Protected health information
any information about the health status, the provision of care, or the payment for health
care that can be linked to or can identify a patient
longitudinal record
incorporates all of the information from multiple sources gathered over a period of time
interoperability
the ability of different information technology systems and software applications to
communicate and exchange data
interface
a software program that facilitates the exchange of data between the two systems
clinical decision support
software to analyze patient-specific information and generate reminders, alerts, clinical
guidelines, diagnostic support, and relevant reference information
simultaneous access
many individuals can access an EHR at the same time
Health information exchange (HIE)
standardized process of data exchange, allows patient information to be shared
electronically in a secure format that improves the speed, quality, and safety of patient
care while reducing cost
documentation integrity
documentation that is complete and accurate with no mistakes, errors, or
inconsistencies
unintended consequences
a disadvantage of EHR
meaningful use
as the use of certified EHR technology to meet identified goals for improving patient and
public heatlh
access control
is an important security process that includes four components: identification,
authentication, authorization, and accounting *
documentation redundancy
occurs when the same data elements are collected and saved more than once by the
same or different healthcare providers during the same patient encounter
record analysis system
is and independent system that flags deficiencies in physician documentation in the
health record
custodian of the health record
is responsible for the care, the custody, and the control of the patient record during the
normal course of business
protocol
clinical-care guideline, is a pre-established plan for a course of medical treatment that is
grounded in evidence-based medicine
notice of privacy practices