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EHR Flashcards
| Question | Answer |
|---|---|
| Affordable Care Act | Mandates comprehensive health insurance reform; some include: prohibiting the denial of coverage based on pre-existing conditions, preventing insurance companies from rescinding coverage when someone gets sick, eliminating lifetime limits ,etc. |
| American Recovery and Reinvestment Act of 2009 (ARRA) | Consists of three major goals: create and save jobs, spur economic activity and invest in long-term growth, and support accountability and transparency in recovery spending |
| Authorization | Required for any release of patient PHI; consists of specific elements that make it legal and appropriate to release information |
| Busness associate | An organization or individual who provides specific services to a covered entity involving the use or disclosure of PHI; for example, an off-site storage company that houses EMR data. |
| Centers for Medicare and Medicaid Services | Federal agency charged with the administration of the Medicare and Medicaid programs, as well as the Children's Health Insurance Program; operating division of the Department of Health and Human Services (HHS) |
| Certification Commission for Health Information Technology (CCHIT) | Established to evaluate and approve EHR and EMR systems; to participate in incentive programs for EHR adoption and use, facilities must use a certified EHR or EMR product. |
| Computer on Wheels (COW) | Most often refers to a laptop computer that sits on a cart with wheels that can be rolled from patient room to patient room and facilitaties real time documentation or charting of patient care; often called COWs. |
| Computerized Provider Order Entry (CPOE) | Allows providers to order prescription medication, including IV therapies, laboratory tests, imaging studies, rehabilitation services, dietary requirements in the inpatient enviroment |
| Conditions of Participation (CoPs) | Specific practices that CMS mandates for facilities to follow if they treat paitents covered under Medicare or Medicaid; similar to the Joint Commission's accredidation requirements. |
| Continuity of Care Document (CCD) | The widely-accepted and federally-mandated document for sharing patient health information across facilites; replaced the CCR and CDA, which were earlier attempts to addressing the continuity of paitent care between facilities |
| Continuity of Care Record | An early form of a document developed to make communication about patients' course of care available across facilities, CCD replaced it |
| Credentialing | Process used to document a provider's education, licensure, and qualifications in order to allow for the assignment of privileges to practice in a hospital or health care system |
| Current Procedural Terminology (CPT) | A nomenclature or naming system the American Medical Association (AMA) publishes and maintains; allows providers to code for services provided and submit bill for reimbursement |
| Database | Organized collection of pieces of information or data; electronic version of file cabinets with folders and files; the term generally refers to data collected and stored in an electronic environment |
| Digitize | Transform information from a paper-based document into an electronic format; some systems use doc. scanning that includes Optical Character Recognition (OCR) capabilities, which transforms a scanned document from a static image to a searchable document |
| Discharge Summary | Report written by provider when a patient is discharged from inpatient care; summarizes chief complaint, diagnostic test results, txrs administered, outlines recommendations for care & f/u, medication & activity instructions. Dr MUST sign |
| Electronic Health Record | While this term is generic, its use denotes a system-wide record that involves inputs from many systems & is used across a diverse environment of care with mulitiple locations |
| EHR technology | Refers to the conceptual EHR, including the basic structure, functionality, and expected outcomes users expect from any system identified as being an electronic health or medical records system |
| Electronic medical record (EMR) | Another generic term for a digitized medical record; used most often to refer to the SINGLE, standalone record systems in a private practice or smaller outpatient setting. Many EMRs can exchange info with larger EHR using a CCD (Continuity of Care Doc) |
| ePrescribing | Functionality that allows provers to prescribe medications to patients and send the rx to the patient's pharmacy where it will process & be ready for p/u. Similar to CPOE from inpatient environment, |
| Fully-integrated EHR | Functionality that has replaced paper records entirely; few hospitals or health care systems in the U.S. have achieved this yet, but many are moving in this direction |
| Health information technology | General use of computers and related devices to manage the day-to-day functions in a health care environment |
| Health Information Portability and Accountability Act of 1996 (HIPAA) | Legislation that protects employees' insurance coveragae when they are between jobs; formally called Title II (national standards) or the Administrative Simplification provisions of HIPAA; best known for security & privacy protection for health care info. |
| HIPAA Privacy Rule | Mandates the protection of patients' health information by hospitals and health care facilities, know as covered entities; provides a # of rights to patients in regard to their health info, but acknowledges there are times when disclosure is necessary |
| HIPAA Security Rule | Sets forth the administrative, physical and technical safeguards for covered entities in order to protect the confidentiality, integrity and availability of PHI that is stored electronically |
| History and Physical (H and P) | Providers document a patient's history and perform a physical exam when he/she presents for health care services; MUST be filed within 24 hours of admission and CANNOT be more than 30 days old; Dr MUST sign befor the record is complete |
| Health Information Technology for Economic and Clinical Health (HITECH) Act | Encourages the adoption and meaningful use of health information technology; strengthened portions of the HIPAA Privacy & Security regulations; Under this act, ind. & facilities that breach PHI are subject to harsher civil and criminal penalties. |
| Hospital Information System (HIS) | Collection of systems that collect, store and allow manipulation and management of data generated in the daily operations of a facility |
| International Classification of Disease, 1Oth, Clinical Modification (ICD-10-CM) | Coding and classification system that groups disease and disorders into similar categories |
| Information Technology (IT) department | The IT department in facilities has emerged as a necessary response to the transition from a paper-based world to one that is increasingly reliant on technology for commications, data storage, management and retrieval & delivery of patient care |
| Joint Commission on the Accreditation of Health Care Organizataions (The Joint Commission) | Not-for-profit & independent (non-governmental) organization that accredits & certifies more than 19,000 health care facilities and programs in the US; recognized nationally as the gold standard of accreditation & symbolizes the commitment to high-quality |
| Legacy Information System | Department-specific systems that pre-date the implementation of EHRs by several decades, sometimes referred to as legacy systems |
| Master Patient Index (MPI) | Record of every patient who has been treated, seen or evaluated in a facility; by law, this cannot be purged or destroyed after time and it must be forever maintained; also referred to as Master Patient/Person Index (MPPI) |
| Meaningful use (Program) | The Meaningful Use Program are they federal incentives established by CMS for facilities to use EHR technology in a meaningful way |
| Meaningful use (Definition) | Refers to using EHR technology in a manner that makes a meaningful impact on patient care and safety |
| Medical Staff committee | A committee formed to discuss & recommend practices, policies and other activites specific to the medical staff; Also oversees credentialing, or the assignment of privileges; typically reports to Medical Executive Committee who makes final decisions |
| Medical terminology | The language of medicine, which emcompasses terms to describe anatomy, physiological processes, disease, treatment and other terms related to the human body and the care provided in terms of health and disease |
| Medication Reconciliation ** (CMS and Joint Commission require) | Process of gathering & documenting a complete list of patient's medications when he is admitted; includes medications pt was taking when he came into the facility & meds the provider prescribed as new & sending list to the next care provider at discharge |
| National Practicioner Data Bank (NPDB) | National database created in 1986 to collect information on licensed providers; providers are licensed by each state & bad behavior in one state can result in a loss of one's license to practice medicine. Before NPDB, bad providers could move to another s |
| Off-site location | Refers to remote or distant from the place of business; data recovery & storage options are often off-site; & many EMR solutions for drs exist off-site & accessed through a thin-client or web portal. Some hosptials use this or remote access to EHR techno |
| Patient care orders (PCOs) **(also known as nursing orders) | Patient interventions that are ordered by a provider for a nurse to carry out; include: guidance on how much assistance a patient needs to get out of bed; whether to document urinary output and liquid intake; dressing changes; medication orders |
| Physician Desk Reference (PDR) | Traditinally this is a large, bound book that lists all prescription medications availabe on the the market and includes prescribing information from the manufacturers; it's now available in electronic format, accessible through EHR & EMR system or a PC |
| Protected Health Information (PHI) | Information that can individually identify a person; incluldes demographic data or any common identifier, such as a Social Security number, date of birth, address or phone number |
| Release of Information (ROI) | Appropriate and legal relese of patient health information that includes PHI; HIPAA outlines the requirements for proper release of information in various circumstances |
| Role-Based Access Controls (RBACs) | Control the ability to access certain areas of the system, based ono the person's role in the facility, which is associated with thier login ID and password |
| Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) | A medical reference vocabulary that serves to standardize the naming and terminology used in medicine and health care |
| Templates | Pre-designed forms for the capture of data and information; common attributes of templates include dropdown menus, check boxes, and required fields, which will not allow the user to advance without answering the question or providing th data |
| Wireless on Wheels (WOW) | WOW is same as COW; in some environments, patients may be sensitive to the casual use of the word cow, so some facilities prefer to use the WOW acronym to avoid any patient misunderstanding |
| Current Procedural Terminology (CPT) codes | Numeric codes developed by the American Medical Association (AMA) to standardize medical services and procedures |
| Encounter form | A form the provider fills out as he/she sees the patient; lists the service charges and how much the patient paid for the services; can be submitted for billing |
| Face sheet | A standard structured document that contains patient info. such as name, date of birth, insurance info, reason for seeking medical care & religious preference; medical staff uses the document to quickly see the relevant points of care |
| Healthcare Common Procedure Coding System (HCPCS) | A numeric and alphabetic coding system used for billing and pricing of procedures, medical supplies, medications and durable medical equipment |
| International Classification of Disease, Tenth Revision, Clinical Modifications (ICD-10-CM) codes | Coding and classification systems that group diseases, disorders and procedures into standardized codes |
| Insurance Verification | Process used to make sure the service received by the patint is approved and paid for by the insurance company |
| National provider identifier (NPI) number | A unique 10-digit number assigned to providers in the U.S. to identify themselves in all HIPAA restrictions |
| Practice management system | A software designed to assist in the office workflow by streamlining scheduling, insurance information, patient demographics and billing |
| Third-party vendor | A separate business that handles a specific task for a facility; common third-party vendors include billing companies, transcription companies, and coding firms |
| Ad hoc reports | Reports created or programmed in response in an injury or issue that comes up; they are not normally scheduled reports |
| Compliance | Compliance as it relates to paper or electronic medical record refers to the completion of the record & the adherence to medical records and documenation requirement set forth by state & federal law, as well as accreditation & regulatory agencies |
| Database queries | Reports run on records stored in a database to find specific information; an ad hoc report is set up as a query |
| Diagnosis-related groups (DRGs) | Assigned to inpatients based on the principal diagnosis; determines the hospital's reimbursement; based on the prospective payment system |
| Garbage-on, garbage-out (GIGO) | Refers to the fact that poor documentation or data entry results in poor output from a computer or information system |
| Incomplete charts | Charts that are missing signatures, reports or other required elements as outlined in either CMS Conditions for Participation for Medical Record Services or the Joint Commission accreditation guideline for information management |
| Payers | Another word for insurance companies or the reponsible party who will pay for the medical services patients receive; when patients do not have insurance, the payer listed on the bill is self-pay |
| Point-of-care (POC) charting | The ability of providers to document the care and treatment they render in real time, when they are with the patient; it is made much easier with the use of clinical templates, digital dictation, point-and-click menus, and other technology solutions |
| Record destruction policy | Facilities that maintain medical records of any form must have a record destruction policy in place; an attorney should guide the devlopement of any policy on records & consider state & federal laws, along w/ any regulatory & accreditation requirements. |
| Record retention | How long to retain medical records is a policy decision based on state & federal laws & regulatory & accreditation agency guidelines; an attorney should guide the development of any policy & consider facility needs including: pt characteristics, demograph |
| Redundant data storage | Storing data from your facility in more than one location so if one area is hit with a disaster event, the data is restored from a copy located elsewhere |
| Reimbursement | Payment for services rendered; refers to the end result of the revenue cycle |
| Revenue cycle | Five-step process that begins with providing services; after delivering services, providers document the care in the patients record, which drive the assignment of code & establishes charges so a claim/bill can be prepared, submitted & get revenue |
| Upcoding | Intentional or unintentional assignmen of a higher level code than the documentation supports |
| Vendor | Company or organization that sold a product or service to a facility; in EHR technolog issues, EHR specialists should keep comminications open w/vendor so they can work jointly to quickly resolve issues around software updates, hardware or software issues |
| Addendum | Additional documentation added to a health record that represents new data included ini the original documentation |
| Advance directives | Documents that give patients the right to make decisions about their care and designate others to make a decision if they are incapacitated |
| Amendment | An addition to patient record documentation meant to clarify or further explain existing record information |
| American Health Information Management Association (AHIMA) | The national organization for medical records professionals |
| Audit trails | A computer software program that tracks users by login and documents where in an information system users go and which applicants they access |
| Battery | A legal term; harmful or offensive touching of another |
| Compliance Officer | A health care administrator charged with overseeing all compliance activities in the facility; often also serves as the privacy officer |
| Consent forms | Forms patients sign to give permission for treatment |
| Corrections | Entries in a patient health record that correct or change original data |
| De-identify | The stripping of any identifying pieces of data from health records so they can be used in research, education, other public health activities |
| Delete | Removing data or informatio from the health record; this not permitted |
| Late entries | Documentation added to the patient record after the care was provided |
| Mininum necessary standard | The HIPAA standard that requires covered entities to realease only the minimum amount of patient health data to mee the need of the request |
| National Patient Safety Goals | Implemented by Joint Commission in 2002, these goals focus on practices to safeguard patients in the health care delivery system; one example is the universal protocol-requires a time out before any surgical procedure to verify right pt, right side, right |
| Password | A unique set of characters, letter and numbers that is kept private and allows users with an appropriate login ID to access an information system |
| Patient Self-Determination Act (PSDA) | The legislation that gives patients the right to make decisions about their care and outcomes, including being left alone to die and not resuscitated if that is not their desire |
| Privacy Official | HIPAA-required individual who is the point person for any privacy concerns or complaints; leads the facility in communicating privacy practices and reviewing existing practices for compliance with privacy requirements |
| Redundancy | Duplication; generally refers to data |
| Accounts receivable | Patient bill for services that have already been provided that legally are due to a facility |
| Autopsy rates | The percent of autopsies performed on patients who die in the hospital; reasons for not performing an autopsy in the hosptial may include legal inquiry or family preference |
| Average lenght of stay (ALOS) | The total number of patient days in a period divided by the number patients; for example, the ALOS for cardiology services in February was 6.1 days |
| Benchmarks | Goals or metrics a facility want to meet; ex/if the industy standard is 90% of patients should have advance directives entered into the patient record w/in 24 hr of admission & hospital was only meeting this for 45% of the patients, they would use the ext |
| Centers for Disease Control and Prevention (CDC) | A division of the Department of Health and Human Services |
| Chief Executive Officer | Leader of a facility who reports to the Board of Directors |
| Chief Financial Officer | Leader who oversees all the financial and fiscal decisions and issues for a facility; generally reports to the CEO |
| Commerical insurers | Private, non-government insurers; these are often the insurance options available through employers |
| Comorbidity | Disease that exists at the same time as a primary disease that a pt is being treated for at that time; ex/ pt who has cancer is receiving cancer specific environment & is also a diabetic-diabetes mellitus would be the considered the comorbid condition |
| Complications | Unexpected events or circumstances that happen to a pt during the course of his care; hospital-acquired infections, such as those involving MRSA, are considered to be complications, as are reactions to medication or an adverse response to any treatment |
| Copayment | Money the patient must pay toward the bill as contracted between the insurer and provider; amounts range from $5 to $50, & $75 for emergency room and specialist visits; provider's office visits are often in the $10 to $35 range |
| Daily census | The count of how many patients are in beds by patient care unit for an inpatient facility |
| Department of Health and Human Services (HHS) | Principle agency for protecting American's health |
| Institute of Medicine (IOM) | Non-governmental, independent, and nonprofit organization that provides unbiased, expert advice to governmental and private decision makers, as well as the public |
| Morbidity | Refers to disease |
| Mortality (death) rate | The percentage of all discharged patients who are discharged due to death witihin a prescribed period; ex/if a hospital has discharged 30 pts in a month, & of those 5 were deaths, the mortality rate for the month would be expressed as 5/30 or 16.7% |
| National Ambulatory Medical Care Survey (NAMCS) | Collects data on ambulatory medical care provided in the U.S.; the data is collected from visits to office-based providers who provide direct patient care |
| National Center for Health Statistics (NCHS) | Nation's primary statistics organization; it works to compile, anaylze, and disseminate information on the nation's health to influence and guide health policy and practice in a manner that best serves the population |
| National Hospital Inpatient Quality Measures | A set of specific data that hosptials must collect and report to CMS and the Joint Commission to document quality patient care |
| Occupancy rate | The percentage of licensed beds in a hospital that have a patient assigned to them, and thus are generating revenue |
| Patient care unit (PCU) | For the purpose of census data, a PCU has a defined number of beds and is staff assigned; also called floors, units or wards |
| Prospective Payment System (PPS) | System initially implemented by Medicare in the early 1980's that replaced fee-for-service payments for the provision of health services with predetermined payments based on the principal diagnosis of the patient |
| Services lines | Groups of pt services by speciality; hospitals define these individually & they vary by facility with some similarities, such as obsterics; exs/ cardiology & thoracic surgery. Some hospitals combine ex/cardio-thoracic surgery. Useful-compliling financial |
| Total inpatient service days | The # of inpatients receiving care each day summed for the days in the period under study; ex/if you are reviewing the total inpatient service days for the month of Sept, which has 30 days, add the pt for Sept 1 (125), Sept 2 (119) etc; the total is sum o |
Created by:
Danielle Mulhern
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