D220 Study Guide – If you see a ** by something, then that was seen on a D220 test by SOMEONE.
According to some, there are handful of questions on the OA from the PA.
Access Levels- User can only see information that they access to. (CNA cannot see everything an RN can)
Administrative Safeguards of Electronic Health Information- Restricting access of all authorized users of
the EHR according to their position within the healthcare system
Admission-Transfer-Discharge (ADT) System - Classified under the hospitals' administrative info system.
It’s one foundational system that allows operational activities such as bed placement, transportation
coordination, room readiness, & the general coordination of services focused on the pt's phase of
movement. Tracks a pt's activities & location from admission to discharge.
American Recover & Reinvestment Act (ARRA) – Authorized INCENTIVE PAYMENTS to specific types of
hospitals & healthcare pros for adopting & using interoperable Health Information Technology & EHR’s.
ARRA provides economic stimuli & incentives for the adoption of EHRs.
Analytical Science – Answers 2 basic questions: What do I have? How much of it do I have? Environment,
pharmacy, safety & security, fraud detection, & healthcare diagnostics.
Asynchronous Applications – Pt-centered & allows consumers to participate in their own care by using
designated health technology to share health metrics & data w/ their healthcare provider via technology
(remote pt-monitoring - the use of devices to capture pt data at one location & then transmit it
electronically to healthcare pros at a different location, allowing the review of data for clinical decision-
making, i.e. MobileHealth).
**Audit Trails– Software that is used for detecting security violations, performance problems, & flaws.
Records activity by users & system. **Goal is to improve data integrity. An audit trail must contain the
name of the user, the application triggering the audit, the workstation, the specific document, a
description of event being audited, & the date/time to determine integrity of data.
Authentication – Action that verifies the authority of users to receive specified data.
Barcode Medication Administration - MANDATED BY FDA.
**Benchmark– Continual process of measuring services & practices against the toughest competitors in
the healthcare industry. Comparing the performance of an organization or clinician to others.
Big Data – Very large data sets beyond human capability to analyze or manage without the aid of
information technology. Considered data originating from very large data sets that help identify patterns &
trends. Big data cannot be managed without the use of technology to analyze its output. 5 properties-
Variety, velocity, volume, value, veracity.
Change Management/ Change Control- INVOLVES EMPLOYEES IN THE DECISION-MAKING PROCESS. Helps
prioritize limited resources & ensure systems standards are upheld. For example, medication
administration. SHOULD EXCLUDE SUBJECT MATTER EXPERTS WHEN DISCUSSING CHANGE CONTROL.
,**Clinical Decision Support System (CDSS)- Supports healthcare practitioners in making pt-care decisions
by integrating pt data w/ current clinical knowledge. Provides recommendations for care & must be
balanced w/ professional judgment, not used in place of it.
**Clinical Information System– Software used to access client data, plan, implement, & evaluate care.
May be specific to certain departments: lab, radiology, pharmacy, or pt populations. Provides pt centric
decision-making functionality to help guide a RN w/ decision-making. Acquires pt data so that healthcare
pros can review it & use information to deliver care.
Computer Literacy – Familiarity w/ the use of personal computers. The knowledge & ability to use
computers & technology efficiently. Computer literacy allows pts to interact w/ the internet.
Computerized Provider Order Entry (CPOE) – Prescriber’s decisions to enter orders & immediately share
orders w/ appropriate health pros who execute orders & departments that need to dispense, schedule, or
immediately deliver services to pts. CPOE can check for duplicate orders, alert departments to carry out
orders, & provide the status of each order.
**Confidentiality– Unspoken understanding that private information shared in a situation, in which a
relationship has been established for the purpose of treatment or delivery of services will remain
protected.
Configurability – Extent that a given software product can be adapted or changed to meet a user’s
preference.
Connected Health – Model or platform by which technology assisted healthcare is delivered between at
least 2 points, involving either synchronous or asynchronous exchange.
**Consolidated-Clinical Document Architecture (C-CDA) – Allows interoperability of health information
exchange between hospital systems.
Consumer Health Informatics (CHI) – Use of electronic information & communication to improve medical
outcomes & health-care decision making from the pt/consumer perspective. 3 barriers include: Privacy
issues, cognitive disabilities, low health literacy. Five examples: Personal Health Records, Telehealth,
Mobile Health, Games for Health, & Health 2.0. Telehealth is defined as healthcare at a distance using
technology that connects the pt & the clinician in real time.
**Continuity of Care Record (CCD) – Snapshot of a pt’s health & healthcare to provider who does not have
access to the person’s EHR.
Cumulative Index to Nursing & Allied Health Literature (CINAHL) – Primary database used for nursing
literature.
Data – Collection of #s, characters, or facts that are gathered according to some perceived need for
analysis.
**Data Analysis – The processing of data that identify trends & patterns of relationships.
,Data Information Knowledge Wisdom (DIKW) Framework - Data is most discrete component of the DIKW
framework. Mostly presented as discrete observations w/ little interpretation. Information is a continuum
of progressively developing & clustered data. Relations & interactions are not yet evident in information
alone. Knowledge is information that is processed & organized so relations & interactions are identified.
Wisdom is appropriate use of knowledge to manage & solve human problems. Wisdom includes ethics or
knowing why certain things/procedures should/should not be implemented in specific cases.
**Data Integrity – Ability to collect, store, retrieve correct, complete, & current data so that the data are
available to authorized users when needed. Can be compromised by incorrect entry of information, data
tampering, & system failure. Prevention by implementing security measures, audit trails, & having detailed
policies & procedures. Data integrity is the state wherein data are uncorrupted, accurate, & valid.
**Data Mining – Technique that look for hidden patterns & relationships in large groups of data using
software.
Data Scrubbing - Data scrubbing is the process by which incorrect, incomplete, duplicate, or improperly
formatted items are removed using special software designated for this purpose.
Data Warehouse – Provides a powerful method of managing & analyzing data.
**Decision Support Tool / Clinician Decision Support (CDS) / Decision Support System/Software (DDS) –
Software/app to help in human decision process. Software will look at the pt’s data & suggest appropriate
medical/nursing interventions. Can also trigger prompts/alerts to user. Requires human user input.
Decreases pt safety risk & increases positive pt outcomes (alerts for abnormal vs, lab results, med
contraindication, etc.) The right components of a CDS include a trigger, such as med order; input data,
such as lab values; intervention info, such as other options provided; & action step, such as action selected
by the Dr.
**Electronic Health Record (EHR) – Database of individual’s healthcare data during healthcare encounters.
It’s comprised of any pt data stored in electronic form. Electronic form/ database of a pt’s past medical
history, medical test, medications, images, etc. stored in electronic form. Enables many functions needed
to create & maintain EHRs. You will know if the EHR is successful if the customer’s needs were met.
**Electronic Medical Record (EMR) – Legal record created in hospitals & ambulatory settings of single
encounter/visit that is source of data for EHR. Brings together diagnostic & treatment info for an individual
in specific healthcare setting. ** Usually found in a physician’s office.
Electronic Medical Record Adoption Model (EMRAM) – Measures clinical outcomes, pt engagement, &
clinical use of EMR technology to strengthen organizational performance & health outcomes across pt
populations. Basically evaluates Health Information Systems.
Ergonomics – Scientific study of work & space, including details that impact productivity & health.
**Evidenced Based Practice (EBP) – Current, best evidence for pt care. Improves consistency & quality of
pt outcomes. Foundation of clinical practice & guides clinicians. Found in standing orders (ex. Sepsis
protocol).
, Expert System – A type of CDS/DDS but does NOT need human intervention, uses artificial intelligence (ex.
Insulin pump).
**Fishbone – A tool for analyzing the organizational processes & its effectiveness. Helps team members
visually diagram a problem or condition’s root causes, allowing them to truly diagnose the problem rather
than focusing on symptoms.
Five Rights to Clinical Decision Support: Right Information, Right Person, Right Intervention, Right time in
the workflow, & where.
**Health Information Exchange (HIE) - Electronic sharing of pt information between healthcare providers
according to nationally recognized standards, allows insurance companies & providers to share data, must
be secure & maintain integrity. Works by improving speed, quality, safety, & cost of pt care. Query-based
exchange often used for unplanned events. (ex. ER) It allows providers to find & request info on a pt from
other providers. Directed exchange is used to support coordinated care & allows the ability to send &
receive secure information electronically between care providers. Consumer-mediated exchange allows
the ability for pts to review, manage, & control the use of their health information among providers.
Allows insurance companies & providers to share data (or across delivery settings). Nationally recognized
standards/ Federal legislation demands for safer, more efficient healthcare. Increases efficiency & quality
care. All states have implemented Health Information Exchange. Must be secure & maintain integrity.
**Health Information Technology (HIT) – Various systems & technology used to record, monitor, & deliver
pt care, as well as perform managerial & organizational functions. HIT is used to support systems that
collect data needed for pt care, population health management, & for the sharing of this information
within a secure system. Large datasets resulting from Meaningful Use (MU) & other incentives will provide
increased evidence to support HIT policy decisions that weigh national, as well as global implications.
**Health Information Technology for Economic & Clinical Health Act (HITECH Act) – The HITECH Act
provides funds & incentives to increase EHRs by providers, improve policy decisions, & allocate services,
funded workforce training, & new technology research. HITECH strongly recommends increasing
meaningful use of HIT to decrease overall healthcare cost & to improve population health.
**Health Insurance Portability & Accountability Act (HIPAA) - Sets the national Standard of Personal
Health Information. Legal Protection for PHI. Electronic transactions need to have HIPAA compliant codes.
Signing into devices should require authentication encryption & should never be left unattended. Email &
instant messaging may carry PHI that can be intercepted. Fines prior to 2/18/09 are $100/violation w/ a
max of $25000 yearly. If after 2009, fine can be $100-50000+/violation, w/ a max of $1.5 million yearly.
Criminal penalty fines can be up to $50000 & 1-year in jail.
**Health Level 7 (HL7) – A standard/framework for the exchange of data (PHI) between information
systems w/ extensive set of rules that applies to all data that is exchanged, shared, integrated, or
retrieved. Refers to both organization & its standards to exchange data. Specifies how the data is coded.
**Health Literacy - capacity of an individual to express their needs & preferences & to respond to the
need for info about services provided for them. Low health literacy highly impacted by culture, ethnicity,
race, environment, & social class. Health literacy involves teaching pts enough info about their illnesses &
about how the health system works so they can appropriately management their health. Most common
According to some, there are handful of questions on the OA from the PA.
Access Levels- User can only see information that they access to. (CNA cannot see everything an RN can)
Administrative Safeguards of Electronic Health Information- Restricting access of all authorized users of
the EHR according to their position within the healthcare system
Admission-Transfer-Discharge (ADT) System - Classified under the hospitals' administrative info system.
It’s one foundational system that allows operational activities such as bed placement, transportation
coordination, room readiness, & the general coordination of services focused on the pt's phase of
movement. Tracks a pt's activities & location from admission to discharge.
American Recover & Reinvestment Act (ARRA) – Authorized INCENTIVE PAYMENTS to specific types of
hospitals & healthcare pros for adopting & using interoperable Health Information Technology & EHR’s.
ARRA provides economic stimuli & incentives for the adoption of EHRs.
Analytical Science – Answers 2 basic questions: What do I have? How much of it do I have? Environment,
pharmacy, safety & security, fraud detection, & healthcare diagnostics.
Asynchronous Applications – Pt-centered & allows consumers to participate in their own care by using
designated health technology to share health metrics & data w/ their healthcare provider via technology
(remote pt-monitoring - the use of devices to capture pt data at one location & then transmit it
electronically to healthcare pros at a different location, allowing the review of data for clinical decision-
making, i.e. MobileHealth).
**Audit Trails– Software that is used for detecting security violations, performance problems, & flaws.
Records activity by users & system. **Goal is to improve data integrity. An audit trail must contain the
name of the user, the application triggering the audit, the workstation, the specific document, a
description of event being audited, & the date/time to determine integrity of data.
Authentication – Action that verifies the authority of users to receive specified data.
Barcode Medication Administration - MANDATED BY FDA.
**Benchmark– Continual process of measuring services & practices against the toughest competitors in
the healthcare industry. Comparing the performance of an organization or clinician to others.
Big Data – Very large data sets beyond human capability to analyze or manage without the aid of
information technology. Considered data originating from very large data sets that help identify patterns &
trends. Big data cannot be managed without the use of technology to analyze its output. 5 properties-
Variety, velocity, volume, value, veracity.
Change Management/ Change Control- INVOLVES EMPLOYEES IN THE DECISION-MAKING PROCESS. Helps
prioritize limited resources & ensure systems standards are upheld. For example, medication
administration. SHOULD EXCLUDE SUBJECT MATTER EXPERTS WHEN DISCUSSING CHANGE CONTROL.
,**Clinical Decision Support System (CDSS)- Supports healthcare practitioners in making pt-care decisions
by integrating pt data w/ current clinical knowledge. Provides recommendations for care & must be
balanced w/ professional judgment, not used in place of it.
**Clinical Information System– Software used to access client data, plan, implement, & evaluate care.
May be specific to certain departments: lab, radiology, pharmacy, or pt populations. Provides pt centric
decision-making functionality to help guide a RN w/ decision-making. Acquires pt data so that healthcare
pros can review it & use information to deliver care.
Computer Literacy – Familiarity w/ the use of personal computers. The knowledge & ability to use
computers & technology efficiently. Computer literacy allows pts to interact w/ the internet.
Computerized Provider Order Entry (CPOE) – Prescriber’s decisions to enter orders & immediately share
orders w/ appropriate health pros who execute orders & departments that need to dispense, schedule, or
immediately deliver services to pts. CPOE can check for duplicate orders, alert departments to carry out
orders, & provide the status of each order.
**Confidentiality– Unspoken understanding that private information shared in a situation, in which a
relationship has been established for the purpose of treatment or delivery of services will remain
protected.
Configurability – Extent that a given software product can be adapted or changed to meet a user’s
preference.
Connected Health – Model or platform by which technology assisted healthcare is delivered between at
least 2 points, involving either synchronous or asynchronous exchange.
**Consolidated-Clinical Document Architecture (C-CDA) – Allows interoperability of health information
exchange between hospital systems.
Consumer Health Informatics (CHI) – Use of electronic information & communication to improve medical
outcomes & health-care decision making from the pt/consumer perspective. 3 barriers include: Privacy
issues, cognitive disabilities, low health literacy. Five examples: Personal Health Records, Telehealth,
Mobile Health, Games for Health, & Health 2.0. Telehealth is defined as healthcare at a distance using
technology that connects the pt & the clinician in real time.
**Continuity of Care Record (CCD) – Snapshot of a pt’s health & healthcare to provider who does not have
access to the person’s EHR.
Cumulative Index to Nursing & Allied Health Literature (CINAHL) – Primary database used for nursing
literature.
Data – Collection of #s, characters, or facts that are gathered according to some perceived need for
analysis.
**Data Analysis – The processing of data that identify trends & patterns of relationships.
,Data Information Knowledge Wisdom (DIKW) Framework - Data is most discrete component of the DIKW
framework. Mostly presented as discrete observations w/ little interpretation. Information is a continuum
of progressively developing & clustered data. Relations & interactions are not yet evident in information
alone. Knowledge is information that is processed & organized so relations & interactions are identified.
Wisdom is appropriate use of knowledge to manage & solve human problems. Wisdom includes ethics or
knowing why certain things/procedures should/should not be implemented in specific cases.
**Data Integrity – Ability to collect, store, retrieve correct, complete, & current data so that the data are
available to authorized users when needed. Can be compromised by incorrect entry of information, data
tampering, & system failure. Prevention by implementing security measures, audit trails, & having detailed
policies & procedures. Data integrity is the state wherein data are uncorrupted, accurate, & valid.
**Data Mining – Technique that look for hidden patterns & relationships in large groups of data using
software.
Data Scrubbing - Data scrubbing is the process by which incorrect, incomplete, duplicate, or improperly
formatted items are removed using special software designated for this purpose.
Data Warehouse – Provides a powerful method of managing & analyzing data.
**Decision Support Tool / Clinician Decision Support (CDS) / Decision Support System/Software (DDS) –
Software/app to help in human decision process. Software will look at the pt’s data & suggest appropriate
medical/nursing interventions. Can also trigger prompts/alerts to user. Requires human user input.
Decreases pt safety risk & increases positive pt outcomes (alerts for abnormal vs, lab results, med
contraindication, etc.) The right components of a CDS include a trigger, such as med order; input data,
such as lab values; intervention info, such as other options provided; & action step, such as action selected
by the Dr.
**Electronic Health Record (EHR) – Database of individual’s healthcare data during healthcare encounters.
It’s comprised of any pt data stored in electronic form. Electronic form/ database of a pt’s past medical
history, medical test, medications, images, etc. stored in electronic form. Enables many functions needed
to create & maintain EHRs. You will know if the EHR is successful if the customer’s needs were met.
**Electronic Medical Record (EMR) – Legal record created in hospitals & ambulatory settings of single
encounter/visit that is source of data for EHR. Brings together diagnostic & treatment info for an individual
in specific healthcare setting. ** Usually found in a physician’s office.
Electronic Medical Record Adoption Model (EMRAM) – Measures clinical outcomes, pt engagement, &
clinical use of EMR technology to strengthen organizational performance & health outcomes across pt
populations. Basically evaluates Health Information Systems.
Ergonomics – Scientific study of work & space, including details that impact productivity & health.
**Evidenced Based Practice (EBP) – Current, best evidence for pt care. Improves consistency & quality of
pt outcomes. Foundation of clinical practice & guides clinicians. Found in standing orders (ex. Sepsis
protocol).
, Expert System – A type of CDS/DDS but does NOT need human intervention, uses artificial intelligence (ex.
Insulin pump).
**Fishbone – A tool for analyzing the organizational processes & its effectiveness. Helps team members
visually diagram a problem or condition’s root causes, allowing them to truly diagnose the problem rather
than focusing on symptoms.
Five Rights to Clinical Decision Support: Right Information, Right Person, Right Intervention, Right time in
the workflow, & where.
**Health Information Exchange (HIE) - Electronic sharing of pt information between healthcare providers
according to nationally recognized standards, allows insurance companies & providers to share data, must
be secure & maintain integrity. Works by improving speed, quality, safety, & cost of pt care. Query-based
exchange often used for unplanned events. (ex. ER) It allows providers to find & request info on a pt from
other providers. Directed exchange is used to support coordinated care & allows the ability to send &
receive secure information electronically between care providers. Consumer-mediated exchange allows
the ability for pts to review, manage, & control the use of their health information among providers.
Allows insurance companies & providers to share data (or across delivery settings). Nationally recognized
standards/ Federal legislation demands for safer, more efficient healthcare. Increases efficiency & quality
care. All states have implemented Health Information Exchange. Must be secure & maintain integrity.
**Health Information Technology (HIT) – Various systems & technology used to record, monitor, & deliver
pt care, as well as perform managerial & organizational functions. HIT is used to support systems that
collect data needed for pt care, population health management, & for the sharing of this information
within a secure system. Large datasets resulting from Meaningful Use (MU) & other incentives will provide
increased evidence to support HIT policy decisions that weigh national, as well as global implications.
**Health Information Technology for Economic & Clinical Health Act (HITECH Act) – The HITECH Act
provides funds & incentives to increase EHRs by providers, improve policy decisions, & allocate services,
funded workforce training, & new technology research. HITECH strongly recommends increasing
meaningful use of HIT to decrease overall healthcare cost & to improve population health.
**Health Insurance Portability & Accountability Act (HIPAA) - Sets the national Standard of Personal
Health Information. Legal Protection for PHI. Electronic transactions need to have HIPAA compliant codes.
Signing into devices should require authentication encryption & should never be left unattended. Email &
instant messaging may carry PHI that can be intercepted. Fines prior to 2/18/09 are $100/violation w/ a
max of $25000 yearly. If after 2009, fine can be $100-50000+/violation, w/ a max of $1.5 million yearly.
Criminal penalty fines can be up to $50000 & 1-year in jail.
**Health Level 7 (HL7) – A standard/framework for the exchange of data (PHI) between information
systems w/ extensive set of rules that applies to all data that is exchanged, shared, integrated, or
retrieved. Refers to both organization & its standards to exchange data. Specifies how the data is coded.
**Health Literacy - capacity of an individual to express their needs & preferences & to respond to the
need for info about services provided for them. Low health literacy highly impacted by culture, ethnicity,
race, environment, & social class. Health literacy involves teaching pts enough info about their illnesses &
about how the health system works so they can appropriately management their health. Most common
