International Classification of Disease (ICD-9/ICD-10)
System for classification of surgical, diagnostic, and therapeutic procedures.
Electronic
... [Show More] Signatures in Global and National Commerce Act (ESIGN)
Legislation that gives electronic signatures the same legal status as hand-written signatures.
Electronic health record (EHR)
Digital version of patient data found in traditional paper records. Increasingly used to refer to a longitudinal record ideally of all healthcare encounters.
Data mining
Technique that looks for hidden patterns and relationships in large groups of data using software.
Data exchange standards
Set of agreed-on rules that permit the uniform capture and exchange of data between information systems from different vendors and between different healthcare providers.
Database administrator (DBA)
Person responsible for overseeing all activities related to maintaining a database and optimizing its use.
Current Procedural Terminology (CPT)
Classification system that lists medical services and procedures performed by physicians and is used for physician billing and payer reimbursement.
Continuity of care document (CCD)
Record comprised of contributions from many types of caregivers, with each providing a summary of care provided for the purpose of improved continuity of care when clients move between various points of care.
Computerized physician (or provider/prescriber) order entry (CPOE)
Process by which the physician or provider directly enters orders for patient care into a hospital information system.
Computer-based training (CBT)
Educational format using the computer that is widely used to train persons to use specific computer applications.
Computer-based patient record (CPR)
Automated patient record designed to enhance and support patient care through availability of complete and accurate data as well as bodies of knowledge and other aids to care providers.
Community Health Information Network (CHIN)
Organization that electronically links providers; payers; and purchasers of care for the exchange of financial, clinical, and administrative information via a wide area network in a particular geographic area. Precursor to RHIOs.
Commission on Accreditation of Rehabilitation Facilities (CARF)
Healthcare accrediting body with a focus on the improvement of rehabilitative services to people with disabilities and others in need of rehabilitation.
Clinical information systems (CIS)
Large computerized database management systems used to access the patient data that are needed to plan, implement, and evaluate care. May also be known as patient care information systems.
Clinical Care Classification System (CCC)
Nursing classification designed to document the six steps of the nursing process across the care continuum. Consists of two interconnected terminologies—the CCC of Nursing Diagnosis and Outcomes and the CCC of Nursing Interventions.
Chief privacy officer (CPO)
Individual responsible for the protection of personal health information of patients as required by federal law.
Chief information officer (CIO)
Person responsible for strategic planning, policy development, budgeting, information security, recruitment and retention of information services staff, and overall management of the enterprise's information systems. computer-related positions.
Barcode medication administration (BCMA)
Process or system used to ensure that the correct patient receives the correct medication in the correct dosage via the correct route and at the correct time. Patients and drugs both have barcode identification codes.
American Recovery and Reinvestment Act of 2009 (ARRA)
Legislation that included provisions for health information technology and funding for the Office of the National Coordinator of Health Information Technology (ONCHIT).
Logical Observation Identifiers, Names, and Codes (LOINC)
Terminology that includes laboratory and clinical observations.
Medicare Improvements for Patients and Providers Act (MIPPA)
Legislation that called for financial incentives for e-prescribing.
NANDA International (NANDA-I)
Terminology recognized by the American Nurses Association. Represents Nursing Diagnoses as data elements within SNOMED CT.
National Health Information Network (NHIN)
Office of the National Coordinator (ONC) for Health Information Technology (HIT) initiative to provide the standards, services, and policies that enable secure health information exchange (HIE) over the Internet.
Nursing Interventions Classification (NIC)
Standardized classification of interventions that describes the activities that nurses perform.
Nursing Minimum Data Set (NMDS)
Collection of data comprised of nursing diagnoses; interventions; and outcomes that allows comparison of data across different healthcare settings in order to project trends and stimulate research.
Nursing Outcomes Classification (NOC)
Classification system that describes patient outcomes sensitive to nursing interventions.
Omaha system
American Nurses Association recognized research-based taxonomy that provides a framework for integrating and sharing clinical data. Widely used in settings such as home care, hospice, public health, school health, and prisons.
PeriOperative Nursing Data Set (PNDS)
Standardized perioperative nursing vocabulary provides nurses with a clear, precise, and universal language for clinical problems and surgical treatments.
Request for Information (RFI)
A document sent to vendors that explains the institution's plans for purchasing and installing an information system with the goal of determining which vendors can meet the organization's basic requirements.
Request for Proposal (RFP)
Document sent to vendors detailing the requirements of a potential information system with the purpose of soliciting proposals from vendors that describe their capabilities to meet these requirements.
Request for Quote (RFQ)
Statement of need that focuses upon pricing, service levels, and contract terms.
Resource Utilization Groups (RUGs)
Per diem system of billing for skilled nursing facility patients.
Superuser
Staff person who has become proficient in the use of the system and mentors others.
TIGER Initiative
Plan to promote informatics competencies among nurses in order to transform healthcare.
Meaningful use
Use of health information technology (HIT) legislated by the American Recovery and Reinvestment Act of 2009 to collect specific data with the intent to improve care, engage patients, improve population health, and ensure privacy and security.
International Classification of Nursing Practice (ICNP)
A system that serves to unify various approved nursing languages and classification systems to ensure the acceptance of common meanings across different settings.
HITECH (Health Information Technology for Economic and Clinical Health Act)
Portion of ARRA that amended HIPAA Security and Privacy Rules and provided funds and incentives to increase the use of electronic health records by physicians and hospitals who meet eligibility criteria for Meaningful Use.
Information literacy
Ability to recognize when information is needed as well as the skills to find, evaluate, and use needed information effectively.
Knowledge management
Structured process for the generation, storage, distribution, and application of both tacit knowledge (personal experience) and explicit knowledge (evidence).
Administrative information systems
Systems that support patient care by managing financial and demographic information and providing reporting capabilities.
Informatics Nurse Specialist (INS)
A nurse who has educational preparation to conduct informatics research and generate informatics theory.
Informatics Nurse
A nurse with advanced preparation in information management.
Hospital information system (HIS)/Healthcare information system (HIS)
Group of information systems used within a hospital or enterprise that support and enhance patient care. The HIS consists of two major types of information systems: clinical and administrative./Computer hardware and software dedicated to the collection, storage, processing, retrieval, and communication of patient care information in a healthcare organization.
Health Level 7 (HL7)
Standard for the exchange of clinical data between information systems by means of an extensive set of rules that apply to all data sent.
Healthcare Information Exchange (HIE)
Electronic sharing of patient information such as demographic data, allergies, presenting complaint, diagnostic test values, and other relevant data between providers such as primary physicians, specialists, hospitals, and ambulatory care settings according to nationally recognized standards.
Electronic medical record (EMR)
Legal record created in hospitals and ambulatory settings of a single encounter or visit that is the source of data for the electronic health record.
Electronic patient record (EPR)
Electronic client record, but not necessarily a lifetime record, that focuses on relevant information for the current episode of care.
Digital Image Communication in Medicine (DICOM)
Standard that promotes the communication, storage, and integration of digital images with hospital information systems. [Show Less]