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Medical Dictionary

Ambulatory care Medical care delivered on an outpatient basis.
CCHIT Acronym for Certification Commission for Healthcare Information Technology.
Computerized Patient Record (CPR) Also known as an EMR or EHR. A patient’s past, present, and future clinical data stored in a server.
Computerized Physician Order Entry (CPOE) A system for physicians to electronically order labs, imaging and prescriptions.
Fee Schedule A set maximum fee that an insurance company will pay a healthcare provider.
HIPAA The Health Insurance Portability and Accountability Act of 1996, is a set of federal regulations which establishes national standards for health care information.
ICD-9 Internationally recognizable 3 to 5-digit code representing a medical diagnosis. Currently being replaced by the ICD-10 code.
National Provider Identifier (NPI) A unique number to define healthcare providers.
EHR Electronic Health Records focus on the total health of the patient.
HIT Health Information Technology is the area of IT involving the design, development, creation, use and maintenance of information systems for the healthcare industry.
PACS Picture Archive Communication System is used by radiology and diagnostic imaging organizations to electronically manage information and images.
Patient Portal A secure web physician messages, view lab results, pay their bills electronically, access physician directories.
PPO Preferred Provider Organization is an arrangement between insurers and healthcare providers where providers agree to a discounted fee service in exchange for more patients.
Base EHR EHR Technology that includes fundamental capabilities all providers would need to have.
Certified EHR Technology EHR technology certified under the ONC HIT Certification Program to the 2014 Edition EHR Certification Criteria that has the capabilities required to meet the definition of a base.
Complete EHR EHR technology that has been developed to meet, at a minimum, all mandatory certification criteria adopted by the Secretary for either an ambulatory setting or inpatient
EHR Module An EHR component that meets at least one certification criterion adopted by the Secretary.
Implementation Specification Specific requirements or instructions for implementing a standard.
Inherited Certified Status When a newer version of a previously certified Complete EHR inherits the certified status of the previously certified Complete EHR without requiring the newer version to be recertified.
Inpatient Practice Type Certified EHR that is specific to inpatient practice settings.
Affordable Care Act A US national law enacted on March 23, 2010 that includes comprehensible reforms to healthcare practices and safeguards consumers from abusive insurance company practices.
AHIMA The American Health Information Management System (AHIMA), founded in 1928, is the nation’s premier association of health information management professionals. In an increasingly electronic environment, AHIMA aims to provide leadership in advocacy, certification, and education.
Attestation The process by which individuals/companies validate their participation in EHR technology.
Big Data Information or data so large in volume that it becomes difficult to maintain, store, share and/or analyze. Big data exists in many domains, including health care.
Care Continuum The full range of services that are available to a patient to address his or her health and wellness needs over time. This includes inpatient, outpatient, in home, rehabilitation, nursing, and virtual settings. The concept of a care continuum includes coordinated health services from the initial visit through all levels of care needed thereafter.
Clinical Data Repository (CDR) A database that collects patient information from various clinical sources and presents that information in a single document. CDRs centralize pertinent patient data so that providers may quickly access a file at the point of care, minimizing administrative duties so that physicians may spend more time at the bedside. Clinical data repositories allow for better care quality and cost reduction.
Clinical Decision Support System Healthcare providers use the clinical decision support system for everything from preparing and reviewing diagnosis, to information retrieval and therapy critiquing and planning. However despite the many beneficial features of the CDSS, the system remains challenging to adopt due to the difficulty of integration of the program into an organizations workflow. Most CDSS’s are also individual systems that fail to operate easily with other reporting and electronic health record software.
Clinical Information System An electronic software program that manages a hospital’s medical, administrative, financial, and legal information services. These systems store, organize, and support data retrieval to improve a practice’s efficiency and cost-effectiveness so that they may focus on providing excellent healthcare services.
Cloud Computing In choosing its EHR technology, a company may opt for a web-based system, as opposed to a client-server-based system. This is defined as cloud computing, which often allows the purchasing party to pay on a once-a-month basis. This also allows one to circumvent expensive servers (as well as their associated hardware and software).
Centers for Medicare Medicaid Services CMS is an agency within the Department of Health and Human Services, that oversees the children’s health insurance program(CHIP), the Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments (CLIA) as well as Medicare and Medicaid.
E-Detailing The use of technology to instantly communicate information regarding a product to a physician or other healthcare entity. Pharmaceutical and medical device companies use e-detailing to market their products in a way that is fast, cost-efficient, and allows the consumer to access it at his or her convenience. Methods of e-detailing include online materials, interactive programs, or face-to-face video communication between vendor and consumer.
E-Encounter Telecommunication between a healthcare professional and a patient. It allows patients to share questions or concerns with his or her physician from a remote location and for the practitioner to respond remotely as well. Clinical information can be discussed instantly via network connection, without the geographic limitations associated with face-to-face exchanges.
Early Event Detection (EED) Term referring to the preventative and preemptive measures used to identify and manage a significant health event. EED estimates the size, location, and expanse of an incident and puts into play the appropriate resources to prevent further harm. Examples of major health events include highly communicable disease outbreaks, toxic accidents, and bioterrorism. Trained professionals use ongoing data reports to plan and adjust event containment operations.
Electronic Claim A digital statement filed by a medical professional for billing purposes. Electronic claims are sent to healthcare insurance plans to be approved for coverage. This billing method fast-tracks financial operations and organizes patient payment histories in one, computerized location.
Electronic Data Capture (EDC) A system used mainly in clinical trials to electronically record, store, and organize research data. Major pharmaceutical, biotech, and clinical research organizations use EDC systems to digitize information collection, fast-tracking the innovation and product development processes. These systems usually consist of a user interface, data validation software, and statistical analytic components for accurate and useful data capture.
Personal Health Information (PHI) This is any personally identifiable health information regarding a patient. For example, if a patient’s name, procedure, and a medical alert is on the appointment screen on the computer, that information is considered PHI and is therefore subject to HIPAA security regulations. When a different patient leans over the desk to identify an appointment time that they would like, if that PHI is visible to the 2nd patient, then that is considered a HIPAA Breach and should be reported to the patient whose information was shared inappropriately. Thankfully CurveHero provides a nifty little feature that turns off all PHI that is visible on the screen for just those occasions.
AAC Average Allowable Cost (of certified EHR technology)
Addendum Text that is added to a document after it has been finalized
AIU Adopt, Implement, Upgrade (certified EHR technology)
Annotator A system function that allows an explanatory note or diagram to be added to an image.
(ARRA) The American Recovery and Reinvestment Act The American Recovery and Reinvestment Act authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “Meaningful Users” of an electronic health record (EHR). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the “Meaningful Use” definition or they will be subject to financial penalties under Medicare.
(ASP) Application Service Provider An Application Service Provider (ASP) is a third party entity that deploys, hosts and manages software from a centrally managed host facility (offsite). Applications are delivered over networks (WAN, Internet) on a subscription fee/rental basis. This model is also been referred to as “software-as-a-service”.
Audit Trail Security system that tracks a user’s access, deletion or modification of data. The term used in healthcare information security refers to a chronological record of system resource usage. This includes user login, file access, other various activities, and whether any actual or attempted security violations occurred, legitimate or unauthorized.
Authentication The verification of the identity of a person or process.
Bandwidth A data transmission rate; the maximum amount of information (bits/second) that can be transmitted along a channel.
Bar Code A printed horizontal strip of vertical bars which represent decimal digits used for identification. Bar codes must be read by a bar code reader.
Biometrics Biometrics are automated methods of recognizing a person based on a physiological characteristic such as fingerprints, retina, voice etc.
Browser Short for Web browser, a software application used to locate and display Web pages.
CAH Critical Access Hospital
CAHPS Consumer Assessment of Healthcare Providers and Systems
Case Management A process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize the outcome.
CCN CMS Certification Number
(CDR) Clinical Data Repository A real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. It is optimized to allow clinicians to retrieve data for a single patient rather than to identify a population of patients with common characteristics or to facilitate the management of a specific clinical department.
(CDSS) Clinical Decision support system A clinical decision support system (CDSS) is software designed to aid clinicians in decision making by matching individual patient characteristics to computerized knowledge bases for the purpose of generating patient-specific assessments or recommendations.
CFR Code of Federal Regulations
Chart Medical record
Chart Note A document, written by the clinician or provider, which describes the details of a patient’s encounter. Sometimes referred to as a progress note.
CHIP Children’s Health Insurance Program
CHIPA Children’s Health Insurance Program Reauthorization Act of 2009
Client/Server architecture An information-transmission arrangement, in which a client program sends a request to a server. When the server receives the request, it disconnects from the client and processes the request. When the request is processed, the server reconnects to the client program and the information is transferred to the client. This usually implies that the server is located on site as opposed to the ASP (Application Server Provider) architecture.
Clinical Guidelines (Protocols) Clinical guidelines are recommendations based on the latest available evidence for the appropriate treatment and care of a patient’s condition.