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| Question | Answer |
| Chapter 1: Healthcare Delivery Systems | Allied Health Professionals |
| Professional Organizations: American Health Information Management Association (AHIMA) | Supports the healthcare industry promoting high quality information standards through accreditation of schools, continuing education, professional development, educational publications, and legislative and regulatory advocacy Website: ahima.org |
| Professional Organizations: Centers for Medicare and Medicaid Services (CMS) | The division of the Department of Health and Human Services that administers medicare and medicaid |
| Ownership | Non-for-profit and For-profit hospitals tax status difference |
| For-profit | Organization has owners. It can have a few or many (shareholders) |
| Not-for-profit | Organization that operates for the good of the community and is owned by the community. Doesn't have shareholders. Certain tax benefits granted include exemption from property and certain corporate income taxes. |
| Net Income | Also called surplus, is the excess of revenue (mostly income from patient services) over expenses (resources used to provide the services) over a specific period |
| Board of Directors | Board members are elected by the shareholders. It authorizes actions and oversees all business affairs of the hospital. The key role of the board of directors is to ensure the hospital’s mission, vision, and values are carried out. |
| Board of Directors members | MANAGEMENT: The highest-ranking officers in the management division deal primarily with the business concerns of the HCO. Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Financial Officer (CFO) Patient Care and Information: Officers are directly concerned more with patient care. Chief Medical Officer (CMO), Chief Information Officer (CIO), Chief Medical Information Officer (CMIO) Chief of Staff (COS) |
| Chief Executive Officer (CEO) | Reports to board of directors Carries out the mission of the organization and addresses global issues Directs hospital staff Oversees corporate strategies |
| Chief Operating Officer (COO) | Reports to CEO Responsible for delegation of day-to-day operations Develops business policies and procedures Responsible for quality and delivery of service |
| Chief Financial Officer (CFO) | Reports to CEO Responsible for the strategic plan of financial operations Manages legal matters, properties, and partnerships Manages operating budget |
| Chief Medical Officer (CMO) | A physician Responsible primarily for utilization of EHR system Ensures compliance with federal and state government regulations Represents the interests and concerns of hospital management |
| Chief Information Officer (CIO) | Responsible for all patient information Ensures IT systems comply with regulatory requirements such as HIPAA and meaningful use Responsible for all aspects of creation and maintenance of medical and information technology tools, including EHR |
| Chief Medical Information Officer (CMIO) | Responsible for quality of care for patients Facilitates use and development of health information systems (HIM and HIT) Liaison between the CMO and CIO |
| Chief of Staff (COS) | Reports to the CEO Elected by the staff physicians and manages physician privileges and accreditation, medical policies, and continuing medical education. Is the governing body of the physicians and works closely with nurses and other clinical staff members. Represents the interests and concerns of the physicians. |
| Credentials | An individuals specific professional qualifications. Also refers to the letters that a professionally qualified person is entitled to list behind his or her name |
| Accreditation: The Joint Commission | Voluntary compliance, a process involving both self-assessment and external peer assessment by which organizations measure their performance against established standards and identify any areas that might need improvement. Is earned by an ENTIRE HCO. Each HCO is audited to ensure compliance. |
| Licensure | Government mandatory approval required for a facility to operate in a given state and is specific to the type of healthcare facility being operated. A state's legislature passes a hospital licensing act (law) that requires HCO to be licensed & delegates authority to regulate this process to a state agency. The delegated agency develops & administers its detailed regulations, which are part of the state's administrative code. |
| Compliance | Meeting standards. The development, implementation, and enforcement of policies and procedures that ensure that standards are met |
| Joint Commission: Accreditation & Certification | The most important accrediting body in healthcare is a nongovernmental, nonprofit agency Sets standards for acute care, ambulatory care, long term care, and rehabilitation facilities, also some specialties such as hospice and home healthcare. On-site surveys (facility review) are every 3 years. Accredits and entire HCO. Certifies programs within HCO devoted to chronic diseases and conditions. created three methods to ensure patient safety: National Patient Safety Goals (NPSG) Universal Protocol Speak Up program |
| National Patient Safety Goals (NPSG) Universal Protocol Speak Up | Guidelines for healthcare professionals to follow to prevent errors. The NPSGs were established to help accredited organizations address specific areas of concern in regard to patient safety. The three principal components of the Universal Protocol are preprocedure verification (of correct patient, procedure, and surgicial site), site marking (ideally with the patient’s involvement), and a timeout, immediately before the procedure, during which the healthcare team verifies the correct patient, site, and procedure and checks that all equipment, drugs, documentation, and so on, are in pl ace. The speak Up program encourages patients to help prevent medical errors by asking questions, educating themselves, and actively participating in their treatment. |
| Department of Health & Human Services | Federal agency with regulatory oversight of American healthcare. Divisions under DHHS are food & drug administration, centers for medicare & medicaid services, national institute health centers for disease control and prevention, health resources and services administration, Indian health service |
| Chapter 2: Collecting Healthcare Data | Data is plural Datum is singular |
| Data | items, observations or raw facts |
| Information | Processed data presented in an appropriate frame of reference |
| Health data | Elements related to a patient's diagnosis and procedures and factors that may affect the patient's condition |
| Health Information | Organized data that have been collected about a patient or group of patients |
| Aggregate data | A group of like data elements compiled to provide information about the group. A summary of information about all patients a physician has seen |
| Data Analytics | The process of analyzing data and exploring them to create information |
| Assessment | An evaluation. In medical decision making, physician's evaluation of the subjective and objective evidence. Also refers to the evaluation of a patient by any clinical discipline |
| Treatment | A procedure, medication, or other measure designed to cure or alleviate the symptoms of disease |
| Mortality | Causes of death |
| Morbidity | A disease or illness |
| Vital statistic | Public health data collected thru birth certificates, death certificates, and other data gathering tools. |
| Epidemiology | The study of morbidity (diseases) trends and occurrences |
| Payer | Individual, insurance company, or government agency (medicaid/medicare)that is primarily responsible for the reimbursement for a particular healthcare service. Usually the insurance company or third party. Primary payer is billed first. |
| Reimbursement | The amount of money that healthcare facility receives from party responsible for paying the bill. Healthcare services are paid after services have been rendered. |
| Medicare | Federally funded healthcare insurance plan for older adults and for certain categories of chronically ill patients |
| Centers for Disease Control and Prevention (CDC) | A federal agency that collects health information to provide research for the improvement of public health. A division of DHHS. |
| National Center for Health Statistics (NCHS) | A division of CDC that collects and analyses vital statistics. One of the ICD-10-CM operating parties. |
| SOAP format | Subjective, Objective, Assessment and Plan. The medical decision-making process used by physicians to assess the patient at various intervals |
| SOAP: Subjective | The first step of the physician's medical evaluation process. The patient's description of symptoms or other complaints (the medical problem) |
| SOAP: Objective | The second stage of diagnosis. The physician's observations including evaluation of diagnostic test results. Conduct of physical exam exploring problem area that was subjectively stated. other possible diagnoses are called differential diagnoses. Physician's objective notation is the specific anatomical location of problem, vital signs (blood pressure, temperature, pulse) and review of CPOE lab tests |
| SOAP: Assessment | A description of what the physician thinks is wrong with the patient: the diagnosis or possible (provisional) diagnoses. |
| SOAP: Plan of Treatment | Physician writes a plan of treatment or for further evaluation |
| Rule out | Related to objective. The process of systematically eliminating list of potential diagnoses |
| Outcome | The results of a patient's treatment |
| Discharge | Discharge occurs when the patient leaves the facility to go home, transfer to another healthcare facility or by death |
| Diagnosis | The process of identifying the patient's condition or illness |
| Symptom | The patient's report of physical or other complaints |
| Health data | Elements related to a patient's diagnosis and procedures and factors that might affect the patient's condition |
| Demographic data | Identification of the elements that distinguish one patient from another (name, address, birth date) |
| Socioeconomic data | Elements that pertain to a patient's personal life and personal habits (marital status, religion, culture) |
| Financial data | Elements that describe the payer (group number and member number of patient's insurance company etc) |
| Guarantor | The individual or organization that promises to pay for the rendered healthcare services after all other services (such as insurance) are exhausted |
| Clinical data | All medical data that have been recorded about a patient's (health) stay or visit, including diagnoses and procedures |
| Attending physician | The primary physician who is primarily responsible for coordinating the care of the patient in the hospital; usually the physician who ordered patient's admittance to hospital |
| Primary Care Physician | In insurance, the physician who has been designated by the insured to deliver routine care to the insured and to evaluate the need for referral to a specialist, if applicable |
| Data base: EHR, character, field, record, file | An organized collection of data |
| Data: character | A single letter, number or symbol |
| Data: field | a collection or series of related characters (a word, group of words a number or code etc) An alphanumerical field contains for alphabetical and numerical characters |
| Data: records | A collection of related fields. Refers to all data collected about a patient's visit or all the patient's visits |
| Data: files | Numerous records of different types of related data |
| Electronic Health Record (EHR) | A secure point of care patient centered information resource for clinicians allowing access to patient information when and where needed, and incorporating evidence based decision support. Includes Patient history, demographics, problem lists, list of current medications, patient's allergies, physician clinical notes (patient's medical history and followup notes). Provides certain prompts or alerts specific to a physician's orders and drug-drug and drug-allergy interaction checks. INTEROPERABILITY |
| Data consistency | Data is the same wherever it appears |
| Data accessibility | Data can be obtained when needed by authorized individuals |
| Data validity | The quality that data reflect the known or acceptable range of values for the specific data |
| Data accuracy | The quality that data are correct |
| Data dictionary | A list of details that describe each field in a data base |
| Master Patient Index (MPI) | A system containing a list of patients who have received care at a healthcare facility and their encounter information |
| Patient Account Number | a numerical identifier assigned to a specific encounter or healthcare service received by a patient; a new number is assigned to each encounter but the patient will retain the same medical record number |
| Medical Record Number | A unique number assigned to each patient in a healthcare system; this code will be used for the rest of the patient's encounters with that specific healthcare system |
| Health Record | Also called record or medical record. It contains all of the data collected for an individual patient. |
| Medication Administration | Clinical data including the name of the medication, dosage, date and time of administration, method of administration, and the nurse who administered it |
| Face Sheet | The 1st page in a paper record, usually contains at least the demographic data and space for physician to record and authenticate the discharge diagnosis and procedures. The admission record can also be used as the face sheet. |
| Physician's Order | The physician's directions regarding the patient's care, and refers to the data collection device (paper or computer hardware) which these elements are captured. |
| Computerized Physician Order Entry (CPOE) | A health information system in which physicians enter patient orders electronically for medications, tests, treatments, or procedures. Includes clinical decision support system elements and alerts for drug lists, allergies, interactions & other contraindications. System provides a list of medications for the specific treatment of a patient's diagnosis. Nothing can happen in a healthcare facility with a patient unless the physician writes an order. |
| Radiology | The study of x-rays. The diagnostic imaging department. |
| Authenticate | To assume responsibility by an electronic signature for data collection as form of identification. Related to but different from authorship. |
| Electronic signature | When the authenticator uses a password or PIN to electronically sign a document. The computer can be programmed to reject orders that do not contain an appropriate authentication. Program looks for both existence of authentication (for data completeness) and the correct authentication (for data validity) |
| Countersigned | Evidence of supervision subordinate personnel, such as physician residents |
| Master Forms File | A file containing blank copies of all current paper forms used in a facility |
| Integrated Record | A paper record in which the pages are organized sequentially, in the chronological order they were generated. Also known as a date-oriented record or sequential record. Paper records are sorted in one or combination of three ways: by date, source or diagnosis. |
| Source-Oriented Record | A paper record in which the pages are organized by discipline, department and/or type of form |
| Problem-Oriented Record | A paper record with pages organized by diagnosis or problem. Is useful when the patient has several major chronic conditions that may be addressed at different times. |
| PROBLEM LIST | A chronological summary of the patient's conditions and treatments |
| Medical Home Model | The PCP refers patients to specialists, coordinates follow-up visits and any subsequent required care. Transitioning from one setting to another is a key component. |
| Data set | A group of data elements collected for a specific purpose. It requires a standard method of reporting data elements so it can be compared to other data. Collected data must be in the same manner so it can be easily converted into the same format. |
| Inpatient Outpatient | Someone who is admitted to the hospital with intention of staying overnight Someone whose hospital stay is 24 hours or less |
| Uniform Bill (UB-04) | The standardized form used by hospitals for inpatient and outpatient billing to CMS and other 3rd party payers. The HIPAA 837I data set is the government mandated format for billing patients. |
| Uniform Hospital Discharge Data Set (UHDDS) | The government mandated data set for hospital INPATIENTS, for ACUTE CARE HOSPITALS. Includes demographics, clinical and financial data about individual patient visits. Prescribed by CMS |
| Minimum Data Set (MDS 3.0) | The detailed data collected about patients receiving long-term care, FOR SKILLED NURSING FACILITIES. Prescribed by CMS |
| Outcome and Assessment Information Set (OASIS) | Associated with HOME HEALTH CARE, this data set monitors patient care by identifying markers over the course of patient care. Prescribed by CMS |
| ICD-10-CM | International Classification of Diseases, 10th revision, clinical modification. An encrypted code set used for documenting diagnosis of disease. |
| Reimbursement | The amount of money the healthcare facility receives from the party responsible for paying the bill. |
| Benchmarking | Comparing one facilities process with that of another facility that has been noted to have superior performance. |
| Health Insurance Portability and Accountability Act (HIPAA) | Public law 104-191, a federal legislation passed in 1996 that outlines the guidelines of managing patient information in terms of privacy, security and confidentiality. The legislation also outlines penalties for noncompliance (breach) |
| Chapter 3: | Electronic Health Records |
| Hybrid Record | A record in which both electronic and paper media are used. Used by healthcare facilities transitioning to EHR systems |
| Point-of-care documentation | Clinical data recorded at the time treatment is delivered to the patient |
| Interface | Computer configuration of two systems allowing information to pass from one system to another (communicate with each other) |
| Admission | Admission requires a physicians order. The act of accepting a patient into a nonabulatory healthcare facility |
| Encounter | A patient's healthcare experience (doctor's visit). a unit of measure for the volume of ambulatory care services provided |
| History and Physical (H&P) | Health record documentation compromising the patient's history and physical examination |
| Report | The result from a query. A list from a database. |
| Digital Signature | An electronic means to identify the authenticity and integrity of the user's identification. Statement also includes the date and time user signed the document. |
| Discharge Summary | The recap of an inpatient stay, usually dictated (read or spoken aloud and recorded) by the attending physician and transcribed (typed) into a formal report |
| Document Imaging | Scanning or faxing printed papers into a computer system. Performed at discharge or point of care. |
| Indexing | Identifies the report by type and organizes them for easier retrieval when needed. |
| Bar coding | A type of automated indexing that is sometimes used to decrease errors and improve productivity in the indexing process |
| Electronic Document Management System (EDMS) | Computer software and hardware, typically scanners that allow health record documents to be stored, retrieved and shared. Used to scan records transferred from another facility to the EHR. |
| Clinical Decision Support System (CDSS) | Includes: EHRs with CPOE component, e-prescribing systems, & problem list of health concerns. Provisions by the HITECH Act to require use of CDSS to advance quality of patient care and patient safety. It's main purpose is to assist clinicians in diagnosis & analysis of patient data & is helpful @ all stages of care (diagnostic, treatment, follow-up). Also has reminders (alerts) for preventing disease, complications & adverse reactions. |
| Evidence-based Decision Support | Information systems that provide clinical best knowledge practices to make decisions about patient care |
| Order Sets | Predefined, evidence-based physician orders for common clinical conditions or diseases. Included in clinical decision support systems, can be added to the CPOE to expedite ordering process. |
| E-prescribing (eRx) | An objective of meaningful use stage 1. Referred for outpatient order entries of medication. Includes clinical decision support guidelines, alerts for drug interactions, contraindication warnings provided, identified preferred drugs for a patient's insurance company, transmission to the patient's preferred pharmacy. It increases legibility of orders, improves quality of care and patient safety by reducing handwriting errors. |
| Evidence-based Medicine (EBM) | Healthcare delivery that uses clinical research to make decisions in patient care. |
| Clinical Pathway | A predetermined standard of treatment for a particular disease, diagnosis or procedure designed to facilitate the patient's progress through the healthcare encounter. Is an algorithm. |
| Coding | Assigning alphanumerical values to a word, phrase or other nonnumerical expression. In healthcare it is used to encrypt diagnosis and procedure descriptions. |
| Analysis | Review of a record to evaluate its completeness, accuracy or compliance with predetermined standards (meaningful use) or other criteria. |
| Workflow | Process of work flowing through a set of procedures to complete a healthcare record |
| Algorithum | A set of step by step instructions for solving a problem |
| Data Repository | Stores data from unrelated software programs and make them usable through use of an interface without the need to run reports from each system. The software programs can be created by different vendors and have different applications. |
| Data warehouse | Where information from different databases (data repository) is collected and organized to be use to ad hoc reports and analytical research. Stakeholders use this info for analyzing revenue (calculate cost of treating patient), clinical management (determine correct amount of medicine given to a patient for a specific condition in a certain age group), operational applications (assess staffing patterns for patients with a specific medical condition *diabetic nursing unit*) & outcome management (estimated percentage of patients who showed improvement after treatment) |
| Health Information Exchange (HIE) | Allows healthcare providers to request and receive patients' records from other providers. the It benefits healthcare providers by reducing costs through elimination of duplication of tests and increased staff efficiencies, easy access to health records, better continuity of care for patients, decreased medical errors with ability to reconcile medications, improve patient outcomes and quality of care |
| Meaningful Use | A set of measurements to gauge the level of health information technology used by a provider and required in three stages, in order to receive financial incentives from CMS. |
| Private Sectors: Health Level Seven (HL7) Markle Foundation Certification Commission for Health Information Technology (CCHIT) | Private groups that advocate, encourage and monitor use of EHRs in effort to improve patient care and safety. |
| Markle Foundation | A current goal is to eliminate barriers in the implementation of the EHR. Two barriers: lack of interoperability among computer systems and privacy issues. Fosters collaboration in private/public sectors through initiative called Connecting to Health (promotes standards for electronic medical information). Promotes development of meaningful use and HIEs. www.markle.org |
| Health Level Seven (HL7) | A non for profit group that develops standards that will aide the interoperability of the exchange of electronic data among healthcare organization. HL7 works to provide standards for CLINICAL & ADMINISTRATIVE domains, specifically the exchange management & integration of data supporting clinical patient care & the evaluation of health services. Allows for transfer of data between providers and organizations. HL7 specifications ensure that data from one system or organization can be accepted & interpreted by HIE systems. |
| Certification Commission for Health Information Technology (CCHIT) | A non profit organization, www.cchit.org |
| Interoperability | The ability to exchange information and communicate between disciplines and healthcare organizations, EHR |
| Office of the National Coordinator for Health Information Technology | An executive division of the U.S. Department of Health and Human Services that coordinates and promotes the national implementation of technology (interoperable EHR in public/private healthcare). ONC established the Nationwide Health Information Network (NHIN) |
| National Health Information Network (NHIN) | Established by ONC. Its goal is to provide an interoperable health information exchange among providers, consumers, & other supporters of healthcare that is secure and capable of sharing information nationwide online. |
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