LCHI LCHI Glossary

What I will pass

What I will pass

The RHIA Exam

30-day readmission

Hospitals can be penalized 1 percent of their Medicare reimbursement when patients with myocardial infarction, congestive heart failure, or pneumonia were readmitted within 30 days of discharge.

ABC Coding Solutions

A joint venture of the Foundation for Integrative Healthcare and Alternative Link. It provides more than 4,500 codes to describe complementary and alternative medicine and nursing services.

Abstracting

The process of extracting information form a document or record, often to create a brief summary of a patient's illness, treatment, and outcome or enter them into an automated system for subsequent processing.

Acceptance testing

Final review during EHR implementation to ensure that all test have been performed and all issues have been resolved; usually triggers the final payment for the system, and when a maintenance contract becomes effective.

Access controls

A computer software program designed to prevent unauthorized use of an information resource.

Accountability

A property that ensures that the actions of an entity can be traced solely to this entity.

Accountable Care Organization (ACO)

An organization of hospitals, physicians, and other healthcare providers that share responsibility for the quality, cost, and overall care of Medicare beneficiaries who are assigned to the program.

Accounts Receivable (A/R)

The total amount of money owed to a provider for services and supplies provided to all its patients (or other customers).

Acquisition strategy

The long-term process used to select and license software wherein a healthcare organization chooses, or defaults to using, either one primary vendor (considered a "best-of-fit" acquisition strategy) or many vendors (considered a "best-of-breed" acquisition strategy). For all healthcare information technology applications.

Active (CDS) Advice

A process of providing alerts and reminders to clinicians in which a specific action is required in response.

Active Directory

The location within the Microsoft operating system where network access controls are set and authentication of users takes place.

Actuarial models

Statistical techniques for predicting financial risk

Ad hoc information requirements analysis

Determination of the functions desired to be included in an EHR application performed in a non-structured manner that may yield incomplete results.

Adaptive Case Management (ACM)

A process improvement technique most suitable for knowledge workers where processes performed are often not predictable and systems must be able to adapt to such situations.

ADKAR model of communication

A model that encompasses the stages of awareness, desire, knowledge, abilities, and reinforcement and recognizes a continuum of messages for projects that introduce a great amount of change, and it illustrates the relationship between types of messages and project phases.

Administrative safeguards

Under HIPAA, are actions and policies and procedures to manage the selection, development and measures to protect electronic protected information and to manage the conduct of the covered entity i.e., business associate's workforce in relation to the protection of that information

Administration Simplification

The streamlining of financial and administrative operations in healthcare, undertaking with a goal to improve efficiency, enhance accuracy, and reduce costs. Title II of HIPAA requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. Nine standards were required.

Admissibility

Ability to introduce records into a court of law as evidence. The condition of being admitted into evidence in a court of law.

Admission-Discharge-Transfer (ADT) System

An information system used to record admissions of inpatients to hospitals, discharges of inpatients from hospitals, and transfers of inpatients within hospitals. It also records registrations of outpatients for ambulatory services.

Adoption

The phase after implementation in which intended users become acclimated to the EHR and regularly use more of its functionality; Utilization of a system as intended to achieve its benefits.

Adverse Drug Event (ADE)

A patient injury resulting from a medication, either because of an unanticipated pharmacological reaction to a normal dose or because of a preventable result occurring from an error.

Adverse Drug Reaction (ADR)

A harmful or unpleasant reaction produced by the use of a medication in the recommended manner; subset of Adverse Drug Events and are non-preventable.

Agent

In the context of computer security, is and individual with the motivation and resources to carry out a threat (for example, a computer-savvy disgruntled employee or a cybercriminal).

Aggregate data

Data from a population that are combined to form de-identified information that can be compared and analyzed.

Agile

Able to move quickly and easily, while still ensuring that an effective process is followed; relating to or denoting a method of project management, used especially for software development, that is characterized by the division of tasks into short phases of work called iterations, and frequent reassessment and adaptation of plans.

Agile modeling

A methodology for information modeling that is based on best practices; it uses UML 2.x to envision a project, brainstorm through details, prioritize requirements, engage all stakeholders (including users), and produce an information model that is sufficient to develop software.

Agile Scrum

A technique where system-wide workflows are evaluated for the purpose of quickly and flexibly improving management, software development, and managing value.

Alert

Is a visible or audible signal to the user that some condition of the patient needs immediate attention - e.g., the patient's recent lab values are above threshold. May vary according to the severity of the condition, taking the form of "suggestions" or "warnings."

Alert fatigue

A circumstance that occurs when clinicians find frequent and numerous alerts to be annoying and time-consuming, rendering those alerts less effective in drawing attention to potentially serious situations encountered during Clinical Provider Order Entry (CPOE) or while a patient's vital signs are being monitored in an Intensive Care Unit (ICU) or equivalent setting.

Algorithm

A set of rules to be processed by a computer program that involves repetition of a finite number of steps.

Alpha site

The first healthcare facility to implement the information system

American National Standards Institute (ANSI)

Oversees the creation, promulgation and use of thousands of norms and guidelines that directly impact businesses in nearly every sector; the SDO for the United States and a representative to the ISO

American Recovery and Reinvestment Act of 2009 (ARRA)

A law, often called the economic stimulus package, enacted by the 111th United States Congress and signed by President Obama on February 17, 2009, intended to improve the economy and create jobs. It includes measures to improve use of health information technology to achieve greater healthcare value.

Analytical database

An organized collection of data that support statistical analysis; also called "data warehouse" - however this latter term generally is reserved for collections of data from multiple sources rather than a single source.

Analytics

A discipline and tool set that identifies meaningful patterns and knowledge in data through the use of statistical, mathematical, and machine-learning techniques as well as predictive modeling.

Ancillary

Subordinate; helping, auxiliary.

Ancillary departments

Laboratory, radiology, and pharmacy are considered these departments in most healthcare institutions.

Ancillary systems

These are health information applications whose primary purpose is to management departments that produce clinical information for patient care, such as laboratory information systems and pharmacy information systems. Also called departmental systems.

Anecdotal benefits

Specific examples of events that occurred or were avoided when the EHR was used.

Anesthesia Information System (AIS)

A system that collects information on preoperative, operative, and postoperative anesthesia-related clinical information. This system follow the patient through the surgical process.

Anti-kickback rules

Statutes that provide criminal penalties where remuneration is solicited or received in return for referring an individual to another Medicare provider or for acquiring gods and services that are paid for by Medicare.

Appeal

A process whereby a provider requests review of a claim that was previously denied.

Application Program Interface (API)

Messengers or translators that work behind the scenes to help software programs communicate with one another. They enable information systems to communicate and transfer data among each other.

Application service provider (ASP)

A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage or transaction-based pricing.

Applications inventory

Identifying all the applications that currently exist and how they may be related to one another (or not).

Architecture

The configuration, structure, and relationships of hardware (the machinery of the computer including input/output devices, storage devices, and so on) in an information system.

ASC X12

The official designation of the U.S. national standards body for the development and maintenance of Electronic Data Interchange (EDI) standards.

ASTM International

An international standards organization that develops and publishes voluntary consensus technical standards for a wide range of materials, products, systems, and services.

Attributes

Properties or characteristics of data elements (such as their names, whether they are alphabetic or numeric, and so on) that are included in a relational database.

Audit controls

The mechanisms that record and examine activity in information systems.

Audit logs

An electronic footprint of the actions that occurred in a particular file in an information system or that were performed by a specified individual.

Auditing

The performance of internal and/or external reviews to identify variations from established baselines (for example, review of users who accessed information as compared with the users' access privileges).

Authentication

1. The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature.

Automated history taking

Computer applications focused on having patients (or family members) respond to an electronic questionnaire that inquires about their personal and family medical history.

Automated informed consent system

An application that provides patients a comprehensive and consistent set of information about the benefits and risks of a surgical or other procedure requiring a signed permission to perform.

Availability

Data can continue to be able to be provided to authorized users at a required level of performance in situations ranging from normal through disastrous.

Backup Site

Location where an organization can easily relocate following a disaster, such as fire, flood, terrorist threat or other disruptive event. This is an integral part of the disaster recovery plan and wider business continuity planning of an organization.

Bad debt

A payment that is not collected from a party who was obligated to pay.

Balance after insurance

May include the co-pay, any deductible amount that has not yet been fulfilled, and/or a co-insurance if the patient has a health insurance plan in which the patient owes a portion of the total bill, not just a co-pay and deductible.

Balance sheet

A report that shows the total dollar amounts in accounts, expressed in accounting equation format, at a specific point in time.

Balanced scorecard

A quality improvement technique that measures and manages define metrics derived from institutional sources and aligns the metrics with the strategic goals of the organization.

Bar code

Representation of information that may be read by optical scanners called barcode readers or scanned from an image by special software.

Bar Code Medication Administration Record (BC-MAR)

System that uses barcoding technology for positive patient and drug identification during the process of giving a drug to a patient.

Baseline

The original estimates for a project's schedule, work, and cost.

Baseline data

Data about how a process currently performs that serve as a comparison to how a process performs after a change.

Basic EHR

An EHR that includes computerized documentation but offers minimal or no clinical decision support that alerts clinicians of potential issues with their patients.

Benchmarking

The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization; or the systematic comparison of one organization's outcomes with regional or national standards.

Benefits portfolio

The set of quantitative, financial, and qualitative benefits that make the business case for making an investment.

Benefits realization

The process of collecting and studying the same type of data bout process performance - to determine that improvements have been achieved under the new process.

Benefits realization study

The process of collecting and studying [after a process change or system implementation] the same type of data about process performance [as were collected prior to a process change or system implementation] - for the new process to determine that improvements have been achieved.

Best-of-breed strategy

A strategy used when purchasing HIT that refers to acquiring applications that are considered the top performing in their class, even when each is from a different vendor.

Best-of-fit strategy

A strategy used when purchasing HIT in which all the applications required by the healthcare facility are available from one vendor.

Best-of-suite

A strategy used when purchasing HIT in which applications are acquired from only two primary vendors, usually the incumbent vendor providing the financial/administrative functions and another vendor providing the clinical functionality.

Bidder's conference

A meeting held by an organization to which potential EHR vendors are invited, at which questions may be asked by vendors about specific requirements of the organization with regard to EHR.

Big bang

An EHR implementation strategy where all components of the EHR are required to be used by all users starting at one time.

Big data

The massive amount of data available to study, which is often in unstructured formats.

Bitcoin

An innovative payment network and a new kind of money that uses peer-to-peer technology to operate with no central authority or banks; managing transactions and the issuing of bitcoins is carried out collectively by the network. Bitcoin is open-source; its design is public, nobody owns or controls Bitcoin and everyone can take part. Through many of its unique properties, Bitcoin allows exciting uses that could not be covered by any previous payment system.

Bitcoin Blockchain

A transaction database shared by all nodes participating in a system based on the Bitcoin protocol. A full copy of a currency's block chain contains every transaction ever executed in the currency. With this information, one can find out how much value belonged to each address at any point in history.

Blue Button initiative

A project sponsored by the Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs (VA) to make it easy for their beneficiaries to access claims data (and for veterans to create and maintain a web-based Personal Health record (PHR) with the VA' MyHealtheVet application).

Bridge

A network bridge connects multiple network segments at the data link layer (layer 2) of the OSI model.

Bridge Technologies

Technologies such as document imaging and/or clinical messaging that provide some, but not all, the benefits of an EHR.

Bring Your Own Device (BYOD)

Refers to the policy of permitting employees to bring personally owned devices (laptops, tablets, and smart phones) to their workplace, and to use those devices to access privileged company information and applications.

Broadband

A term that refers to high-volume, high-speed telecommunication transmissions using a variety of networks and types of media

Brute-force attack

A hacking method to find passwords or encryption keys by trying every possible combination of characters until the correct one is found.

Bundled payment

Also called episode-of-care payment; a method in which payments to providers are based on the expected costs for a clinically defined episode or bundle of related healthcare services, including cost associated with preventable complications.

Bus

In local area networks where this topology is used, each machine is connected to a single cable. Each computer or server is connected to the single cable through some kind of connector. A terminator is required at each end of the cable to prevent the signal from bouncing back and forth on the cable.

Business case

An economic justification, usually for a capital expenditure.

Business process management

A continuous quality improvement technique that focuses not only on workflow and process changes to effect positive results but also the broader picture of creating a positive leadership culture, improved interpersonal relationships, and new management skills.

Caching

A process wherein data and instructions that are used repeatedly are temporarily stored in a computer to speed up access.

Capitation

A fixed payment amount given to providers for the care that patients may receive in a given time period, such as a month or year.

CAPTCHA - Completely Automated Public Turing test to tell Computers and Humans Apart

A program that protects websites against bots by generating and grading tests that humans can pass but current computer programs cannot.

Care coordination

Deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services,it may include facilitation among providers as well as social services.

Care management

A function of a health plan or provider that attempts to improve medical practice and assist consumers to be more engaged in their healthcare in order to achieve quality of care and cost improvements.

Care map

A tool typically used by nurses in an acute care setting that outlines the steps and decision points in the management of a specific healthcare condition. It can be customized to represent care for a specific patient.

Care pathway

A standardized, day-to-day course of care for patients with the same condition to achieve consistent outcomes. They are often developed by a hospital, a long-term care facility, or a health plan; are modified for specific patients; and are more commonly used by nurses than by physicians.

Care plan

The specific goals in the treatment of an individual patient, amended as the patient's condition requires. Used by physicians and nurses to communicate steps in a treatment regimen and assess outcomes of care; serves as a template for ongoing documentation of a patient's care, condition, and needs.

Case law

Unwritten law originating from court decisions where no applicable statue exits.

Case management

The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectiveness of the clinical services being provided to a patient.

Case mix

The distribution of patients into categories reflecting differences in severity of illness or resource consumption.