Health Information Management - Chapter 11

Office of the National Coordinator for Health Information Technology (ONC)

agency within the federal government tasked to be the health information technology (typically referred to as the head IT) resource to the nation

Federal Health IT Strategic Plan 2015-2020

Issued by the Office of the National Coordinator for Health Information Technology (ONC), this plan describes a vision of high-quality care, lower costs, healthy population, and engaged people and mission to improve the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most

knowledge

the application of experience to information that provides value to the information beyond only serving as evidence of actions taken

Data

raw facts and figures without context or meaning

information

data that have been processed in a useful and meaningful manner

provider

Physician, clinic, hospital, nursing home, or other healthcare entity (second party) that delivers healthcare services

Health IT

Under HITECH, hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information (Public Law 111-5 2009)

Health information system

the term used to describe the full scope of adopting health information technology

System

all the components (technology, standards, people, policy, and process) that must work together to achieve a desired goal (interoperability)

Computerized provider order entry (CPOE)

Electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically. These systems usually contain error prevention software that provides the user with prompts that warn against the possibility of drug interaction, allergy, or overdose and other relevant information

Diagnostic Studies

All diagnostic services of any type, including history, physical examination, laboratory, x-ray or radiography, and others that are performed or ordered pertinent to the patient's reasons for the encounter

Logical observations, Identifiers, Names, and Codes (LOINC)

a database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research that enable exchange and aggregation of electronic health data from many independent systems

Clinical Laboratory Improvement Amendments (CLIA) of 1988

established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test is (Public Law 90-174 1967)

Portals

Windows into information systems

Telehealth

A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment

Health Information Exchange (HIE)

The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies

Health Information Technology for Economic and Clinical Health (HITECH) Act

legislation created to promote the adoption and meaningful use of health information technology in the United States. Subtitle D of the Act provides for additional privacy and security requirements that will develop and support electronic health information, facilitate information exchange, and strengthen monetary penalties. Signed into law on February 17, 2009, as part of ARRA (Public Law 111-5-2009)

Meaningful Use (MU) program

now known as promoting interoperability; a regulation that was issued by CMS on July 28, 2010, outlining an incentive program for professionals (EPs), eligible hospitals, and CAHs participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology

Alternative Payment Models (APMs)

New methods of reimbursement used by the federal government

Value-based care (VBC)

Reimbursement strategy designed to improve the quality of care and reduce healthcare costs

value

improving the quality of care to achieve a healthier nation, which can result in reducing the cost of care overall

Implementation

technology having been installed and configured to meet the basic requirements of the healthcare organization

end users

those persons who will use the information system in the course of their daily processes and procedures

use

the fact that those who are supposed to apply the technology to their daily work have been trained and are starting to apply the technology at a simple level

Templates

a guide for documentation

meaningful use

a term used by the federal government for the program designed to incentivize use of EHRs

adoption

reflects the fact that the organization has implemented all of the major components of technology, although there may be some available technology that is more specialized, costly, or time-consuming to implement that has not yet been implemented

Optimization

the state that demonstrates not only effective adoption of health information systems for routine operations, but also an understanding and appropriate use of the technology's features with workflow and process improvements that can improve clinical efficiency

power users

people whose expertise in the information system is above others, are able to use technology to significantly improve their productivity and will likely see healthcare quality and cost benefits as well

source systems

capture and supply the EHR and other broad health information systems with data

Business Intelligence (BI)

the end product or goal of knowledge management

Registration-Admission, Discharge, Transfer (R-ADT)

a type of administrative information system that stores demographic information and performs functionality related to registration, admission, discharge, and transfer of patients within the organization

Patient financial system (PFS)

Information system that manages patient accounts

revenue cycle management (RCM)

Refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services

transactions

the RCM functions that exchange data between providers and health plans

Accredited Standards Committee X12 (ASC X12)

A committee accredited by ANSI responsible for the development and maintenance of EDI standards for many industries. The ASC "X12N" is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms

operating rules

Rules that further explain the business requirements so their use is consistent across health plans

Claims data

data supplied on a claim for reimbursement purposes

document imaging

the process by which paper-based documentation id captured, digitized, stored, and made available for retrieval by the end user

XML (Extensible Markup Language)

language used to share information such as on the internet

Speech dictation

Method of collecting information in an information system through spoken word

Discrete reportable transcription (DRT)

Transcription system that combines speech dictation with natural language processing

Natural Language Processing (NLP)

A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence

Consent management systems

Systems that help maintain patient preferences about who may have access to their health information

Chart tracking

A process that identifies the current location of a paper record or information

Ancillary systems

Systems that serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR

Laboratory information system (LIS)

Health information system that includes hardware; software; communications and network technologies; operational and cultural adaptations that people must make to use the technologies in performing diagnostic studies on various specimens collected from patients and to apply professional judgement in evaluating the quality of the data representing the results; policies and standards form the local organization in which the system is housed as well as accrediting and licensing bodies that must be followed for design of the technology and its use; and workflow and process designs assure the most efficient and effective use of the technology

Auto-analyzer

Device that analyzes the specimen

structured data

data able to be processed by the computer

Radiology Information System (RIS)

Performs functions similar to LIS, receiving an order for a procedure, scheduling it, notifying hospital personnel or the patient if performed as an outpatient, tracking the performance of the procedure and its output, tracking preparation of the report, performing quality control, maintaining an inventory of equipment and supplies, and managing departmental staffing and budget

Picture Archiving and Communication System (PACS)

An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images)

Digital Imaging and Communications in Medicine (DICOM)

an ISO standard that promotes a digital image communications format and picture archive and communications systems for use with digital images

pharmacy information system

this system receives an order for a drug in a hospital, aids the hospital's pharmacist in checking for contraindications, directs staff in compounding any drugs requiring special preparation, aids in dispensing the drug in the appropriate dose and for the appropriate route of administration, maintains inventory (documenting medications in stock using the National Drug Code, the terminology maintained by the Food and Drug Administration [FDA] for use in identifying FDA-approved drugs), supports staffing and budgeting, and performs other departmental operations

Contraindications

situations that should be avoided as potentially harmful to a patient

national drug codes(NDC)

codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few select over-the-counter products

Population Health

the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals

population health management (PHM)

the aggregation of data across multiple health information system resources and the analysis of that data into actions providers can use to improve both clinical and financial outcomes

smart peripherals (AKA automated medical devices)

generally not been considered information systems, even though they have generated data as well as information

Certification

an evaluation performed to establish an extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements

results management

An EHR application that enables diagnostic study results (primarily lab results) to be both reviewed in a report format and the data within the reports to be processed

point of care (POC) documentation

applications intended to inform the user what data needs to be recorded for the patient and to use that data to supply clinical decision support (CDS), including alerts and reminders, at the time, when the clinician is able to be most responsive to alerts and reminders

Nursing Information System

System that manages the nursing department, including staffing, credentialing, training, budgeting, and other managerial functions

Patient acuity staffing

The number of nurses and other care providers is based on how sick the patient is

scribe

an individual who enters clinical documentation into the EHR to reduce administrative burden

unstructured data

narrative information not able to be uniquely processed by a computer

Patient Safety

Preventing harm to patients, learning from errors, and building a culture of safety

Closed-loop medication management

Information systems used to provide patient safety when ordering and administering medications

e-prescribing (e-Rx)

When a prescription is written from the personal digital assistant and an electronic fax or an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy's information system

medication reconciliation

Process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to ICU

Alert fatigue

the ignoring of alerts due to their volume and irrelevancy

drug knowledge database

A subscription service that provides current information about drugs and is accessible to users and CDS

evidence-based medicine

Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies

unintended consequence

an unanticipated and undesired effect of implementing and using an EHR

Rx Norm

a system maintained by the National Library of Medicine to normalize drug names across disparate vocabularies

National Council for Prescription Drug Programs (NCPDP)

a standards development organization that sets standards for the pharmacy industry

SCRIPT

standard developed for electronically transmitting a prescription

e-Prescribing for Controlled Substances (EPCS)

The submission of a prescription electronically for narcotics and other controlled substances

Identity proofing

Authentication credentials used to electronically sign prescriptions

two-factor authentication

A signature type that includes at least two of the following three elements: something known, such as a password; something held, such as a token or digital certificate; and something that is personal, such as a biometric in the form of a fingerprint, retinal scan, or other

Biometrics

fingerprints, retinal scan

digital certificate

An electronic document that establishes a person's online identity

Certificate Authority

An organization that verifies a person's credentials and can revoke the certificate if the credentials are revoked

bar code medication administration recoding (BC-MAR)

the documentation of administering medication to a patient and is a function by nurses in a hospital

Medication five rights

The right drug, in the right dose, through the right route, at the right time, and to the right patient

Radio Frequency Identification (RFID)

An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and does not require direct contact

workstations on wheels (WOWs)

Notebook computers mounted on carts that can be moved through the facility by users

Automated drug dispensing machines

System that makes drugs available for patient care

clinical decision support (CDS)

The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts

Protocols

specifications of appropriate processes, based on expert best practices and clinical research findings

clinical decision support system (CDSS)

CDS that requires the combination of data from more than one sources and the ability to deliver the alert back to the appropriate system or systems

Analytics

Statistical processing of data to reveal new information.

personalized medicine/precision medicine

2 names for an emerging practice that tailors treatment to the individual, given not only comorbidities but genomic characteristics and predispositions

Clinical data repository (CDR)

A central database that focuses on clinical information

Online Transaction Processing (OLTP)

the real-time processing of day-to-day business transactions from a database

Online Analytical Processing (OLAP)

A data access architecture that allows the user to retrieve specific information from a large volume of data

Clinical data warehouse (CDW)

A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface

Big Data

very large volume of data that offers greater reliability and validity

Data Quality

adherence to standard data definitions and metadata requirements

Metadata

data about data

data model

a picture or abstraction of real conditions used to describe the definitions of fields and records and their relationships in a database