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223 Cards in this Set
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The Unified Medical Language System® (UMLS®) Metathesaurus®
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is a large, multi-purpose, and multi-lingual thesaurus that contains millions of biomedical and health related concepts, their synonymous names, and their relationships.
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What are the three UMLS components:
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the Metathesaurus, the Semantic Network, and the SPECIALIST Lexicon.
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The National Library of Medicine (NLM)
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updates the UMLS twice a year in May and November.
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EMR (Electronic Medical Record)
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System Any clinical computing system that includes features beyond simple document storage
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PM (Practice Management)
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System Handles billing, insurance claim filing, financial reporting, and sometimes scheduling and patient reminders
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Computerized Chart
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Medical document management system
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EHR (Electronic Health Record)
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An electronic record containing data about a patient that is integrated across multiple systems
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The minimum content for a continuity care record is called
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Core data set
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A reason to implement an EHR is to
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Improve patient care
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Which of the following is an example of a reminder
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Patient is due for MMR immunization
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The system that includes patient information from both the patient and the healthcare provider is
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PHR
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To receive the full benefits of the EHR, one should document
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at the point of care
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The component of the EHR that allows patients to manage their own data is
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PHR
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Which component of the EHR allows patients to retrieve their test results?
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Patient-provider portal
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The ability of a healthcare facility to provide EHR software to physicians is allowed through
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an exception to the Stark Law
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CCHIT's role in the EHR is
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certification
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What is the trend of adoption of the EHR in the U.S.
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The U.S. is rapidly increasing the rate of adoption of EHRs
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Money is an example of a _____ to the EHR
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Barrier
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What function is typically found in the ambulatory EHR but not in the inpatient EHR?
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Practice management
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Which of the following is a benefit of the EHR
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Improved efficiency
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Which of the following is an example of cost avoidance?
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Not repeating tests
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Which statement is true about the EHR
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The EHR is different based on the setting in which it operates
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The most secure type of signature used in the EHR is
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Digital Signature
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SNOMED is an example of
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nomenclature
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The mapping system used to convert ICD-9-CM to ICD-10-CM is
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GEMs
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Which of the following organizations accredits SDOs?
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ANSI
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Which of the following is used to identify drugs?
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NDC
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Which of the following standards is the messaging standard used in most clinical information systems?
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HL7
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DICOM is an example of a
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Messaging standard
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Which of the following is a database that is updated in real time
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Data repository
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Checkboxes are a method of data entry used in
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Structured data entry
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Which of the following is used as part of the design process
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Use case
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Which of the following is an organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards?
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Health information exchange organization
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The purpose of which organization is to provide training and other support to help physicians and other professionals implement and adopt EHRs?
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Regional extension center
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The program that provides incentive payments to healthcare providers who meet certain criteria for using the EHR is
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meaningful use
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What is the term used for healthcare providers who are a part of the meaningful use program
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Eligible professional
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Which of the following is a health information exchange model?
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Directed exchange
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American Health Information Community (AHIC)
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an advisory committee to the US Department of Health and Human Services that operated from 2005 to 2008
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American National Standards Institute (ANSI)
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an organization that governs standards in many aspects of public and private business; developer of the Health Information Technology Standards panel
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Backward map
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A map that links the two coding systems in the opposite direction, moving from ICD-10 version to ICD-9
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Centers for Medicare and Medicaid Services (CMS)
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the Department of Health and Human Services agency responsible for Medicare and parts of Medicaid. Historically, CMS has maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCMPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set
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Certification commission on Health Information Technology (CCHIT)
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an independent, voluntary private sector initiative organized as a limited liability corporation that has been awarded a contract by the US Department of Heath and Human Services to develop, create prototypes for and evaluate the certification criteria and inspection process for electronic health record products
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Certified EHR technology
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under HITECH, EHR technology certified under the ONC HIT Certification program that has: (1) the capabilities required to meet the base EHR definition; and (2) all other capabilities that are necessary to meet the objectives and associated measures under 42 CFR 495.6 and successfully report the clinical quality measures selected by CMS (or other states, as applicable) for the stage of meaningful use that an eligible professional, eligible hospital, or critical access hospital seeks to achieve
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Classification systems
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used to group similar items together, such as diagnoses or procedures
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Clinical decision support system (CDSS)
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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
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Clinical messaging
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the function of electronically delivering data and automating the workflow around the management of clinical data
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Clinical provider order entry (CPOE)
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electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically
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Cluster Map
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an entry in a GEM where one code from the many target codes can become a map to the source code
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Combination map
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an entry where more than one code is required in the target code set to replicate the complete meaning of the source system
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Complex map
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represents multiple code combinations and alternatives that are required to translate a source to a target code
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Continuity of care record (CCR)
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a core data set of the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the community of care
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Data content standards
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clear guidelines for the acceptable values for specified data fields. These standards make it possible to exchange health information using electronic networks
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Data repository
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an open-structure database that is not dedicated to the software of any particular vendor or data supplier, in which data from diverse sources are stored so that an integrated, multidisciplinary view of the data can be achieved
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Data set
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a list of recommended data elements with uniform definitions that are relevant for a particular use
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Data structure
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the form in which data are stored, as in a file, a database, a data repository, and so on
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Database
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an organized collection of data, text, references, or pictures in a standardized format, typically stored in a computer system for multiple applications
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Digital Imaging and Communications in Medicine (DICOM)
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an ISO standard that promotes a digital image communications format and picture archive
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Digital signature
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an electronic signature that binds a message to a particular individual and can be used by the receiver to authenticate the identity of the sender
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Digitized signature
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a scanned image of an individual's actual signature
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Document management system
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an electronic method of capturing and managing documents
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Electronic health record (EHR)
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an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
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Electronic medication administration record (EMAR)
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a system designed to prevent medication errors by checking a patient's medication information against his or her bar-coded wristband
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Electronic signature
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a generic, technology-neutral term for the various ways that an electronic record can be signed, such as a digitized image of a signature, a name typed at the end of an email message by the sender, a biometric identifier, a secret code or PIN, or a digital signature
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Eligible professional (EP)
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under HITETECH, specific to the Medicare program, means a physician as defined in section 1861(r) of the Act, which includes, with certain limitations, all of the following types of professionals: (1) a doctor of medicine or osteopathy, (2) a doctor of dental surgery or medicine, (3) a doctor of podiatric medicine, (4) a doctor of optometry, (a) a chiropractor
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Forward map
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map that translates an ICD-9 code as source code, to IC9-10 as its target code
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General Equivalence Mappings (GEMS)
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a program created to facility the translation between ICD-9-CM and ICD-10-CM/PCS (CMS 2010)
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Graphical user interface (GUI)
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a style of computer interface in which typed commands are replaced by images that represent tasks
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Health Level 7 (HL7)
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a not-for-profit, ANSI-accredited standards-developing organization, dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services
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Hybrid electronic record
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any combination of paper and electronic records; a health record that includes both paper and electronic elements
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Interoperability
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the capability of different information systems and software applications to communicate and exchange data
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Logical Observation Identifiers Names and Codes (LOINC)
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a database protocol developed by the Regenstrief Institute for healthcare 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
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Mapping
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the process of associating concepts from one coding system with concepts to another coding system and defining their equivalence in accordance with a documented rationale and a given purpose
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Meaningful use
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a regulation outlining an incentive program for professionals, eligible hospitals, and CAHs participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use or certified EHR technology
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MEDCIN
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a proprietary clinical terminology developed as a point-of-care tool for electronic medical record documentation at the time and place of patient care
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Messaging standards
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protocols that help ensure that data transmitted from one system to another remain comparable
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National Council for Prescription Drug Programs (NCPDP)
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a not-for-profit ANSI- accredited standards development organization founded in 1977 that develops standards for exchanging prescription and payment information
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National drug codes (NDC)
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codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected over-the-counter products
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National eHealth Collaborative (NeHC)
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successor of AHIC, working to enable secure and interoperable nationwide health information exchange to advance health and improve healthcare
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Order entry/results reporting
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a software application where healthcare professionals can enter patient care orders and then see the results of the test results
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Patient provider portal
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a secure method of communication between the healthcare provider an d the patient, just the providers or the provider and the payer
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Personal health record (PHR)
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an electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care
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Population health
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the capture and reporting of healthcare data that are used for public health purposes. It allows the healthcare provider to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials.
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Radiofrequency identification device (RFID)
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An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and does not require direct contact.
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Regional extension center
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mandated by the HITECH Act to assist EPs in the implementation and use of EHR. The purpose is to provide training and other support to help physicians and other professionals implement and adopt EHRs including technical support
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Regional health information organization (RHIO)
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An organization that manages the local deployment of systems promoting and facilitating the exchange of healthcare data within a national health information network.
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Semantics
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The meaning of a word or term; sometimes refers to comparable meaning, usually achieved through a standard vocabulary
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Source code
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(1) The programing code that was used to develop the system (2) the origin of the map, or the data set from which one maps.
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Source system
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(1) A system in which data were originally created (2) independent information system application that contributes data to an EHR, including departmental clinical applications and specialty clinical applications.
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Systematized Nomenclature of Medicine Clinical Terms(SNOMED-CT)
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The most comprehensive, multilingual clinical healthcare terminology in the world. It contributes to the improvement of patient care by underpinning the development of electronic health records that record clinical information in ways that enable meaning -based retrieval.
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Standards development organizations (SDOs)
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A private or government agency involved in the development of healthcare informatics standards at a national or international level.
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Structured data
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generally found in checkboxes, drop-down boxes, and other data entry means whereby the user chooses from options already built into the system
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Syntax
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the rules and conventions that one needs to know or follow in order to validly record information, or interpret previously recorded information, for a specific purpose. Such rules and conventions may be either explicit or implicit
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Target Code
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the destination map, or the data set in which one attempts to find equivalence or establish the code relationship
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Template-based entry
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a cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient
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Unified Medical Language System (UMLS)
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a program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biological concepts, words, and expressions and their interrelationships; includes concepts and terms from many different source vocabularies
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Unstructured data
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allows the data entered to be more specific and detailed for each patient than structured data
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Use case
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a technique that develops scenarios based on how users will use information to assist in developing information systems that support the information requirements
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Vocabulary standards
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a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field
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Health Information Exchange Organization |
allows healthcare professionals and patients to appropriately access and securely share a patient’s vital medical information electronically.
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Nationwide Health Information Network (NwHIN) |
is a network of networks sharing patient information to provide immediate access across the nation to improve patient care, streamline disability claims, and improve public health reporting. |
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Natural Language Processing (NLP) |
is the ability of a computer program to understand human speech as it is spoken.
It is a component of artificial intelligence (AI). |
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Office of the National Coordinator of Health Information Technology (ONC) |
is a position within the US Department of Health & Human Services (HHS). The position was created by Executive Order in 2004 and written into legislation by the HITECH Act. It's purpose is to promote a national health Information Technology infrastructure and oversee its development and for setting the stage for interoperability.
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Reminders |
can notify physicians of screenings that should be performed based on the patient's age and gender. |
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RxNorm |
is a clinical drug nomenclature developed by the FDA , the VA, and HL7 to provide standard names given to clinical drugs and drug delivery devices in the United States to enable interoperability and clear communication between electronic systems, regardless of software and hardware compatibility.
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continuum of care, documentation, clinical decision making, knowledge building.
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The EHR affords access to longitudinal health information about an individual across the _____, assist in _____, support ____, and provide for _____.
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multiple sources, point of care, decision making process
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The EHR integrates data from ______, compares data at the _____, assists providers in ______.
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source systems
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Information systems that populate the EHR.
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clinical, administrative, financial
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Source systems are ____, ____, and ____.
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continuity of care record
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A snapshot of data from the EHR and includes basic information such as diagnoses, allergies, medications, and future treatment.
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CCR
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A subset of the EHR that is used for subsequent patient care is a
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patient care
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Implementing an EHR can improve ____
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rules engine
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The infrastructure required for the EHR includes which component not found in most information systems?
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rules engine
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This controls alerts, reminders, order sets, and protocols.
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PHR
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System that includes patient information from both the patient and the provider.
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longitudinal record
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The phrase womb to tomb refers to ____.
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stark law
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This prevents physicians from receiving a fee for referring patients for any healthcare services whose care is paid for by a federally funded program.
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stark law
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This prohibits physicians or their family members from owning businesses to whom the physician refers patients for health services.
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CPOE
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This contains preprogrammed clinical decision support designed to assist the user through making an entry appropriately.
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order communication system
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This part of the EHR notifies clinical departments of orders made by the physician.
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electronic document management system
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This part of the EHR utilizes scanning to capture patient information from the paper record.
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clinical messaging
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This part of the EHR connects the medical staff and hospital by providing access to systems.
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clinical messaging
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This is the secure transmission of clinical information from one entity to another, including providers to providers, patients to providers, etc.
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structured, unstructured
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Patient care charting generally allow ____ and ____ data.
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structured
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This type of data is generally found in checkboxes, drop down boxes, and other means where the user chooses from options built into the system.
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unstructured
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This type of data can be entered in free text format by the user.
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patient safety, reminders, alerts
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The use of the CPOE can lead to significant improvements in _____ because _____ and ____ are built into the system.
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electronic medication administration record
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This part of the EHR automates many of the medication administration process in a facility.
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electronic medication administration record
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This part of the EHR can provide alerts to assist in medication timing and provide the nurse with reference material on the medication.
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clinical decision support system
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This part of the EHR provides help in association with data entry into an EHR system performed directly by the caregiver at the point of care.
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clinical decision support system
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This part of the EHR may notify the care provider of patient allergies or contraindications for medication or other treatment.
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patient provider portal
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This part of the EHR is a secure method of communication between the health care provider and the patient, just the providers or the provider and payer.
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patient provider portal
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This part of the EHR may include secure email or remote access to test results and provide patient monitoring - or access to patient education materials.
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population health
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This part of the EHR is the capture and reporting of healthcare data used for public health purposes.
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population health
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This part of the EHR allows healthcare providers to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials.
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exception to the Stark Law
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The ability of a healthcare facility to provide EHR software to physician is allowed through _____.
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certification
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CCHITs role in the EHR is
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larger facilities, physician practices
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Most EHRs are found in _____ and _____.
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cost savings, cost avoidance, productivity improvement
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Economic benefits of the EHR are ______, _____, and _____.
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easier access, faster diagnosis and treatment, quality of care, mistakes, documentation
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Clinical benefits of the EHR include _____, ______, improvement to ______, reduction in ______, and enhanced ______.
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providers, patients
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The EHR can improve communication between ______ and allow physicians to spend more time with ______.
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cost, uniform standards, training, fear
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Barriers to implementing the EHR include ____, lack of ______, ______, and ____.
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interoperability
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The lack of consistent standards in the EHR prevents _______.
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infrastructure
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This is made up of hardware, network, database, server, personnel.
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storing patient information
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The core function of the EHR is ______.
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medical devices
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The EHR can link with _______ allowing the capture of monitoring and testing.
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practice management system, billing, scheduling
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The ambulatory EHR frequently is combined with the ________ to perform ____ and _______.
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digitized
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Scanned image of an individual's actual signature.
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electronic
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Type of signature that requires a password or two-tiered authentication.
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digital
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Type of signature that used encryption and nonrepudiation to prove authenticator's identity.
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classification systems
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These are used for secondary data and group similar items together.
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reimbursement, quality of care, planning, statistics, public health reporting
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Classifications are used for which five tasks?
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interoperability
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Standards are important for ______.
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health information technology standards panel
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This organization works collaboratively with public and private sectors to achieve widespread interoperability among healthcare software applications.
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standards development organizations
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Organizations that create standards.
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american national standards institute
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This organization is responsible for accrediting standards development organizations.
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health information technology standards panel, standards development organizations, american national standards institute
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HITSP, SDO, ANSI
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vocabulary, messaging, data content
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For a system to be interoperable, it needs to follow the specific standards in which three categories:
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SNOMED
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The most widely recognized nomenclature in healthcare is
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systematized nomenclature of medicine, logical observation identifiers names and codes, unified medical language system, national drug codes
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SNOMED, LOINC, UMLS, NDC
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SNOMED
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This nomenclature system includes diagnoses, procedures, signs, symptoms, and cause of injury.
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LOINC
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This is a laboratory vocabulary used to order and report laboratory tests and record clinical observations.
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RxNorm
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This is a vocabulary for medications and provides standards for drug ingredients and strength as well as dose formats and relationships to other drugs.
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UMLS
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A database that catalogues bibliographic citations for biomedics and was developed to improve search capabilities.
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NDC
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These were developed by the FDA to act as a universal unique identifier for human drugs.
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MEDCIN
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This nomenclature and knowledge based system is designed to provide intelligent clinical database for documentation by the clinician at the time of care.
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mapping
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This is a crosswalk between the various terminologies; links between terminologies.
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use cases
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These are frequently used to create maps and describes how the user will interact with the system and what the system will do.
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digital
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The most secure type of signature used in the EHR is
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classification system
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ICD 9 is an example of a
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SNOMED
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The nomenclature used in the EHR to capture detailed clinical information is called
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SDO
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HITSP is considered a
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messaging standards
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Also called interoperability or data exchange standards.
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messaging
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With these standards, proprietary systems are able to talk to one another and allow the exchange of data.
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HL7
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This SDO provides standards for interoperabiltiy that improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer for all stakeholders.
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DICOM
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The use of this standard allows images to be transferred between systems from different vendors and allowing imaging to share information with clinical systems and EHR.
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Digital imaging and communications in medicine, national council for prescription drug programs
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DICOM, NCPDP
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NCPDP
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These standards are used by pharmacies and payer and control data to be shared for new prescriptions, refills, and other communications.
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data structures
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Refers to data stored in EHR and the way it is managed.
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data set
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Group of data elements that are the minimum accepted level of information to be collected for a specific purpose along with uniform definitions.
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data sets
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UHDDS, UACDS, MDS, DEEDS are all _____.
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Uniform hospital discharge data set, uniform ambulatory care data set, minimum data set, data elements for emergency department systems
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UHDDS, UACDS, MDS, DEEDS
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Joint Commission
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ORYX is a data set developed by the ______ to study outcomes and healthcare performance.
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database
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Collection of data carefully organized to be of value to the user.
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databases
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The EHR is a collection of ______.
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data repository
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Database that is developed in an open format allowing the facility to use it for multiple systems from one source - updated in real time.
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data warehouse
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Database containing data from other source systems in the healthcare facility - not updated in real time but is better suited for allowing querying and data analysis.
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presentation layer
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This controls the screen layout, data entry, and data retrieval.
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unstructured
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Also called narrative or free text data, this is usually entered using a keyboard, dictation, or voice recognition.
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unstructured
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This type of data allows data entered to be mores specific and detailed.
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reporting
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Unstructured data is not beneficial for _____ purposes.
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structured
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Drop down lists, check boxes, radio buttons, and other forms of controlled data entry are used in ______ data entry.
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template based entry
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This is a cross between free text and structured data entry where the user is able to pick and choose data that are entered frequently.
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interoperability
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The ability of one computer system to exchange data with another computer system.
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basic, functional, semantic
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Interoperability is divided into which three levels?
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basic
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Type of operability where the computer can send data to another computer but the receiving computer is unable to interpret the data.
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functional
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Type of operability that defines the structure of the messages so that the receiving computer can interpret the data.
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semantic
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Type of operability that allows the information to be used in a meaningful way.
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hybrid record.
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System with functional components that include both paper and electronic documents and use both manual and electronic processes.
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HL7
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____ is the messaging standard used in most information systems.
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messaging standard
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DICOM is an example of a ____
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real time
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A data warehouse is not updated in ____.
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structured data
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Check boxes are a form of ____.
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reminder
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I am entering orders on patient in my office. The computer tells me that I should order a mammogram. This is a ____.
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EMAR
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This component of the EHR uses bar codes to identify patients.
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provider portal
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The provider would use the _____ to check test results of a patient.
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healthcare providers
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The EHR improves communication between ____.
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practice management
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The ______ function is seen in the ambulatory EHR but not inpatient.
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data content
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Standard that controls content of data elements.
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SNOMED CT
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Terminology used to capture detailed clinical information.
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national drug codes
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This system is used to provide an universal unique identifier for human drugs.
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mapping
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A way to link ICD 9 and ICD 10 is through ____.
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more specific
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An advantage of unstructured data is that it can be ____.
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graphical user interface
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This provided tool such as icons, colors, buttons, and menus to help users navigate through an information system.
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NCPDP
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This is a messaging standard that is used by pharmacies and payers.
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HL7
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This messaging standard is used for clinical and administrative data.
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use cases
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Tools that provide very detailed information for programmers to use when developing they system.
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clinical data repository
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The infrastructure of the EHR should include a _____.
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subpoena audit trails
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A legal concern regarding the EHR is the ability to _____.
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False
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True or false. The US leads the way in EHR adoption by physicians.
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False
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True or false The EHR is not used for public health purposes.
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multiple ways
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In the EHR, data can be viewed in ____.
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printing, access
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In the hybrid environment, we must address issues such as ____ and ____.
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False
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True or false. The order entry/results reporting system is always utilized by the physician.
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