Health Information Management Practice Flashcards

Vocabulary terms and definitions related to Health Information Management (HIM), data registries, data quality, electronic health records (EHR), and clinical documentation integrity based on the lecture transcript.

Master Patient Index (MPI)

The most important resource in a healthcare facility for tracking patient activity, used to accurately match patients being registered for care with their records.

Enterprise Master Patient Index (EMPI)

Provides access to multiple repositories of information from overlapping patient populations maintained in separate systems and databases; it consolidates information from registration, scheduling, financial, and clinical software systems.

Biometric Authentication

A component used in patient registration to enhance identification and decrease duplicate entries; examples include retina or iris scanning, voice recognition, and palm vein scanning.

Palm Vein Scanning

A biometric identification method utilizing the patient's vein patterns under the skin of the palm; it is considered less intrusive and does not involve radiation.

Physician Index

Categorizes patients by primary physician and guides the retrieval of cases treated by a particular physician, surgeon, or specialist.

Disease Index

An index arranged by diagnosis codes that allows the retrieval of patient information to facilitate the study of patients with similar conditions.

Operation Index

An index arranged by procedure codes used to facilitate the study of patients with similar treatments.

Registry

A chronological list of patients with a common characteristic, containing more extensive information than an index.

Case Definition

The registry maintenance activity that involves describing the patients who are to be included in the registry.

Case Finding

The registry maintenance activity of identifying specific patients to be included in the registry.

Case Abstracting

The process of extracting specific information from health records to be included in a registry.

Cancer Registry

Aggregates information on new cases of cancer to improve clinical diagnosis and treatment, and can be facility-based or population-based.

Accession Number

A number used in cancer registries to identify a case; the first two digits represent the year the patient was first seen at the facility.

Trauma Registry

Tracks patients with severe traumatic injuries from initial treatment to death to provide information for quality improvement.

National Practitioner Data Bank (NPDB)

An electronic repository of medical malpractice payments, adverse licensure actions, and professional review actions taken against healthcare providers.

Data Quality Management (DQM) Domains

The four main areas of DQM: Application, Collection, Warehousing, and Analysis.

Accuracy (Data Quality)

The extent to which data are free of identifiable errors.

Accessibility (Data Quality)

The characteristic that data items are easily obtainable and legal to access with strong protections and controls.

Comprehensiveness (Data Quality)

The extent to which all required data items are included, ensuring the entire scope of data is collected.

Consistency (Data Quality)

The extent to which healthcare data are reliable and remain the same across various applications.

Currency (Data Quality)

The extent to which data are up-to-date for a specific point in time.

Granularity (Data Quality)

The level of detail at which the attributes and values of healthcare data are defined.

Precision (Data Quality)

The characteristic that data values should be strictly stated to support the intended purpose.

Relevancy (Data Quality)

The extent to which healthcare-related data are useful for the specific purposes for which they were collected.

Timeliness (Data Quality)

Whether data is up-to-date and available within a useful time frame based on the context of use.

Primary Data Source

The health record itself, containing patient-specific data documented by professionals who provided care.

Secondary Data Source

Data taken from the health record and entered into registries or databases, also known as aggregate data.

Interoperability

The ability of different information technology systems and software applications to communicate and exchange data accurately and effectively.

Legacy System

A previous electronic health record system that can still be accessed for its data but is no longer updated.

Hybrid Health Record

A health record that includes both paper and electronic formats, such as audio, film, images, or microfiche.

Workflow

The specific process followed to complete a task, job, or responsibility.

Cybersecurity

The ability to protect electronic data against unauthorized and criminal use.

Medical Identity Theft

The fraudulent presentation of a patient for care using someone else's identity to access medical care or insurance benefits.

Migration Path

A series of coordinated and planned steps required to successfully transition from one software system to another.

Best of Fit

An implementation approach where a new EHR interfaces with existing systems from a single vendor, though it may not be the best product on the market.

Best of Breed

An approach where the best individual products are selected from multiple vendors, requiring interfaces to be built for system communication.

System Development Life Cycle (SDLC)

A continual cycle for implementing information systems including: Evaluate need, Define requirements, Obtain EHR, Test, Implement, and Maintain.

Data Dictionary

A descriptive list of names, definitions, and attributes of data elements to standardize definitions and ensure consistent use in a database.

Metadata

Data about data, such as the creation time of a document or the tracking of who accessed a specific record and when.

Structured Data

Data entry that offers preset choices such as drop-down menus, calendars, radio buttons, and checkboxes for consistent formatting.

Unstructured Data

Data entry that includes free text fields, video recordings, and photos which are more difficult to abstract via query reports.

Computerized Physician Order Entry (CPOE)

A prescribing system used by physicians to write and send prescriptions electronically, often including error alert functionality.

Telemedicine

Medical care where the physician speaks to or treats the patient via telecommunication modes such as phone or video.

Discharge Summary

A reference document signed by the attending physician providing an outline of a patient's admission and instructions for care after discharge.

Clinical Decision Support (CDS)

A process where data elements are represented by special codes to provide clinical reminders, alerts, and treatment options to improve patient safety.

Data Warehouse

A database designed to receive large amounts of data from multiple databases and perform high-level analytical processes.

Audit Trail

A chronological record of all access and changes to data records, used to promote accountability and prove documentation legitimacy.

Clinical Documentation Integrity (CDI)

A program designed to ensure physicians provide complete, clear, reliable, and precise documentation consistent with clinical findings.

Evidence-Based Medicine

The practice of medicine using only the best scientific data available.