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT)

"A comprehensive, controlled clinical vocabulary developed by the College of American Pathologists"

Virus

"A computer program, typically hidden, that attaches itself to other programs and has the ability to replicate and cause various forms of harm to the data"

Point-of-care information system

"A computer system that captures data at the location (for example, bedside, exam room, or home) where the healthcare service is performed"

Transaction-processing system

"A computer-based information system that keeps track of an organization's business transactions through inputs (for example, transaction data such as admissions, discharges, and transfers in a hospital) and outputs (for example, census reports and bills)"

Information resource management

"A concept that assumes that information is a valuable resource that must be managed, regardless of the form it takes or the medium in which it is stored"

Systematized Nomenclature of Medicine Reference Terminology (SNOMED RT)

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

Chief complaint

"A concise statement, usually stated in the patient's words, describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for a healthcare encounter"

Public Health Informatics Institute (PHII)

"A cooperative of public health services, health information systems, and informatics experts established to develop health information systems for public and population health purposes"

Uniform Hospital Discharge Data Set (UHDDS)

"A core set of data elements adopted by the U.S. Department of Health, Education, and Welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems"

Applications and data criticality analysis

"A covered entity's formal assessment of the sensitivity, vulnerabilities, and security of its programs and the information it generates, receives, manipulates, stores, and/or transmits"

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)"

Reflective learning

"A cycle of reflection, interpretation, application of learning, and action that is the basis of total quality management and other continuous improvement philosophies"

Peter Principle

"A cynical belief that employees will advance to their highest level of competence, and then be promoted to their level of incompetence where they will remain (named after the 1993 book by Laurence J. Peter)"

Repository

"A data structure where data are stored for subsequent use by multiple, disparate systems"

Geographic information system (GIS)

"A decision support system that is capable of assembling, storing, manipulating, and displaying geographically referenced data and information"

Nonprogrammed decision

"A decision that involves careful and deliberate thought and discussion because of a unique, complex, or changing situation"

Unstructured decision

"A decision that is made without following a prescribed method, formula, or pattern"

Hospital-based ambulatory surgery center

"A department of an inpatient facility that provides same-day surgical services using the facility's equipment, staff, and support services"

Evaluation research

"A design of research that examines the effectiveness of policies, programs, or organizations"

Job description

"A detailed list of a job's duties, reporting relationships, working conditions, and responsibilities"

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"

Deficiency slip

"A device for tracking information (for example, reports) missing from a paper-based health record"

Variance

"A disagreement between two parts; the square of the standard deviation; a measure of variability that gives the average of the squared deviations from the mean; in financial management, the difference between the budgeted amount and the actual amount of a line item; in project management, the difference between the original project plan and current estimates"

Notifiable disease

"A disease that must be reported to a government agency so that regular, frequent, and timely information on individual cases can be used to prevent and control future cases of the disease"

Coronary care unit (CCU)

"A facility dedicated to the care of patients who suffer from heart attacks, strokes, or other serious cardiopulmonary problems"

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"

Corporate compliance program

"A facilitywide program that comprises a system of policies, procedures, and guidelines that are used to ensure ethical business practices"

Civilian Health and Medical Program - Uniformed Services (CHAMPUS)

"A federal program providing supplementary civilian-sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees and their dependents, and certain others"

Temporary assistance for needy families (TANF)

"A federal program that provides states with grants to be spent on time-limited cash assistance for low-income families, generally limiting a family's lifetime cash welfare benefits to a maximum of five years and permitting states to impose other requirements; replaced the Aid of Families with Dependent Children program"

Minimum Data Set for Long-Term Care Version 2.0 (MDS 2.0)

"A federally mandated standard assessment form that Medicare- and/or Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements"

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"

Informatics

"A field of study that focuses on the use of technology to improve access to, and utilization of, information"

National provider file (NPF)

"A file developed by the Centers for Medicare and Medicaid Services that includes all healthcare providers, including nonphysicians, and sites of care"

Archive file

"A file in a collection of files reserved for later research or verification for the purposes of security, legal processes, and/or backup"

Family numbering

"A filing system, sometimes used in clinic settings, in which an entire family is assigned one number"

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])"

Comorbidity

"1. A medical condition that coexists with the primary cause for hospitalization and affects the patient's treatment and length of stay 2. Preexisting 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])"

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)"

Controlled vocabulary

"1. A predefined set of terms and their meanings that may be used in structured data entry or natural language processing to represent expressions 2. A restricted set of phrases, generally enumerated in a list and perhaps arranged into a hierarchy (Hardiker and Casey 2000)"

Process

"1. A systematic series of actions taken to create a product or service; a formal writing (writ) issued by authority of law; any means used by the court to acquire or to exercise jurisdiction over a person or a specified property; a term from Donabedian's model of quality assessment that focuses on how care is provided 2. The interrelated activities of healthcare organizations-including governance, managerial support, and clinical services-that affect patient oucomes across departments and disciplines within an integrated environment"

Network

"1. A type of information technology that connects different computers and computer systems so that they can share information 2. Physicians, hospitals, and other providers who provide healthcare services to members of a managed care organization; providers may be associated through formal or informal contracts and agreements"

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"

Method

"1. A way of performing an action or task 2. A strategy used by a researcher to collect, analyze, and present data"

Caregiver

"1. Any clinical professional (physician, nurse, technologist, or therapist, for example) who provides care directly to patients 2. A nonprofessional who provides supportive assistance in a residential setting to a relative, friend, or client who is seriously ill"

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"

Patient-specific/identifiable data

"1. Data in the health record that relates to a particular patient identified by name 2. Personal information that can be linked to a specific patient, such as age, gender, date of birth, and address-specific data"

Retention

"1. Mechanisms for storing records, providing for timely retrieval, and establishing the length of times that various types of records will be retained by the healthcare organization 2. The ability to keep valuable employees from seeking employment elsewhere"

Peer review

"1. Review by like professionals, or peers, established according to an organization's medical staff bylaws, organizational policy and procedure, or the requirements of state law; the peer review system allows medical professioanls to candidly critique and criticize the work of their colleagues without fear of reprisal 2. The process by which experts in the field evaluate the quality of a manuscript for publication in a scientific or professional journal"

Physical access controls

"1. Security mechanisms designed to protect an organization's equipment, media, and facilities from physical damage or intrusion 2. Security mechanisms designed to prevent unauthorized physical access to health records and health record storage areas"

Access

"1. The ability of a subject to view, change, or communicate with an object in a computer system 2. One of the rights protected by the Privacy Rule; an individual has a right of access to inspect and obtain a copy of his or her own PHI that is contained in a designated record set, such as a health record "

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 (IRF PPS). In the HHPPS, the HIPPS code is derived or computed from the home health resource group (HHRG); in the IRF PPS, the HIPPS code is derived from the case mix group and comorbidity. Reimbursement weights for each HIPSS code correspond to the levels of care provided"

SOAPIER

"A form of charting narrative notes that requires subjective, objective, assessment, plan, intervention, evaluation, and revision in the note structure"

Issue log

"A form of documentation that describes the questions, concerns, and problems that must be solved in order for a task to be completed"

Interview

"A formal meeting, often between a job applicant and a potential employer"

Grievance

"A formal, written description of a complaint or disagreement"

Net present value (NPV)

"A formula used to assess the current value of a project when the monies used were invested in the organization's investment vehicles rather than expended for the project; this value is then compared to the allocation of the monies and the cash inflows of the project, both of which are adjusted to current time"

Progressive discipline

"A four-step process for shaping employee behavior to conform to the requirements of the employee's job position that begins with a verbal caution and progresses to written reprimand, suspension, and dismissal upon subsequent offenses"

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)"

Discounting

"1. The application of lower rates of payment to multiple surgical procedures performed during the same operative session under the outpatient prospective payment system; the application of adjusted rates of payment by preferred provider organizations 2. Reducing the payment in the hospital outpatient prospective payment system (HOPPS) (payment status indicator= T). In the CMS's discounting schedule, Medicare will pay 100 percent of the Medicare allowance for the principle procedure (exclusive of deductible and copayment) and 50 percent (50 percent discount) of the Medicare allowance for each additional procedure. For example, if two CT scans (APC group 0349) are performed in the same visit, the first is reimbursed at the full APC group rate, the second at 50 percent of the APC group rate "

Medical necessity

"1. The likelihood that a proposed healthcare service will have a reasonable beneficial effect on the patient's physical condition and quality of life at a specific point in his or her illness or lifetime 2. healthcare services and supplies that are proven or acknowledged to be effective in the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms and to be consistent with the community's accepted standard of care. Under medical necessity, only those services, procedures, and patient care warranted by the patient's condition are provided; 3. The concept that procedures are only eligible for reimbursement as a covered benefit when they are performed for a specific diagnosis or specified frequency; also called the 'Need to Know' principle"

Case management

"1. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient 2. A process that integrates and coordinates patient care over time and across multiple sites and providers, especially in complex and high-cost cases, with goals of continuity of care, cost-effectiveness, quality, and appropriate utilization 3. The process of developing a specific care plan for a patient that serves as a communication tool to improve quality of care and reduce cost"

Certification

"1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements"

Compliance

"1. The process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization's ethical and business policies 2. The act of adhering to official requirements 3. Managing a coding or billing department according to the laws, regulations, and guidelines that govern it"

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 "

Revenue cycle

"1. The process of how patient financial and health information moves into, through, and out of the healthcare facility, culminating with the facility receiving reimbursement for services provided 2. The regularly repeating set of events that produces revenue"

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"

Outcome measures

"1. The process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status, for the purpose of improving care 2. A measure that indicates the result of the performance (or nonperformance) or a function or process"

Level of service

"1. The relative intensity of services given when a physician provides one-on-one services for a patient (such as minimal, brief, limited, or intermediate) 2. The relative intensity of services provided by a healthcare facility (for example, tertiary care)"

Triage

"1. The sorting of, and allocation of treatment to, patients 2. An early assessment that determines the urgency and priority for care and the appropriate source of care"

Integrity

"1. The state of being whole or unimpaired 2. In the context of data security, data integrity means the protection of data from accidental or unauthorized intentional change. (JC 2004 IM-12) "

Lexicon

"1. The vocabulary used in a language or a subject area or by a particular speaker or group of speakers 2. A collection of words or terms and their meanings for a particular domain, used in healthcare for drug terms"

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"

Global Assessment of Functioning (GAF) Scale

"A 100-point tool rating overall psychological, social, and occupational functioning of individuals, excluding physical and environmental impairment"

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 refusing to treat indigent emergency department patients because of their inability to pay "

Operation Restore Trust

"A 1995 joint effort of the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and the Administration of Aging (AOA) to target fraud and abuse among healthcare providers"

Pareto chart

"A bar graph that includes bars arranged in order of descending size to show decisions on the prioritization of issues, problems, or solutions"

Column/field

"A basic fact within a table, such as LAST_NAME, FIRST_NAME, and date of birth"

Transitional nonfacility relative value unit

"A blend of charge-based relative value units and resource-based relative expense for services provided in a practice setting other than a facility, for example, a physician's office or freestanding clinic"

Criminal law

"A branch of law that addresses crimes that are wrongful acts against public health, safety, and welfare, usually punishable by imprisonment and/or fine"

Statistics

"A branch of mathematics concerned with collecting, organizing, summarizing, and analyzing data"

Excisional breast biopsy

"A breast biopsy that includes the removal of the entire lesion, whether benign or malignant"

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 fourteen days of admission to a long-term care facility"

Outlier

"1. A case in a prospective payment system with unusually long lengths of stay or exceptionally high costs; day outlier or cost outlier, respectively 2. An extreme statistical value that falls outside the normal range"

Access control

"1. A computer software program designed to prevent unauthorized use of an information resource 2. The process of designing, implementing, and monitoring a system for guaranteeing that only individuals who have a legitimate need are allowed to view or amend specific data sets"

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"

Change management

"1. A group of interpersonal and communication techniques used to help people understand the process of change and accept improvements in the way they perform their work 2.The formal process of introducing change, getting it adopted, and diffusing it throughout the organization "

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"

AQA Alliance

"A broad based coalition of physicians, consumers, purchasers, health insurance plans, and others who are committed to effectively and efficiently improve performance measurement, data aggregation, and reporting in the ambulatory care setting"

Double distribution

"A budgeting concept in which overhead costs are allocated twice, taking into consideration that some overhead departments provide services to each other"

Step-down allocation

"A budgeting concept in which overhead costs are distributed once, beginning with the area that provides the least amount of non revenue-producing services"

Merger

"A business situation where two or more companies combine, but one of them continues to exist as a legal, business entity, while the others cease to exist legally and their assets and liabilities become part of the continuing company"

Administrative information systems

"A category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions"

Rubric

"A category; in ICPC, the two digits following the first character of an ICPC code and representing the second axis, components"

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"

Intrahospital transfer

"A change in medical care unit, medical staff unit, or responsible physician during hospitalization"

Audit trail

"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 and/or transaction from its beginning to end. Includes who performed what event and when it occurred"

Functional status domain

"A classification made up of six activities of daily living, including upper and lower body dressing, bathing, toileting, transferring, and moving"

Stage of the neoplasm

"A classification of malignancies (cancers) according to the anatomic extent of the tumor, such as primary neoplasm, regional lymph nodes, and metastases"

RxNorm

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

Managed care

"A generic term for reimbursement and delivery systems that integrate the financing and provision of healthcare services by means of entering contractual agreements with selected providers to furnish comprehensive healthcare services and developing explicit criteria for the selection of healthcare providers, formal programs of ongoing quality improvement and utilization review, and significant financial incentives for members to use providers associated with the plan"

Flowchart

"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"

Medical specialties

"A group of clinical specialties that concentrates on the provision of nonsurgical care by physicians who have received advanced training in internal medicine, pediatrics, cardiology, endocrinology, psychiatry, oncology, nephrology, neurology, pulmonology, gastroenterology, dermatology, radiology, and nuclear medicine, among many other concentrations"

Surgical specialties

"A group of clinical specialties that concentrates on the provision of surgical services by physicians who have received advanced training in obstetrics/gynecology, ophthalmology, orthopedics, cardiovascular surgery, otorhinolaryngology, trauma surgery, neurosurgery, thoracic surgery, urology, plastic and reconstructive surgery, anesthesiology, and pathology"

Complementary and alternative medicine (CAM)

"A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (National Center for Complementary and Alternative Medicine 2005)"

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"

Designated record set

"A group of records maintained by or for a covered entity that may include patient medical and billing records; the enrollment, payment, claims adjudication, and cases or medical management record systems maintained by or for a health plan; or information used, in whole or in part, to make patient care-related decisions"

Panel

"A group of tests commonly performed together for a given purpose, usually for one diagnosis"

Nominal group technique

"A group process technique that involves the steps of silent listing, recording each participant's list, discussing, and rank ordering the priority or importance of items; allows groups to narrow the focus of discussion or to make decisions without becoming involved in extended, circular discussions"

Medicare carrier

"A health plan that processes Part B claims for services by physicians and medical suppliers (for example, the Blue Shield plan in a state)"

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 twenty-four-hour basis over a long period of time"

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 organization

"A healthcare provider or facility that offers preventive, diagnostic, therapeutic, and rehabilitative services to individuals not classified as inpatients or residents"

Clinician

"A healthcare provider, including physicians and others who treat patients"

Opportunity for improvement

"A healthcare structure, product, service, process, or outcome that does not meet its customers' expectations and, therefore, could be improved"

Initiating structure

"A leadership orientation toward tasks, procedures, goals, and production"

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"

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"

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"

Partial hospitalization

"A limited patient stay in the hospital setting, typically as part of a transitional program to a less intense level of service; for example, psychiatric and drug and alcohol treatment facilities that offer services to help patients reenter the community, return to work, and assume family responsibilities"

Operation index

"A list of the operations and surgical procedures performed in a healthcare facility, which is sequenced according to the code numbers of the classification system in use"

Vocabulary standards

"A list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field"

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"

DSM-IV-TR Classification

"A listing of psychiatric disorders that includes corresponding ICD-9-CM codes (i.e. 315.31, Expressive Language Disorder)"

Skilled nursing facility (SNF)

"A long-term care facility with an organized professional staff and permanent facilities (including inpatient beds) that provides continuous nursing and other health-related, psychosocial, and personal services to patients who are not in an acute phase of illness but who primarily require continued care on an inpatient basis"

TRICARE Senior Prime

"A managed care demonstration TRICARE program designed to better serve the medical needs of military retirees, dependents, and survivors who are sixty-five years old and over"

Data quality model

"A managerial process that ensures the integrity (accuracy and completeness) of an organization's data during data collection, application, warehousing, and analysis"

Point and click

"A means of data entry in which the user moves the computer's cursor by way of a mouse, up-and-down arrows, or some other pointing or navigational device to choose an icon or data element"

Process measures

"A measure that focuses on a process that leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome"

Semantic differential scale

"A measure that records a group's perception of a product, organization, or program through bipolar adjectives on a seven-point continuum, resulting in a profile"

Outcome indicator

"A measurement of the end results of a clinical process (for example, complications, adverse effects, patient satisfaction) for an individual patient or a group of patients within a specific diagnostic category"

Risk-transfer mechanism

"A mechanism whereby risk is passed from a regulated insurer to a quasi-regulated, regulated, or nonregulated provider"

Special care unit

"A medical care unit in which there is appropriate equipment and a concentration of physicians, nurses, and others who have special skills and experience to provide optimal medical care for critically ill patients or continuous care of patients in special diagnostic categories"

Current Dental Terminology (CDT)

"A medical code set of dental procedures, maintained and copyrighted by the American Dental Association (ADA), referred to as the Uniform Code on Dental Procedures and Nomenclatures until 1990 "

Motion video

"A medium for storing, manipulating, and displaying moving images in a format, such as frames, that can be presented on a computer monitor"

Developmental disability

"A mental or physical limitation affecting major life activities, arising before adulthood, and usually lasting throughout life"

Third-party payers administrator (TPA)

"A method by which an outside person or firm maintains all records, pays claims, and/or generally administers the benefits program of an employer group regarding the persons covered under the insurance plan"

Prospective payment

"A method of determining reimbursement based on predetermined factors, not individual services"

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"

Bar coding 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"

Gesture recognition technology

"A method of encoding handwritten, print, or cursive characters and of interpreting the characters as words or the intent of the writer"

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"

Nuclear medicine

"A method of examination in which technologists using a special camera introduce radioactive substances into the body orally, intravenously, or by ventilated aerosol or gas. A special camera is used to detect the radioactive substances as they circulate through the body and produce an image"

Job ranking

"A method of job evaluation that arranges jobs in a hierarchy on the basis of each job's importance to the organization, with the most important jobs listed at the top of the hierarchy and the least important jobs listed at the bottom"

360-degree evaluation

"A method of performance evaluation in which the supervisors, peers, and other staff who interact with the employee contribute information"

Unit work division

"A method of work organization where each task is performed by one person at the same time that another person is doing a task, but one does not have to wait for the other"

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"

Alias

"A name added to, or substituted for, the proper name of a person; an assumed name"

Health Information Management and Systems Society (HIMSS)

"A national membership association that provides leadership in healthcare for the management of technology, information, and change"

North American Association of Central Cancer Registries (NAACCR)

"A national organization that certifies state, population-based cancer registries"

Institute of Electrical and Electronics Engineers (IEEE)

"A national organization that develops standards for hospital system interface transactions, including links between critical care bedside instruments and clinical information systems"

American Society for Testing and Materials (ASTM)

"A national organization whose purpose is to establish standards on materials, products, systems, and services"

Object-oriented framework

"A new way of programming and representing data that uses commands that act as small, self-contained instructional units that may be combined in various ways to produce larger programs"

Spin-off

"A new, separate company formed by a parent company whose shares are distributed to existing shareholders of the parent company in proportion to the new entity's relationship to the parent company"

Well newborn

"A newborn born at term, under sterile conditions, with no diseases, conditions, disorders, syndromes, injuries, malformations, or defects diagnosed, and no operations other than routine circumcisions performed"

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)"

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 represent an opaque identifier found in the UMLS Metathesaurus "

Purchase order

"A paper document or electronic screen on which all details of an intended purchase are reported, including authorizations"

Nursing Home Reform Act

"A part of the Omnibus Budget Reconciliation Act of 1987 whose purpose is to guarantee the quality of nursing home care and to ensure that the care that residents receive helps them to achieve or maintain the 'highest practicable' level of physical, mental, and psychosocial well-being"

National Guideline Clearinghouse (NGC)

"A partnership among the Agency for Healthcare Research and Quality, the American Medical Association, and the American Association of Health Plans that allows free online access to its clinical guidelines"

National Alliance for Health Information Technology (NAHIT)

"A partnership of government and private sector leaders from various healthcare organizations working to use technology to achieve improvements in patient safety, quality of care, and operating performance; founded in 2002"

Adverse drug event

"A patient injury resulting from a medication, either because of a pharmacological reaction to a normal dose, or because of a preventable adverse reaction to a drug resulting from an error. Source: TJC)"

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"

Observation patient

"A patient who presents with a medical condition with a significant degree of instability and disability and who needs to be monitored, evaluated, and assessed to determine whether he or she should be admitted for inpatient care or discharged for care in another setting"

Minimum Data Set for Post Acute Care (MDS-PAC)

"A patient-centered assessment instrument that must be completed for every Medicare patient, which emphasizes a patient's care needs instead of provider characteristics"

Self-pay

"A payer category in which the patient or patient's family, rather than a third-party payer, (such as an insurance company) pays the bill for care"

Packaging

"A payment under the Medicare outpatient prospective payment system that includes items such as anesthesia, supplies, certain drugs, and the use of recovery and observation rooms"

Inpatient psychiatric facility PPS (IPFPPS)

"A per diem prospective payment system that is based on fifteen diagnosis-related groups, which became effective on January 1, 2005"

Skilled nursing facility prospective payment system (SNF PPS)

"A per-diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries"

Plan-do-check-act (PDCA) cycle

"A performance improvement model developed by Walter Shewhart, but popularized in Japan by W. Edwards Deming"

Team member

"A performance improvement team role responsible for participating in team decision making and plan development; identifying opportunities for improvement; gathering, prioritizing, and analyzing data; and sharing knowledge, information, and data that pertain to the process under study"

Longitudinal health record

"A permanent, coordinated patient record of significant information listed in chronological order and maintained across time, ideally from birth to death"

Temporary employee

"A person who is employed for a temporary, definite period of time, such as to complete a specific project or to fill in for a permanent employee on vacation or other leave; or a person who is employed for an indefinite period of time but who receives none of the fringe benefits offered to permanent employees"

Microcomputer

"A personal computer characterized by its relatively small size and fast processing speed; also called desktop computer, laptop computer, or PC"

Universal patient identifier

"A personal identifier applied to a patient, such as a number or code, that is used permanently for many and varied purposes"

Clinical drug

"A pharmaceutical product given to (or taken by) a patient with a therapeutic or diagnostic intent; has a clinical drug name, which includes the routed generic, the strength, and dose form"

Positivism

"A philosophy of research that assumes that there is a single truth across time and place and that researchers are able to adopt a neutral, unbiased stance and establish causation"

Token

"A physical device, such as a key card, inserted into a door to admit an authorized person or into a computer to authenticate a computer user"

Alias policy

"A policy that is implemented when resident confidentiality is require by the resident, family, or responsible party"

Chart depletion policy

"A policy that outlines the documents that can be removed, or depleted, from resident records over time"

Chief privacy officer

"A position that (1) oversees activities related to the development, implementation, and maintenance of, and adherence to, organizational policies and procedures regarding the privacy of and access to patient-specific information and (2) ensures compliance with federal and state laws and regulations and accrediting body standards concerning the confidentiality and privacy of health-related information"

Chief knowledge officer (CKO)

"A position that oversees the entire knowledge acquisition, storage, and dissemination process and that identifies subject matter experts to help capture and organize the organization's knowledge assets"

Budget period

"A predetermined period of time, such as a fiscal year, in which a project budget will be spent"

Commission on Accreditation of Rehabilitation Facilities (CARF)

"A private, not-for-profit organization that develops customer-focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards"

Needs assessment

"A procedure performed by collecting and analyzing data to determine what is required, lacking, or desired by an employee, a group, or an organization"

Significant procedure ambulatory payment classification

"A procedure that constitutes the reason for the visit, dominates the time and resources rendered during the visit, and is not subject to payment reduction/discounting"

Scientific inquiry

"A process that comprises making predictions, collecting and analyzing evidence, testing alternative theories, and choosing the best theory"

Compliance plan

"A process that helps an organization, such as a hospital, accomplish its goal of providing high-quality medical care and efficiently operating a business under various laws and regulations"

Priority focus process (PFP)

"A process used by the Joint Commission to collect, analyze, and create information about a specific organization being accredited in order to customize the accreditation process"

Focused review

"A process whereby a health record is analyzed to gather specific information about the diagnoses, treatments, or providers"

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 "

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"

Unified Medical Language System (UMLS)

"A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies"

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"

Voluntary Disclosure Program

"A program unveiled in 1998 by the OIG that encourages healthcare providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs"

Healthcare provider

"A provider of diagnostic, medical, and surgical care as well as the services or supplies related to the health of an individual and any other person or organization that issues reimbursement claims or is paid for healthcare in the normal course of business. A provider is legally responsible for the patient's diagnosis and treatment"

Provider-based entity

"A provider of healthcare services, a rural health clinic, or a federally qualified health clinic, as defined in section 405-2401 of the Code of Federal Regulations, that is either created or acquired by a main provider for the purpose of furnishing healthcare services under the name, ownership, and administrative and financial control of the main provider, in accordance with the provisions of the proposed rule"

Main provider

"A provider that either creates or owns another entity in order to deliver additional healthcare services under its name, ownership, and financial and administrative control"

American Society for Quality (ASQ)

"A quality improvement organization whose members' interests are related to statistical process control, quality cost measurement and control, total quality management, failure analysis, and zero defects"

Health Care Quality Improvement Program (HCQIP)

"A quality initiative begun in 1992 by the Health Care Financing Administration and implemented by peer review organizations that uses patterns of care analysis and collaboration with practitioners, beneficiaries, providers, plans, and other purchasers of healthcare services to develop scientifically based quality indicators and to identify and implement opportunities for healthcare improvement"

Key indicator

"A quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria"

Performance measure

"A quantitative tool used to assess the clinical, financial, and utilization aspects of a healthcare provider's outcomes or processes"

Strategic issue

"A question, topic, opportunity, or concern that is addressed through strategic management"

Data store

"A real-time, sensitive, operationally oriented form of data warehousing, retaining small amounts of key indicators to run day-to-day processes"

Occupational safety and health record

"A record kept on an employee as part of employment that contains any and all information related to such items as medical tests, drug tests, examinations, physical abilities, immunizations, screenings required by law, biohazardous exposure, physical limitations"

Secondary patient record

"A record, derived from the primary record, that contains selected data elements to aid nonclinical persons in patient care support, evaluation, or advancement"

Physician-patient relationship

"A relationship in which the physician trusts the patient to be forthcoming and honest in providing the information necessary for diagnosis and treatment, and the patient trusts the physician to use that information responsibly and in his or her best interest and to protect it from becoming public knowledge"

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"

Balance sheet

"A report that shows the total dollar amounts in accounts, expressed in accounting equation format, at a specific point in time"

Physical data repository

"A repository organized into data fields, data records, and data files, storing structured, discrete, clinical, administrative, and financial data as well as unstructured, patient free-text, bit-mapped, real audio, streaming video, or vector graphic data"

Hawthorne effect

"A research study that found that novelty, attention, and interpersonal relations have a motivating effect on performance"

Transfer record

"A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility"

Critic

"A role in organizational innovation in which an idea is challenged, compared to stringent criteria, and tested against reality"

Municipal ordinance/code

"A rule established by a local branch of government such as a town, city, or county"

Enforcement rule

"A rule that created standardized procedures and substantive requirements for investigating complaints and imposing civil monetary penalties (CMPs) for HIPAA violations, as well as a uniform compliance and enforcement mechanism that addresses all of the Administrative Simplification regulations, including privacy, security, and transactions and code sets"

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"

Quota sampling

"A sampling technique where the population is first segmented into mutually exclusive subgroups, just as in stratified sampling, and then judgment is used to select the subjects or units from each segment based on a specified proportion"

Core communications

"A series of triggered, event-specific communications based on need and data such as age, sex, and health profile that gives providers an appropriate time and personalized reason to communicate with recipients"

Felony

"A serious crime such as murder, larceny, rape, or assault for which punishment is usually severe "

Orientation

"A set of activities designed to familiarize new employees with their jobs, the organization, and its work culture"

Quality improvement (QI)

"A set of activities that measures the quality of a service or product through systems or process evaluation and then implements revised processes that result in better healthcare outcomes for patients, based on standards of care"

Reference terminology

"A set of concepts and relationships that provide a common consultation point for the comparison and aggregation of data about the entire healthcare process, recorded by multiple individuals, systems, or institutions"

Standard cost profile (SCP)

"A set of data that identifies, analyzes, and defines the activities, including the costs, of departments within the organization to produce a service unit"

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"

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)"

Research methodology

"A set of procedures or strategies used by researchers to collect, analyze, and present data"

Significant change in condition (SCIC) adjustment

"A single episode payment under multiple home health resource groups, each prorated to the number of service days delivered"

Leader-member relations

"A situation in contingency theory describing how well the leader is liked, respected, and followed"

Emergency

"A situation in which a patient requires immediate medical intervention as a result of severe, life-threatening, or potentially disabling conditions "

Repudiation

"A situation in which a user or system denies having performed some action, such as modifying information"

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"

Microcontroller

"A small, low-cost computer (embedded chip) installed in an appliance or electronic device to perform a specific task or program"

Minicomputer

"A small, mainframe computer"

Search engine

"A software program used to search for data in databases (for example, a structured query language)"

Sniffer

"A software security product that runs in the background of a network, examining and logging packet traffic and serving as an early warning device against crackers"

Worm

"A special type of computer virus, usually transferred from computer to computer via e-mail, that can replicate itself and use memory but cannot attach itself to other programs"

Data definition language (DDL)

"A special type of software used to create the tables within a relational database, the most common of which is structured query language"

Scheduling engine

"A specific functionality in project management software that automates the assignment of task start-and-finish dates and, as a result, the expected project finish date"

Occasion of service

"A specified identifiable service involved in the care of a patient that is not an encounter (for example, a lab test ordered during an encounter)"

Universal Medical Device Nomenclature System (UMDNS)

"A standard international nomenclature and computer coding system for medical devices, developed by ECRI"

Patient assessment instrument (PAI)

"A standardized tool used to evaluate the patient's condition after admission to, and at discharge from, the healthcare facility"

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. "

Belmont Report

"A statement of ethical principles to prevent the unethical use of human subjects in research, sponsored by the Department of Health and Human Services"

Objective

"A statement of the end result expected, stated in measurable terms, usually with a time limitation (deadline date) and often with a cost estimate or limitation"

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"

Geometric mean length of stay (GMLOS)

"A statistically adjusted value of all cases of a given 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"

Standard of law

"A statute or regulation, or common practice, established by professional associations to identify what an individual is expected to do or not do in a given situation unless determined otherwise by a court"

Job procedure

"A structured, action-oriented list of sequential steps involved in carrying out a specific task or solving a problem"

Single-blinded study

"A study design in which (typically) the investigator but not the subject, knows the identity of the treatment and control groups"

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)"

Account

"A subdivision of assets, liabilities, and equities in an organization's financial management system"

Hospital-based outpatient care

"A subset of ambulatory care that utilizes a hospital's staff, equipment, and resources to render preventive and/or corrective healthcare services"

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"

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"

Resident classification system

"A system for classifying skilled nursing facility residents into mutually exclusive groups based on clinical, functional, and resource-based criteria"

Moral values

"A system of principles by which one guides one's life, usually with regard to right or wrong"

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"

EHR 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 enhance the quality, safety, and efficiency of patient care; and supports efficient processes for healthcare delivery"

Literature review

"A systematic investation of all the knowledge available about a topic from sources such as books, journal articles, theses, and dissertations"

Data type

"A technical category of data (text, numbers, currency, date, memo, and link data) that a field in a database can contain"

Administrative simplification

"A term referring to the Health Insurance Portability and Accountability Act (HIPAA) provisions which include standards for transactions and code sets that are used to exchange health data, standard identifiers for use on transactions, and privacy and security standards to protect personal health information. HIPAA included these administrative simplification provisions in order to improve the efficiency and effectiveness of the healthcare system."

Treatment difficulty

"A term referring to the patient management problems that a particular illness presents to the healthcare provider, usually problems associated with illnesses without a clear pattern of symptoms, illnesses requiring sophisticated and technically difficult procedures, and illnesses requiring close monitoring and supervision"

Syntax

"A term that refers to the comparable structure or format of data, usually as they are being transmitted from one system to another"

Cross-functional

"A term used to describe an entity or activity that involves more than one healthcare department, service area, or discipline"

Patient Care Data Set (PCDS)

"A terminology of patient problems, patient care goals, and patient care orders that represents and captures clinical data for inclusion in patient care information systems"

Normal distribution

"A theoretical family of continuous frequency distributions characterized by a symmetric bell-shaped curve, with an equal mean, median, and mode, any standard deviation, and with half of the observations above the mean and half below it"

Kolb's 'Learning Loop'

"A theory of experiential learning involving four interrelated steps: concrete experiences, observation and reflection, formation of abstract concepts and theories, and testing new implications of theory in new situations"

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"

Healthcare information system (HIS)

"A transactional system used in healthcare organizations (for example, patient admitting, accounting, and receivables)"

Stealth virus

"A type of computer virus that can hide itself, making it difficult to locate"

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)"

Object-oriented database (OODB)

"A type of database that uses commands that act as small, self-contained instructional units (objects) that may be combined in various ways"

Strategic decision making

"A type of decision making that is usually limited to individuals, such as boards of directors, chief executive officers, and top-level executives, who make decisions about the healthcare organization's strategic direction"

Managed behavioral healthcare organization (MBHO)

"A type of healthcare organization that delivers and manages all aspects of behavioral healthcare or the payment for care by limiting providers of care, discounting payment to providers of care, and/or limiting access to care"

Managed care organization (MCO)

"A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, and/or limiting access to care; also known as a coordinated care organization"

Tertiary care

"A type of highly specialized care provided by specialists (such as neurosurgeons, fertility specialists, or immunologists) who use sophisticated technology and support services"

Task structure

"A type of leadership orientation toward goals, production, and procedures"

Case study

"A type of nonparticipant observation in which researchers investigate one person, one group, or one institution in depth"

Population-based registry

"A type of registry that includes information from more than one facility in a specific geopolitical area, such as a state or region"

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"

Physician practice management (PPM)

"A type of software that automates a physician office's patient appointment scheduling, registration, billing, and payroll functions"

Sub acute care

"A type of step-down care provided after a patient is released from an acute care hospital (including nursing homes and other facilities that provide medical care, but not surgical or emergency care)"

Mohs' micrographic surgery

"A type of surgery performed to remove complex or ill-defined skin cancer, requiring a single physician to act in two integrated, but separate and distinct, capacities: surgeon and pathologist"

Knowledge management system (KMS)

"A type of system that supports the creation, organization, and dissemination of business or clinical knowledge and expertise to providers, employees, and managers throughout a healthcare enterprise"

Single sign-on

"A type of technology that allows a user access to all disparate applications through one authentication procedure, thus reducing the number and variety of passwords a user must remember and enforcing and centralizing access control"

Resident assessment instrument (RAI)

"A uniform assessment instrument developed by the Centers for Medicare and Medicaid Services to standardize the collection of skilled nursing facility patient data; includes the Minimum Data Set 2.0, triggers, and resident assessment protocols"

Unique personal identifier

"A unique number assigned by a healthcare provider to a patient that distinguishes the patient and his or her medical record from all others in the institution, assists in the retrieval of the record, and facilitates the posting of payment"

Newborn bassinet count day

"A unit of measure that denotes the presence of one newborn bassinet, either occupied or vacant, set up and staffed for use in one 24-hour period"

Breach of confidentiality

"A violation of a formal or implied contract in which private information belonging to one party, but entrusted to another party, is disclosed by that individual without the consent of the party to whom the information pertains; an unauthorized disclosure of confidential information"

Breach of security

"A violation of security (for example, when standards of confidentiality are broken)"

Stem and leaf plot

"A visual display that organizes data to show its shape and distribution, using two columns with the stem in the left-hand column and all leaves associated with that stem in the right-hand column; the 'leaf' is the ones digit of the number, and the other digits form the 'stem'"

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"

Flex years

"A work arrangement in which employees can choose, at specific intervals, the number of hours they want to work each month over the next year"

Flextime

"A work schedule that gives employees some choice in the pattern of their work hours, usually around a core of midday hours"

Consent to use and disclose information

"A written statement of permission given by a patient to a healthcare provider that allows the provider to use or disclose healthcare information for the purposes of treatment, payment, and healthcare operations"

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"

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"

Individual

"According to the HIPAA privacy rule, a person who is the subject of protected health information"

Business associate

"According to the HIPAA privacy rule, an individual (or group) who is not a member of a covered entity's workforce but who helps the covered entity in the performance of various functions involving the use or disclosure of patient-identifiable health information or disclosure of individually identifiable health information"

Continuing medical education (CME)

"Activities such as accredited sponsorship, nonaccredited sponsorship, medical teaching, publications that advance medical care and other learning experiences, proof of which is required for a physician to maintain certification"

New technology

"Advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries. Applicants for the status of new technology must submit a formal request, including a full description of the clinical applications of the technology and the results of any clinical evaluations demonstrating that the new technology represents a substantial clinical improvement, along with data to demonstrate the technology meets the high cost threshold"

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 "

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"

Hospital ambulatory care

"All hospital-directed preventive, therapeutic, and rehabilitative services provided by physicians and their surrogates to patients who are not hospital inpatients"

Procedures and services (outpatient)

"All medical procedures and services of any type (including history, physical examination, laboratory, x-ray or radiograph, and others) that are performed pertinent to the patient's reasons for the encounter, all therapeutic services performed at the time of the encounter, and all preventive services and procedures performed at the time of the encounter"

Local Codes

"Also known as HCPCS Level III Codes, these codes were developed by local Medicare and/or Medicaid carriers and were eliminated December 31, 2003, to comply with HIPAA"

Network computer

"Also known as a thin client; a personal computer with a computer processing unit but no storage; a type of computer that is used to run applications on servers over a network rather than from the hard disk, and all updated data is stored on the server"

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"

Pixel

"An abbreviation for the term picture element, which is defined by many tiny bits of data or points"

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 "

National Research Act of 1974

"An act that required the Department of Health, Education, and Welfare (now the Department of Health and Human Services) to codify its policy for the protection of human subjects into Federal regulations, and created a commission that generated the Belmont Report "

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)"

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, and/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"

Plug-and-play

"An adapter card hardware that sets connections through software rather than hardware, making hardware easier to install"

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"

Risk sharing

"An agreement in which a vendor assumes at least part of the responsibility, from a financial perspective, for the successful implementation of a computer system"

Singleton ambulatory patient groups

"An ambulatory patient group assigned to a patient claim that, after consolidation of significant procedures and packaging of ancillaries, is part of a visit with no remaining multiple significant procedures"

Public health

"An area of healthcare that deals with the health of populations in geopolitical areas, such as states and counties"

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"

Legibility

"An aspect of the quality of provider entries in which an entry or notation is readable; if an entry cannot be read, it must be assumed that it cannot or was not used in the patient care process "

Prosecutor

"An attorney who prosecutes a defendant accused for a crime on behalf of a local, state, or federal government"

Chief medical informatics officer (CMIO)

"An emerging position, typically a physician with medical informatics training, that provides physician leadership and direction in the deployment of clinical applications in healthcare organizations"

Full-time employee

"An employee who works 40 hours per week, 80 hours per two-week period, or 8 hours per day"

Sheltered employment

"An employment category provided in a special industry or workshop for the physically, mentally, emotionally, or developmentally handicapped"

Hybrid entity

"An entity that performs both covered and noncovered functions under the Privacy Rule; for example, a university that educates students and maintains student educational records is not covered by the Privacy Rule; however, the same university that operates a medical center is covered by the Privacy Rule as it meets the definition of 'healthcare provider'"

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"

Outcomes assessment

"An evaluation that measures the actual outcomes of patient care and service against predetermined criteria (expected outcomes), based on the premise that care is delivered in order to bring about certain results"

All patient refined diagnosis-related groups (APR-DRGs)

"An expansion of the inpatient classification system that includes four distinct subclasses (minor, moderate, major, and extreme) based on the severity of the patient's illness"

Biometric identification system

"An identification system that analyzes biological data about users, such as voiceprints, fingerprints, handprint, retinal scan, faceprints, and full-body scans"

DRG creep

"An increase in a case-mix index that occurs through the coding of higher-paying principal diagnoses and of more complications and comorbidities, even though the actual severity level of the patient population did not change"

ECRI

"An independent nonprofit health services research agency established to promote safety, quality, and cost-effectiveness in healthcare to benefit patient care through research, publishing, education, and consultation; formerly known as the Emergency Care Research Institute"

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 U.S. 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). (www.cchit.org)"

Skilled nursing facility (SNF) market basket index

"An index consisting of the most commonly used cost categories for skilled nursing facility routine services, ancillary services, and capital-related expenses that reflects changes over time in the prices of an appropriate mix of goods and services included in covered skilled nursing facility services"

Medicare economic index (MEI)

"An index used by the Medicare program to update physician fee levels in relation to annual changes in the general economy for inflation, productivity, and changes in specific health-sector expense factors including malpractice, personnel costs, rent, and other expenses"

Profitability index

"An index used to prioritize investment opportunities, where the present value of the cash inflows is divided by the present value of the cash outflows for each investment and the results are compared"

Boarder

"An individual such as a parent, caregiver, or other family member who receives lodging at a healthcare facility but is not a patient"

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"

New patient

"An individual who has not received professional services from the physician, or any other physician of the same specialty in the same practice group within the past three years"

Systems analyst

"An individual who investigates, analyzes, designs, develops, installs, evaluates, and maintains an organization's healthcare information systems; is typically involved in all aspects of the systems development life cycle; and serves as a liaison among end users and programmers, database administrators, and other technical personnel"

Healthcare-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"

Health management information system (HMIS)

"An information system whose purpose is to provide reports on routine operations and processing (for example, a pharmacy inventory system, radiological system, or patient-tracking system)"

National health information infrastructure (NHII)

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

Community health information network (CHIN)

"An integrated collection of computer and telecommunications capabilities that facilitates communications of patient, clinical, and payment information among multiple providers, payers, employers, and related healthcare entities within a community"

Customer

"An internal or external recipient of services, products, or information"

Claim

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

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 a central data repository or, when related specifically to healthcare data, a clinical data repository"

UNIX

"An operating system developed by Bell Labs in the late 1960s, and one of the best systems for mission-critical applications"

Read

"An operation involving the flow of information from an object to a subject, without allowing alteration (which is the write function) of the information"

Likert scale

"An ordinal scaling and summated rating technique for measuring the attitudes of respondents; a measure that records level of agreement or disagreement along a progression of categories, usually five (five-point scale), often administered in the form of a questionnaire"

Continuing care retirement community

"An organization established to provide housing and services, including healthcare, to people of retirement age"

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"

Credential verification organization (CVO)

"An organization that verifies healthcare professionals' background, licensing, and schooling, and tracks continuing education and other performance measures"

Random sampling

"An unbiased selection of subjects that includes methods such as simple random sampling, stratified random sampling, systematic sampling, and cluster sampling"

Sentinel event

"An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase 'or risk thereof' includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called 'sentinel' because they signal the need for immediate investigation and response"

Reportable event

"An unintended act, either of omission or commission, or an act that does not achieve its intended outcome"

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"

Peripheral

"Any hardware device connected to a computer (for example, a keyboard, mouse, or printer)"

Preexisting condition

"Any injury, disease, or physical condition occurring prior to an arbitrary date before the insured's enrollment date of coverage, medical advice, diagnosis, care, or treatment was recommended or received; Healthcare coverage may be denied for a period of time for a pre-existing condition, but the Health Insurance Portability and Accountability Act constrains the use of exclusions for pre-existing conditions and establishes requirements exclusions for pre-existing conditions must satisfy"

Unsupervised learning

"Any learning technique that has as its purpose to group or cluster items, objects, or individuals"

Physical restraint

"Any manual or mechanical device, material, or equipment attached or adjacent to a resident's body that restricts freedom of movement and prevents the resident's normal access to his or her own body"

Low-birth-weight neonate

"Any newborn baby, regardless of gestational age, whose birth weight is less than 2500 grams"

Confidential communication

"As defined by HIPAA, a request that PHI be routed to an alternative location or by an alternative method"

Health care record

"As distinguished from a medical record. The health care record is the service provider's care data collection and processing tool as well as the documentation of care in a broader sense. This term includes that information processing that, while useful, would not meet the definitional requirements of a medical record, thus encompassing purposes that extend outside or do not qualify as meeting requirements for the more well-defined domain of a medical record. This also then is inclusive of those documentation and data gathering activities that may not meet the validity requirements of a true medical record. "

Long-term assets

"Assets whose value to the organization extends beyond one fiscal year, for example, buildings, land, and equipment are long-term assets"

Countersignature

"Authentication by a second provider that signifies review and evaluation of the actions and documentation, including authentication, of a first provider "

Applied healthcare informatics

"Automated information systems applied to healthcare delivery business and work-flow processes, including the diagnosis, therapy, and systems of managing health data and information within the healthcare setting"

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)"

Diagnostic image data

"Bit-mapped images used for medical or diagnostic purposes (for example, chest x-rays or computed tomography scans)"

Diagnostic mammography

"Breast imaging, either unilateral or bilateral, done to provide information on a patient with a suspected breast condition "

Administrative services

"Business-related services provided by an insurance organization to self-insured employers or other parties according to an administrative services only contract (for example, actuarial support, benefit plan design, claims processing, data recovery and analysis, employee benefits communication, financial advice, medical care conversions, stop-loss coverage, and other services as requested)"

Category III codes

"CPT codes that describe new and emerging technology. They may be published at any time during the year, rather than on the annual publication cycle, and can be found on the AMA Web site (www.ama-assn.org) and immediately preceding the alphabetic index in the CPT codebook "

Category II codes

"CPT codes that describe services or test results that are agreed upon as contributing to positive health outcomes and high-quality patient care. They are for performance measurement, and use of these codes is optional "

Selective catheter placement

"Catheter placement into any arterial or venous vessel other than the aorta, vena cava, or the original vessel that was punctured"

Non selective catheter placement

"Catheter placement into the aorta, vena cava, or the vessel punctured"

Rehabilitation impairment category (RIC)

"Clusters of impairment group codes (IGCs) that represent similar impairments and diagnoses. RICs are the larger umbrella division within the inpatient rehabilitation facility prospective payment system (IRF PPS). From the RICs, the case-mix groups (CMGs) are determined"

Administrative data

"Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance"

HCPCS level III

"Codes, often called local codes, developed by local Medicare and/or Medicaid carriers for use in their particular geographic locations; eliminated on December 31, 2003 "

Bioethics and privacy commissions

"Commissions that U.S. government has formed to specifically address issues related to privacy, electronic systems, and research; for example, in 1972-1973, the Health Education and Welfare (HEW) secretary established the Advisory Committee on Automated Personal Data Systems, the first attempt to establish fair information practices for automated personal data systems"

Standing committees

"Committees that are put in place to oversee ongoing and cross-functional issues (examples include the medical staff committee, a quality improvement committee, or an infection control committee)"

Consulting agencies

"Companies outside the healthcare organization that provide assistance with various issues, including security awareness training "

Physician work (WORK)

"Component or element of the relative value unit (RVU) that should cover the physician's salary. This work is the time the physician spends providing a service and the intensity with which that time is spent. The four elements of intensity are:(a) mental effort and judgment, (b) technical skill, (c) physical effort, and (d) psychological stress"

Database management system (DBMS)

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

Metropolitan statistical area (MSA)

"Core-based statistical area associated with at least one urbanized area that has a population of at least 50,000. The MSA comprises the central county or counties containing the core, plus adjacent outlying counties"

Third opinion

"Cost containment measure to prevent unnecessary tests, treatments, medical devices, or surgical procedures"

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 "

HCPCS level I

"Current Procedural Terminology, developed by the American Medical Association"

Electronically stored information (ESI)

"Data or documents, including e-mail and electronic health records, that are stored electronically rather than physically"

Nominal-level data

"Data that fall into groups or categories that are mutually exclusive and with no specific order (for example patient demographics such as third party payer, race, and sex)"

Metadata

"Data that provides a detailed description about other data; Information about a particular data set or document that describes how, when, and by whom it was collected, created, accessed, or modified and how it is formatted. Metadata can be altered intentionally or inadvertently and can be extracted when native files are converted to images. Some metadata, such as file dates and sizes, can easily be seen by users; other metadata can be hidden or embedded and unavailable to computer users who are not technically adept. Metadata is generally not reproduced in full form when a document is printed. (The Sedona Conference 2005, 28)"

Discrete data

"Data that represent separate and distinct values or observations; that is, data that contain only finite numbers and have only specified values"

Interval-level data

"Data with a defined unit of measure, no true zero point, and equal intervals between successive values"

Knowledge-based DSS

"Decision support system in which the key element is the knowledge base; often referred to as a rule-based system because the knowledge is stored in the form of rules (for example, the IF, THEN, ELSE format)"

Office for Civil Rights (OCR)

"Department in HHS responsible for enforcing civil rights laws that prohibit discrimination on the basis of race, color, national origin, disability, age, sex, and religion by health care and human services entities over which OCR has jurisdiction, such as state and local social and health services agencies; and hospitals, clinics, nursing homes or other entities receiving Federal Financial Assistance from HHS. This office also has the authority to investigate alleged violations of the HIPAA Privacy Rule."

Medications prescribed

"Descriptions (including, where possible, the national drug code, dosage, strength, and total amount prescribed) of all medications prescribed or provided by the healthcare practitioner at the encounter (for outpatients) or given on discharge to the patient (for inpatients)"

Material safety data sheet (MSDS)

"Documentation maintained on the hazardous materials used in a healthcare organization; the documentation outlines such information as common and chemical names, family name, and product codes; risks associated with the material, including overall health risk, flammability, reactivity with other chemicals, and effects at the site of contact; descriptions of the protective equipment and clothing that should be used to handle the material; and other similar information"

Contingency plan

"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"

Work products

"Documents produced during the completion of a task that may be a component of, or contribute to, a project deliverable"

Explicit knowledge

"Documents, databases, and other types of recorded and documented information"

American Standard Code for Information Interchange (ASCII)

"Electronic code that represents text, which makes it possible to transfer data from one computer to another "

Health maintenance organization (HMO)

"Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: (1) organized healthcare delivery system to a geographic area, (2) set of basic and supplemental health maintenance and treatment services, (3) voluntarily enrolled members, and (4) predetermined fixed, periodic prepayments for members' coverage"

Surgical review

"Evaluation of operative and other procedures, invasive and noninvasive, 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"

Pass-through

"Exception to the Medicare prospective payment systems (PPSs) for a high-cost service. The exception minimizes the negative financial impact of the lump-sum payments of the PPSs. Pass-throughs are not included in the PPSs and are passed through to cost-based (retrospective) payment mechanisms. In the hospital outpatient prospective payment system (HOPPS), the CMS created exceptions for some expensive drugs, pharmaceuticals, biologicals, and devices. Rather than being bundled or packaged, these exceptions to the CMS's HOPPS are 'passed-through' the HOPPS to other payment mechanisms (payment status indicators F, G, H, and J). The inpatient prospective payment system (IPPS) passes through the costs of medical education and organ acquisition and some capital costs "

Circuit courts

"Federal appellate courts distributed through the United States, including the District of Columbia and U.S. territories, so that each court represents a specific number of the district courts"

Labor-Management Reporting and Disclosure Act (Landrum-Griffin Act)

"Federal legislation passed in 1959 to ensure that union members' interests were properly represented by union leadership; created, among other things, a bill of rights for union members"

Uniformed Services Employment and Reemployment Rights Act (1994)

"Federal legislation that prohibits discrimination against individuals because of their service in the Armed Forces Reserves, National Guard, or other uniformed services"

Project definition

"First step in the project management life cycle that sets expectations for the what, when, and how of a project the organization wants to undertake "

Maternal death rate (hospital based)

"For a hospital, the total number of maternal deaths directly related to pregnancy for a given time period divided by the total number of obstetrical discharges for the same time period; for a community, the total number of deaths attributed to maternal conditions during a given time period in a specific geographic area divided by the total number of live births for the same time period in the same area"

Diagnostic criteria

"For each mental disorder listed in the DSM-IV, a set of extensive diagnostic criteria is 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"

Disposition

"For outpatients, the healthcare practitioner's description of the patient's status at discharge (no follow-up planned; follow-up planned or scheduled; referred elsewhere; expired); for inpatients, a core health data element that identifies the circumstances under which the patient left the hospital (discharged alive; discharged to home or self-care; discharged and transferred to another short-term general hospital for inpatient care; discharged and transferred to a skilled nursing facility; discharged and transferred to an intermediate care facility; discharged and transferred to another type of institution for inpatient care or referred for outpatient services to another institution; discharged and transferred to home under care of organized home health services organization; discharged and transferred to home under care of a home intravenous therapy provider; left against medical advice or discontinued care; expired; status not stated)"

Categorical data

"Four types of data (nominal, ordinal, interval, and ratio) that represent values or observations that can be sorted into a category"

Services classification

"Functionally autonomous units (departments, services, or divisions) of the medical staff organization in a hospital"

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/or social history); and comprehensive (chief complaint; extended history of present illness; complete system review; complete past, family, and social history)"

Inventory

"Goods on hand and available to sell, presumably within a year (a business cycle)"

Healthcare information standards

"Guidelines developed to standardize data throughout the healthcare industry (for example, developing uniform terminologies and vocabularies)"

Covered condition

"Health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay"

Occupational health services

"Health services involving the physical, mental, and social well-being of individuals in relation to their work and working environment"

Out-of-pocket expenses

"Healthcare costs paid by the insured (for example, deductibles, copayments, and coinsurance) after which the insurer pays a percentage (often 80 or 100 percent) of covered expenses"

Primary care provider (PCP)

"Healthcare provider who provides, supervises, and coordinates the healthcare of a member; primary care physicians can be family and general practitioners, internists, pediatricians, and obstetricians/gynecologists; other PCPs are nurse practitioners and physician assistants"

Evidence-based medicine

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

Sole community hospital

"Hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other hospitals (as determined by the Secretary of the Department of Health and Human Services [DHHS]), is the sole source of patient hospital services reasonably available to individuals in a geographical area who are entitled to benefits"

Fully Specified Name

"In SNOMED CT, the unique text assigned to a concept that completely describes that concept"

Description

"In a controlled medical vocabulary, a description is the combination of a concept and a term"

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"

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"

Key

"In cryptography, a secret value used to encrypt and decrypt messages; in a symmetric cryptographic algorithm, only one key is needed to encrypt and decrypt a message, but in an asymmetric algorithm, two keys are needed"

Private key

"In cryptography, an asymmetric algorithm restricted to one entity"

Charge

"In healthcare, a 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"

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"

Cross-claim

"In law, a complaint filed against a codefendant"

Preemption

"In law, the principle that a statute at one level supercedes or is applied over the same or similar statute at a lower level (for example, the federal HIPAA privacy provisions trump the same or similar state law with certain exceptions)"

Topology

"In networking terms, the physical or logical arrangement of a network"

Efficacy

"In the language of The Joint Commission (JC), the degree to which the treatment intervention used for a patient has been shown to accomplish the desired/projected outcomes"

Efficiency

"In the language of The Joint Commission (JC), the ratio of the outcomes for a patient to the resources consumed in delivering the care"

Identity management

"In the master patient index, policies and procedures that manage patient identity, such as prohibiting the same record number for duplicate patients or duplicate records for one patient"

Protected health information (PHI)

"Individually identifiable health information, transmitted electronically or maintained in any other form, that is created or received by a healthcare provider or any other entity subject to HIPAA requirements"

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"

Behavioral healthcare information

"Information related to treatment for conditions such as mental disorders, mental retardation, and other developmental disabilities"

Long-term care diagnosis related group (LTC-DRG)

"Inpatient classification that categorizes patients who are similar in terms of diagnoses and treatments, age, resources used, and lengths of stay. 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. LTC-DRGs are exactly the same as the DRGs for the inpatient prospective payment system (IPPS)."

Corrective controls

"Internal controls designed to fix problems that have been discovered, frequently as a result of detective controls"

National health information network (NHIN)

"Interoperable information infrastructure that links various healthcare information systems together, allowing patients, physicians, healthcare institutions, and other entities nationwide to share clinical information privately and securely; network of networks"

Research

"Investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories, or laws in the light of new facts, or practical application of such new or revised theories or laws; the collecting of information about a particular subject"

Knowledge production

"Involves the creation of knowledge through collection, generation, synthesis, identification and organization of knowledge through codification, storage, packaging, and coordination"

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"

Medicare Modernization Act of 2003 (MMA)

"Legislation passed in 2003 designed to expand healthcare services for seniors, with a major focus on prescription drug benefits"

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"

Physical safeguards

"Measures such as locking doors to safeguard data and computer programs from undesired occurrences and exposures; a set of four standards defined by the HIPAA Security Rule including facility access controls, workstation use, workstation security, and device and media controls"

Specified low-income Medicare beneficiaries (SLMBs)

"Medicare beneficiaries who have resources similar to qualified Medicare beneficiaries, but higher incomes, although still less than 120 percent of the federal poverty level"

Branding communications

"Messages sent to increase awareness of, and to enhance the image of, a product in the marketplace"

Systematic literature review

"Methodical approach to literature review that reduces the possibility of bias; characterized by explicit search criteria to identify literature, inclusion and exclusion criteria to select articles and information sources, and evaluation against consistent methodological standards"

Team group dynamics

"Models of team development uniformly define four stages of progression in team group dynamics (Montebello 1997 and Buzzotta 1993): cautious affiliation, competitiveness, harmonious cohesiveness, and collaborative teamwork"

Medical foundation

"Multipurpose, nonprofit service organization for physicians and other healthcare providers at the local and county level; as managed care organizations, medical foundations have established preferred provider organizations, exclusive provider organizations, and management service organizations, with emphases on freedom of choice and preservation of the physician-patient relationship"

Product trade name

"Name (also referred to as catalog name) assigned or supplied by the labelers (firms) as required under the Food, Drug, and Cosmetic Act"

Local Coverage Determination (LCD)

"New format for LMRPs, Coverage rules, at a fiscal intermediary (FI) or carrier level, that provide information on what diagnoses justify the medical necessity of a test; LCDs vary from state to state"

Neural networks

"Nonlinear predictive models that, using a set of data that describe what a person wants to find, detect a pattern to match a particular profile through a training process involving interactive learning"

Diagnostic codes

"Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries"

Descriptive text

"One component of the DSM, text that describes mental disorders under the following headings: Diagnostic Features; Subtypes and/or Specifiers; Recording Procedures; Associated Features and Disorders; Specific Culture, Age, and Gender Features; Prevalence, Course, Familial Pattern, and Differential Diagnosis"

Priority focus area (PFA)

"One of fourteen areas that The Joint Commission considers vital in the successful operation of a hospital; includes processes, systems, and structures that have a substantial effect on patient care services"

Medical staff unit

"One of the departments, divisions, or specialties into which the organized medical staff of a hospital is divided"

Medicare secondary payer

"One of the edits in the outpatient and inpatient code editors that reviews claims to determine if the claim should be paid by another form of insurance, such as workers' compensation or private insurance in the event of a traffic accident"

Technical skills

"One of the three managerial skill categories, related to knowledge of the technical aspects of the business"

Semantic clinical drug component (SCDC)

"One of the two types of semantic normal forms created in RxNorm for every clinical drug, the SCDC consists of an active ingredient and strength"

Health care provider dimension (HCPD)

"One of three dimensions of the National Health Information Infrastructure concept that includes information obtained during the patient care process and integrates it with clinical guidelines, protocols, and selected information the provider is authorized to access from the personal health record, as well as information relevant to the patient's care from the community health dimension "

Association of Record Librarians of North America (ARLNA)

"Organization formed ten years after the beginning of the hospital standardization movement whose original objective was to elevate the standards of clinical record keeping in hospitals, dispensaries, and other healthcare facilities; precursor of the American Health Information Management Association"

Office of Research Integrity (ORI)

"Organization that provides integrity in biomedical and behavioral research, monitoring incidents of research misconduct and facilitating responsible research conduct through educational, preventive, and regulatory activities"

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)"

Vendors

"Outside companies such as consultants and those who sell equipments and supplies, perform release-of-information functions, provide laundry or food services, or repair equipment, who have a presence in a healthcare facility and may or may not be business associates"

Limited data set

"PHI that excludes direct identifiers of the individual, the individual's relatives, employers, or household members but still does not deidentify the information"

Dollars received

"Payments agreed on through diagnosis-related group selection, contractual agreements, or other payer payment methods"

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"

Medical savings account (MSA) plans

"Plans that provide benefits after a single, high deductible has been met whereby Medicare makes an annual deposit to the MSA and the beneficiary is expected to use the money in the MSA to pay for medical expenses below the annual deductible"

Major medical insurance

"Prepaid healthcare benefits that include a high limit for most types of medical expenses and usually require a large deductible and sometimes place limits on coverage and charges (for example, room and board); also known as catastrophic coverage"

Ambulatory care

"Preventive or corrective healthcare services provided on a nonresident basis in a provider's office, clinic setting, or hospital outpatient setting"

Temporary privileges

"Privileges granted for a limited time period to a licensed, independent practitioner on the basis of recommendations made by the appropriate clinical department or the president of the medical staff"

Strategic communications

"Programs created to advance specific organizational goals such as promoting a new center or service, establishing a new program, or positioning the organization as a center of excellence in a specific discipline such as cardiology or oncology"

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)"

Structure indicators

"Quality indicators that measure the attributes of an organizational setting, such as number and qualifications of staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures"

Identifier standards

"Recommended methods for assigning unique identifiers to individuals (patients and clinical providers), corporate providers, and healthcare vendors and suppliers"

Patient's expected sources of payment

"Regardless of payment method, the primary source expected to be responsible for the largest percentage of a patient's current bill"

Project components

"Related parameters of scope, resources, and scheduling with regard to a project"

Motor

"Related to movement of muscles and coordination; includes both large motor skills, such as walking, and fine motor skills, such as buttoning and zipping clothing"

Misfeasance

"Relating to negligence, improper performance during an otherwise correct act"

Direct costs

"Resources expended that can be identified as pertaining to specific goods and/or services (for example, medications pertain to specific patients)"

Variable costs

"Resources expended that vary with the activity of the organization, for example, medication expenses vary with patient volume"

Retaliation and waiver

"Rights protected under the Privacy Rule; to ensure the integrity of individuals' right to complain about alleged Privacy Rule violations, covered entities are expressly prohibited from retaliating against anyone who exercises his rights under the Privacy Rule, assists in an investigation by the HHS or other appropriate investigative authority, or opposes an act or practice that the person believes is a violation of the Privacy Rule and individuals cannot be required to waive the rights that they hold under the Privacy Rule in order to obtain treatment, payment, or enrollment/benefits eligibility"

Privacy standards

"Rules, conditions, or requirements developed to ensure the privacy of patient information"

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"

Civil Monetary Penalties Act (CMP)

"Section 1128A of the Social Security Act, passed in 1981 as one of several administrative remedies to combat increases in healthcare fraud and abuse, which authorized the Secretary and Inspector General of Health and Human Services (HHS) to impose, civil monetary penalties, assessment, and program exclusions on individuals and entities whose wrongdoing caused injury to HHS programs or their beneficiaries "

Application controls

"Security strategies, such as password management, included in application software and computer programs"

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"

Cultural competence

"Skilled in awareness, understanding, and acceptance of beliefs and values of the people of groups other than one's own"

Pricer

"Software module in a Medicare claim-processing systems, specific to certain benefits, used in pricing claims and calculating payment rates and payments, most often under prospective payment systems"

Storage management software

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

Catastrophic expense limit

"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"

Stop-loss benefit

"Specific amount, in a certain timeframe 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"

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"

School special education

"Specifically designed instruction provided by qualified teachers within the context of school with the goal of helping students acquire academic, vocational, language, social, and self-care skills (includes adapted physical education and the use of specialized techniques to overcome intrinsic learning deficits)"

Security standards

"Statements that describe the processes and procedures meant to ensure that patient-identifiable health information remains confidential and protected from unauthorized disclosure, alteration, and destruction"

Regression analysis

"Statistical technique that uses an independent variable to predict the value of a dependent variable. In the inpatient psychiatric facility prospective payment system (IPF PPS), patient demographics and length of stay (independent variables) were used to predict cost of care (dependent variable)"

Census statistics

"Statistics that examine the number of patients being treated at specific times, the length of their stay, and the number of times a bed changes occupants"

Regional health information network (RHIN)

"System that links various healthcare information systems in a region together so that patients, healthcare institutions, and other entities can share clinical information"

Shared systems

"Systems developed by data-processing companies in the 1960s and 1970s to address the computing needs of healthcare organizations that could not afford, or chose not to purchase, their own mainframe computing systems"

Cybernetic systems

"Systems that have standards, controls, and feedback mechanisms built in to them"

Mark sense technology

"Technology that detects the presence or absence of hand-marked characters on analog documents; used for processing questionnaires, surveys, and tests, such as filled-in circles by Number 2 pencils on exam forms"

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"

Stress testing

"Testing performed toward the end of EHR implementation to ensure that the actual number, or load, of transactions that would be performed during peak hours can be performed"

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"

Clinical Laboratory Improvement Act (CLIA)

"The 1988 reenactment of the 1967 Clinical Laboratory Improvement Act; A law that provides that clinical laboratories are only to disclose test results or reports to 'authorized persons,' who are defined by the law as the person who orders the test unless state law defines them otherwise"

CPT-5 Project

"The AMA initiative to improve CPT to address the needs of hospitals, managed care organizations, and long-term care facilities"

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"

European Committee for Standardization (CEN)

"The European Committee for Standardization, consisting of the national standards bodies in Europe as well as associates representing broad industrial sectors and social and economic partners, adopts European Standards and other formal documents that promote free trade, the safety of workers and consumers, interoperability of networks, environmental protection, exploitation of research and development programs, and public procurement"

Orion Project

"The Joint Commission's initiative designed to assess accreditation models, develop a continuous accreditation process, and test alternative processes for reporting survey findings to hospitals"

Ambulatory payment classification (APC) system

"The Medicare reimbursement methodology system referred to as the hospital outpatient prospective payment system (OPPS). Hospital providers subject to the OPPS utilize the ambulatory payment classification (APC) system, which determines payment rates "

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"

Nursing Information and Data Set Evaluation Center (NIDSEC)

"The Nursing Information and Data Set Evaluation Center was established by the American Nurses Association (ANA) to review, evaluate against defined criteria, and recognize information systems from developers and manufacturers that support documentation of nursing care within automated nursing information systems (NIS) or within computer-based patient record systems (CPR)"

Image processing

"The ability of a computer to create a graphic representation of a text block, photograph, drawing, or other image and make it available throughout an information system"

Construct validity

"The ability of an instrument to measure hypothetical, nonobservable traits"

Generalizability

"The ability to apply research results, data, or observations to groups not originally under study"

Skill

"The ability, education, experience, and training required to perform a job task"

Inpatient coding compliance

"The accurate and complete assignment of ICD-9-CM diagnostic and procedural codes, along with appropriate sequencing (for example, identification of principal diagnosis) to determine the appropriate diagnosis-related group and resultant payment"

Disclosure

"The act of making information known; in the health information management context, the release of confidential health information about an identifiable person to another person or entity"

Ethics training

"The act of teaching others about moral principles, theories, and values"

Tacit knowledge

"The actions, experiences, ideals, values, and emotions of an individual that tend to be highly personal and difficult to communicate (for example, corporate culture, organizational politics, and professional experience)"

Medical services

"The activities relating to medical care performed by physicians, nurses, and other healthcare professional and technical personnel under the direction of a physician"

Physical

"The actual organization of data in a system (for example, a single file divided into many pieces scattered across a disk); the opposite of logical"

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"

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"

e-health

"The application of e-commerce to the healthcare industry, including electronic data interchange and links among healthcare entities"

Risk treatment

"The application of risk control and risk financing techniques to determine how a risk should be treated, often aimed at preventing or reducing the chances and/or effects of a loss occurrence"

Strategic management

"The art and science of formulating, implementing, and evaluating cross-functional decisions that enable an organization to achieve its objectives"

Nutritional assessment

"The assessment performed by a registered dietitian to obtain information about a patient's diet history, weight and height, appetite and food preferences, and food sensitivities and allergies"

Linking

"The assignment of diagnosis codes to individual line items (1 through 4) on a CMS-1500 claim form to cross-reference the procedure to the diagnosis code, establishing the medical necessity of the procedure"

Sixty-day episode payment

"The basic unit of payment under home health prospective payment system that covers a beneficiary for sixty days regardless of the number of days furnished unless the beneficiary elects to transfer, has a significant change in condition, or is discharged and then returns to the same agency within the sixty-day episode"

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"

Operating budget

"The budget that summarizes the anticipated expenses for a department's routine, day-to-day operations"

Expectations

"The characteristics that customers want to be evident in a healthcare product, service, or outcome"

State Children's Health Insurance Program (SCHIP)

"The children's healthcare program implemented as part of the Balanced Budget Act of 1997; sometimes referred to as the Children's Health Insurance Program, or CHIP"

Denial

"The circumstance when a bill has been accepted, but payment has been denied 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)"

Routed generic

"The combination of an active ingredient(s), or generic name, plus a route; useful in decision support functions for drug interactions to distinguish a topical drug, which may not interact with another drug, from its oral formulation, which may interact"

Multimedia

"The combination of free-text, raster or vector graphics, sound, and/or motion video/frame data"

Hospital information system (HIS)

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

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"

Life cycle costs

"The costs of a project beyond its purchase price, for example, setup costs, maintenance costs, training costs, and so on, as well as costs incurred throughout the project's estimated useful life"

Disk mirroring

"The creation of an exact copy of one disk from another, for backup"

Information cycle

"The cycle of gathering, recording, processing, storing, sharing, transmitting, retrieving, and deleting information"

Federal Register

"The daily publication of the U.S. Government Printing Office that reports all changes in regulations and federally mandated standards, including HCPCS and ICD-9-CM codes"

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"

Date of service (DOS)

"The date a test, procedure, and/or service was rendered"

Neonatal death

"The death of a liveborn infant within the first twenty-seven days, twenty-three hours, and fifty-nine minutes following the moment of birth"

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"

Managerial accounting

"The development, implementation, and analysis of systems that track financial transactions for management control purposes, including both budget systems and cost analysis systems"

Diagnosis chiefly responsible for services provided (outpatient)

"The diagnosis, condition, problem, or reason for an encounter/visit that is chiefly responsible for the services provided"

Principal diagnosis

"The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit or the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"

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)"

Strategic plan

"The document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help set the long-term direction of the organization as a business entity"

Progress notes

"The documentation of a patient's care, treatment, and therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient's care, including nurses, physicians, therapists, and social workers"

Accounting period

"The entire process of identifying and recording a transaction, and ultimately reporting it as part of an organization's financial statement"

Valuation

"The estimated market value of a project, an object, a merger, and so on"

Data consistency

"The extent to which the healthcare data is valid, accurate, usable and has integrity, so that each end user has a consistent view of the data"

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"

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"

Consolidated Omnibus Budget Reconciliation Act of 1975 (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"

Freedom of Information Act (FOIA)

"The federal law, applicable only to federal agencies, through which individuals can seek access to information without the authorization of the person to whom the information applies"

Hill-Burton Act

"The federal legislation enacted in 1946 as the Hospital Survey and Construction Act to authorize grants for states to construct new hospitals and, later, to modernize old ones"

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 preexisting medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size; requires covered entities (most healthcare providers and organizations) to transmit healthcare claims in a specific format; 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. Also known as Public Law 104-191 and the Kassebaum-Kennedy Law"

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"

Omnibus Budget Reconciliation Act (OBRA) of 1989

"The federal legislation that mandated important changes in the payment rules for Medicare physicians; specifically, the legislation that requires nursing facilities to conduct regular patient assessments for Medicare and Medicaid beneficiaries"

Social Security Act of 1935

"The federal legislation that originally established the Social Security program as well as unemployment compensation, and support for mothers and children; amended in 1965 to create the Medicare and Medicaid programs"

Employer identification number (EIN)

"The federal tax identification number of a business, designated in HIPAA as the standard identifier for employers"

Customary fee

"The fee normally charged by physicians of the same specialty, in the same geographic area "

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"

Dose form

"The form in which a drug is administered to a patient, as opposed to the form in which the manufacturer had supplied it"

Data structure

"The form in which data are stored, as in a file, a database, a data repository, and so on"

Systems

"The foundations of caregiving, which include buildings (environmental services), equipment (technical services), professional staff (human resources), and appropriate policies (administrative)"

Magnetic resonance image (MRI)

"The generation of a powerful magnetic field that surrounds the patient, creating computer-interpreted radio frequency imaging"

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 "

Authorization

"The granting of permission to disclose confidential information; as defined in terms of the HIPAA privacy rule, an individual's formal, written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment, or healthcare operations"

Supreme Court

"The highest court in the U.S. legal system; hears cases from the U.S. Courts of Appeals and the highest state courts when federal statutes, treaties, or the U.S. Constitution is involved"

Conceptual data model

"The highest level of data model, representing the highest level of abstraction, independent of hardware and software"

Evaluation and management (E/M) services

"The history, examination, and medical decision-making services that physicians must perform in evaluating and treating patients in all healthcare settings "

Assets

"The human, financial, and physical resources of an organization"

Addressable standards

"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"

Network administrators

"The individuals involved in installing, configuring, managing, monitoring, securing, and maintaining network computer applications and responsible for supporting the network infrastructure and controlling user access"

Knowledge

"The information, understanding, and experience that give individuals the power to make informed decisions"

Resources

"The labor, equipment, or materials needed to complete a project"

Federal Employees' Compensation Act (FECA)

"The legislation enacted in 1916 to mandate workers' compensation for civilian federal employees, whose coverage includes lost wages, medical expenses, and survivors' benefits"

Lower courts

"The lowest level of the U.S. judicial system, where state and local criminal and civil cases are tried"

District court

"The lowest tier in the federal court system, which hears cases involving felonies and misdemeanors that fall under federal statute and suits in which a citizen of one state sues a citizen of another state"

Trial court

"The lowest tier of state court, usually divided into two courts: the court of limited jurisdiction, which hears cases pertaining to a particular subject matter or involving crimes of lesser severity or civil matters of lower dollar amounts; and the court of general jurisdiction, which hears more serious criminal cases or civil cases that involve large amounts of money"

Race

"The major biological category to which an individual belongs as a result of a pedigree analysis or with which the individual identifies in cases where the data are inconclusive; usually includes American Indian/Eskimo/Aleut, Asian or Pacific Islander, black, white, other, and unknown/not stated"

Care

"The management of, responsibility for, or attention to the safety and well-being of other persons in the context of healthcare settings"

Treatment

"The manipulation, intervention, or therapy; a broad term used by researchers to generically mean some act, such as a physical conditioning program, a computer training program, a particular laboratory medium, or the timing of prophylactic medications"

Marital status

"The marital state of the patient at the start of care (for example, married, living together, not living together, never married, widowed, divorced, separated, or unknown/not stated)"

Semantics

"The meaning of a word or term; sometimes refers to comparable meaning, usually achieved through a standard vocabulary"

Scalable

"The measure of a system to grow relative to various measures of size, speed, number of users, volume of data, and so on"

Tonometry

"The measurement of tension or pressure, especially the indirect estimation of the intraocular pressure, from determination of the resistance of the eyeball to indentation by an applied force "

Home healthcare

"The medical and/or personal care provided to individuals and families in their place of residence with the goal of promoting, maintaining, or restoring health or minimizing the effects of disabilities and illnesses, including terminal illnesses"

Transfer of records

"The movement of a record from one medium to another (for example, from paper to microfilm or to an optical imaging system) or to another records custodian "

Pharmacy and therapeutics (P and T) committee

"The multidisciplinary committee that oversees and monitors the drugs and therapeutics available for use, the administration of medications and therapeutics, and the positive and negative outcomes of medications and therapeutics used in a healthcare organization"

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 Current Procedural Terminology (CPT) coding system"

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"

American Occupational Therapy Association (AOTA)

"The nationally recognized professional association of more than 40,000 occupational therapists, occupational therapy assistants, and students of occupational therapy"

Unfavorable variance

"The negative difference between the budgeted amount and the actual amount of a line item, where actual revenue is less than budget or where actual expenses exceed budget"

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"

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"

Weight

"The numerical assignment that is part of the formula by which a specific dollar amount, or reimbursement, is calculated for each diagnosis-related group or each ambulatory payment classification"

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"

World Organization of Family Doctors (Wonca)

"The organization instrumental in the development of the International Classification of Primary Care; formerly called the World Organization of National Colleges, Academics, and Academic Associations of General Practitioners/Family Physicians (Wonca)"

Baseline

"The original estimates for a project's schedule, work, and cost"

Security management

"The oversight of facilities, equipment, and other resources, including human resources and technology, to reduce the possibility of harm to or theft of these assets of an organization"

Denominator

"The part of a fraction below the line signifying division that functions as the divisor of the numerator and, in fractions with 1 as the numerator, indicates into how many parts the unit is divided"

Product Code

"The part of the National Drug Code that identifies a specific strength, dosage form, and formulation for a particular drug"

Partial mastectomy

"The partial removal of breast tissue, leaving the breast nearly intact; sometimes called a lumpectomy"

Research method

"The particular strategy used by a researcher to collect, analyze, and present data"

Risk pool

"The people in an insured group, their medical and mental histories, other factors, such as age, and their predicted health "

Auditing

"The performance of internal and/or external reviews (audits) to identify variations from established baselines (for example, review of outpatient coding as compared with CMS outpatient coding guidelines)"

Project management life cycle

"The period in which the processes involved in carrying out a project are completed, including project definition, project planning and organization, project tracking and analysis, project revisions, change control, and communication"

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; various responsibilities according to the research study protocol"

History

"The pertinent information about a patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems"

Technology management

"The planning and implementation of technological resources, as needed, to effectively and efficiently carry out the organization's mission"

Source of admission

"The point from which a patient enters a healthcare organization, including physician referral, clinic referral, health maintenance organization referral, transfer from a hospital, transfer from a skilled nursing facility, transfer from another healthcare facility, emergency department referral, court or law enforcement referral, and delivery of newborns"

Media controls

"The policies and procedures that govern the receipt, storage, and removal of hardware, software, and computer media (such as disks and tapes) into and out of the organization"

Technical component (TC)

"The portion of radiological and other procedures that is facility based or nonphysician based (for example, radiology films, equipment, overhead, endoscopic suites, and so on)"

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"

Jurisdiction

"The power and authority of a court to hear, interpret, and apply the law to and decide specific types of cases"

Assumption coding

"The practice of assigning codes on the basis of clinical signs, symptoms, test findings, or treatments without supporting physician documentation"

Aging of accounts

"The practice of counting the days, generally in thirty-day increments, from the time a bill was sent to the payer to the current day"

Case-mix group payment rate

"The predetermined, per-discharge reimbursement amount for each case-mix group that includes all of the inpatient operating and capital costs incurred in furnishing covered rehabilitation services, but not the costs associated with bad debts, approved educational activities, and other costs not paid for under the prospective payment system"

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"

Prognosis

"The probable outcome of an illness, including the likelihood of improvement or deterioration in the severity of the illness, the likelihood for recurrence, and the patient's probable life expectancy"

Report generation

"The process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record; the formatting and/or structuring of captured information"

Performance measurement

"The process of comparing the outcomes of an organization, work unit, or employee against preestablished performance plans and standards"

Process and workflow modeling

"The process of creating a representation of the actions and information required to perform a function, including decomposition diagrams, dependency diagrams, and data flow diagrams"

Delivery

"The process of delivering a liveborn infant or dead fetus (and placenta) by manual, instrumental, or surgical means"

Data mining

"The process of extracting information from a database and then quantifying and filtering discrete, structured data"

Recruitment

"The process of finding, soliciting, and attracting employees"

Development

"The process of growing or progressing in one's level of skill, knowledge, or ability"

Care planning

"The process of organizing and documenting the specific goals in the treatment of an individual patient, amending the goals as the patient's condition requires, and assessing the outcomes of care"

Job redesign

"The process of realigning the needs of the organization with the skills and interests of the employee and then designing the job to meet those needs (for example, in order to introduce new tools or technology or provide better customer service)"

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/or computed about a patient as part of health care "

Ethical decision making

"The process of requiring everyone to consider the perspectives of others, even when they do not agree with them"

Rehabilitation

"The process of restoring a disabled insured to maximum physical, mental, and vocational independence and productivity (commensurate with their limitations) through the identification and development of residual capabilities, job modifications, or retraining"

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"

Outcomes management

"The process of systematically tracking a patient's clinical treatment and responses to that treatment, including measures of morbidity and functional status, for the purpose of improving care"

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"

Encounter

"The professional, direct personal contact between a patient and a physician or other person who is authorized by state licensure law and, if applicable, by medical staff bylaws to order or furnish healthcare services for the diagnosis or treatment of the patient; 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"

Request for applications (RFA)

"The project announcement that describes the project and encourages researchers to apply, may list additional criteria specific to the announcement"

Accounting rate of return

"The projected annual cash inflows, minus any applicable depreciation, divided by the initial investment"

Computer system security

"The protection of computer hardware, software, and data from accidental or malicious access, use, modification, destruction, and/or disclosure"

Permanence

"The quality of being in a constant, continuous state. (ASTM 2005 3.1.11)"

Privacy

"The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons, or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information"

Infection rate

"The ratio of all infections to the number of discharges, including deaths"

Subcutaneous mastectomy

"The removal of breast tissue, leaving the skin of the breast and nipple intact. This type of mastectomy usually requires that a breast implant be inserted "

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"

Model

"The representation of a theory in a visual format, on a smaller scale, or with objects"

Data stewardship

"The responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing, or otherwise making use of personal health information (AMIA 2007) "

Zero balance

"The result of writing off the balance of an account, which closes off the account and ends the days in accounts receivable"

Return on assets

"The return on a company's investment, or earnings, after taxes divided by total assets"

Amendment request

"The right of individuals to ask that a covered entity amend their health records, as provided in Section 164.526 of the Privacy Rule "

Leadership

"The senior governing, administrative, and management groups of a healthcare organization that are responsible for setting the mission and overall strategic direction of the organization"

Retinal detachment

"The separation of two layers of the retina from each other, which usually occurs when the vitreous adheres to the retina (the sensitive layer of the eye) and 'pulls,' resulting in retinal holds that tears that may lead to retinal detachment"

Seven dimensions of data quality

"The seven characteristics-relevancy, granularity, precision, timeliness, currency, consistency, and accuracy-used to evaluate the quality of data"

Shaving

"The sharp removal, by transverse incision or horizontal slicing, of epidermal and superficial dermal lesions without a full-thickness dermal excision; includes local anesthesia and chemical or electrocauterization of the wound but does not require suture closure"

Bill hold period

"The span of time during which a bill is suspended in the billing system awaiting late charges, diagnosis and/or procedure codes, insurance verification, or other required information"

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"

Morbidity

"The state of being diseased (including illness, injury, or deviation from normal health); the number of sick persons or cases of disease in relationship to a specific population"

Medicare discharge

"The status of Medicare patients who are formally released from a hospital, die in a hospital, or are transferred to another hospital or unit excluded from the prospective payment system"

Medicare nonparticipation

"The status with the Medicare program in which the provider has not signed a participation agreement and does not accept the Medicare allowable fee as payment in full, with the result that the payment goes directly to the patient and the patient must pay the bill up to Medicare's limiting charge of 115% of the approved amount"

Revenue cycle management

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

Intracapsular lens extraction

"The surgical removal of the entire lens and its capsule, generally followed by insertion of an anterior chamber intraocular lens"

Extracapsular lens extraction

"The surgical removal of the front portion and nucleus of the lens, leaving the posterior capsule in place. A posterior chamber intraocular lens is generally inserted after this procedure "

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 otucomes with regional or national standards"

Measurement

"The systematic process of data collection, repeated over time or at a single point in time"

Flat-panel display

"The technology using liquid crystal display or other low-emission substances, once found primarily on laptops and now being used for desktop monitors, large-screen wall monitors, and high-density television"

Deemed status

"The term used for the assumption by the Centers for Medicare and Medicaid Services (CMS) that an organization meets the Medicare and Medicaid Conditions of Participation as a result of prior accreditation by AAAHC, AOA, CARF, or The Joint Commission"

Unit testing

"The testing step in EHR implementation that ensures that each data element is captured, recorded, and processed appropriately within a given application"

Member months

"The total membership each month accumulated for a given time period (for example, one hundred members serviced each month for six months equals six hundred member months)"

American Association of Health Plans (AAHP)

"The trade organization for health maintenance organizations, preferred provider organizations, and other network-based health plans created by the merger of the Group Health Association of America and the American Managed Care and Review Association"

CMS-1500

"The universal insurance claim form developed and approved by the American Medical Association and the Centers for Medicare and Medicaid Services. Physicians use it to bill Medicare, Medicaid, and private insurers for professional services provided"

Enterprise resource planning (ERP)

"The use of software tools to automate tasks and track data generated by specific departments (primarily finance, inventory, and human resources) in order to optimize resource utilization"

Metathesaurus

"The very large, multipurpose, and multilingual vocabulary database that is the central vocabulary component of the Unified Medical Language System"

Date of procedure (inpatient)

"The year, month, and day of each significant procedure"

Date of birth

"The year, month, and day when an individual was born"

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"

Critical performance measures

"Those outputs by which the quality of an organization's services will be measured by patients, clients, visitors, and the community"

Waiting period

"Time between the effective date of a healthcare insurance policy and the date the healthcare insurance plan will assume liability for expenses related to certain health services, such as those related to pre-existing conditions"

Exacerbation

"To make more violent, bitter, or severe"

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"

In-service education

"Training that teaches employees specific skills required to maintain or improve performance, usually internal to an organization"

Clinical Care Classification (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"

Physician care group (PCG)

"Type of outpatient prospective payment method for physician services in which patients are classified into similar, homogenous categories"

Case-based payment

"Type of prospective payment method in which the third party payer reimburses the provider a fixed, pre-established payment for each case"

Electronic Protected Health Information (ePHI)

"Under HIPAA, all individually identifiable information that is created or received electronically by a healthcare provider or any other entity subject to HIPAA requirements "

Ambulatory surgery center or ambulatory surgical center (ASC)

"Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, record keeping, 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"

Major diagnostic category (MDC)

"Under diagnosis-related groups (DRGs), one of twenty-five categories based on single or multiple organ systems into which all diseases and disorders relating to that system are classified"

Assumptions

"Undetermined aspects of a project that are considered to be true (for example, assuming that project team members have the right skill set to perform their duties)"

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 deteriororation or impairment, are life threatening, result in death, or result in congenital anomalies. (Source: Joint Commission)"

Qualifying circumstances

"Unusual situations such as extreme age, total body hypothermia, controlled hypotension, and emergency situations that complicate the provision of anesthesia"

Face sheet

"Usually the first page of the health record, which contains resident identification, demographics, original 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"

PFSH

"past, family, and/or social history"

Qui tam litigation

'Provisions within the law that allow for persons or entities with evidence of fraud against federal programs or contracts to sue the wrongdoer on behalf of the government' (Source: The False Claims Act Legal Center)

Normalization

1. A formal process applied to relational database design to determine which variables should be grouped together in a table in order to reduce data redundancy across and within the table 2. Conversion of various representational forms to standard expressions so that those that have the same meaning will be recognized by computer software as synonymous in a data search

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

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

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

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

Budget neutral

1. Adjustment of payment rates when policies change so that total spending under the new rules is the same as it would have been under the previous payment rules 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

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

Policies

1. Governing principles that describe how a department or an organization is supposed to handle a specific situation 2. Binding contracts issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury; such contracts may also be referred to as health plan agreements and evidence of coverage

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

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

Carrier

1. The insurance company; the insurer that sold the policy and administers the benefits 2. Entity that has a contract with the Centers for Medicare and Medicaid Services (CMS) to determine and make Medicare payments for Part B benefits

Project scope

1. The intention of a project 2. The range of a project's activities or influence

Transfer

1. The movement of a patient from one treatment service or location to another 2. Discharge of a patient from a hospital and readmission to postacute care or another acute care hospital on the same day

Office of the Inspector General (OIG)

1. The office through which the federal government established compliance plans for the healthcare industry 2. A division of the Department of Health and Human Services (DHHS) that investigates issues of noncompliance in the Medicare and Medicaid programs such as fraud and abuse; overseen by the Department of Justice

Risk

1. The probability of incurring injury or loss; 2. The probable amount of loss foreseen by an insurer in issuing a contract 3. A formal insurance term denoting liability to compensate individuals for injuries sustained in a healthcare facility

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

Private right of action

1. The right of an injured person to secure redress for violation of his or her rights 2. A legal right to maintain an action growing out of a given transaction or state of facts and based thereon or a legal term pertaining to remedy and relief through judicial procedure

Accountability

1. The state of being liable for a specific activity 2. All information is attributable to its source (person or device)

Current Procedural Terminology (CPT) Category III Code

A CPT code that represents emerging technologies for which a Category I Code has yet to be established

Current Procedural Terminology (CPT) Category II Code

A CPT code the represents services and/or test results that contribute to positive health outcomes and quality patient care

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

Payer of last resort (Medicaid)

A Medicaid term that means that Medicare pays for the services provided to individuals enrolled in both Medicare and Medicaid until Medicare benefits are exhausted and Medicaid benefits begin

CMS-485

A Medicare form used to document care plans

Midnight rule

A Medicare regulation that states the day preceding a leave of absence becomes a nonbillable day for Medicare purposes when a Part A beneficiary takes a leave of absence and is not present in the skilled nursing facility at midnight

Resource-based relative value scale (RBRVS)

A Medicare reimbursement system implemented in 1992 to compensate physicians according to a fee schedule predicated on weights assigned on the basis of the resources required to provide the services

Medicare-required assessment

A Minimum Data Set for Long-Term Care completed solely for the purpose of Medicare rate setting for skilled nursing facilities

Durable power of attorney for healthcare (DPAHC)

A third party designated by a competent individual to make healthcare decisions for that individual should he or she become incompetent

Laser

A tool such as the argon laser and the Nd:YAG laser used to cut or destroy tissue; acronym for light amplification by stimulated emission of radiation

SPECIALIST Lexicon

A tool that supplies the lexical information needed for the SPECIALIST natural language processing system

Asynchronous transfer mode (ATM)

A topology for transmitting data across large wide-area networks

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

Role playing

A training method in which participants are required to respond to specific problems they may actually encounter in their jobs

Simulation

A training technique for experimenting with real-world situations by means of a computerized model that represents the actual situation

Encounter history database

A transaction file that summarizes all the coded data for each patient seen in the physician office

Cyclical staffing

A transitional staffing solution wherein workers are brought in for specific projects or to cover in busy times

Speech-language therapy (SLP)

A treatment intended to improve or enhance the resident's ability to communicate and/or swallow

Occupational therapy (OT)

A treatment that uses constructive activities to help restore the resident's ability to carry out needed activities of daily living and improves or maintains functional ability

Pilot study

A trial run on a smaller scale

Program for Evaluation Payment Patterns Electronic Report (PEPPER)

A benchmarking database maintained by the Texas Medical Foundation that supplies individual QIOs with hospital data to determine state benchmarks and monitor hospital compliance

Halo effect

A bias that occurs when someone allows certain information to influence a decision disproportionately

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

Least-Preferred Coworker Scale (LPC)

A bipolar scale used by Fiedler to measure task-relationship orientation in contingency theory

National Regulatory Commission

A body that has oversight responsibility for the medical use of ionizing radiation and to which medical events must be reported

Contract law

A branch of law based on common law that deals with written or oral agreements that are enforceable through the legal system

Middleware

A bridge between two applications or the software equivalent of an interface

Activity-based budget

A budget based on activities or projects rather than on functions or departments

Forecast budget

A budgeting approach that simply divides the amount budgeted by the number of months in the fiscal period

Direct method of allocation

A budgeting concept in which the cost of overhead departments is distributed solely to the revenue-producing areas

Postdischarge plan of care

A care plan used to help a resident discharged from the long-term care facility to adapt to his or her new living arrangement

Care path

A care-planning tool similar to a clinical practice guideline that has a multidisciplinary focus emphasizing the coordination of clinical services; also known as clinical algorithm

Cost inlier

A case in which the cost of treatment falls within the established cost boundaries of the assigned ambulatory patient group payment

All patient diagnosis-related groups (AP-DRGs)

A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes

Phacoemulsification

A cataract extraction technique that uses ultrasonic waves to fragment the lens and aspirate it out of the eye

Unified Medical Language System (UMLS) Semantic Network

A categorization of all concepts UMDNS in the UMLS Metathesaurus

Ethnicity

A category in the Uniform Hospital Discharge Data Set that describes a patient's cultural or racial background

Clinical information system (CIS)

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

Laggards

A category of adopters of change who are very reluctant to accept proposed changes and may resist transition

Episode-of-care (EOC) reimbursement

A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period; also called bundled payments because they include multiple services and may include multiple providers of care

Bundled payments

A category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/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

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

Variable

A characteristic or property that may take on different values

Movement diagram

A chart depicting the location of furniture and equipment in a work area and showing the usual flow of individuals or materials as they progress through the work area

History of present illness (HPI)

A chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present

K-nearest neighbor (K-NN)

A classic technique used to discover associations and sequences when the data attributes are numeric; nonparametric estimator of a function

Nursing Outcomes Classification (NOC)

A classification of patient/client outcomes developed to evaluate the effects of nursing interventions

Elective surgery

A classification of surgery that does not have to be performed immediately to prevent death or serious disability

Nursing vocabulary

A classification system used to capture documentation on nursing care

Healthcare practitioner

A clinical professional who is directly responsible for providing patient services

Patient status code

A code that describes patient status at discharge or at the end of period in form locator 22 of the CMS-1450 form

Controlled medical terminology

A coded vocabulary of medical concepts and expressions used in healthcare

Contract coder

A coder who is hired as an independent contractor on temporary basis to assist with coding backlog

Institute for Clinical Systems Improvement (ICSI)

A collaboration of healthcare organizations that provides an objective voice dedicated to supporting healthcare quality and helping its members identify and achieve implementation of best practices for their patients

Medicare Provider Analysis and Review (MEDPAR) File

A collection of data from reimbursement claims submitted to the Medicare program by acute care hospitals and skilled nursing facilities that is used to evaluate the quality and effectiveness of the care being provided

Project team

A collection of individuals assigned to work on a project

Signing out of health records internally to other facility departments

A collection of mechanisms to ensure that charts are tracked when taken out of the HIM department

Unique identification number

A combination of numbers or alphanumeric characters assigned to a particular patient

Accredited Standards Committee X12 (ASC X12)

A committee of the American National Standards Institute (ANSI) responsible for the development and maintenance of electronic data interchange (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

Unified modeling language (UML)

A common data-modeling notation used in conjunction with object-oriented database design

Functional status

A commonly-used measure of a patient's mental and/or physical abilities measuring the patient's ability to perform the activities of daily living

Physician query process

A communication tool and educational mechanism that provides a clearer picture of specific resident diagnoses when in question

Videoconferencing

A communications service that allows a group of people to exchange information over a network by using a combination of video and computer technology

Control group

A comparison study group whose members do not undergo the treatment under study

Center for Drug Evaluation and Research (CDER) Data Standards Manual

A compilation of standardized nomenclature monographs for sharing information regarding manufactured drug dosage forms

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

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

Morality

A composite of the personal values concerning what is considered right or wrong in a specific cultural group

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

Artificial neural network (ANN)

A computational technique based on artificial intelligence and machine learning in which the structure and operation are inspired by the properties and operation of the human brain

Turnkey product

A computer application that may be purchased from a vendor and installed without modification or further development by the user organization

Mainframe

A computer architecture built with a single central processing unit to which dumb terminals and/or personal computers are connected

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

Code look-up

A computer file with all of the indexes and codes recorded on magnetic disk or CD-ROM

Facility-specific system

A computer information system developed exclusively to meet the needs of one healthcare organization

Wide-area network (WAN)

A computer network that connects devices across a large geographical area

Rules engine

A computer program that applies sophisticated mathematical models to data that generate alerts and reminders to support healthcare decision making

DRG grouper

A computer program that assigns inpatient cases to diagnosis-related groups and determines the Medicare reimbursement rate

Information kiosk

A computer station located within a healthcare facility that patients and families can use to access information

Vendor system

A computer system developed by a commercial company not affiliated with the healthcare organization

Continuous speech technology

A computer technology that automatically translates voice patterns into written language in real time. Sometimes called continuous speech recognition

Galen Common Reference Model (CRM)

A computer-based clinical terminology developed in Europe for representing medical concepts

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

Management information system (MIS)

A computer-based system that provides information to a healthcare organization's managers for use in making decisions that affect a variety of day-to-day activities

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

Extreme immaturity

A condition referring to a newborn with a birth weight of fewer than 1000 grams and/or gestation of fewer than 28 completed weeks

Edit

A condition that must be satisfied before a computer system can accept data

Peritoneal dialysis

A continuous or intermittent procedure in which dialyzing solution is introduced into and removed from the peritoneal cavity to cleanse the body of metabolic waste products

Cap

A contract maximum

Role-based access control (RBAC)

A control system in which access decisions are based on the roles of individual users as part of an organization

Interim payment system (IPS)

A cost-based reimbursement system that was used until the prospective payment system was phased in

Strategy

A course of action designed to produce a desired (business) outcome

Default judgment

A court ruling against a defendant in a lawsuit who fails to answer a summons for a court appearance

Misdemeanor

A crime that is less serious than a felony

Multidimensional online analytical processing (MOLAP)

A data access methodology that is coupled tightly with a multidimensional database management system to allow the user to perform business analyses

Living arrangement

A data element that denotes whether the patient lives alone or with others

Data Elements for Emergency Department Systems (DEEDS)

A data set designed to support the uniform collection of information in hospital-based emergency departments

Perioperative Nursing Dataset (PNDS)

A data set developed by the Association of Perioperative Registered Nurses to identify the perioperative experience of the patient from preadmission to discharge

Nursing Minimum Data Set (NMDS)

A data set that provides uniform definitions and categories of nursing care; built on the uniform minimum health data sets (UMHDS)

Wireless local-area network (WLAN)

A data transmission network that uses an unguided medium such as radio waves or microwaves

Medicare Provider Analysis and Review (MEDPAR) database system

A database containing information and files submitted by fiscal intermediaries that is used by the Office of the Inspector General to identify suspicious billing and charge practices

Relational database management system (RDBMS)

A database management system in which data are organized and managed as a collection of tables

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

Knowledge base

A database that not only manages raw data but also integrates them with information from various reference works

Uniform Ambulatory Care Data Set (UACDS)

A dataset developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient/client-specific data elements to be collected in ambulatory care settings

Structured decision

A decision made by following a formula or a step-by-step process

Multivoting technique

A decision-making method for determining group consensus on the prioritization of issues or solutions

Correlational research

A design of research that determines the existence and degree of relationships among factors

Trojan horse

A destructive piece of programming code hidden in another piece of programming code (such as a macro or e-mail message) that looks harmless

Router

A device programmed to filter out or to allow certain types of data to pass through

Outguide

A device used in paper-based health record systems to track the location of records removed from the file storage area

Discrete variable

A dichotomous or nominal variable whose values are placed into categories

T1

A digital phone line that can carry data at speeds of up to 1.544 megabits per second

Documentation paradigm

A disease-specific format developed by the individual provider for the purpose of establishing standard clinical documentation forms

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

Statement of work

A document that defines the scope and goals of a specific project

Trigger

A documented response that alerts a skilled nursing facility resident assessment instrument assessor to the fact that further research is needed to clarify an assessment

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

Medicare fee schedule (MFS)

A feature of the resource-based relative value system that includes a complete list of the payments Medicare makes to physicians and other providers

National Vital Statistics System (NVSS)

A federal agency responsible for the collection of official vital statistics for the United States

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

Medicare

A federally funded health program established in 1965 to assist with the medical care costs of Americans sixty-five years of age and older as well as other individuals entitled to Social Security benefits owing to their disabilities

Dental informatics

A field of information science concerned with the management of data and information used to support the practice and delivery of dental healthcare through the application of computers and computer technologies

Clinical informatics

A field of information science concerned with the management of data and information used to support the practice and delivery of patient care through the application of computers and computer technologies

Discipline

A field of study characterized by a knowledge base and perspective that is different from other fields of study

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

Payback period

A financial method used to evaluate the value of a capital expenditure by calculating the time-frame that must pass before inflow of cash from a project equals or exceeds outflow of cash

Permanent variance

A financial term the refers to the difference between the budgeted amount and the actual amount of a line item that is not expected to reverse itself during a subsequent period

Cash budget

A forecast of needs for available funds throughout the year

Type of bill (TOB)

A form of coding that represents the nature of each form CMS-1450 claim

Data encryption

A form of technical security used to ensure that data transferred from one location on a network to another is secure from anyone eavesdropping or seeking to intercept the data

Integration testing

A form of testing during EHR implementation performed to ensure that the interfaces between applications and systems work

Interagency transfer form (W-10)

A form that contains sufficient information about a patient to provide continuity of care during transfer or discharge

Acknowledgement

A form that provides a mechanism for the resident to acknowledge receipt of important information

Time ladder

A form used by employees to document time spent on various tasks

Nursing assessment record (NAR)

A form used to track patients' functional status; supports the Minimum Data Set (MDS) process

Operative report

A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery

Capital budget process

A four-stage process organizations follow to determine what capital projects to include in the budget

Structured query language (SQL)

A fourth-generation computer language that includes both DDL and DML components and is used to create and manipulate relational databases

Regenstrief LOINC Mapping Assistant (RELMA)

A free Microsoft Windows software download that provides LOINC users help in working with LOINC database files

Payment locality

A geographic pricing area historically used by Medicare carriers to calculate physicians' customary and prevailing charges for payment of Part B services

Medicare volume performance standard (MVPS)

A goal for the annual rate of growth in Part B expenditures for physicians' services

Registered nurse (RN)

A graduate nurse who has passed examinations for registration

Scatter diagram

A graph that visually displays the linear relationships among factors

Storyboard

A graphic display tool used to communicate the details of PI activities; a type of poster that includes text and graphics to describe and illustrate the activities of a performance improvement project

Security pyramid

A graphic representation of security measures in which each depends on the one below it

Pictogram

A graphic technique in which pictures are used in the display of data

Affinity diagram

A graphic tool used to organize and prioritize ideas after a brainstorming session

Graph

A graphic tool used to show numerical data in a pictorial representation

Privacy board

A group formed by a HIPAA-covered entity to review research studies where authorization waivers are requested and to ensure the HIPAA privacy rights of research subjects

Centers for Disease Control and Prevention (CDC)

A group of federal agencies that oversee health promotion and disease control and prevention activities in the United States

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

Survey team

A group of individuals sent by an accrediting agency (usually The Joint Commission) to review a healthcare organization for accreditation purposes

Regional health information organization (RHIO)

A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in the community

Cafeteria plan

A health plan that allows employees to choose among two or more benefits

Straight numeric filing system

A health record filing system in which health records are arranged in ascending numerical order

Active record

A health record of an individual who is a currently hospitalized inpatient or an outpatient

Managed fee-for-service reimbursement

A healthcare plan that implements utilization controls (prospective and retrospective review of healthcare services) for reimbursement under traditional fee-for-service insurance plans

Physician assistant (PA)

A healthcare professional licensed to practice medicine with physician supervision

Work breakdown structure

A hierarchical structure that decomposes project activities into levels of detail

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

Insured

A holder of a health insurance policy

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

Major teaching hospital

A hospital that provides clinical education to one hundred or more resident physicians

Low-volume hospital

A hospital with fewer than 5000 outpatient visits per year

Alternative hypothesis

A hypothesis that states that there is an association between independent and dependent variables

Foreign key

A key attribute used to link one entity/table to another

Target population

A large group of individuals who are the focus of a study

Privacy Act of 1974

A law that requires federal agencies to safeguard personally identifiable records and provides individuals with certain privacy rights

Leadership grid

A leadership model proposed by Blake and Mouton and based on a grid measure of concern for people and production

Leader-member exchange

A leadership theory in which a group that shows high potential (the 'in-group') is given opportunities for special assignments in exchange for their loyalty and extra work

Audioconferencing

A learning technique in which participants in different locations can learn together via telephone lines while listening to a presenter and looking at handouts or books

Confidentiality

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

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

Nonmaleficence

A legal principle that means 'first do no harm'

Negligence

A legal term that refers to the result of an action by an individual who does not act the way a reasonably prudent person would act under the same circumstances

Accounting of disclosures

A list of all disclosures made of a patient's health information; Section 164.528 of the Privacy Rule states that an individual has the right to receive an accounting of certain disclosures made by a covered entity within the six years prior to the date on which the accounting is requested

Accession registry

A list of cases in a cancer registry in the order in which they were entered

Disease index

A list of diseases and conditions of patients sequenced according to the code numbers of the classification system in use

Fee schedule

A list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them developed by a third-party payer to represent the approved payment levels for a given insurance plan

Physician index

A list of patients and their physicians that is usually arranged according to the physician code numbers assigned by the healthcare facility

Pull list

A list of requests for records to be pulled for review during the audit process

Statement

A list of unpaid invoices; sometimes a cumulative list of all transactions between purchaser and vendor during a specific time period

Master resident index

A listing or database that a long-term care facility keeps to record all the residents who have ever been admitted or treated there

Patient

A living or deceased individual who is receiving or has received healthcare services

Facsimile

A machine that allows the remote transmission of text and graphics through telephone lines or a communication sent via this method

Management by objectives (MBO)

A management approach that defines target objectives for organizing work and comparing performance against those objectives

Human relations movement

A management philosophy emphasizing the shift from a mechanistic view of workers to concern for their satisfaction at work

Total quality management (TQM)

A management philosophy that includes all activities in which the needs of the customer and the organization are satisfied in the most efficient manner by using employee potentials and continuous improvement

Evidence-based management

A management system in which practices based on research evidence will be effective and produce the outcomes they claim

Customer relationship management (CRM)

A management system whereby organizational structure and culture and customer information and technology are aligned with business strategy so that all customer interactions can be conducted to the long-term satisfaction of the customer and to the benefit and profit of the organization

Acceptance theory of authority

A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions

General ledger

A master list of individual revenue and expense accounts maintained by an organization

National conversion factor (CF)

A mathematical factor used to convert relative value units into monetary payments for services provided to Medicare beneficiaries

Intelligent prompting

A means in tables and forms for displaying only clinically relevant items

Direct observation

A means of gathering data about a process in which participants in the process are observed

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

Mean

A measure of central tendency that is determined by calculating the arithmetic average of the observations in a frequency distribution

Reliability

A measure of consistency of data items based on their reproducibility and an estimation of their error of measurement

Standard deviation

A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement; the square root of the variance

Placebo

A medication with no active ingredients

Plain text

A message that is not encrypted

Tactic

A method for accomplishing an end

Data display

A method for presenting or viewing data

Accrual accounting

A method of accounting that requires business organizations to report income in the period earned and to deduct expenses in the period incurred

Constructive confrontation

A method of approaching conflict in which both parties meet with an objective third party to explore perceptions and feelings

Medical classification system

A method of arranging related diseases and conditions into groups to be reported as quantitative data for statistical purposes

Case definition

A method of determining criteria for cases that should be included in a registry

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

A method of ensuring data security

Case finding

A method of identifying patients who have been seen and/or treated in a healthcare facility for the particular disease or condition of interest to the registry

Coordination of benefits (COB)

A method of integrating benefits payments from all health insurance sources to ensure that they do not exceed 100 percent of a plan member's allowable medical expenses

Point method

A method of job evaluation that places weight (points) on each of the compensable factors in a job whereby the total points associated with a job establish its relative worth and jobs that fall within a specific range of points fall into a pay grade with an associated wage

Ethnography

A method of observational research that investigates culture in naturalistic settings using both qualitative and quantitative approaches

Network control

A method of protecting data from unauthorized change and corruption during transmission among information systems

Nonparticipant observation

A method of research in which researchers act as neutral observers who do not intentionally interact or affect the actions of the population being observed

Observational research

A method of research in which researchers obtain data by watching research participants rather than by asking questions

On-the-job training

A method of training in which an employee learns necessary skills and processes by performing the functions of his or her position

Staging system

A method used in cancer registers to identify specific and separate different stages or aspects of the disease

Rate of return method

A method used to justify a proposed capital expenditure in which the organization tries to find out what rate of return it would get if it invests in a particular project

Simple payback method

A method used to justify a proposed capital expenditure where the asset cost is divided by the net annual income of the asset to determine how long it will take for the asset to 'pay back' what it cost the organization

Component alignment model (CAM)

A model for strategic information systems planning that includes seven major interdependent components that should be aligned with other components in the organization

Organizational pull model

A model in which the organization views information systems technology as the means to enable people in the organization to work more efficiently and effectively

Uniform Health-care Decisions Act (UHCDA)

A model law created in 1993 that provides that an individual may give an oral or written instruction to a healthcare provider that remains in force even after the individual loses capacity and suggests decision-making priority for that individual's surrogates

Information model

A model that combines the elements necessary to fully represent the meaning of clinical information and that supports semantic interoperability among the heterogeneous computer-based systems that form an integrated information system

Snowflake schema

A modification of the star schema in which the dimension tables are further divided to reduce data redundancy

Service bonus

A monetary reward given to long-term staff in recognition of their skills and commitment to the organization

Public assistance

A monetary subsidy provided to financially needy individuals

Parents and children

A name for exploding charges wherein the parent is the item that explodes into other items and appears on the bill

Conversion factor

A national dollar amount that Congress designates to convert relative value units to dollars; updated annually

Medical Group Management Association (MGMA)

A national organization composed of individuals actively engaged in the business management of medical groups consisting of three or more physicians in medical practice

National Health Care Survey

A national public health survey that contains data abstracted manually from a sample of acute care hospitals or from discharged inpatient records or that are obtained from state or other discharge databases

National Information Infrastructure--Health Information Network Program (NII--HIN)

A national quasi-governmental organization that provides oversight of all healthcare information standards in the United States

Electronic health record system (EHRS)

A network of electronically stored health records

Boarder baby

A newborn who remains in the nursery following discharge because the mother is still hospitalized or a premature infant who no longer needs intensive care but remains for observation

Training and development model

A nine-step plan designed to help the health information manager or human resources department identify the training needs of an employee group

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

Standard normal distribution

A normal distribution with a mean equal to zero and standard deviation equal to one

Public Company Accounting Oversight Board (PCAOB)

A not-for-profit organization that oversees the work of auditors of public companies

Accession number

A number assigned to each case as it is entered in a cancer registry

Lecture

A one-way method of delivering education through speaking in which the teacher delivers the speech and the student listens

Corporate Code of Conduct

A part of the compliance plan which 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

Short-stay patient

A patient admitted to the hospital for an intended stay of less than twenty-four hours and who is considered an outpatient and not included in inpatient hospital census statistics

Hospital newborn inpatient

A patient born in the hospital at the beginning of the current inpatient hospitalization

Capitated patient

A patient enrolled in a managed care program that pays a fixed monthly payment to the patient's identified primary care provider

Medical Outcomes Study Short-Form Health Survey

A patient survey that reflects the patients' disease and symptom intensity to characterize the total burden of the disease

Clinic outpatient

A patient who is admitted to a clinical service of a clinic or hospital for diagnosis or treatment on an ambulatory basis

Client

A patient who receives behavioral or mental health services

Residence

A patient's full address and zip code

Outpatient visit

A patient's visit to one or more units located in the ambulatory services area (clinic or physician's office) of an acute care hospital

Template

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

Systems analysis and design

A performance improvement methodology that can be applied to any type of system

Plan-do-study-act (PDSA) cycle

A performance improvement model designed specifically for healthcare organizations

External reviews (audits)

A performance or quality review conducted by a third-party payer or consultant hired for the purpose

Probationary period

A period of time in which the skills of a potential employee's work are assessed before he or she assumes full-time employment

Continued-stay utilization review

A periodic review conducted during a hospital stay to determine whether the patient continues to need acute care services

Coder/biller

A person in an ambulatory care or a physician office setting who is generally responsible for processing the superbill

Trainee

A person who is learning a task or skill

Discovery request

A petition for discovery

Naturalism

A philosophy of research that assumes that multiple contextual truths exist and bias is always present

Qualitative research

A philosophy of research that assumes that multiple contextual truths exist and bias is always present

Microfilming

A photographic process that reduces an original paper document into a small image on film to save storage space

Osteopath

A physician licensed to practice in osteopathy (a system of medical practice that is based on the manipulation of body parts as well as other therapies)

Network provider

A physician or another healthcare professional who is a member of a managed care network

Vision

A picture of the desired future that sets a direction and rationale for change

Cookie

A piece of information passed from a Web server to the user's Web browser that is accessible only to the server/domain that sent it and is retrieved automatically through a program called an intelligent agent whenever the server's Web page is visited; used to store passwords and ordering information and to set preferences and bookmarks

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

Health information exchange (HIE)

A plan in which health information is shared among providers

Budget

A plan that converts the organization's goals and objectives into targets for revenue and spending

Data backup plan

A plan that ensures the recovery of information that has been lost or becomes inaccessible

Physician query process policy

A policy that addresses request from physicians for additional information as part of the coding and reimbursement process

Chart-tracking/requests policy

A policy that outline the way in which charts are signed out of the permanent files and how requests for records are handled

General health record documentation policy

A policy that outlines documentation practices within the facility

Records removal policy

A policy that outlines how and when records may be removed from the health record department

Release of protected health information policy

A policy that outlines how residents and others may obtain copies of their health records

Analysis of discharged health records policy

A policy that outlines steps to be taken to process discharged resident records

Census-reporting policy

A policy that outlines the process for census reporting and tracking

Forms management policy

A policy that outlines the process for the creation of new forms

Subpoena policy

A policy that outlines the steps required to handle the subpoena processing for protected health information

Damaged record recovery policy

A policy that outlines the steps the facility should take to recover paper and/or electronic records in the event of a disaster

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 order policy

A policy that provides a detailed listing of all documents and defines their order and section location within the health record

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

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

Solo practice

A practice in which the physician is self-employed and legally the sole owner

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

Medigap

A private insurance policy that supplements Medicare coverage

Data Encryption Standard (DES)

A private key encryption algorithm adopted as the federal standard for the protection of sensitive unclassified information and also used extensively for the protection of commercial data

National Committee for Quality Assurance (NCQA)

A private not-for-profit accreditation organization whose mission is to evaluate and report on the quality of managed care organizations in the United States

Standards development organization (SDO)

A private or government agency involved in the development of healthcare informatics standards at a national or international level

Radioimmunoassay

A procedure that combines the use of radioactive chemicals and antibodies to detect hormones and drugs in a patient's blood

Significant procedure

A procedure that is surgical in nature or carries a procedural or an anesthetic risk or requires specialized training

Operational decision making

A process for addressing problems that come up in the day-to-day operation of a business unit or the day-to-day execution of a work task

Discharge utilization review

A process for assessing a patient's readiness to leave the hospital

Digital dictation

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

Inductive reasoning

A process of creating conclusions based on a limited number of observations

Security audit process

A process put into place by a healthcare organization to monitor the effectiveness of its security program and to ensure compliance with it

Vocabulary mapping process

A process that connects one clinical vocabulary to another

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

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 exsist and if an ongoing performance measure should be established to monitor process stability

Accrediting body

A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessment of the performance of individual healthcare organizations

Software

A program that directs the hardware components of a computer system to perform the tasks required

Business continuity plan

A program that incorporates policies and procedures for continuing business operations during a computer system shutdown; sometimes called contingency and disaster planning

Program evaluation and review technique (PERT) chart

A project management tool that diagrams a project's time lines and tasks as well as their interdependencies

MEDCIN

A proprietary clinical terminology developed as a point-of-care tool for electronic medical record documentation at the time and place of patient care

Admitting diagnosis

A provisional description of the reason why a patient requires care in an inpatient hospital setting

Coroner

A public officer whose principal duty is to inquire via an inquest into the cause of death that there is reason to suppose is not due to natural causes

American Health Information Community (AHIC)

A public-private federal advisory committee associated with the Office of the National Coordinator that makes recommendations to the secretary on how to accelerate adoption of interoperable electronic health information technology

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

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

Institute for Healthcare Improvement (IHI)

A quality and safety improvement group

Discounted fee for service

A rate agreed to between the provider and the health plan that is lower than the provider's customary fee

Maternal mortality rate (community based)

A rate that measures the deaths associated with pregnancy for a specific community for a specific period of time

Relative risk (RR)

A ratio that compares the risk of disease between two groups

Cost justification

A rationale developed to support competing requests for limited resources

Discharge summary

A recapitulation of an individual'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

Medical nomenclature

A recognized system of preferred terminology for naming disease processes

Essential Medical Data Set (EMDS)

A recommended data set designed to create a health history for an individual patient treated in an emergency service

Secondary record

A record derived from the primary record and containing selected data elements

Primary data source

A record developed by healthcare professionals in the process of providing patient care

Partial episode payment (PEP) adjustment

A reduced episode payment that may be based on the number of service days in an episode

Downsizing

A reengineering strategy to reduce the cost of labor and streamline the organization by laying off portions of the workforce

Scales of measurement

A reference standard for data collection and classification

Traditional fee-for-service (FFS) reimbursement

A reimbursement method involving third-party payers who compensate providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers

Balance billing

A reimbursement method that allows providers to bill patients for charges in excess of the amount paid by the patients' health plan or other third-party payer (not allowed under Medicare or Medicaid)

One-to-many relationship

A relationship that exists when one instance of an entity is associated with multiple instances of another entity

Odds ratio

A relative measure of occurrence of an illness; the odds of exposure in a diseased group divided by the odds of exposure in a nondiseased 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

Referral

A request by a provider for a patient under the provider's care to be evaluated and/or treated by another provider

Requisition

A request from an authorized health record user to gain access to a medical record

Motion for summary judgment

A request made by the defendant in a civil case to have the case ruled in his or he favor based on the assertion that the plaintiff has no genuine issue to be tried

Causal-comparative research

A research design that resembles experimental research but lacks random assignment to a group and manipulation of treatment

Historical research

A research design used to investigate past events

Participant observation

A research method in which researchers also participate in the observed actions

Omaha System

A research-based taxonomy designed to generate data following routine client care

Mortality review

A review of deaths as part of an analysis of ongoing outcome and performance improvement

Clinical pertinence review

A review of medical records performed to assess the quality of information using criteria determined by the healthcare organization; includes quantitative and qualitative components

Admission utilization review

A review of planned services (intensity of service) and/or a patient's condition (severity of illness) to determine whether care must be delivered in an acute care setting

Closed-record review

A review of records after a patient has been discharged from the organization or treatment has been terminated

Quantitative analysis

A review of the health record to determine its completeness and accuracy

Open-record review

A review of the health records of patients currently in the hospital or under active treatment; part of The Joint Commission survey process

Loss prevention

A risk management strategy that includes developing and revising policies and procedures that are both facilitywide and department specific

Inventor

A role in organizational innovation that requires idea generation

Regulation

A rule or order having the force of law issued by executive authority of the government

Convenience sampling

A sampling technique where the selection of units from the population is based on easy availability and/or accessibility

Operations research (OR)

A scientific discipline primarily begun during the Second World War that seeks to apply the scientific method and mathematical models to the solution of a variety of management decision problems

Automatic log-off

A security procedure that ends a computer session after a predetermined period of inactivity

Medical staff organization (MSO)

A self-governing entity that operates as a responsible extension of the governing body and exists for the purpose of providing patient care

Fax on demand

A service in which a user may select from a list of available fax sources by keying the corresponding number of a fax title or from multiple fax messages via a twelve-digit telephone keypad

Pediatric service

A service that provides diagnostic and therapeutic services for patients under the age of fourteen years

V codes

A set of ICD-9-CM codes used to classify occasions when circumstances other than disease or injury are recorded as the reason for the patient's encounter with healthcare providers

Row/record

A set of columns or a collection of related data items in a table

Network protocol

A set of conventions that governs the exchange of data between hardware and/or software components in a communications network

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

Medical Data Interchange Standard (MEDIX)

A set of hospital system interface transaction standards developed by the Institute of Electrical and Electronic Engineers

Action plan

A set of initiatives that are to be undertaken to achieve a performance improvement goal

System

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

Test statistics

A set of statistical techniques that examines the psychometric properties of measurement instruments

Sample

A set of units selected for study that represents a population

Programming language

A set of words and symbols that allows programmers to tell the computer what operations to follow

Vision statement

A short description of an organization's ideal future state

Values statement

A short description that communicates an organization's social and cultural belief system

Visit

A single encounter with a healthcare professional that includes all of the services supplied during the encounter

Position power

A situation in contingency theory in which the leader is perceived as having the authority to give direction

Discharge and readmit

A situation in which a home health provider receives a prorated partial episode payment for the original episode when a beneficiary is discharged and readmitted to the same agency within the same sixty-day period

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

Security threat

A situation that has the potential to damage a healthcare organization's information system

Path-goal theory

A situational leadership theory that emphasizes the role of the leader in removing barriers to goal achievement

Nursing Home Quality Initiative

A six-state pilot project performed in 2002 by the Centers for Medicare and Medicaid Services (CMS) that identifies quality measures that reflect the quality of care in nursing homes

Screen prototype

A sketch of the user interface of each screen that is anticipated in a project

Multiservice contractor

A small company that provides coding services or services related to coding

Computer virus

A software program that attacks computer systems with the intention of damaging or destroying files

Language translator

A software system that translates a program written in a particular computer language into a language that other types of computers can understand

Clinical decision support system (CDSS)

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

Randomized clinical trial (RCT)

A special type of clinical trial in which the researchers follow strict rules to randomly assign patients to groups

Transcriptionist

A specially trained typist who understands medical terminology and translates physicians' verbal dictation into written reports

Goal

A specific description of the services or deliverable goods to be provided as the result of a business process

Time period

A specific span of dates to which data apply

Statute of limitations

A specific time frame allowed by a statute or law for bringing litigation

Entity relationship diagram (ERD)

A specific type of data modeling used in conceptual data modeling and the logical-level modeling of relational databases

Exclusion

A specified condition or circumstance listed in an insurance policy for which the policy will not provide benefits

Outcomes and Assessment Information Set (OASIS)

A standard core assessment data tool developed to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs

Arden syntax

A standard language for encoding medical knowledge representation for use in clinical decision support systems

Clinical Context Object Workgroup (CCOW)

A standard protocol developed by HL7 to allow clinical applications to share information at the point of care

Electronic data interchange (EDI)

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

Instrument

A standardized and uniform way to collect data

Abnormal Involuntary Movement Scale (AIMS)

A standardized form that can be used in facilities to document involuntary movements

Statement of cash flow

A statement detailing the reasons why cash amounts changed from one balance sheet period to another

Statement of retained earnings

A statement expressing the change in retained earnings from the beginning of the balance sheet period to the end

Physician's certification

A statement from a physician confirming a Medicare-eligible resident's need for long-term care services

Code of ethics

A statement of ethical principles regarding business practices and professional behavior

Secondary diagnosis

A statement of those conditions coexisting during a hospital episode that affect the treatment received or the length of stay

Evidence of insurability

A statement or proof of a person's physical condition and/or other factual information necessary to obtain healthcare insurance in certain situations

Indemnification statement

A statement that exempts the signer from incurring liabilities or penalties

Documentation guideline (DG)

A statement that indicates what health information must be recorded to substantiate use of a particular CPT code

Tactical plan

A strategic plan at the level of divisions and departments

Balanced score card (BSC)

A strategic planning tool that identifies performance measures related to strategic goals

Occurrence report

A structured data collection tool that risk managers use to gather information about potentially compensable events

Decision tree

A structured data-mining technique based on a set of rules useful for predicting and classifying information and making decisions

Prospective study

A study designed to observe outcomes or events that occur after the identification of a group of subjects to be studied

Workgroup on Electronic Data Interchange (WEDI)

A subgroup of Accreditation Standards Committee X12 that has been involved in developing electronic data interchange standards for billing transactions

Health Industry Business Communications Council (HIBCC)

A subgroup of the American Standards Committee X12 that focuses on electronic data interchange for billing transactions

Resident assessment protocol (RAP)

A summary of a long-term care resident's medical condition and care requirements

Medicare summary notice (MSN)

A summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided

Private branch exchange (PBX)

A switching system for telephones on private extension lines that allows access to the public telephone network

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

Grouping

A system for assigning patients to a classification scheme via a computer software program

Case-mix system

A system for grouping cases that are clinically similar and ordinarily consume similar resources; used to provide information about the types of patients treated by a facility

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

Universal chart order

A system in which the health record is maintained in the same format while the patient is in the facility and after discharge

Extranet

A system of connections of private Internet networks outside an organization's firewall that uses Internet technology to enable collaborative applications among enterprises

Numeric filing system

A system of health record identification and storage in which records are arranged consecutively in ascending numerical order according to the health record number

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

Source-oriented health record format

A system of health record organization in which information is arranged according to the patient care department that provided the care

Serial work division

A system of work organization where each task is performed by one person in sequence

Multi-axial system

A system that can classify an entity in several different ways

Access control system

A system that defines who has access to what information in a computer system and specifies each user's rights and/or restrictions with respect to that information

Chart tracking

A system that identifies the current location of a paper record or information

Point-of-care documentation

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

Environmental scanning

A systematic and continuous effort to search for important cues about how the world is changing outside and inside the organization

Theory

A systematic organization of knowledge that predicts or explains the behavior or events

Use case diagram

A systems analysis technique used to document a software project from a user's perspective

Access control grid

A tabular representation of the levels of authorization granted to users of a computer system's information and resources

Deliverable

A tangible output produced by the completion of project tasks

Successor

A task in a dependency relationship between two tasks that is dependent on the predecessor task

Predecessor

A task that affects the scheduling of a successor task in a dependency relationship

Affinity grouping

A technique for organizing similar ideas together in natural groupings

Use case

A technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements

Linkage analysis

A technique used to explore and examine relationships among a large number of variables of different types

Phacofragmentation

A technique whereby the lens is broken into fragments by a mechanical means or by ultrasound

Resident's right to access

A term encompassing the mechanisms in place to allow residents to review their own health information

Resident record

A term frequently used in long-term care in lieu of health record

Plan of care (POC)

A term referring to Medicare home health services for homebound beneficiaries that must be delivered under a plan established by a physician

Univariate

A term referring to the involvement of one variable

Textual

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

Nationwide Health Information Network (NHIN)

A term that refers to the building blocks or foundation for interoperability; the physical and national network components that make EHRs interoperable

Need for intervention

A term that relates to the severity-of-illness consequences that would result from the lack of immediate or continuing medical care

Terminal

A term used to describe the hardware in a mainframe computer system by which data may be entered or retrieved

Accept assignment

A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided

Terminology standard

A terminology adopted by the appropriate standards-setting organizations for use in healthcare

Nursing Interventions Classification (NIC)

A terminology that describes the treatments that nurses perform

Maslow's Hierarchy of Needs

A theory developed by Abraham Maslow suggesting that a hierarchy of needs might help explain behavior and guide managers on how to motivate employees

Scalar chain

A theory in the chain of command in which everyone is included and authority and responsibility flow downward from the top of the organization

Place of service

A two-digit code used in box 24b of the CMS-1500 claim form to describe the location where the service was performed

Modifier

A two-digit numeric code listed after a procedure code that indicates that a service was altered in some way from the stated CPT descriptor without changing the definition; also used to enhance a code narrative to describe the circumstances of each procedure or service and how it individually applies to a patient

Push technology

A type of active computer technology that sends information directly to the end user as the information becomes available

Two-tailed hypothesis

A type of alternative hypothesis in which the researcher makes no prediction about the direction of the results

Project management software

A type of application software that provides the tools to track a project

Incisional breast biopsy

A type of breast biopsy done through an incision that does not include removal of the entire lesion

Operational budget

A type of budget that allocates and controls resources to meet an organization's goals and objectives for the fiscal year

Milestone budget

A type of budget without a fixed 12-month calendar in which cost is determined and budget allocation is established for the next period as events are completed

Request for proposal (RFP)

A type of business correspondence asking for very specific product and contract information that is often sent to a narrow list of vendors that have been preselected after a review of requests for information during the design phase of the systems development life cycle

Custodial care

A type of care that is not directed toward a cure or restoration to a previous state of health but includes medical or nonmedical services provided to maintain a given level of health without skilled nursing care

Registered health information administrator (RHIA)

A type of certification granted after completion of an AHIMA-accredited four-year program in health information management and a credentialing examination

Registered health information technician (RHIT)

A type of certification granted after completion of an AHIMA-accredited two-year program in health information management and a credentialing examination

Not otherwise specified (NOS)

A type of classification that denotes a lack of information in the record and means unspecified rather than not elsewhere classified

Not elsewhere classified (NEC)

A type of classification that indicates that there is no separate code for the condition even though the diagnostic statement is specific

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

Retrospective coding

A type of coding that takes place after the patient has been discharged and the entire health record has been routed to the health information management department

Interpreter

A type of communications technology that converts high-level language statements into machine language one at a time

Macro virus

A type of computer virus that infects Microsoft Word or similar application by inserting unwanted words or phrases; most are relatively harmless

Parallel work division

A type of concurrent work design in which one employee does several tasks and takes the job from beginning to end

Relationship

A type of connection between two terms

Specific consent to treatment

A type of consent that explains the potential risks and benefits of a particular treatment or procedure and constitutes the resident's permission to the healthcare provider to perform the treatment or procedure

Line chart

A type of data display tool used to plot information on the progress of a process over time

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

Resident Assessment Validation and Entry (RAVEN)

A type of data-entry software developed by the Centers for Medicare and Medicaid Services for long-term care facilities and used to collect Minimum Data Set assessments and to transmit data to state databases

Object-relational database

A type of database (both object oriented and relational) that stores both objects and traditional tables

Relational database

A type of database that stores data in predefined tables made up of rows and columns

Mentoring

A type of employee coaching and training in which an individual is matched with a more experienced individual who serves as an advisor or counselor

Pretty good privacy (PGP)

A type of encryption software that uses public key cryptology and digital signatures

Assisted living

A type of freestanding long-term care facility where residents receive necessary medical services but retain a degree of independence

Run chart

A type of graph that shows data points collected over time and identifies emerging trends or patterns

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

Pathology report

A type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure

Structured data entry

A type of healthcare data documentation about an individual using a controlled vocabulary rather than narrative text

Pay for quality (P4Q)

A type of incentive to improve the quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts

Patient care system

A type of information system that has traditionally been designed for nursing documentation

Expert system (ES)

A type of information system that supports the work of professionals engaged in the development or evaluation of complex activities that require high-level knowledge in a well-defined and usually limited area

Unique identifier

A type of information that refers to only one individual or organization

Public law

A type of legislation that involves the government and its relations with individuals and business organizations

At risk contract

A type of managed care contract between Medicare and a payer or a payer and a provider according to which patients receive care during the entire term of the contract even if actual costs exceed the payment established by the agreement

Group practice without walls (GPWW)

A type of managed care contract that allows physicians to maintain their own offices and share administrative services

Point-of-service (POS) healthcare insurance plan

A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost

Palliative care

A type of medical care designed to relieve the patient's pain and suffering without attempting to cure the underlying disease

Nonfeasance

A type of negligence meaning failure to act

Naturalistic observation

A type of nonparticipant observation in which researchers observe certain behaviors and events as they occur naturally

Convenience sample

A type of nonrandom sampling in which researchers use any unit at hand

Ranked data

A type of ordinal data where the group of observations is first arranged from highest to lowest according to magnitude and then assigned numbers that correspond to each observation's place in the sequence

Health systems agency (HSA)

A type of organization called for by the Health Planning and Resources Development Act of 1974 to have broad representation of healthcare providers and consumers on governing boards and committees

Peer-reviewed journal

A type of professional or scientific journal for which content experts evaluate articles prior to publication

Physician profiling

A type of quality improvement and utilization management software that enables provider and payer organizations to monitor how and with what resources physicians are treating patients

Unstructured question

A type of question that allows free-form responses

Interview survey

A type of research instrument with which the members of the population being studied are asked questions and respond orally

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

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

Respite care

A type of short-term care provided during the day or overnight to individuals in the home or institution to temporarily relieve the family home caregiver

Data warehouse management system (DWMS)

A type of software that manages a data warehouse

Severity of illness (SI or SOI)

A type of supportive documentation reflecting objective clinical indicators of a patient illness (essentially the patient is sick enough to be at an identified level of care) and referring to the extent of physiologic decompensation or organ system loss of function

Intensity of service (IS or IOS)

A type of supportive documentation that reflects the diagnostic and therapeutic services for a specified level of care

Questionnaire

A type of survey in which the members of the population are questioned through the use of electronic or paper forms

Sample survey

A type of survey that collects data from representative members of a population

Wireless technology

A type of technology that uses wireless networks and wireless devices to access and transmit data in real time

System testing(s)

A type of testing performed by an independent organization to identify problems in information systems

Systems testing

A type of testing performed by an independent organization to identify problems in information systems

Highly active antiretroviral therapy (HAART)

A type of therapy that consists of multiple drugs commonly given to HIV-positive individuals before they develop AIDS

Retrospective

A type of time frame that looks back in time

Computer-based training

A type of training that is delivered partially or completely using a computer

Alarm

A type of warning that is generated by an automated medical device

Hospital identification

A unique institutional number within a data collection system

Healthcare practitioner identification

A unique national identification number assigned to the healthcare practitioner of record for each encounter

Unique provider identification number (UPIN)

A unique number assigned by the Centers for Medicare and Medicaid Services to identify physicians and suppliers who provide medical services or supplies to Medicare beneficiaries

Health record number

A unique numeric or alphanumeric identifier assigned to each patient's record upon admission to a healthcare facility

Social Security number (SSN)

A unique numerical identifier assigned to every U.S. citizen

Unique physician identification number (UPIN)

A unique numerical identifier created by the Centers for Medicare and Medicaid Services for use by physicians who bill for services provided to Medicare patients

Universal personal identifier

A unique numerical identifier for each citizen in the United States

Facility identification

A unique universal identification number across data systems for a facility

Inpatient service day (IPSD)

A unit of measure equivalent to the services received by one inpatient during one 24-hour period

Productivity

A unit of performance defined by management in quantitative standards

Step-down unit

A unit used for cardiac patients for care between the cardiac intensive care unit and a general medical/surgical unit

Percentage

A value computed on the basis of the whole divided into 100 parts

Present value

A value that targets the current dollar investment and interest rate needs to achieve a particular investment goal

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

Sole proprietorship

A venture with one owner in which all profits are considered the owner's personal income

Breach

A violation of the law

Strategy map

A visual representation of the cause-and-effect relationships among the components of an organization's strategy

Telecommuting

A work arrangement (often used by coding and transcription personnel) in which at least a portion of the employee's work hours is spent outside the office (usually in the home) and the work is transmitted back to the employer via electronic means

Job rotation

A work design in which workers are shifted periodically among different tasks

Job sharing

A work schedule in which two or more individuals share the tasks of one full-time or one full-time-equivalent position

Request for information (RFI)

A written communication often sent to a comprehensive list of vendors during the design phase of the systems development life cycle to ask for general product information

Corrective action plan (CAP)

A written plan of actions to be taken in response to identified issues or citations from an accrediting or licensing body

Mission statement

A written statement that sets forth the core purpose and philosophies of an organization or PI team.; defines why an organization exists and what it is for

Malfeasance

A wrong or improper act

Concomitant

Accessory; taking place at the same time

Error

Act involving an unintentional deviation from truth or accuracy (ASTM 2005 3.1.7)

Interoperable

Adjective form of interoperability

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

Withhold pool

Aggregate amount withheld from all providers' capitation payments as an amount to cover expenditures in excess of targets

Total billed charges

All charges for procedures and services rendered to a patient during a hospitalization or encounter

ACOG

American College of Obstetrics and Gynecology

ASA

American Society of Anesthesiologists

Expenses

Amounts that are charged as costs by an organization to the current year's activities of operation

Chart conversion

An EHR implementation activity in which data from the paper chart are converted into electronic form

Unified Medical Language System (UMLS) SPECIALIST Lexicon

An English-language lexicon containing biomedical terms

Standard generalized markup language (SGML)

An International Standards Organization standard that establishes rules for identifying elements within a text document

Groupware

An Internet technology that consolidates documents from different information systems within an organization into a tightly integrated workflow

Data model

An abstraction model of real conditions that describes how data is represented and accessed

Unbilled account

An account that has not been billed and is not included in accounts receivable

Objectivity

An accounting concept in which assets are classified at historical cost or current value

Tort

An action brought when one party believes that another party caused harm through wrongful conduct and seeks compensation for that harm

Criminal proceeding

An action instituted and conducted for the purpose of preventing the commission of a crime or for fixing the guilt of a crime already committed and punishing the offender

Institute of Electrical and Electronics Engineers Standards Association (IEEE-SA)

An activity of the IEEE that develops standards in a broad-range of industries including healthcare

Habit

An activity repeated so often that it becomes automatic

Cost driver

An activity that affects or causes costs

Late entry

An addition to the health record when a pertinent entry was missed or was not written in a timely manner

Baseline adjustment for volume and intensity of service

An adjustment to the conversion factor needed to fulfill the statutory budget neutrality requirement

Urgent admission

An admission in which the patient requires immediate attention for treatment of a physical or psychiatric problem

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

Payment status indicator (PSI)

An alphabetic code assigned to CPT/HCPCS codes to indicate whether a service or procedure is to be reimbursed under the Medicare outpatient prospective payment system

Low-utilization payment adjustment (LUPA)

An alternative (reduced) payment made to home health agencies instead of the home health resource group reimbursement rate when a patient receives fewer than four home care visits during a sixty-day episode

One-tailed hypothesis

An alternative hypothesis in which the researcher makes a prediction in one direction

Incident report review

An analysis of incident reports or an evaluation of descriptions of adverse events

Discharge analysis

An analysis of the health record at or following discharge

Fuzzy logic

An analytic technique used in data mining to handle imprecise concepts

Systems theory

An approach to understanding organizations based on the organization and interconnections of its parts

Applied artificial intelligence

An area of computer science that deals with algorithms and computer systems that exhibit the characteristics commonly associated with human intelligence

Machine learning

An area of computer science that studies algorithms and computer programs that improve employee performance on some task by exposure to a training or learning experience

Virtual reality (VR)

An artificial form of reality experienced through sensory stimuli and in which the participant's actions partly affect what happens

Preoperative anesthesia evaluation

An assessment performed by an anesthesiologist to collect information on a patient's medical history and current physical and emotional condition that will become the basis of the anesthesia plan for the surgery to be performed

External validity

An attribute of a study's design that allows its findings to be applied to other groups

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

Blanket authorization

An authorization for the release of confidential information from a certain point in time and any time thereafter

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

Authorization to disclose information

An authorization that allows the healthcare facility to verbally disclose or send health information to other organizations

Programmed decisions

An automated decision made by people or computers based on a situation being so stable and recurrent that decision rules can be applied to it

Radio frequency identification (RFID)

An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and does not require direct contact

Innovator

An early adopter of change who is eager to experiment with new ways of doing things

Activity-based costing (ABC)

An economic model that traces the costs or resources necessary for a product or customer

Massed training

An educational technique that requires learning a large amount of material at one time

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 and/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

Trauma center

An emergency care center that is specially staffed and equipped (usually with an air transport system) to handle trauma patients

Web services architecture (WSA)

An emerging architecture that utilizes Web-based tools to permit communication among different software applications

Knowledge worker

An employee who improves his or her performance by sharing his or her experience and expertise with other employees

Float employee

An employee who is not assigned to a particular shift or function and who may fill in as needed in cases of standard employee absence or vacation

Medicaid

An entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and federal governments and legislated by the Social Security Act

Pro forma

An estimate

Performance review

An evaluation of an employee's job performance

Medication usage review

An evaluation of medication use and medication processes

Confounding variable

An event or a factor that is outside a study but occurs concurrently with the study

Data quality review

An examination of health records to determine the level of coding accuracy and to identify areas of coding problems

Planning

An examination of the future and preparation of action plans to attain goals; one of the four traditional management functions

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

Key field

An explanatory notation that uniquely identifies each row in a database table

Groupthink

An implicit form of group consensus in which openness and effective decision making are sacrificed to conformity

Certificate authority (CA)

An independent licensing agency that vouches for a person's identity in encrypted electronic communications

Financial Accounting Standards Board (FASB)

An independent organization that sets accounting standards for businesses in the private sector

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

Security officer or chief security officer

An individaul responsible for overseeing privacy policies and procedure and managing the organization's information security program

Data element

An individual fact or measurement that is the smallest unique subset of a database

Policyholder

An individual or entity that purchases healthcare insurance coverage

Physician champion

An individual who assists in educating medical staff on documentation procedures for accurate billing

Hacker

An individual who bypasses a computer system's access control by taking advantage of system security weaknesses and/or by appropriating the password of an authorized user

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

Ethical agent

An individual who promotes and supports ethical behavior

Champion

An individual within an organization who believes in an innovation or change and promotes the idea by building financial and political support

Change agent

An individual within an organization whose primary responsibility is to facilitate change

Minor

An infant or person under the age of legal competence

Nosocomial infection

An infection acquired by a patient while receiving care or services in a healthcare organization

Executive dashboard

An information management system providing decision makers with regularly updated information on an organization's key strategic measures

Executive information system (EIS)

An information system designed to combine financial and clinical information for use in the management of business affairs of a healthcare organization

Operations support systems (OSS)

An information system that facilitates the operational management of a healthcare organization

Source system

An information system that operates independently of a CPR system but provides data to it

Packet switching

An information transmission system in which data are encoded into short units (packets) and sent through an electronic communications network

Contrast material

An ingested or injected substance that enhances the appearance of anatomical structures when they undergo imaging

Day outlier

An inpatient hospital stay that is exceptionally long when compared with other cases in the same diagnosis-related group

Newborn (NB)

An inpatient who was born in a hospital at the beginning of the current inpatient hospitalization

Self-directed learning

An instructional method that allows students to control their learning and progress at their own pace

Summons

An instrument used to begin a civil action or special proceeding and is a means of acquiring jurisdiction over a party

System catalog

An integrated data dictionary (which is a component of a database management system) that generally contains information on data tables and relationships in addition to data definitions

Internal rate of return (IRR)

An interest rate that makes the net present value calculation equal zero

Internet

An international network of computer servers that provides individual users with communications channels and access to software and information repositories worldwide

United Nations International Standards Organization (ISO)

An international standards organization that coordinates all international standards development

Panel interview

An interview format in which the applicant is interviewed by several interviewers at the same time

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

Group process

An intragroup activity of relevance to organizational effectiveness that includes elements such as socialization of new members and conflict resolution

Cause-and-effect diagram

An investigational technique that facilitates the identification of the various factors that contribute to a problem

Hippocratic oath

An oath created by ancient Greeks to embody a code of medical ethics

Systems thinking

An objective way of looking at work-related ideas and processes with the goal of allowing people to uncover ineffective patterns of behavior and thinking and then finding ways to make lasting improvements

Transition

An ongoing plan used in establishing and maintaining the Medicare fee schedule

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

Queuing theory

An operations management technique for examining customer flow and designing ideal wait or scheduling times

Near miss

An opportunity to improve patient safety-related practices based on a condition or incident with potential for more serious consequences

Medically needy option

An option in the Medicaid program that allows states to extend eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups but whose income and/or resources fall above the eligibility level set by their state

National Association of Healthcare Quality (NAHQ)

An organization devoted to advancing the profession of healthcare quality improvement through its accreditation program

Health Information Security and Privacy Collaboration (HISPC)

An organization for exchanging ideas and developing solutions to promote interoperability

National Cancer Registrars Association (NCRA)

An organization of cancer registry professionals that promotes research and education in cancer registry administration and practice

Professional standards review organization (PSRO)

An organization responsible for determining whether the care and services provided to hospital inpatients were medically necessary and met professional standards in the context of eligibility for reimbursement under the Medicare and Medicaid programs

Going concern

An organization that can be assumed to continue indefinitely unless otherwise stated

Insurer

An organization that pays healthcare expenses on behalf of its enrollees

Clearinghouse

An organization that processes and/or reformats electronic claims to insurers on behalf of multiple healthcare providers

Appreciative inquiry

An organizational development technique in which successful practices are identified and expanded throughout the organization

Patient care unit (PCU)

An organizational entity of a healthcare facility organized both physically and functionally to provide care

Care unit

An organizational entity of a healthcare facility; healthcare facilities are organized both physically and functionally into units to provide care

Periodic performance review (PPR)

An organizational self-assessment conducted at the halfway point between triennial on-site accreditation surveys conducted by The Joint Commission

Focus

An organized form of charting narrative notes in which nursing terminology is used to explain the resident's health status and resulting nursing action

Hospital-based ambulatory care center

An organized hospital facility that provides nonemergency medical or dental services to patients who are not assigned to a bed as inpatients during the time services are rendered (an emergency department in which services are provided to nonemergency patients is not considered an ambulatory care center)

Emergency department

An organized hospital-based facility providing unscheduled episodic services to patients who present for immediate medical attention

Delivery system

An organized method of providing healthcare services to a large number of individuals in a geopolitical region or a contractually defined population

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

Primary source

An original work of a researcher who conducted an investigation

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

Duplex scan

An ultrasonic scanning procedure that displays both two-dimensional structure and motion with time; utilizes Doppler ultrasonic signal documentation with spectral analysis and/or color flow velocity mapping or imaging

Home health (HH)

An umbrella term that refers to the medical and nonmedical services provided to patients and their families in their places of residence

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

Special-cause variation

An unusual source of variation that occurs outside a process but affects it

Fiscal year

Any consecutive twelve-month period an organization uses as its accounting period

Protective order

Any court order or decree whose purpose is to protect a person from personal harassment or service of process or discovery

Supervised learning

Any learning technique that has as its purpose to classify or predict attributes of objects or individuals

Analyte

Any material or chemical substance subjected to analysis

Postterm neonate

Any neonate whose birth occurs from the beginning of the first day (two hundred ninety-fifth day) of the forty-third week following onset of the last menstrual period

Preterm neonate

Any neonate whose birth occurs through the end of the last day of the thirty-eighth week (two hundred sixty-sixth day) following onset of the last menstrual period

Whole number

Any of the set of nonnegative integers

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

Interim period

Any period that represents less than an entire fiscal year

Workflow

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

Medical care evaluation studies

Audits required by the Medicare Conditions of Participation that dictate the use of screening criteria with evaluation by diagnosis and/or procedure

Advanced decision support

Automated clinical practice guidelines that are built in to electronic health record systems and designed to support clinical decision making

Machine language

Binary codes made up of zeroes and ones that computers use directly to represent precise storage locations and operations

Abstract

Brief summary of the major parts of a research study

Clinical care plans

Care guidelines created by healthcare providers for individual patients for a specified period of time

Post-acute care

Care provided to patients who have been released from an acute care facility to recuperate at home

Medical staff privileges

Categories of clinical practice privileges assigned to individual practitioners on the basis of their qualifications

Categorically needy eligibility groups

Categories of individuals to whom states must provide coverage under the federal Medicaid program

CPC

Certified Professional Coder

CCA

Certified coding associate

Temporary National Codes

Codes established by insurers when a code is needed before the next January 1 annual update for permanent national codes; these codes are independent of the permanent national codes

Concept permanence

Codes that represent the concept in a controlled medical terminology are not reused; therefore meanings do not change

Hospital Payment Monitoring Program (HPMP)

Coding compliance monitoring program created by the 7th Scope of Work which ensures that proper payment is made for Medicare beneficiary admissions

Abuses

Coding errors that occur without intent to defraud the government

Structure and content standards

Common data elements and definitions of the data elements to be included in an electronic patient record

CWF

Common working file

Word-processing services

Companies outside the healthcare facility that specialize in the deciphering and typing of medical dictation

Reimbursement

Compensation or repayment for healthcare services

Communications technology

Computer networks in an information system

Imaging technology

Computer software designed to combine health record text files with diagnostic imaging files

System infectors

Computer viruses that infect the system areas of diskettes or the hard drive of a computer

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

Reference check

Contact made with an individual that a prospective employee has listed to provide a favorable account of his or her work performance or personal attributes

Revisions

Corrections or alterations to the health record

Coinsurance

Cost sharing in which the policy or certificate holder pays a pre-established percentage of eligible expenses after the deductible has been met; the percentage may vary by type or site of service

Mixed costs

Costs that are part variable and part fixed

Mapping

Creation of a cross map that links the content from one classification or terminology scheme to another

Secondary research

Data collected from a literature review

Primary research

Data collected specifically for a study

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

Free-text data

Data that are narrative in nature

Numerical data

Data that include discrete data and continuous data

Research data

Data used for the purpose of answering a proposed question or testing a hypothesis

Epidemiological data

Data used to reveal disease trends within a specific population

Ordinal-level data

Data with inherent order and with higher numbers usually associated with higher values

Data-based DSS

Decision support system that focuses on providing access to the various data sources within the organization through one system

HHS

Department of Health and Human Services

Topography

Description of a part of the body

Implementation specifications

Descriptions that define how HIPAA standards are to be implemented

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

Checksum

Digits or bits summed according to arbitrary rules and used to verify the integrity of numerical data

D & C

Dilation and curettage

"International Classification of Impairments

Disabilities, and Handicaps (ICIDH)","Published by the World Health Organization to measure the consequences of disease and divided into three classifications: impairments, disabilities, and handicaps; the precursor to ICF"

"International Classification on Functioning

Disability and Health (ICF)","Classification of health and health-related domains that describe body functions and structures, activities, and participation"

Six Sigma

Disciplined and data-driven methodology for getting rid of defects in any process

Continuous variables

Discrete variables measured with sufficient precision

Range

Distance or extent between possible extremes

Rider

Document added to a healthcare insurance policy that provides details about coverage or lack of coverage for special situations that are not usually included in standard policies; may function as an exclusion or limitation

Local medical review policies (LMRPs)

Documents that define Medicare coverage of outpatient services via lists of diagnoses defined as medically reasonable and necessary for the services provided

Bills of Mortality

Documents used in London during the seventeenth century to identify the most common causes of death

Term type (TTY)

Each element of the normalized term in RxNorm

Byte

Eight bits treated as a single unit by a computer to represent a character

EEG

Electroencephalogram

Esprit de corps

Enthusiasm among the members of a group supporting the group's existence

Cost outlier

Exceptionally high costs associated with inpatient care when compared with other cases in the same diagnosis-related group

Administrative agencies

Executive branch agencies; source of administrative law

EPF

Expanded problem focused

Case-mix group (CMG) relative weights

Factors that account for the variance in cost per discharge and resource utilization among case-mix groups

FCA

False Claims Act

Occupational Safety and Health Administration (OSHA)

Federal Occupational Safety and Health Administration (OSHA) regulations ensure that an employee (or designated representative) is given access to his or her own medical and exposure records within 15 days of a request

Labor-Management Relations Act (Taft-Hartley Act)

Federal legislation passed in 1947 that imposed certain restrictions on unions while upholding their right to organize and bargain collectively

Age Discrimination in Employment Act (1967)

Federal legislation that prohibits employment discrimination against persons between the ages of forty and seventy and restricts mandatory retirement requirements except where age is a bona fide occupational qualification

Workers' Adjustment and Retraining Notification (WARN) Act

Federal legislation that requires employers to give employees a sixty-day notice in advance of covered plant closings and covered mass layoffs

Carriers (Medicare Part B)

Financial agents that serve under contract with the Centers for Medicare and Medicaid Services to work with providers and the federal government to locally administer Medicare Part B claims

Change drivers

Forces in the external environment of organizations or industries that force organizations or industries to change the way they operate in order to survive

Source of admission code

Form locator 20 on the CMS-1450 form

Medicare+Choice

Former name of Medicare Advantage (Part C)

"Current Procedural Terminology

Fourth Edition (CPT)","A comprehensive, descriptive list of terms and associate 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"

Reengineering

Fundamental rethinking and radical redesign of business processes to achieve significant performance improvements

State workers' compensation insurance funds

Funds that provide a stable source of insurance coverage for work-related illnesses and injuries and serve to protect employers from underwriting uncertainties by making it possible to have continuing availability of workers' compensation coverage

Rural area

Geographic area outside an urban area and its constituent counties or count equivalents. Any area not designated as a metropolitan statistical area for the purposes of case-mix index sets and wage index adjustments to federal Medicare reimbursement rates

User groups

Groups composed of users of a particular computer system

Cost centers

Groups of activities for which costs are specified together for management purposes

General Rules

HIPAA data security provisions that provide the objective and scope for the HIPAA security rule as a whole

Clinical Document Architecture (CDA)

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

Indemnity plans

Health insurance coverage provided in the form of cash payments to patients or providers

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

Nursing notes

Health record documentation that describes the nursing staff's observations of the patient and records the clinical and therapeutic services provided to the patient as well as the patient's response to treatment

Interval note

Health record documentation that describes the patient's course between two closely related hospitalizations directed toward the treatment of the same complaint

Labor and delivery record

Health record documentation that takes the place of an operative report for patients who give birth in the obstetrics department of an acute care hospital

Health information management (HIM) department

Healthcare facility department responsible for the management and safeguarding of information in paper and electronic form

Disproportionate share hospital (DSH)

Healthcare organizations that meet governmental criteria for percentages of indigent patients

Benefit

Healthcare service for which the healthcare insurance company will pay

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

Swing beds

Hospital-based acute care beds that may be used flexibly to serve as long-term care beds

Short-stay outlier

Hospitalization that is five-sixths of the geometric length of stay for the long-term care diagnosis related group (LTC-DRG)

Relevance

How applicable information is to some matter

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

Complications/comorbidities (CC)

Illnesses or injuries that coexist with the condition for which the patient is primarily seeking healthcare

Emergency services

Immediate evaluation and therapy rendered in urgent clinical conditions and sustained until the patient can be referred to his or her personal practitioner for further care

Clinical Data Abstraction Centers (CDACs)

Independent review firms that contract with CMS to perform data collection

Medical informatics professionals

Individuals who work in the field of medical informatics

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

Administrative information

Information used for administrative and healthcare operations purposes such as billing and quality oversight

Medical malpractice insurance

Insurance that protects a party from claims for medical negligence or other tortious injury arising out of care provided to patients

Preventive controls

Internal controls implemented prior to an activity and designed to stop an error from happening

Human Genome Nomenclature (HUGN)

Interoperability standard for exchanging information regarding the role of genes in biomedical research and healthcare

IOL

Intraocular lens

Endorsement

Language or statements within a healthcare insurance policy providing additional details about coverage or lack of coverage for special situations that are not usually included in standard policies; may function as a limitation or exclusion

Androgynous leadership

Leadership in which cultural stereotyped masculine and feminine styles are integrated into a more effective hybrid style

Refreezing

Lewin's last stage of change in which people internalize new practices following transition

Discoverability

Limitations on the ability of parties to discover pretrial information held by another

Crosswalks

Lists of translating codes from one system to another

Strategic goals

Long-term objectives set by an organization to improve its operations

Supervisory management

Management level that oversees the organization's efforts at the staff level and monitors the effectiveness of everyday operations and individual performance against preestablished standards

Supervisory managers

Managers who oversee small (two- to ten-person) functional workgroups or teams and often perform hands-on functions in addition to supervisory functions

Hierarchy of needs

Maslow's theory that suggested that human needs are organized hierarchically from basic physiological requirements to creative motivations

Ratio analysis

Mathematical computations that compare elements of an organization's financial statements to past and future performance trends and industry benchmarks

Acute care

Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or a short-term illness

MPFSDB

Medicare Provider Fee Schedule Data Base

Medicare Part D

Medicare drug benefit created by the Medicare Modernization Act of 2003 (MMA) that offers outpatient drug coverage to beneficiaries for an additional premium

Certification/recertification

Medicare requirement for the physician's official recognition of skilled nursing care needs for the resident

"Carrier

Medicare",An organization under contract with the Centers for Medicare and Medicaid Services to serve as the financial agent that works with providers and the federal government to locally administer Medicare eligibility and payments

Certificate holder

Member of a group for which an employer or association has purchased group healthcare insurance

Global payment method

Method of payment in which the third party payer makes one consolidated payment to cover the services of multiple providers who are treating a single episode of care

Unallocated reserves

Monies that have not been assigned a specific use

Impairment group code (IGC)

Multidigit code that represents the primary reason for a patient's admission to an inpatient rehabilitation facility

Semantic interoperability

Mutual understanding of the meaning of data exchanged between information systems

"Logical Observation Identifiers

Names and Codes (LOINC)","A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research"

NCI

National Cancer Institute

NIH

National Institutes of Health

Miscellaneous codes

National codes used when a supplier is submitting a bill for an item or service where no existing national code exists to describe the item or service being billed

National Coverage Determination (NCD)

National medical necessity and reimbursement regulations

"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

Psychotherapy notes

Notes recorded in any medium by a mental health professional to document or analyze the contents of conversations between therapists and clients during private or group counseling sessions

Notice of Proposed Rulemaking (NPRM)

Notice published in the Federal Register calling for public comment on its policy; the public at large has a specified time period to submit comments

North American Nursing Diagnosis Association International Taxonomy (NANDA II)

Nursing terminology used to develop and classify nursing diagnoses in a taxonomy

Duty

Obligation

Postpartum

Occurring after childbirth

Asynchronous

Occurring at different times

Synchronous

Occurring at the same time

Prepartum

Occurring prior to childbirth

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

Risk prevention

One component of a successful risk management program

Health information management services (HIMS)

One of several names for the health record department. This name is meant to provide a better description of the function of the department- the management of health information

Control

One of the four management functions in which performance is monitored in accordance with organizational policies and procedures

Regenstrief Medical Records System (RMRS)

One of the nation's first electronic medical record systems and the keystone of Regenstrief Institute activities

Western blot

One of the tests used to confirm a diagnosis of acquired immunodeficiency syndrome

Radioimmunoprecipitation assay (RIPA)

One of the tests used to confirm a diagnosis of acquired immunodeficiency syndrome (AIDS)

Population health dimension (PHD)

One of three dimensions of the National Health Information Infrastructure privacy concept that addresses protecting and promoting the health of the community

Fraction

One or more parts of a whole

Surgical operation

One or more surgical procedures performed at one time for one patient via a common approach or for a common purpose

Bylaws

Operating documents that describe the rules and regulations under which a healthcare organization operates

Rules and regulations

Operating documents that describe the rules and regulations under which a healthcare organization operates

ORT

Operation Restore Trust

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

Standing orders

Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure

Leapfrog Group

Organization that promotes healthcare safety by giving consumers the information they need to make better-informed choices about the hospitals they choose

Medical service bureaus

Organized groups of physicians who were paid by employers to provide healthcare services to their employees during the early 1900s

Birth certificate

Paperwork that must be filed for every live birth regardless of where it occurred

Topography axis

Part of the body affected by disease

Clinic cases

Patient encounters that take place on an outpatient basis in a clinic within a teaching environment

Purged records

Patient health records that have been removed from the active file area

Payment Error Prevention Program (PEPP)

Payment compliance program established under the 6th Scope of Work to help healthcare facilities identify simple mistakes that are causing payment errors; monitored by Quality Improvement Organizations (QIOs)

Out-of-pocket

Payment made by the policyholder or member

Third-party payment

Payments for healthcare services made by an insurance company or health agency on behalf of the insured

Sanctions

Penalties or other mechanisms of enforcement used to provide incentives for obedience with the law or with rules and regulations

Indirect medical education (IME) adjustment

Percentage increase in Medicare reimbursement to offset the costs of medical education that a teaching hospital incurs

Clinical value compass

Performance improvement approach that measures the association of quality and value

Capital assets

Physical asset with an estimated useful life of more than 1 year

Hospitalist

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

Function axis

Physiological or chemical disorders and alterations resulting from a disease or injury

POS

Place of service or point of service

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

Administrative controls

Policies and procedures that address the management of computer resources

Quintile

Portion of a frequency distribution containing one-fifth of the total cases

Accreditation standards

Pre-established statements of the criteria against which the performance of participating healthcare organizations will be assessed during a voluntary accreditation

Health Care Financing Administration (HCFA)

Previous name of the Centers for Medicare and Medicaid Services

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)

Category I codes

Procedures or services identified by a five-digit CPT code and organized within the six sections

Prior approval (authorization)

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

Open systems

Processes that are affected by what is going on around them and must adjust as the environment changes

PIN

Provider identification number

Cost-sharing

Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism

Acquisition

Purchase

Radioactive source

Radioactive elements packaged in a small configuration used for permanent implantation into tumors

Wage index

Ratio that represents the relationship between the average wages in a healthcare setting's geographic area and the national average for that healthcare setting. Wage indexes are adjusted annually and published in the Federal Register.

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

Workforce trends

Referring to changes that will likely take place in the workforce in the future

X12N

Referring to standards adopted for electronic data interchange

Market basket index

Relative measure that averages the costs of a mix of goods and services; used in the home health prospective payment system to reflect changes over time in the prices of an appropriate mix of goods and services and to develop the national sixty-day episode payment rates

Uniform Bill-92 (UB-92)

Replaced by the UB-04 in 2007; It was a Medicare form for standardized uniform billing

Scorecards

Reports of outcomes measures to help leaders know what they have accomplished; sometimes called dashboards

Dashboards

Reports of process measures to help leaders follow progress to assist with strategic planning- sometimes called scorecards

Accountable

Required to answer to a supervisor for performance results

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 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

Analysis

Review of health record for proper documentation and adherence to regulatory and accreditation standards

Public health services (PHS)

Services concerned primarily with the health of entire communities and population groups

Evidence-based practices

Services that use decision support systems and best practices in medicine rather than relying on subjective information

Multidimensional analysis

Simultaneous analysis of data from multiple dimensions using different data elements

Interval scale

Situation where the intervals between adjacent scale values are equal with respect to the attributes being measured

Server redundancy

Situation where two servers are duplicating effort

Practice management system (PMS)

Software designed to help medical practices run more smoothly and efficiently

Password crackers

Software programs used to identify an unknown or forgotten password

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

Incentive

Something that stimulates or encourages an individual to work harder

Portals

Special Web pages that offer secure access and entry of data upon authorization of the owner of the page

Process indicators

Specific measures that enable the assessment of the steps taken in rendering a service

Transaction standards

Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another

Transmission standards

Standards that support the uniform format and sequence of data during transmission from one healthcare entity to another

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

Tort laws

State legislation that applies to civil cases dealing with wrongful conduct or injuries

Descriptive statistics

Statistics that are used to describe the basic features of the data gathered. They provide simple summaries about the sample and the measures

Scenarios

Stories describing the current and feasible future states of the business environment

Time and motion studies

Studies in which complex tasks are broken down into their component motions to determine inefficiencies and to develop improvements

Epidemiological studies

Studies that are concerned with finding the causes and effects of diseases and conditions

Performance measure/measurement system

System designed to improve performance by providing feedback on whether goals have been met

Web-based systems and applications

Systems and applications that use Internet technology

Web browser-based systems

Systems and applications written in one or more Web programming languages

Workflow technology

Technology that allows computers to add and extract value from document content as the documents move throughout an organization

"International Classification of Diseases

Tenth Revision (ICD-10)",The most recent revision of the disease classification system developed and used by the World Health Organization to track morbidity and mortality information worldwide (not yet adopted by the United States)

"International Classification of Diseases

Tenth Revision, Clinical Modification (ICD-10-CM)","The planned replacement for ICD-9-CM, volumes 1 and 2, developed to contain more codes and allow greater specificity "

Computers on wheels (COWs)

Term affectionately used to refer to notebook computers mounted on carts and moved with the users

Best practice

Term used to refer to services that have been deemed effective and efficient with certain groups of clients

Honesty (integrity) tests

Tests designed to evaluate an individual's honesty using a series of hypothetical questions

Ability (achievement) tests

Tests used to assess the skills an individual already possesses

Outpatient prospective payment system (OPPS)

The Medicare prospective payment system used for hospital-based outpatient services and procedures that is predicated on the assignment of ambulatory payment classifications

Multi-axial

The ability of a nomenclature to express the meaning of a concept across several axes

Interoperability

The ability of different information systems and software applications to communicate and exchange data

Connectivity

The ability of one computer system to exchange meaningful data with another computer system

Statement of changes in net assets

The accounting statement that explains the differences in net assets from period to period on the balance sheet

Mirrored processing

The act of entering data into a primary and a secondary server simultaneously so that the secondary server can continue to process the data in the event the primary server crashes

Self-monitoring

The act of observing the reactions of others to one's behavior and making the necessary behavioral adjustments to improve the reactions of others in the future

Revocation

The act of withdrawing an authorization or permission that was previously granted

Selection

The act or process of choosing

Write-off

The action taken to eliminate the balance of a bill after the bill has been submitted and partial payment has been made or payment has been denied and all avenues of collecting the payment have been exhausted

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

Recalibration

The adjustment of all ambulatory payment classification weights to reflect changes in relative resource consumption

Capital budget

The allocation of resources for long-term investments and projects

Depreciation

The allocation of the dollar cost of a capital asset over its expected life

Usual fee

The amount a physician normally charges the majority of the patients seen for that service

Scope

The amount of effort and materials needed to produce project deliverables

Dollars billed

The amount of money billed for services rendered

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

Credits

The amounts on the right side of a journal entry

Business process reengineering (BPR)

The analysis and design of the work flow within and between organizations

Primary analysis

The analysis of original research data by the researchers who collected them

Universal precautions

The application of a set of procedures specifically designed to minimize or eliminate the passage of infectious disease agents from one individual to another during the provision of healthcare services

Organizational development (OD)

The application of behavioral science research and practices to planned organizational change

Chemical destruction

The application of chemicals to destroy tissue

Active listening

The application of effective verbal communication skills as evidenced by the listener's restatement of what the speaker said

e-HIM

The application of technology to managing health information

Operating room (OR)

The area in a healthcare facility that is equipped and staffed to provide facilities and personnel for the performance of surgical procedures

Staffing structure

The arrangement of staff positions within an organization

Nursing assessment

The assessment performed by a nurse to obtain clinical and personal information about a patient shortly after he or she has been admitted to a nursing unit

Delegation of authority

The assignment of authority or responsibility

Randomization

The assignment of subjects to experimental or control groups based on chance

Cash flow

The availability of money to pay the organization's bills (receipts minus disbursements)

Arithmetic mean length of stay (AMLOS)

The average length of stay for all patients

Bed turnover rate

The average number of times a bed changes occupants during a given period of time

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

Object

The basic component in an object-oriented database that includes both data and their relationships within a single structure

Judicial law

The body of law created as a result of court (judicial) decisions

Nosology

The branch of medical science that deals with classification systems

Partnership

The business venture of two or more owners for whom the profits represent the owners' personal income

Department of Health and Human Services (HHS or DHHS)

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

Backward compatibility

The capability of a software or hardware product to work with earlier versions of itself

Critical care

The care of critically ill patients in a medical emergency requiring the constant attention of the physician

Etiology axis

The cause of a disease or injury

Revenue

The charges generated from providing healthcare services; earned and measurable income

Photochemotherapy

The combination of light and chemical therapy in treating skin diseases

Platform

The combination of the hardware and operating system on which an application program can run

Logical (or conceptual) repository

The compilation of multiple physical repositories

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

Patient safety

The condition of a patient being safe from harm or injury

Admissibility

The condition of being admitted into evidence in a court of law

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

Three-dimensional imaging

The construction of pictures generated from computer data in three dimensions

Clinical communication space

The context and range of electronic and interpersonal information exchanged among staff and patients

Primary care

The continuous and comprehensive care provided at first contact with the healthcare provider in an ambulatory care setting

Performance improvement (PI)

The continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired outcomes

Medical transcription

The conversion of verbal medical reports dictated by healthcare providers into written form for inclusion in patients' health records

Entity authentication

The corroboration that an entity is who it claims to be

Interest

The cost of borrowing money; payment to creditors for using money on credit

Per-diem rate

The cost per day derived by dividing total costs by the number of inpatient care days

Matching expenses

The costs that are recorded during the same period as the related revenue

Stable monetary unit

The currency used as the measurement of financial transactions

Debt service

The current obligations of an organization to repay loans

Eligibility date

The date on which a member of an insured group may apply for insurance

Early fetal death

The death of a product of human conception that is fewer than twenty weeks of gestation and 500 grams or less in weight before its complete expulsion or extraction from the mother

Certainty factor

The defined certainty percentage rate with which an occurrence must present itself to satisfy quality standards

Roles and responsibilities

The definition of who does what on a project and the hierarchy for decision making

Health information services department

The department in a healthcare organization that is responsible for maintaining patient care records in accordance with external and internal rules and regulations

Pull-down menu

The design of a data-entry screen of a computer in which categories of functions or structured data elements may be accessed through that category element

Electrodesiccation

The destruction of tissue by way of a small needle heated by passing electricity through it

Temporary budget variance

The difference between the budgeted and actual amounts of a line item that is expected to reverse itself in a subsequent period; the timing difference between the budget and the actual event

Net income

The difference between total revenues and total expenses

e-Discovery

The discovery of evidence contained in electronic documents such as e-mails or electronic health records

Variability

The dispersion of a set of measures around the population mean

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

Charges

The dollar amounts actually billed by healthcare facilities for specific services or supplies and owed by patients

Motivation

The drive to accomplish a task

Board of directors

The elected or appointed group of officials who bear ultimate responsibility for the successful operation of a healthcare organization

Patient-elected transfer

The elective transfer of a patient from one home health agency to another during a sixty-day episode

Health information exchange (HIE)

The electronic movement of health-related information among organizations according to nationally recognized standards

Coordination of benefits (COB) transaction

The electronic transmission of claims and/or payment information from a healthcare provider to a health plan for the purpose of determining relative payment responsibilities

Activity date or status

The element in the chargemaster that indicates the most recent activity of an item

Drug components

The elements that together constitute a clinical drug

Business intelligence (BI)

The end product or goal of knowledge management

Working conditions

The environment in which work is performed (surroundings) and the physical dangers or risks involved in performing the job (hazards)

Vocational rehabilitation

The evaluation and training aimed at assisting a person to enter or reenter the labor force

Compulsory review

The examination of a healthcare facility and its processes and infrastructures as required by state laws and regulations

Financial transaction

The exchange of goods or services for payment or the promise of payment

Data accuracy

The extent to which data are free of identifiable errors

Data precision

The extent to which data have the values they are expected to have

Data availability

The extent to which healthcare data are accessible whenever and wherever they are needed

Data comprehensiveness

The extent to which healthcare data are complete

Data accessibility

The extent to which healthcare data are obtainable

Independent variables

The factors in experimental research that researchers manipulate directly

Government Accounting Standards Board (GASB)

The federal agency that sets the accounting standards to be followed by government entities

Equal Pay Act of 1963 (EPA)

The federal legislation that requires equal pay for men and women who perform substantially the same work

Utilization Review Act

The federal legislation that requires hospitals to conduct continued-stay reviews for Medicare and Medicaid patients

Fair Labor Standards Act of 1938 (FLSA)

The federal legislation that sets the minimum wage and overtime payment regulations

Security rule

The federal regulations created to implement the security requirements of the Health Insurance Portability and Accountability Act of 1996

Healthcare informatics

The field of information science concerned with the management of all aspects of health data and information through the application of computers and computer technologies

Consumer informatics

The field of information science concerned with the management of data and information used to support consumers by consumers (the general public) through the application of computers and computer technologies

Physical therapy (PT)

The field of study that focuses on physical functioning of the resident on a physician-prescribed basis

System maintenance and evaluation

The final phase of the systems development life cycle

Ending

The first stage of Bridges's model of transition management in which people experience losses because of change

Unfreezing

The first stage of Lewin's change process in which people are presented with disconcerting information to motivate them to change

Legal health record (LHR)

The form of a health record that is the legal business record of the organization and serves as evidence in lawsuits or other legal actions; what constitutes an organization's legal health record varies depending on how the organization defines it

Elective admission

The formal acceptance by a healthcare organization of a patient whose condition permits adequate time to schedule the availability of a suitable accommodation

Quartile

The fourth equal part of a distribution

Location or address of encounter

The full address and nine-digit zip code for the location at which outpatient care was received from the healthcare practitioner of record

Clinical messaging

The function of electronically delivering data and automating the work flow around the management of clinical data

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

Bundled

The grouping of Common Procedural Terminology codes related to a procedure when submitting a claim

Primary care manager (PCM)

The healthcare provider assigned to a TRICARE enrollee

Coding specialist

The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements

Years of schooling

The highest grade of schooling completed by the enrollee or patient

Outsourcing

The hiring of an individual or a company external to an organization to perform a function either on site or off site

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

Histocompatibility

The immunologic similarity between an organ donor and a transplant recipient

Justice

The impartial administration of policies or laws that takes into consideration the competing interests and limited resources of the individuals or groups involved

Required standards

The implementation specifications of the HIPAA Security Rule that are designated 'required' rather than 'addressable;' required standards must be present for the covered entity to be in compliance

Nonrepudiation

The inability to dispute a document's content or authorship. (JC 2004 IM-13)

Federal poverty level (FPL)

The income qualification threshold established by the federal government for certain government entitlement programs

Transactions

The individual events or activities that provide the basic input to the accounting process

Principal investigator

The individual with primary responsibility for the design and conduct of a research project

Middle managers

The individuals in an organization who oversee the operation of a broad scope of functions at the departmental level or who oversee defined product or service lines

Primary insurer (payer)

The insurance company responsible for making the first payment on a claim

Wisdom

The intelligence that gives individuals the empowerment and courage to act

Fraud and abuse

The intentional and mistaken misrepresentation of reimbursement claims submitted to government-sponsored health programs

Synergy

The interaction of parts to produce a greater outcome than would be obtained by the parts acting separately

Trier of fact

The judge or jury hearing a civil or criminal trial

Patient's right to privacy

The justifiable expectation on the part of a patient that the information in his or her health record will be used only in the context of providing healthcare services

Simulation and inventory modeling

The key components of a plan that are computer simulated for testing and experimentation so that optimal operational procedures can be found

Performance improvement council

The leadership group that oversees performance improvement activities in some healthcare organizations

Transformational leadership

The leadership of a visionary who strives to change an organization

Transactional leadership

The leadership style of a manager who strives to maintain high levels of efficiency in an organization by balancing tasks with social orientation

License

The legal authorization granted by a state to an entity that allows the entity to provide healthcare services within a specific scope of services and geographical location; states license both individual healthcare professionals and healthcare facilities; licensure usually requires an applicant to pass an examination to obtain the license initially and then to participate in continuing education activities to maintain the license thereafter

Physician-patient privilege

The legal protection from confidential communications between physicians and patients related to diagnosis and treatment from being disclosed during civil and some misdemeanor litigation

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

Risk corridor

The limits established to prevent immediate large financial gains or losses for hospitals because of the implementation of a prospective payment system

Morgue

The location where the bodies of deceased persons are kept until identified and claimed or are released for burial

Physical data model

The lowest level of data model with the lowest level of abstraction

Hardware

The machines and media used in an information system

Middle management

The management level in an organization that is concerned primarily with facilitating the work performed by supervisory- and staff-level personnel as well as by executive leaders

External fee schedule

The maximum amount an insurance company is willing to pay for the listed services; also known as schedule of benefits or maximum benefits

Maximum allowable charges (MAC)

The maximum charges allowed for a service rendered

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

Workers' compensation

The medical and income insurance coverage for certain employees in unusually hazardous jobs

Object request broker (ORB)

The messenger at the heart of the object-oriented framework that acts as a relay station between client and server

Average record delinquency rate

The monthly average number of discharges divided by the monthly average number of delinquent records

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

Blue Cross and Blue Shield Association (BCBSA)

The national association of state and local Blue Cross and Blue Shield plans

National Uniform Billing Committee (NUBC)

The national group responsible for identifying data elements and designing the CMS-1500

Scope of command

The number and type of employees who report to a specific management position in a defined organizational structure

Newborn autopsy rate

The number of autopsies performed on newborns who died during a given time period divided by the total number of newborns who died during 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

Nosocomial 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

Bed count

The number of inpatient beds set up and staffed for use on a given day

Census

The number of inpatients present in a healthcare facility at any given time

Incidence

The number of new cases of a specific disease

Sample size

The number of subjects needed in a study to represent a population

Utilization

The number of times a service is performed or supply is provided during a given period of time

Absolute frequency

The number of times that a score of value occurs in a data set

Procedural codes

The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients

Dual option

The offering of health maintenance organization coverage as well as indemnity insurance by the same carrier

CPT Assistant

The official publication of American Medical Association that addresses CPT coding issues

Reverse mentoring

The opposite of the usual coaching process where the younger goes to the older instructor

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

Net assets

The organization's resources remaining after subtracting its liabilities

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

Inpatient 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

Pueperal

The period immediately following childbirth

Eligibility period

The period of time following the eligibility date (usually thirty-one days) during which a member of an insured group may apply for insurance without evidence of insurability

Secondary storage

The permanent storage of data and programs on disks or tapes

Concurrent conditions

The physical disorders present at the same time as the primary diagnosis that alter the course of the treatment required or lengthen the expected recovery time of the primary condition

Data storage

The physical location and maintenance of data

Chief of staff

The physician designated as leader of a healthcare organization's medical staff

Point of care (POC)

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

Organization

The planned coordination of the activities of more than one person for the achievement of a common purpose or goal

Grievance management

The policies and procedures used to handle employee complaints

Medicare Part A

The portion of Medicare that provides benefits for inpatient hospital services

Dividends

The portion of an organization's profit that is distributed to its investors

Project schedule

The portion of the project plan that deals specifically with task start and finish dates

Threat

The potential for exploitation of a vulnerability

Overcoding

The practice of using a billing code that provides a higher reimbursement rate than the code applicable to the service actually furnished to the patient

Semantic normal form (SNF)

The preferred term for clinical drugs in RxNorm

Market value

The price at which something can be bought or sold on the open market

Average wholesale price (AWP)

The price commonly used when negotiating pharmacy contracts

Respect for Persons

The principle that all people are presumed to be free and responsible and should be treated accordingly

Principal procedure

The procedure performed for the definitive treatment of a condition (as opposed to a procedure performed for diagnostic or exploratory purposes) or for care of a complication

Scanning

The process by which a document is read into an optical imaging system

Data collection

The process by which data are gathered

Optical imaging technology

The process by which information is scanned onto optical disks

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

Employee orientation

The process in which employees are introduced to an organization and a new job

Job evaluation

The process of applying predefined compensable factors to jobs to determine their relative worth

Clinical coding

The process of assigning numeric or alphanumeric classifications to diagnostic and procedural statements

Coding

The process of assigning numeric or alphanumeric representations to clinical documentation

Debt financing

The process of borrowing money at a cost in the form of interest

Text processing

The process of converting narrative text into structured data for computer processing

Discharge planning

The process of coordinating the activities related to the release of a patient when inpatient hospital care is no longer needed

Insurance certification

The process of determining that the patient has insurance coverage for the treatment that is planned or expected

Data input

The process of entering data into a healthcare database

Privileging process

The process of evaluating a physician's or other licensed independent practitioner's quality of medical practice and determining the services or procedures he or she is qualified to perform

Text mining

The process of extracting and then quantifying and filtering free-text data

Autocoding

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

Computer-assisted coding

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

Career development

The process of growing or progressing within one's profession or occupation

Reinforcement

The process of increasing the probability of a desired response through reward

Marketing

The process of issuing a communication about a product or service with the purpose of encouraging recipients of the communication to purchase or use the product or service

Data security

The process of keeping data safe from unauthorized 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

Analysis session

The process of mining a data segment

Data retrieval

The process of obtaining data from a healthcare database

Change control

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

Authorization management

The process of protecting the security and privacy of the confidential data in a database

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

Redisclosure

The process of releasing confidential health record information that was originally created and disclosed by another healthcare provider

Degaussing

The process of removing or rearranging the magnetic field of a disk in order to render the data unrecoverable

Systematic random sampling

The process of selecting a sample of subjects for a study by drawing every nth unit on a list

Simple random sampling

The process of selecting units from a population so that each one has exactly the same chance of being included in the sample

Work measurement

The process of studying the amount of work accomplished and how long it takes to accomplish work in order to define and monitor productivity

Optimization

The process of thoroughly reviewing the health record to identify all procedures performed and services rendered by the physician to ensure accurate and complete coding for optimum reimbursement

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

Data analysis

The process of translating data into information that can be used by an application

Adjustment

The process of writing off an unpaid balance on a patient account to make the account balance

Compression algorithm

The process or program for reducing a message without significantly losing information

Release and disclosure

The processes that make health record information available to legitimate users

American College of Obstetricians and Gynecologists (ACOG)

The professional association of medical doctors specializing in obstetrics and gynecology.

American College of Radiology-National Electrical Manufacturers Association (ACR-NEMA)

The professional organizations (ACR) and trade associations (NEMA) that work collaboratively to develop digital imaging standards

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

Death rate

The proportion of inpatient hospitalizations that end in death

Cancer mortality rate

The proportion of patients that die from cancer

Prevalence rate

The proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time

Autopsy rate

The proportion or percentage of deaths in a healthcare organization that are followed by the performance of autopsy

Patient's bill of rights

The protections afforded to individuals who are undergoing medical procedures in hospitals or other healthcare facilities

Induced termination of pregnancy

The purposeful interruption of an intrauterine pregnancy that did not result in a live birth

Sample size calculation

The qualitative and quantitative procedures to determine an appropriate sample size

Measure

The quantifiable data about a function or process

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

Anesthesia death rate

The ratio of deaths caused by anesthetic agents to the number of anesthesias administered during a specified period of time

Online/real-time transaction processing (OLTP)

The real-time processing of day-to-day business transactions from a database

Bad debt

The receivables of an organization that are uncollectible

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

Rebasing

The redetermination of the ambulatory payment classification weights to reflect changes in relative resource consumption

Risk factor reduction

The reduction of risk in the pool of members

Continuous monitoring

The regular and frequent assessment of healthcare processes and their outcomes and related costs

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)

Home health prospective payment system (HH PPS)

The reimbursement system developed by the Centers for Medicare and Medicaid Services to cover home health services provided to Medicare beneficiaries

Project network

The relationship between tasks in a project that determines the overall finish date

Dependency

The relationship between two tasks in a project plan

Need-to-know principle

The release-of-information principle based on the minimum necessary standard that means that only the information needed by a specific individual to perform a specific task should be released

Admission type

The required classification used to indicate the priority of an admission/visit required for submitting claims using the electronic 837I format or the equivalent CMS-1450 claim form

Consultation

The response by one healthcare professional to another healthcare professional's request to provide recommendations and/or opinions regarding the care of a particular patient/resident

Divestiture

The result of a parent company selling a portion of the company to an outside party for cash or other assets

Equity financing

The retained earnings or profits generated by an organization

Due process

The right of individuals to fair treatment under the law

Authority

The right to make decisions and take actions necessary to carry out assigned tasks

Anesthetic risk

The risk of harm resulting from the administration of anesthetic agents

Actor

The role a user plays in a system

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

Logical data model

The second level of data model that is drawn according to the type of database to be developed

System design

The second phase of the systems development life cycle

Design phase

The second phase of the systems development life cycle during which all options in selecting a new information system are considered

Chief 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

Critical path or critical pathway

The sequence of tasks that determine the project finish date

Decentralization

The shift of decision-making authority and responsibility to lower levels of the organization

Operational plan

The short-term objectives set by an organization to improve its methods of doing business and achieve its planned outcomes

Materiality

The significance of a dollar amount based on predetermined criteria

Episode

The sixty-day unit of payment for the home health prospective payment system

Common-cause variation

The source of variation in a process that is inherent within the process

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

Heterogeneity

The state or fact of containing various components

Outpatient Service Mix Index (SMI)

The sum of the weights of ambulatory payment classification groups for patients treated during a given period divided by the total volume of patients treated

Project deliverables

The tangible end results of a project

For-profit organizations

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

Mainframe architecture

The term used to refer to the configuration of a mainframe computer

System implementation

The third phase of the systems development life cycle

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

Timeliness

The time between the occurrence of an event and the availability of data about the event. Timeliness is related to the use of the data. (JC 2004 IM-15)

Learning curve

The time required to acquire and apply certain skills so that new levels of productivity and/or performance exceed prelearning levels (productivity often is inversely related to the learning curve)

Current ratio

The total current assets divided by total current liabilities

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

Case fatality rate

The total number of deaths due to a specific illness during a given time period divided by the total number of cases during the same 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

Net death rate

The total number of inpatient deaths minus the number of deaths that occurred less than forty-eight hours after admission for a given time period divided by the total number of inpatient discharges minus the number of deaths that occurred less than forty-eight hours after admission for the same time period

Therapy threshold

The total number of therapy visits (ten) for an episode of care in the Medicare system

Cross-training

The training to learn a job other than the employee's primary responsibility

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

Personal/unique identifier

The unique name or numeric identifier that sets apart information for an individual person for research and administrative purposes

Population

The universe of data under investigation from which a sample is taken

Order entry

The use of a computer and decision support to record and initiate the transmission of a physician's order

Information modeling

The use of clinical code sets with application software to create information that is meaningful to the end user

e-learning

The use of the Internet and its derived technologies to deliver training and education

Owner's equity

The value of the investment in an organization by its owners

Y-axis

The vertical axis on a graph that displays frequency

Technology push model

The view of information technology as being able to push organizations into new business areas

Human immunodeficiency virus (HIV)

The virus that causes acquired immunodeficiency syndrome (AIDS)

No man's land

The zone in the palmar or volar surface of the hand between the distal palmar crease (the crease in the palm closest to the fingers) and the middle of the middle phalanx (middle finger)

"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"

Forecast

To calculate or predict some future event or condition through study and analysis of available pertinent data

Boxplot

Tool in the form of a graph that displays five-number data summary

Awareness training

Training designed to help individuals understand and respond to information technology concerns

Retrospective payment system

Type of fee-for-service reimbursement in which providers receive recompense after health services have been rendered

Network model

Type of health maintenance organization (HMO) in which the HMO contracts with two or more medical groups and reimburses the groups on a fee-for-service or capitation basis

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

Per diem (per day)

Type of prospective payment method in which the third party payer reimburses the provider a fixed rate for each day a covered member is hospitalized

Zero-based budgets

Types of budgets in which each budget cycle poses the opportunity to continue or discontinue services based on available resources so that every department or activity must be justified and prioritized annually to effectively allocate resources

Etiologic diagnosis

Underlying cause or origin of a problem that leads to a certain diagnosis or condition

Retained earnings

Undistributed profits from a for-profit organization that stay in the business

Food and drug interactions

Unexpected conditions that result from the physiologic incompatibility of therapeutic drugs and food consumed by a patient

Reserves

Unused profits from a not-for-profit organization that stay in the business

Common law

Unwritten law originating from court decisions where no applicable statute exists

Judge-made law

Unwritten law originating from court decisions where no applicable statute exists

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

Knowledge sources

Various types of reference material and expert information that are compiled in a manner accessible for integration with patient care information to improve the quality and cost-effectiveness of healthcare provision

VLBW

Very low birth weight

Restraints and seclusion

Ways of managing behavior; the right of patients to be free from non-medically necessary restraints and seclusion is protected under the Medicare Conditions of Participation

Alliance Standards Directory

Web site that includes 850 voluntary and mandatory standards and links to more than 200 standards development organizations (nahit.org/hitsdir/)

Electronic prescribing (e-Rx)

When a prescription is written from the personal digital assistant and an electronic fax or when an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy's information system

Descriptor

Wording that represents the official definition of an item or service that can be billed using a particular code

Statutory law

Written law established by federal and state legislatures

ADFM

active duty family member; a designation used under TRICARE

"Correction

addendum, and appending health records policy","A policy that outlines how corrections, addenda, or appendages are made in a health record"

ALJ

administrative law judge

CC

chief complaint

COMP

comprehensive

CT

computed tomography

CABG

coronary artery bypass grafting

"Usual

customary, and reasonable (UCR) charges",Method of evaluating providers' fees in which the third party payer pays for fees that are 'usual' in that provider's practice; 'customary' in the community; and 'reasonable' for the situation

"Usual

customary, and reasonable (UCR)","Type of retrospective fee-for-service payment method in which the third party payer pays for fees that are usual, customary, and reasonable, wherein 'usual' is usual for the individual provider's practice; 'customary' means customary for the community; and 'reasonable' is reasonable for the situation"

"Use

disclosures, and requests","Three types of situations in which personal health information is handled: use, which is internal to a covered entity or its business associate; disclosure, which is the dissemination of PHI from a covered entity or its business associate; and requests for PHI made by a covered entity or its business associate"

E/M

evaluation and management

IPPB

intermittent positive pressure breathing

LEEP

loop electrode excision procedure

LBW

low birth weight

OB

obstetrics

OMT

osteopathic manipulative treatment

PICU

pediatric intensive care unit

PTCA

percutaneous transluminal coronary angioplasty

"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"

PMD

primary medical doctor

PF

problem focused

POMR

problem-oriented medical record

"Labor-related share (portion

ratio)","Sum of facilities' relative proportion of wages and salaries, employee benefits, professional fees, postal services, other labor-intensive services, and the labor-related share of capital costs from the appropriate market basket. Labor-related share is typically 70 to 75 percent of healthcare facilities' costs. Adjusted annually and published in the Federal Register"

"Understandable

reproducible, and useful (URU) principle","The guiding principal for modeling concepts in SNOMED CT, which states that all concepts must be understandable, reproducible, and useful"

SOF

signature on file

SEPs

somatosensory evoked potentials

SF