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CONCEPTS
◉Electronic Signatures in Global and National Commerce Act (ESIGN)
. Answer: Legislation that gives electronic signatures the same legal
status as hand-written signatures.
◉Electronic health record (EHR) . Answer: 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 . Answer: Technique that looks for hidden patterns and
relationships in large groups of data using software.
◉Data exchange standards . Answer: 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) . Answer: Person responsible for
overseeing all activities related to maintaining a database and optimizing
its use.
◉Current Procedural Terminology (CPT) . Answer: 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) . Answer: 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) .
Answer: Process by which the physician or provider directly enters
orders for patient care into a hospital information system.
◉Computer-based training (CBT) . Answer: Educational format using
the computer that is widely used to train persons to use specific
computer applications.
◉Computer-based patient record (CPR) . Answer: 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.