Hit: Chapter 5

Front 1

data element

Back 1

single fact or measurement
- represents fact

ie. age, gender, blood pressure

Front 2

data information

Back 2

data that has been analyzed and interpreted
-represents meaning

Front 3

aggregate data

Back 3

extracted from individual patients used to develop info about groups
-represents commonalities

Front 4

data sets

Back 4

identifies/lists of data elements with uniform meaning
-identify and define common terms

Front 5

hospital discharge abstract systems

Back 5

compiles aggregate data on discharged patients

Front 6

healthcare information standards

Back 6

supports EHR development and info exchange

Front 7

Office of National Coordinator of HIT (ONC)

Back 7

harmonization of standards from multiple sources

Front 8

National Committee on Vital and Health Statistics (NCVHS)

Back 8

guidelines for info from multiple locations so they can be exchanged with equitable rules

Front 9

Nationwide Health Information Network (NHIN)

Back 9

supports implementation of EHRs and data sets
-improves patient care, safety and decision making securely and seamlessly

Front 10

data dictionary

Back 10

first step in implementing EHRs
-adopt recognized standards
-normalize defintions

Front 11

Uniform Hospital Discharge Data Set (UHDDS)

Back 11

hospital INPATIENT data
-short term stay
-sex, dob,race, etc
-conditions, discharge

Front 12

Uniform Ambulatory Care Data Set (UACDS)

Back 12

OUTPATIENT data
-walk in/walk out, same day
-has Medicare limits

Front 13

Healthcare Information Technology Standards Panel (HITSP)

Back 13

specifies terminology for clinical documents and messages

Front 14

National Center for Health Statistics (NCHS)

Back 14

developed data sets

Front 15

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

Back 15

mandated assessment form collecting demographic and clinical data on nursing home residents
-long-term resident care plan

Front 16

Minimum Data Set (MDS)

Back 16

-long term care
-extensive
-safety/ quality
- "gets a RAP" (resident assessment)

Front 17

Resident Assessment Protocol (RAP)

Back 17

organize resident info and develop a resident care plan

-conditions, risks, care plan, referrals, evaluations

Front 18

Department of Health and Human Services (HHS)

Back 18

implements MDS and RAP

Front 19

Outcomes and Assessment Information Set (OASIS-C)

Back 19

data set designed to gather data about Medicare beneficiaries receiving home health care
-reimbursement

Front 20

Health Plan Employer Data and Information Set (HEDIS)

Back 20

set of standard performance measures used to compare the performance of healthcare plans

Front 21

Data Elements for Emergency Department Systems (DEEDS)

Back 21

collects uniform data about hospital emergency encounters
-trauma

Front 22

ORYX initiative
by Joint Commission

Back 22

integrates outcome data and performance measurement data into it accreditation process
-research internal quality/safety

Front 23

Joint Commission

Back 23

largest user of healthcare data and information
-accreditation of hospitals and organizations

Front 24

NHIN Dimensions and Core Data Elements

Back 24

**personal- individual can edit data
*healthcare provider- provider can access info
*population/community- population based health data and surveyllience

Front 25

transaction standards

Back 25

uniform format and sequence of data from one to provider to another
-with ANSI ASC X12N (billing)

Front 26

transmission standards

Back 26

when data crosses an entire network

Front 27

Benefits of Data Exchange Standards

Back 27

collect, maintain and transfer data among other computer systems
-common language

Front 28

American Recovery and Reinvestment Act (ARRA)

Back 28

economic stimulus that provides reimbursement incentives to "meaningful users" of EHR

Front 29

Meaningful use of EHR

Back 29

uses EHR technology to improve quality of care
-gives incentives
-used by ARRA/HITECH

Front 30

Health Information Technology for Economic and Clinical Health Act (HITECH)

Back 30

deals with health information communication and technology provisions
-"meaningful use" incentives

Front 31

Office of National Coordinator (ONC)

Back 31

uses $$ by ARRA to improve quality of consumers to manage their care and safety

Front 32

Health Information Technology (HIT) Policy Committee

Back 32

provides recommendations to the National Coordinator (ONC) on policies
-HHS advisory group

Front 33

Health Information Technology (HIT) Standards Committee

Back 33

provides recommendations to the ONC on implementation of policies

Front 34

Standard defined

Back 34

well-defined approach that supports a business
-publicly agreed upon
-rules and intended purposes
-voluntary consensus

Front 35

Standards Development Organizations (SDOs)

Back 35

creation or revision of standards
-created through concensus

Front 36

consensus

Back 36

implements healthcare informatics standards

Front 37

American National Standards Institute (ANSI)

Back 37

coordinates the development of voluntary standards
-electronic billing

Front 38

Health Level 7 (HL7)

Back 38

SDO that develops messaging, data content and document standards to support the exchange of clinical info
-non profit

Front 39

LOINC

Back 39

lab data successfully transferred back and forth

Front 40

structure and content standards

Back 40

provide clear and uniform definitions of data elements used in EHRs

Front 41

continuity of care record (CCR)

Back 41

core data set of administrative, demographic and clinical info that helps communicate from one provider to another

Front 42

American Society for Testing and Materials (ASTM)

Back 42

SDO that develops standards of the EHR for a variety of industries in USA to share info from one provider to another

Front 43

ASTM and CCR

Back 43

work together to share info from one provider to another

Front 44

Technical/Interoperability standards

Back 44

-content and structure
-vocabulary
-how data is transmitted
-protocols (rules)

Front 45

Institute of Electrical and Electronics Engineers (IEEE)

Back 45

pertains to connectivity and configuration of medical devices

Front 46

Digital Imaging and Communication in Medicine (DICOM)

Back 46

used by medical professions that use imaging

ie. radiology, dentistry

Front 47

Vocabulary/Terminology/Classification standards

Back 47

consistent definition of entities and attributes

Front 48

Extensible Markup Language (XML)

Back 48

universal language to facilitate storage and transmission of data published on the Internet

Front 49

ASC X12N

Back 49

ANSI accredited Insurance Subcommittee
-set of rules applying to billing

Front 50

Outcomes and Assessment Information Set (OASIS)

Back 50

standard patient assessment
-Medicare certified HOME HEALTHCARE

Front 51

semantics

Back 51

meaning of a clinical concept

Front 52

National Council for Prescription Drug Programs (NCPDP)

Back 52

committee for exchanging prescription payment info

Front 53

Centers for Medicare/Medicaid Services (CMS)

Back 53

provides hospital quality measures
-ups payment rate = more $$
-long-term -OASIS

Front 54

Primary purpose of MDS (minimum data standard)

Back 54

recommend common data elements to be collected in health records

Front 55

Health Insurance Portability and Accountability Act (HIPAA) Title2

Back 55

federal law that health care services (HHS) develop standards governing data exchange and security

Front 56

Health Insurance Portability and Accountability Act (HIPAA) Title2

Back 56

medical liability reform
-prevents fraud and abuse
-simplifies privacy, identifiers, code sets

Front 57

6 Important Data Sets

Back 57

OASIS- home health
MDS- long term
UHDDS- inpatient
UACDS- outpatient
HIPAA- title 2 security/privacy
ANSI- electronic billing standard

Front 58

Data Quality
Aunt Annie craves chocolate cake, donuts, grits, potatoes, rice, tomatoes

Back 58

Accuracy, Accessibility, Comprehensiveness, Currency, Consistency, Definition, Granularity,Precision, Relevancy, Timeliness

Front 59

Social Security number

Back 59

number that has been processed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns

Front 60

World Health Organization (WHO)

Back 60

Published and revised ICD-9 and ICD-10 (ICD disease codes)
-helps to standardize terminology for the collection and processing of medical information

Front 61

ICD-9 and ICD-10
International Classification of Diseases

Back 61

used to provide dx codes to medical records

Front 62

World Health Organization (WHO)

Back 62

published and revised IDC-9 and ICD-10 coding books
-helped standardize terminolology of medical information

Front 63

International Classification of Diseases (ICD)

Back 63

used to provide dx codes to medical records