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131 Cards in this Set
- Front
- Back
A uniform coding system that consists of
descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by providers and is maintained by the AMA. |
CPT
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|
Analyzing information in a database using
tools that look for trends or anomalies with- out knowledge of the data’s meaning. Mining a clinical database may produce new insights on outcomes, alternate treatments, or effects of treatment on different races and genders. |
Data Mining
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A list of preferred pharmaceutical products
that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescrip- tion drugs without sacrificing quality. |
Drug Formulary
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Requirements to store data, applications,
backup, multimedia, etc., on a storage medium (disk, tape, CD, DVD, etc.). Ex- pressed in Megabytes, Gigabytes, Terabytes, and Petabytes. |
Data Storage
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A computer application that allows a physi-
cian’s orders for diagnostic and treatment ser- vices (such as medications, laboratory, and other tests) to be entered electronically in- stead of being recorded on order sheets or prescription pads. |
CPOE
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Standardized electronic format for business
transactions sent from one computer to an- other computer system. Consists of strings of data in a pre-arranged accepted format by both sending and receiving computer systems. Also includes electronic claims submission, electronic remittance notices and electronic eligibility checks, etc. |
EDI
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A code set with descriptive terms developed
and updated by the American Dental Associ- ation (ADA) for reporting dental services and procedures to dental benefit plans. Many of the codes are published by CMS as HCPCS D-codes under arrangement with the ADA. |
CDT
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Process of overcoming resistance to change
and promoting adoption (of EHR). Change management strategies are often incentive- based, behavioral norm-based, sanction- based, or adoption based. |
Change Management
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A database acting as an information storage
facility. Although often used synonymously with data warehouse, a repository does not have the analysis or querying capabilities of a warehouse. |
Data Repository
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A list that describes the specifications and
locations of all data contained in a system. |
Data Dictionary
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The use of electronic technology to gather
and collect data, especially in the context of clinical trials. Allows data to be aggregated, sorted, shared, and searched more easily than paper-based records. May be Web-based, use handheld computers, etc. |
EDC
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This term is sometimes used interchange-
ably with EMR. Typically covers: *Pathology and radiology order entry and results report- ing; *Medication prescribing, supply and ad- ministration; *Clinical work lists; *Problem lists; *Clinical notes; and *Decision support. |
CIS
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Health care information from which indi-
vidual identifying information (as specified by HIPAA) has been stripped. |
De-Identified Data
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Primary area of electronic circuitry in a
computer where processing takes place. |
CPU
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A set of computer programs for organizing
the information in a database. These pro- grams support the structuring of the database in a standard format and provides tools for data input, verification, storage, retrieval, query, and manipulation. |
DBMS
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An itemized statement of health care ser-
vices and their costs provided by a hospital, physician’s office or other health care facility. Claims are submitted to the plan by either the plan member or the provider for payment of the costs incurred. |
Claim
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A real time patient health record or any
other information relating to the past, present or future physical and mental health, or con- dition of a patient which resides in computers which capture, transmit, receive, store, re- trieve, link, and manipulate multimedia data for the primary purpose of providing health care and health-related services. |
EHR
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A service providing connectivity between
healthcare providers and payers (HMOs, in- surers, government entities such asMedicare). They translate and reformat claims according to the specifications by payers and re-transmit them to their original destination. They may also add edit functions to check the validity and completeness of the claims. |
Clearinghouse
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Executive with responsibility for leading the
medical affairs of a healthcare provider orga- nization (may have multiple other names). |
CMO
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This is a critical component of any EMR
system. Its focus is to aid the care-giver in the care decision making process by monitoring relevant information and producing alerts or reminders when certain events occur. |
CDSS
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The use of an algorithmic process to trans-
form data into a form in which there is a low probability of assigning meaning without use of a confidential process or key. |
Encryption
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A computer that stores data centrally for
network users. It often uses client/server software to distribute the processing of data among itself and other workstations on the network. |
Database Server
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A computer-based patient medical record
that facilitates: *access of patient data by clinical staff at any given location; *accurate and complete claims processing by insurance companies; *building automated checks for drug and allergy interactions; *clinical notes; *prescriptions; *scheduling; *sending to and viewing by labs. |
EMR
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An aggregation of records or other data
that is updateable. These are used to manage and archive large amounts of information. |
Database
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A classification system that groups patients
according to diagnosis, type of treatment, age and other relevant criteria for the purposes of payment to hospitals. |
DRG
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The process of sending updates between
a mobile computing device and a personal computer or application server in order to keep both sets of files synchronized. Some- times called ”hot syncing.” Sometimes spelled ”synch.” |
Data Synchronization
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Sometimes referred to as Advanced Elec-
tronic Signature. Takes the traditional hand- written signature and creates a digital image of the signature to eliminate the need to print and sign documents. |
Digital Signature
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Type of digital signature that binds the
identity of an individual with a public key in an asymmetric encryption technology. |
Digital Certificate
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The industry standard for transferral and
storage of diagnostic images from medical modalities such as radiology, cardiology, etc. This standard enables digital communication between diagnostic equipment and systems from various manufacturers. |
DICOM
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Compares costs to tangible, financial bene-
fits of an investment. Benefits and costs are often expressed in money terms, and are ad- justed for the time value of money, so that all flows of benefits and flows of project costs over time (which tend to occur at different points in time) are expressed on a common basis in terms of their ”present value.” |
Cost/Benefit Analysis
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A technology for delivering high-bandwidth
service (Internet or data) over ordinary cop- per telephone lines. |
DSL
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Secure transmission of health information messages; often accomplished through provider and/or patient portals.
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CDSS
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An application for payment of benefits un-
der a health care plan. |
Claim Form
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Program written so that data can be shared
across two disparate systems. |
Interface
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A large database that stores information
like a data repository but goes a step fur- ther, allowing users to access data to perform research oriented analysis. |
Data warehouse
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A private sector United States-based not-for-
profit organizationthat operates accreditation programs for a fee to subscriber hospitals and other health care organizations. |
JCAHO
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Project management chart displaying
project tasks and bars indicating duration and progress. |
GANTT chart
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A complete listing of fees used by the plans
to pay providers. |
fee schedule
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Set of rules to exchange messages over the
Internet. It has the task of delivering distin- guished protocol datagrams (packets) from the source host to the destination host solely based on their addresses. |
IP
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Moment in time at which a new information
system is turned on for production use. |
Go-Live
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The ability of software and hardware on
multiple pieces of equipment made by differ- ent companies or manufacturers to communi- cate and work together. |
Interoperability/ Compatibility
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A set of standardized performance mea-
sures, used in NCQA accreditations, designed to ensure that purchasers and consumers have the information they need to reliably com- pare the performance of managed health care plans. |
HEDIS
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A federal health benefits law effective July
1, 1997 that protects people who change jobs, are self-employed or who have pre-existing medical conditions. Standardizes an ap- proach to the continuation of health care ben- efits for individuals and members of small group health plans and establishes parity be- tween the benefits extended to these individ- uals and those benefits offered to employees in large group plans. |
HIPAA
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Specific requirements or instructions for im-
plementing a standard. |
Implementation Specification
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A network in which all computers in the
various facilities of an organization (e.g., a health care system) are connected. |
Enterprise-Wide Network
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Classification system that groups related
disease terms; used throughout the world for reporting mortality data and some morbidity data; ICD-9-CMis the clinical modification of the 9th edition used in the U.S. for reimburse- ment coding of diagnoses (most other parts of the world are using the 10th edition, ICD-10) |
ICD
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A uniform method for providers to report
professional services, procedures, and sup- plies. Includes CPT codes (Level I) and na- tional alphanumeric codes (Level II). |
HCPCS
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A computer dedicated to managing the flow
of information among networked computers and used as a storage location for data and applications shared by network users. |
File Server
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Computer technology in which physicians
use handheld or personal computer devices to review drug and formulary coverage and transmit prescriptions to a printer, EMR or pharmacy. This software can be integrated with existing clinical information systems to allow access to patient-specific information to screen for drug interactions and allergies. |
e-Prescribing/ eRx
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The application of computer technology to
the management of information. |
Informatics
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The process by which an individual’s im-
mune system becomes fortified against an agent (known as the immunogen). |
Immunization
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One of several accredited standards (spec-
ifications or protocols) established by ANSI (American National Standards Institute) for clinical and administrative data. Compliant systems improve the ability for interoperabil- ity and exchange of electronic data. |
HL7
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Tool for describing and analyzing the steps
and their flow in a process. |
Flow Process Chart
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The movement of healthcare information
electronically across organizations within a region or community. Provides the capability to electronically move clinical information be- tween disparate healthcare information sys- tems while maintaining the meaning of the information being exchanged. |
HIE
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A payment method in which the insurer will
reimburse the member or provider directly for each covered medical expense (professional service, laboratory, x-ray, injections, etc.). |
Fee For Service Payment
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A system that secures a network, shield-
ing it from access by unauthorized users. It can be implemented in software, hardware or a combination of both. In addition to pre- venting unrestricted access into a network, it can also restrict data from flowing out of a network. |
Firewall
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In a client/server system, a client that per-
forms most of the necessary data processing itself, rather than relying on the server. |
Fat Client
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Probably the most commonly used stan-
dard for local area network (LAN) architec- ture. It supports data transfer rates of up to 10 megabits per second, although newer sys- tems support transfer rates of 100 Mbps and 1 gigabit (1,000 megabits) per second. |
Ethernet
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An HMO meeting certain federal qualifica-
tions under Title XIII of the Public Health Service Act. |
Federal Qualified
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With the American National Standards In-
stitute (ANSI), this organization of 18 inde- pendent entities serves as a cooperative part- nership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to en- able and support widespread interoperability among healthcare software applications, as they will interact in a local, regional and national health information network for the United States. |
HITSP
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A type of managed-care organization that
provides health care coverage through con- tracts with specific health care providers. Such organizations may restrict coverage to only those services and providers that have been predetermined. |
HMO
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The use of evidence (scientific information)
and clinical expertise to make clinical deci- sions regarding the effectiveness of a specific treatment or diagnostic test, how well it works in comparison to other treatments or tests, and what, if any, risks are associated with a therapy or test. |
Evidence Based Medicine
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The healthcare industry’s membership or-
ganization exclusively focused on providingleadership for the optimal use of healthcare information technology and management sys- tems for the betterment of human health. |
HIMSS
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A form sent to the enrollee after a claim
for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, rea- sons for denying payment, or the claims ap- peal process. |
EOB
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One form of external application used to en-
ter or interface with patient data and EMRs (Electronic Medical Records). Typically used by hospital pathology departments or inde- pendent laboratories to record activity in the department and transmit or store various test results. |
LIS
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The United States government’s principal
agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. |
HHS
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It is intended to foster and improve continuity of patient care, to reduce medical errors, and to assure at least a minimum standard of health information transportability when a patient is referred or transferred to, or is otherwise seen by, another provider.
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CCR
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Prohibits certain solicitations or receipt of remuneration and the offer or payment of certain remuneration. It has generally been applied to broker-style arrangements, whereby an individual offers remuneration to another individual for the purpose of recommending or referring an individual for the furnishing or arranging for an item or service.
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Anti-Kickback Statute
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A real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. It is optimized to allow clinicians to retrieve data for a single patient rather than to identify a population of patients with common characteristics or to facilitate the management of a specific clinical department.
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CDR
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A health insurance payment mechanism in which a fixed amount is paid per person to cover services; a fixed, per capita (per head) payment.
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Capitation
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This is a standard format used for transmitting business data, developed by the Data Interchange Standards Association. The parties who exchange EDI transmissions are referred to as trading partners. Data that is transmitted often includes what would usually be contained in a typical business document or form.
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ANSI X12 Standard
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A wireless networking standard ratified by the IEEE in late 1999 and supported by the largest wireless local area network (WLAN) vendors. Also known as Wi-Fi. 802.11b has data transfer rates of 11Mbs. 802.11g (newer standard has rates of 54 Mbs).
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802.11x
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Hosts applications on servers in ASP data centers to allow users to get connected and use applications as if they were located in the client's own site. An ASP handles maintenance and upgrades to lower the total cost of ownership (TCO) for clients, while minimizing the risks and costs of keeping highly skilled IT talents.
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ASP
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Information technology strategy where the best products are adopted, irrespective of their ability to be integrated.
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Best Of Breed
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Usually a hospital database containing patient admission and discharge data. Often a source of patient demographics through HL7 interface.
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ADT
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A patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or EMR systems, allowing easy interoperability between otherwise disparate entities. Developed by the American Society for Testing and Materials (ASTM).
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ASTM CCR Standard
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An evaluative process in which a healthcare organization undergoes an examination of its policies, procedures and performance by an external organization ("accrediting body") to ensure that it is meeting predetermined criteria. It usually involves both on- and off-site surveys.
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Accreditation
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A community of professionals engaged in health information management, providing support to members and strengthening the industry and profession.
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AHIMA
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Federal government agency within HHS that, among other things, maintains the National Guideline Clearinghouse of clinical guidelines.
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AHRQ
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This is the amount Medicare approves for payment to a physician, but may not match the amount the physician gets paid by Medicare (due to co-pay or deductibles) and usually does not match what the physician charges patients. Medicare normally pays 80 percent of the approved charge and the beneficiary pays the remaining 20 percent. The allowed charge for a nonparticipating physician is 95 percent of that for a participating physician. Non-participating physicians may bill beneficiaries for an additional amount above the allowed charge. The CMS intermediary in each state publishes these rates.
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Allowed Charge
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Professional services by a hospital or other inpatient facility. These may include x-ray, drug, laboratory, or other services.
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Ancillary Services
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Capability of an information system to work with earlier versions. Important consideration in working with legacy systems.
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Backward Compatibility
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Refers to the average length of stay per inpatient hospital visit. The figure is typically calculated for both commercial and Medicare patient populations.
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ALOS
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The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care. Efforts to improve access often focus on providing/improving health coverage.
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Access
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The first professional group to issue guidelines for physician-patient e-mail. AMIA is dedicated to promoting the effective organization, analysis, management, and use of information in health care in support of patient care, public health, teaching, research, administration, and related policy.
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AMIA
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Physical characteristic (e.g., fingerprint) of a computer user used to provide authentication. Confidentiality laws and HIPAA privacy rules refer to biometric identifiers.
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Biometric/Biometric Identifier
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The date the patient was admitted for inpatient care, outpatient service, or start of care. For an admission notice for hospice care, enter the effective date of election of hospice benefits.
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Admission Date
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An economic stimulus package enacted by the 111th United States Congress in February 2009. The Act of Congress was based largely on proposals made by President Barack Obama and was intended to provide a stimulus to the U.S. economy in the wake of the economic downturn. The measures are nominally worth $787 billion. The Act includes federal tax cuts, expansion of unemployment benefits and other social welfare provisions, and domestic spending in education, health care, and infrastructure, including the energy sector.
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ARRA
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A pattern of healthcare in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Specialized personnel using complex and sophisticated technical equipment and materials usually give acute care in a hospital. Unlike chronic care, acute care is often necessary for only a short time.
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Acute Care
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Radio-based device that provides users of wireless devices with access to a local area network (LAN). Also WAP (Wireless Access Point).
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Access Point
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A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.
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Advance Directives
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An automated warning system within an EHR system that provides clinical alerts, preventive health maintenance information, medication interactions, etc., to users.
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Alerts
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An injury to a patient resulting from a medical intervention. As regards clinical studies, adverse events are any adverse changes in health or "side-effects" that occur in a person who participates in a clinical trial while the patient is receiving the treatment (study medication, application of the study device, etc.) or within a pre-specified period of time after their treatment has been completed.
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Adverse Event
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The U.S. government agency at the forefront of public health efforts to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats. The CDC is one of 13 major operating components of the Department of Health and Human Services.
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CDC
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A measure of how much information can be transmitted at once through a communication medium, such as a telephone line, fiber-optic cable, or radio frequency. Usually reported in Megabits per second (Mbps).
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Bandwidth
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A place other than a hospital that does outpatient surgery. At an ambulatory (in and out) surgery center, you may stay for only a few hours and no more than one night.
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Ambulatory Surgical Center
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A voluntary, private-sector organization launched in 2004 to certify health information technology (HIT) products such as electronic health records and the networks over which they interoperate.
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CCHIT
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Health services provided without patient admission or overnight stay. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading provided that the patient remains at the facility less than 24 hours. Also called outpatient care.
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Ambulatory Care
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A Web site that offers a range of resources, such as e-mail, chat boards, search engines, content and online shopping. Typical examples include MSNBC.com and Yahoo.com.
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portal
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the identifying drug number maintained by the Food and Drug Administration. Manufacturers that have executed Pharmaceutical Pricing Agreements (PPA) report quarterly information to the Office of Pharmacy Affairs by NDC number including labeler code, product code, and package size code.
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NDC
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Document that requests a formal proposal from a vendor, to be included as part of contract.
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RFP
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Software in which the source code is available to users, who can read and modify the code. VISTA, the EMR system created by the Veterans Administration hospital system, is an example of open source code EMR.
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Open Source
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Formerly peer review organization (PRO); a company contracted by CMS to conduct utilization reviews for the federal government. The Medicare QIO program consists of a national network of fifty-three QIO's found in each state responsible to work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems. They are associated with the DOQ-IT program.
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QIO
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Typically used by hospital pharmacy de-
partments to record activity in the depart- ment and store or access EMRs. Dispensed medications generated from this system may be initially stored in an intermediate EMR and then sent to an EHR as part of an EHR extract such the current medication list in a discharge summary. |
PIMS
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The United States health program for eligi-
ble individuals and families with low incomes and resources. It is a means tested program that is jointly funded by the state and federal governments, and is managed by the states. |
Medicaid
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The HIPAA-mandated, standard, unique
identifier for health care providers. It is an in- telligence free numeric identifier, which means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization. |
NPI
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Establishing an amount that may be bor-
rowed from a bank at a given cost. |
LOC
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Structure within the Centers for Disease
Control and Prevention (CDC) that supports exchange of public health data. |
PHIN
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A law in several states requiring all regis-
tered motor vehicles to be covered by personal injury protection insurance. Under this law, a person’s own motor vehicle insurance com- pany pays for expenses relating to an accident regardless of who caused the accident. |
No Fault
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The US Department of Health and Human
Services office, established in 2004, to pro- vide leadership for the development and na- tionwide implementation of an interoperable health information infrastructure. |
ONCHIT
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An information system that uses an image
server to store and exchange X-rays, CT Scans and other medical images over a network. |
PACS
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The electronic means by which patient files
are located to assist patients and clinicians to find test results, medical history, prescrip- tion data, and other health information. A record locator would act as a secure health information search tool. |
PRL
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Analysis of processes to effect changes that
bring about benefits. |
Process Improvement
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A nationwide healthcare insurance program
created by the 1965 amendments to the So- cial Security Act and operated under the pro- visions of the Act for the aged (65 and over), disabled, and individuals with end-stage re- nal disease. It consists of two separate but coordinated programs, Part A and Part B. |
Medicare
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Evaluation of direct patient care, measured
around diagnosis, medical condition, or care processes along with outcomes of the medical intervention. |
QI
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Combines physical hard disks into a single
logical unit either by using special hardware or software. Hardware solutions often are de- signed to present themselves to the attached system as a single hard drive. Software so- lutions are typically implemented in the op- erating system, and again would present the array as a single drive to applications. |
RAID
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A database in which all information is ar-
ranged in tables containing predefined fields. Changing a field in one record automatically changes the same field in all related records, allowing for easy global database manage- ment. |
Relational Database
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A procedure used to review and assess the
medical necessity and appropriateness of elec- tive hospital admissions and non-emergency outpatient services before the services are pro- vided. Related to pre-certification. |
Pre-Authorization
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Main memory, sometimes called cache,
where data are placed during processing. |
RAM
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Services that must be coordinated and ap-
proved by the health plan’s medical or be- havioral healthcare management programs to be fully covered by the plan. To avoid a re- duction or denial of benefits, members must precertify. |
Pre-Certified Services
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Chart to manage the scheduling, duration, and progress of tasks in a large project.
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PERT
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Publication (in the Federal Register) of the
intent to issue a rule, or regulation that solic- its comments and public comment |
NPRM
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Individually identifiable health information
protected under the HIPAA Administrative Simplification provisions. |
PHI
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Tool that aids in describing current pro-
cesses so they may be evaluated for improve- ment. |
Process Mapping
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An application responsible for recording and reporting administrative details of a patients encounter in a hospital. Episode details generated from this application may be initially stored in an intermediate EMR and then sent to an EHR as part of an EHR extract such as a discharge summary.
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PAS
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An electronic record of health-related infor-
mation on an individual that conforms to na- tionally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual |
PHR
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|
A standard code set covering medical
terms, procedures and diagnoses maintained by Regenstrief and adopted by the largest commercial laboratories and most Federal agencies. It facilitates the exchange of clini- cal lab results for clinical care, public health outcomes management, and research. |
LOINC
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That portion of the medical office record
which contains financial, demographic and non-medical information about patients. |
PMS
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Use of radio waves via an antenna and
transceiver to transmit data. May be used in inventory management, patient identifica- tion, and medication verification. |
RFID
|
|
A condition, disease, illness or injury for
which medical advice, diagnosis, care or treat- ment was received or recommended within a specified time period prior to enrolling in health plan. |
Pre-Existing Condition
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Describes the technologies, standards, laws,
policies, programs and practices that enable health information to be shared among health decision makers, including consumers and pa- tients, to promote improvements in health and healthcare. |
NHIN
|