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54 Cards in this Set

  • Front
  • Back
What are information systems that capture and feed data into the EHR?
Source Systems
What is a snapshot of data from the EHR and includes basic info. such as diagnoses, allergies, medications, and future treatment?
Continuity of Care Record (CCR)
What has been established as the minimum requirements for the CCR?
A core data set
What is a tool for collecting, tracking and sharing important, up–to–date information on the pt's medical history?
Personal Health Record (PHR)
What does a PHR include?
Allergies, diagnoses, medications, and social and family history
What is built into an EHR to prevent a medication error before the prescription is executed and the EHR can eliminate issues encountered with handwriting and illegibility?
What can notify a physician of screening that should be performed based on the pt's age and gender?
What is a reason to implement the EHR?
Improve pt care
What is an example of a reminder?
Pt is due for MMR immunization
What is the system that includes pt info from both the pt and the healthcare provider?
To receive full benefits of the EHR, when should one document?
At the point of care
What obtained a contract from HHS to develop and evaluate certification criteria and to develop a process to be used to certify vendor products?
What adds further info including charges for services provided and then creates a bill?
Patient Financial Services
What system notifies clinical departments of orders made by the physician?
Order communication system
What system includes intensive care units, anesthesia, and labor and delivery?
Specialty clinical applications
What are systems that capture data such as vital signs and fetal monitoring?
Smart peripherals
What is a structure method of communication between the healthcare provider and the pt, just the providers, or the provider and payer?
Patient–Provider Portal
Also called narrative data, what can be entered in a free text format by the user, usually typing?
Unstructured data
What automates many of the medication administration processes in a healthcare facility?
Electronic Medication Administration Record (EMAR)
What is controlled by the pt?
What is the exchange of health information electronically between providers and others with the same level of interoperability such as labs and pharmacies?
Health Information Exchange (HIE)
Which component of the EHR allows pts to retrieve their test results?
Patient–Provider portal
What is the ability of a healthcare facility to provide EHR software to physicians is allowed through?
Stark law
What is money an example of to the EHR?
What function is typically found in the ambulatory EHR but not the inpt EHR?
Practice Management
What is a benefit of the EHR?
Improved Efficiency
What is an example of cost avoidance?
Not repeating test
What is a scanned image of an individuals actual signature?
Digitized Signature
What requires at least a password but can use a two–factor authentication method?
Electronic Signature
What is used for secondary data?
Classification Systems
What is responsible for accrediting SDOs in the United States?
American National Standards Institute (ANSI)
What does not develop standards but, rather, provides a neutral environment for others to work together to settle on a common agreement?
What facilitate interoperability through the standardization of the structure and content of data elements?
Data Content Standards
What allows for comparison and aggregation of data?
Systematized Nomenclature of Medicine Clinical Terms (SNOMED)
What is a branch of linguistics dealing with the study of meaning, including the ways meaning is structured in language and how changes in meaning and forms occur over time?
What were developed by the food and Drug Administration to act as a universal identifier for human drugs?
National Drug Codes
What is a crosswalk between the various terminologies?
What is the most secure type of signature?
Digital Signature
What is SNOMED an example of?
What is the mapping system used to convert ICD–9–CM to ICD–10–CM?
Who accredits SDOs?
What is used to identify drugs?
What is a SDO that is accredited by ANSI and specialized in standards for clinical and administrative data?
Health Level 7
Whose mission is the provides standards for interoperability that improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer among all of our stakeholders, including healthcare providers, government agencies, the vendor community and fellow SDOs and pts?
What is a standard developed for and used by pharmacies and payers?
National Council for Prescription Drug Programs (NCPDP)
What technology is used to navigate through an information system?
Graphical User Interface (GUI)
What is the messaging standard used in most clinical information systems?
What is DICOM an example of?
messaging standard
What is a database updated in real time?
Data Repository
What method of data entry is checkboxes?
What is part of the design process?
Use case
What organization supports, oversees, or governs the exchange of health–related information among organizations according to nationally recognized standards?
Health Information Exchange Network
What is the program that provides incentive payments to healthcare providers who meet certain criteria for using the EHR?
Meaningful Use
What is a health information exchange model?
Directed exchange