Health Informatics & Information Management Chapter 25

Key terminology and definitions covering health records, HIM functions, HIPAA regulations, and medical coding systems from Chapter 25.

Health Information Management (HIM)

An allied health profession built around the management of the healthcare record, data and information contained within, and services ensuring optimal standards for quality of care and services.

Health Record

Permanent or long-lasting documents of all patient care information applying to an individual patient, which must be maintained a minimum of $5$ years from the date of the last visit.

Electronic Health Record (EHR)

An electronic record of patient health information generated during encounters in any care delivery setting, capable of generating a complete record of any clinical encounter.

Master Patient Index (MPI)

A crucial part of an institution's patient information system that identifies all patients admitted or treated at a healthcare organization and serves as the key to locating patient records.

Demographic Data

A level of $MPI$ data elements containing patient identifying information as defined by the American Health Information Management Association ($AHIMA$).

Visit Level Data

A level of $MPI$ data elements including variable information such as account number, admission date, discharge date, and encounter type.

Inpatient Identification Number

The medical record number used for internal patient identification.

History & Physical

Detailed information on the patient's current needs of care, medical history, physical examination, impression or diagnosis, and plan of care.

Patient Portal

A secure online website that gives patients convenient $24$-hour access to personal Electronic Health Records ($EHR$).

Health Insurance Portability and Accountability Act (HIPAA)

A $1996$ act that mandated patients have a right to access their personal health information and request amendments to their health record.

$21st$ Century Cures Act (Cures Act)

A $2016$ law making it mandatory for hospitals and health systems in the U.S. to provide patients access to $EHR$ via patient portal applications.

Administrative Safeguards

Policies and procedures under the Security Rule designed to prevent, detect, contain, and correct security violations.

Physical Safeguards

Security Rule measures including identification badges and authorized access restricted to buildings or rooms for certain personnel.

Technical Safeguards

Security Rule measures including user identification, passwords, and automatic log offs to protect and control access to personal health information ($PHI$).

Interoperability

The capability that allows for the sharing of information between disparate information systems.

Health Information Exchange

Allows healthcare professionals and patients to appropriately access and securely share a patient’s medical information electronically.

Health Information System (HIS)

Manages healthcare data and allows for sharing of protected health information across the healthcare enterprise.

Radiology Information System (RIS)

System responsible for management of imaging orders, scheduling, and billing, serving as a method of patient management and tracking.

Picture Archiving and Communication System (PACS)

A networked group of computers, servers, and archives used to manage digital images, with storage that is mainly cloud-based.

Artificial Intelligence (AI)

The science of engineering intelligent machines and computer programs that perform a broad range of intelligent functions to transform healthcare.

Ambulatory Payment Classification (APC)

Reimbursement system based on $ICD-10-CM$ codes for diagnosis and $CPT$ codes used for health care in an outpatient setting.

Current Procedural Terminology (CPT)

A listing of medical terms and codes for diagnostic and therapeutic procedures used for coding for physician reimbursement.

International Classification of Diseases, $10th$ Edition, Clinical Modification (ICD-10-CM)

A classification system used for diagnosis coding in all health care settings in the United States.

Diagnosis-Related Group (DRG)

A system that categorizes patients into payment groups who are medically related with respect to diagnosis and treatment and statistically similar regarding length of stay.

The Joint Commission (TJC)

An organization that accredits hospitals and other health care institutions in the United States.

Prospective Payment System (PPS)

A system for Medicare patients implemented by the government in $1983$ whereby payment groups are established in advance.

Informed Consent

A policy developed by medical staff and governing boards stating that a patient has been informed of procedures, risks, and possible consequences.

Index of Radiologic Diagnoses (IRD)

A listing of diagnostic code numbers and an alphabetic index used by the $ACR$ for classifying radiologic specimens.

Performance Improvement

A process that monitors and evaluates the quality of care and services provided to patients; also known as Quality Assurance or Quality Assessment.