WGU D033 "Health Information Systems Management"

Acceptance testing

A type of testing that occurs after the go-live date

Access controls

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

Addressable standards

Must be evaluated by the entity to determine whether or not the standard is reasonable and appropriate

Administrative information system

A system that manages the business of healthcare; is the first information systems to be used in healthcare. The data collected in this system are mainly financial or business-oriented in nature, rather than clinical

Administrative safeguards

Administrative actions, and policies and procedures, to manage the selection, development, implementation, and maintenance of security measure to protect electronic-protected health information and to manage the conduct of the covered entity's workforce in relation to the protection of that information. (45 CFR 160, 162, and 164)

Administrative simplification

Improves the efficiency and effectiveness of the business processes of healthcare by standardizing the EDI of administrative and financial transactions and protects the privacy and security of protected health information (PHI) that is transmitted from one point to another

Alpha site

The first healthcare facility to implement the information system American National Standards Institute (ANSI) The SDO for the United States and a representative to the ISO

American Recovery and Reinvestment Act (ARRA)

Enacted to stimulate the US economy during a recession that started in 2007. A significant portion of ARRA was dedicated to expanding the use of HIT to improve the business efficiency and effectiveness of HCOs while increasing patient safety and positive health outcomes. It also enacted an incentive program known as Meaningful Use

Anesthesia information system

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

Annotation

The ability to add to the image in some way; because the image may be a legal document, the image itself cannot be altered; however, an overlay to the document will show the annotation

ANSI Accredited Standards Committee X12N (ASC X12N)

Responsible for developing the EDI standards used to share information needed for health insurance administrative transactions

Audit controls

The mechanisms that record and examine activity in information systems

Audit log

Or audit trail, an electronic footprint of the actions that occurred in a particular file in an information system or that were performed by a specific individual

Audit trails

The record of information system activities, such as log-in, log-out, unsuccessful log-ins, print, query, and other actions

Audit-reduction tools

Tools that review the audit trail and compare it to criteria specified by the CE, which eliminates routine entries such as the periodic backups

Authorship

The origination or creation of recorded information attributed to a specific individual or entity acting at a particular time

Automated codebook encoder

An encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index

Back-end speech recognition (BESR)

A speech recognition technology in which the physician dictates in the traditional manner and an editor listens to the audio and reviews the document created

Backscanning

The process of scanning past health records into the DMS so there is an existing database of patient information, making the DMS valuable to the user from the first day of implementation

Backward map

A map that links the two coding systems in the opposite direction, moving from ICD-10 to ICD-9

Barcode medication administration record (BC-MAR)

See Electronic medication administration record (EMAR)

Best of breed

Choosing the ISs based on functionality rather than by vendor 313 314 Glossary

Best of fit

The decision to purchase software from a single vendor

Beta sites

The healthcare facilities who subsequently implement the information system

Bidder's conference

A meeting for vendors to come to the healthcare facility to ask questions about the request for proposal, the healthcare facility, and other important points

Biomedical device

An article, instrument, apparatus, or machine that is used in the prevention, diagnosis, or treatment of illness or disease, or for detecting, measuring, restoring, correcting, or modifying the structure or function of the body for some health purpose

Birth certificate information system

A state-approved system in which the birth certificate data are entered, after the HIM staff interviews the mother or other parents or guardians and reviews the health record. This software reports births occurring in the healthcare facility to the state health agency

Blue Button

A campaign that was established by The Office of the National Coordinator for Health IT (ONC). It is a consumer-motivated method to improve healthcare by having the patient or caretaker actively involved in decisions and planning by having direct access to personal health information

Bots

Perform automated tasks, such as gathering information and instant messaging, thus relieving a person the responsibility of doing it

Bring your own device (BYOD)

Healthcare practitioners using their personal smartphones or other devices rather than devices provided by the HCO, the personal device must meet specific encryption and other security protocols to protect PHI as required by the HCO

Cancer registry information system

An information system that tracks information (including very detailed information regarding diagnosis and treatment) about the patient's cancer from the time of diagnosis to the patient's death

Certified EHR technology

An EHR that has been evaluated by a member of the Office of the National Coordinator-Authorized Certification Bodies (ONC-ACBs) and verified that it meets the criteria set by the MU incentive programs

Certified health data analyst (CHDA)

Advanced certification sponsored by AHIMA that covers data management, data analytics, and data reporting

Certified in healthcare privacy and security (CHPS)

Credential that demonstrates advanced privacy and security skills. These advanced privacy and security skills exceed those in the RHIA or RHIT examinations. It is sponsored by AHIMA

Certified information security manager (CISM)

Sponsored by ISACA; an international examination that is designed for leaders in security who oversee the security programs of organizations

Certified information systems security professional (CISSP)

Certification sponsored by the International Information Systems Security Certification Consortium. It is a generic security certification and therefore is not healthcare specific

Change management

The formal process of introducing change, getting it adopted, and diffusing it throughout the healthcare facility

Chargemaster

A financial management form or software that contains information about the healthcare facility's charges for the services it provides to patients (also called a charge description master [CDM]); it automates the coding process for routine procedures

Chart deficiency system

A system that track and record documentation omission due to deficiency in the health record that comes to the HIM department. Deficiencies can be in paper, imaged, or electronic records depending on the information system used

Chart locator system

A system is designed to identify the current location of the paper health record. This tracking is important because paper records are moved from place to place for patient care, quality reviews, coding, and many other purposes

Chart tracking system

See Chart locator system

Clinical data repository (CDR)

A centralized data repository

Clinical decision support (CDS) system

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

Clinical document architecture (CDA)

Standards developed by HL7 for the electronic exchange of clinical documents, such as discharge summaries and progress notes Glossary 315

Clinical documentation improvement (CDI) system

The recognized process assists in identifying ways to improve clinical documentation in the health record

Clinical documentation improvement (CDI)

The process an organization undertakes that will improve clinical specificity and documentation that will allow coding professionals to assign more concise disease and procedural classification codes

Clinical documentation

Any manual or electronic notation or recording made by a physician or other healthcare clinician related to a patient's medical condition or treatment

Clinical informatics coordinator

Individual who requires knowledge of clinical information systems. They are experts in the data retrieval needed by healthcare providers while conducting patient care

Clinical information system (CIS)

A system that collects and stores medical, nursing, clinical ancillary areas (such as radiology and laboratory), and therapy department information related to patient care

Clinical messaging

A tool that connects the medical staff and hospital by providing access to information systems such as order entry and results reporting and DMS Clinical pathways A tool designed to coordinate multidisciplinary care planning for specific diagnoses and treatments

Clinical practice guidelines

A tool that provides a detailed, step-by-step guide used by healthcare practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a medical society

Cloud computing

A computer system that is owned and maintained by a vendor

Cluster map

An entry in a GEM where one code from the many target codes can become a map to the source code

Cluster, combination, and complex

The types of mapping relations between source and target codes that exist in both forward and reverse directions

Code set

A set of codes used to encode data elements

Combination map

This is an entry where more than one code is required in the target code set to replicate the complete meaning of the source system

Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)

Board responsible for establishing the content that accredited masters, bachelor, and associate programs must teach their students

Commission on Certification for Health Information and Information Management (CCHIIM)

The independent body within AHIMA that establishes and grants professional certifications in health informatics and HIM professions

Complex map

This mapping represents multiple code combinations and alternatives that are required to translate a source to a target code

Computer on wheels (COW)

A computer used at the point of care, which involves a wireless computer mounted on a mobile cart that can be moved from patient to patient

Computer-aided software engineering (CASE)

A tool designed to create many of the diagrams and other tools used in the data model

Computer-assisted coding (CAC) system

A software program used to analyze the clinical data found in an electronic health record

Computer-assisted instruction (CAI)

A software program designed to use multimedia and interactive technology to teach a topic

Computerized provider order entry (CPOE)

Preprogrammed clinical decision support designed to assist the user through making an entry appropriately

Conceptual data model

Model that is not tied to a particular database model, but rather defines the requirements for the database to be developed. It is the basis for the logical and physical data models

Consent management

A component of identity management within HIE; because of HIPAA, patients have the right to refuse to participate in the HIE and to limit who can view their information. Consent management has nothing to do with the consent for treatment but rather the patient consents or approves the HIO to transmit health information between two or more authorized entities

Consolidated (centralized) model

Many independent HCOs connected with the HIE and aggregate data was stored and shared within a central repository managed by the HIE 316 Glossary

Consumer engagement

A diverse set of activities that can include interacting with healthcare providers, seeking health information, maintaining a PHR, and playing an active role in making decisions in regard to personal healthcare

Consumer health applications

Healthcare-based applications designed for use by the patient or provider on smart phones, tablets, and other computers Consumer informatics: Also known as consumer health informatics; the field devoted to informatics from multiple consumer or patient views

Consumer-mediated exchange

A type of HIE that is controlled by patients who want to control the use and access of their health information

Content analyst

Individual who designs the clinical information system that will be implemented. Their work is directed by the needs of the users. They are also advocates in the usage of health information technology in healthcare

Context-based authentication

Controls access not only by the role that the employee has in the CE but also by the individual data elements and the context in which the user is working

Contingency plan

Plan that is made up of policies and procedures that identify how a CE will react in the event of an information system emergency such as power failure, natural disaster, or a system failure

Continuity of Care Document (CCD)

An implementation guide for sharing continuity of care record (CCR) patient summary data

Continuity of care record (CCR)

A core data set, which is the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters

Core data set

A data set that contains the most relevant administrative, demographic, and clinical information about a patient's healthcare

Covered entity (CE)

A health plan, healthcare clearinghouse, or healthcare provider that transmits any health information in electronic form for one of the covered transactions

Critical path

The sequence of stages that takes the longest amount of time to complete the project

Current Dental Terminology (CDT)

The system used to code dental procedures such as tooth extractions, tooth implants, and such

Dashboards

Reports of process measures to help leaders follow progress to assist with strategic planning. The dashboard provides the status on key measures

Data accessibility

Data items can be easily obtainable by authorized users

Data accuracy

Data that are free of identifiable errors

Data analyst

Individual who applies his or her skills to manage, analyze, interpret, and transform health data into accurate, consistent, and timely information

Data analytics

The science of examining raw data with the purpose of drawing conclusions about that information. This information can then be used to make business decisions concerning which services to provide and how to improve patient care

Data capture

The process of recording healthcare-related data in a health record system or clinical database

Data cleansing

The process of checking internal consistency and duplication as well as identifying outliers and missing data. In other words, it means looking for errors or problems with the data, such as duplicate patients

Data comprehensiveness

The patient's health record must be complete and all required data must be included

Data consistency

Ensures that like data are the same on each document or computer screen

Data content standards

Clear guidelines for the acceptable values for specified data fields. These standards make it possible to exchange health information using electronic networks, and they identify the structure and content of data elements to be collected by the EHR

Data currency

Ensures that data are up to date Glossary 317

Data definition language (DDL)

A special type of software used to create the tables within a relational database. It translates how data are stored in the computer from the physical view (physical structure of the database) to the logical view (one that is understandable by the user)

Data field

A predefined area within a database in which the same type of information is usually recorded such as the data of birth

Data flow diagrams (DFDs)

A diagram that shows how data moves (input, storage, output) within the database. It is a way to show management and other nontechnical users the system design

Data granularity

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

Data integrity

The extent to which healthcare data are complete, accurate, consistent, and timely

Data integrity analyst

Individual who is responsible for ensuring the quality of the data in HIM information systems. Data integrity analysts must be able to apply data and content standards to data collection and data storage. They must be able to maintain the information systems, ensure compliance with legal and accreditation requirements, and be able to analyze data

Data manipulation language (DML)

A special type of software used to retrieve, update, and edit data in a relational database. The DML accesses, makes changes to, and retrieves data from the database

Data manipulation

Allowing the user to add and delete rows in a table and to sort, find, and compare. Another function of the data manipulation component is to update data

Data mapping

Allows for connections between two systems

Data mart

A subset of the data warehouse designed for a single purpose or specialized use