The various terms, including acronyms, are explained from a conceptual point and may not be the formal definitions.
ADSL (Asymmetric Digital Subscriber Line): A type of DSL that uses copper telephone lines to transmit data faster than a traditional modem. ADSL only works within short distances because it uses high frequencies with short signals.
Allergy List: This is a list of all the patient’s allergies.
Allopathic, Allopathy: Defined as relating to or being a system of medicine that aims to combat disease by using remedies (as drugs or surgery) which produce effects that are different from or incompatible with those of the disease being treated
Ambulatory care: Any medical care delivered on an outpatient basis.
ANM: Auxiliary Nurse Midwife
Archetype: Basically an information model, it is a computable expression of a domain content model in the form of structured constraint statements, based on a reference (information) model. Within the openEHR paradigm, archetypes are based on the openEHR reference model. Archetypes are all expressed in the same formalism. In general, they are defined for wide re-use, however, they can be specialized to include local particularities. They can accommodate any number of natural languages and terminologies.
Artefact: An object made by a human being, typically one of cultural or historical interest. In healthcare IT context, an artefact is any item such as a document, file or drawing, etc. that is generated for use as a reference material or inside a system.
ASHA: Accredited Social Health Activist is usually a literate 25 – 45 year old married/ widowed/ divorced lady selected from the village itself and accountable to it and trained to work as an interface between the community and the public health system. This is position is one of the key components of the National Rural Health Mission aimed at providing every village in the country with a trained female community health activist
ATC: Anatomical Therapeutic Chemical Classification System, controlled by the WHO Collaborating Centre for Drug Statistics Methodology (WHOCC), is used for drug classification.
Authentication: The verification of the identity of a person or process.
Authorization: Any document designating any permission. Authorization or waiver of authorization for the use or disclosure of identifiable health information for research (among other activities) is required. The authorization must indicate if the health information used or disclosed is existing information and/or new information that will be created. The authorization form may be combined with the informed consent form, so that a patient need sign only one form. An authorization must include the following specific elements: a description of what information will be used and disclosed and for what purposes; a description of any information that will not be disclosed, if applicable; a list of who will disclose the information and to whom it will be disclosed; an expiration date for the disclosure; a statement that the authorization can be revoked; a statement that disclosed information may be re-disclosed and no longer protected; a statement that if the individual does not provide an authorization, she/he may not be able to receive the intended treatment; the subject’s signature and date.
AYUSH: Ayurveda, Yoga, Unani, Siddha and Homeopathy. Falls under the broad category of Indian Systems of Medicines and Homoeopathy (ISM&H) governed by Ministry of Health and Family Welfare, Government of India
[ C ]
CCD (Continuity of Care Document): A joint effort of HL7 International and ASTM. CCD fosters interoperability of clinical data by allowing physicians to send electronic medical information to other providers without loss of meaning and enabling improvement of patient care. CCD is an implementation guide for sharing Continuity of Care Record (CCR) patient summary data using the HL7 Version 3 Clinical Document Architecture (CDA), Release 2. It establishes a rich set of templates representing the typical sections of a summary record, and these same templates for vital signs, family history, plan of care, and so on can then be used for establishing interoperability across a wide range of clinical use cases.
CDT: Common Dental Terminology
Chain of Trust Agreement: A contract needed to extend the responsibility to protect health care data across a series of sub-contractual relationships.
Chief Complaint (CC), Reason for Consultation (RFC), Reason of Visit (ROV): for recording a patient’s disease symptoms.
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 Care Provider: Personnel or entities directly related to providing clinical care to patient.
Clinical Data Repository (CDR): 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.
Clinical Decision Support System (CDSS): 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.
Clinical Establishment: Clinical establishment means (1) a hospital, maternity home, nursing home, dispensary, clinic, sanatorium or an institution by whatever name called that offers services, facilities requiring diagnosis, treatment or care for illness, injury, deformity, abnormality or pregnancy in any recognized system of medicine established and administered or maintained by any person or body of persons, whether incorporated or not; or (2) a place established as an independent entity or part of an establishment referred to above, in connection with the diagnosis or treatment of diseases where pathological, bacteriological, genetic, radiological, chemical, biological investigations or other diagnostic or investigative services with the aid of laboratory or other medical equipment, are usually carried on, established and administered or maintained by any person or body of persons, whether incorporated or not. (Clinical Establishment Act – CEA 2010)
Clinical Guidelines (Protocols): Clinical guidelines are recommendations based on the latest available evidence for the appropriate treatment and care of a patient’s condition.
Clinical Messaging: Communication of clinical information within the electronic medical record to other healthcare personnel.
Coded Data: Data are separated from personal identifiers through use of a code. As long as a link exists, data are considered indirectly identifiable and not anonymous or anonymized.
Code Set: Any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions.
Coding: A mechanism for identifying and defining physicians’ and hospitals’ services. Coding provides universal definition and recognition of diagnoses, procedures and level of care. Coders usually work in medical records departments and coding is a function of billing. Medicare fraud investigators look closely at the medical record documentation, which supports codes and looks for consistency. Lack of consistency of documentation can earmark a record as “up-coded” which is considered fraud. A national certification exists for coding professionals and many compliance programs are raising standards of quality for their coding procedures.
Computer-Based Patient Record (CPR): A term for the process of replacing the traditional paper-based chart through automated electronic means; generally includes the collection of patient-specific information from various supplemental treatment systems, i.e., a day program and a personal care provider; its display in graphical format; and its storage for individual and aggregate purposes. CPR is also called “digital medical record” or “electronic medical record”.
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
CPT (Current Procedural Terminology) Code: A recognizable five-digit number used to represent a service provided by a healthcare provider. It is a manual that assigns five digit codes to medical services and procedures to standardize claims processing and data analysis. The coding system for physicians’ services developed by the CPT Editorial Panel of the American Medical Association.
[ D ]
Data Content: All the data elements and code sets inherent to a transaction, and not related to the format of the transaction.
Data: This is factual information (as measurements or statistics) used as a basis for reasoning, discussion, or calculation. It additionally points to the information output by a sensing device or organ that includes both useful and irrelevant or redundant information and must be processed to be meaningful.
Database Management System (DBMS): The separation of data from the computer application that allows entry or editing of data.
DICOM (Digital Imaging and Communications in Medicine): Digital Imaging and Communications in Medicine (DICOM) is a standard to define the connectivity and communication between medical imaging devices.
Disease Management: A type of product or service now being offered by many large pharmaceutical companies to get them into broader healthcare services. Bundles use of prescription drugs with physician and allied professionals, linked to large databases created by the pharmaceutical companies, to treat people with specific diseases. The claim is that this type of service provides higher quality of care at more reasonable price than alternative, presumably more fragmented, care. The development of such products by hugely capitalized companies should be the entire indicator necessary to convince a provider of how the healthcare market is changing. Competition is coming from every direction—other providers of all types, payers, employers who are developing their own in-house service systems, the drug companies.
Document Imaging: Is a process of converting paper documents into an electronic format usually through a scanning process.
Document Management: The Document Manager allows the medical institution to store vital patient documents such as X-Ray’s, Paper Reports, and Lab Reports etc.
Documentation: The process of recording information.
DOHAD: Developmental Origins of Health and Diseases
Drug Formulary: Varying lists of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. Health plans often restrict or limit the type and number of medicines allowed for reimbursement by limiting the drug formulary list. The list of prescription drugs for which a particular employer or State Medicaid program will pay. Formularies are either “closed,” including only certain drugs or “open,” including all drugs. Both types of formularies typically impose a cost scale requiring consumers to pay more for certain brands or types of drugs. See also Formulary.
Drug Formulary Database: This EMR feature is used for electronic prescribing, electronic medical record (EMR), and computerized physician order entry (CPOE) systems to present formulary status to the provider while during the prescribing decision.
DSM: Diagnostic and Statistical Manual for Mental Diseases
[ E ]
EDI: Acronym for Electronic Data Interchange. Electronic communication between two parties, generally for the filing of electronic claims to payers.
EDI Translator: Used in electronic claims and medical record transmissions, this is a software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission. See also Electronic Data Interchange.
EHR/EMR System Designer, Developer, Manufacturer, Vendor, Supplier, Retailer, Re-seller: Any entity that is involved in the design, development, testing, manufacturing, supplying, selling including re-selling of Electronic Health Records or Electronic Medical Records Systems as a whole or part thereof.
Electronic Data Interchange (EDI): The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization. This refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.
Electronic Health Records (EHR): The one or more repositories, physically or virtually integrated, of information in computer processable form, relevant to the wellness, health and healthcare of an individual, capable of being stored and communicated securely and of being accessible by multiple authorized users, represented according to a standardized or commonly agreed logical information model. Its primary purpose is the support of life-long, effective, high quality and safe integrated healthcare. [ISO 18308:2011]
Electronic Medical Records (EMR): The EMR could be considered as special case of the EHR, restricted in scope to the medical domain or at least very much medically focused [ISO/TR 20514]. The Japanese Association of Healthcare Information Systems (JAHIS) has defined a five-level hierarchy of the EMR; Departmental EMR: contains a patient’s medical information entered by a single hospital department (e.g. pathology, radiology, pharmacy); Inter-departmental EMR: contains a patient’s medical information from two or more hospital departments; Hospital EMR: contains a patient’s clinical information from a particular hospital; Inter-hospital EMR: contains a patient’s medical information from two or more hospitals; EHR: longitudinal collection of health information from all sources. [Classification of EMR systems, JAHIS, V1.1, Mar 1996]
Electronic Protected Health Information (ePHI): Electronic Protected Health Information (ePHI) is any protected health information (PHI) that is created, stored, transmitted, or received electronically. Electronic
protected health information includes any medium used to store, transmit, or receive PHI electronically. The following and any future technologies used for accessing, transmitting, or receiving PHI electronically are covered. Media containing data at rest (data storage) like personal computers with internal hard drives used at work, home, or traveling, external portable hard drives, including iPods and similar devices, magnetic tape, removable storage devices, such as USB memory sticks, CDs, DVDs, and floppy disks, PDAs and smartphones and data in transit, via wireless, Ethernet, modem, DSL, or cable network connections, Email, File transfer. (For Protected Health Information – PHI, please see below)
Encounter: A clinical encounter is defined by ASTM as "(1) an instance of direct provider/practitioner to patient interaction, regardless of the setting, between a patient and a practitioner vested with primary responsibility for diagnosing, evaluating or treating the patient’s condition, or both, or providing social worker services. (2) A contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment." Encounter serves as a focal point linking clinical, administrative and financial information. Encounters occur in many different settings -- ambulatory care, inpatient care, emergency care, home health care, field and virtual (telemedicine).
An episode of care consists of all clinically related services for one patient for a discrete diagnostic condition from the onset of symptoms until the treatment is complete [http://www.ncmedsoc.org/non_members/pai/PAI-FinalWorkbookforVideo.pdf
] Thus, for every new problem or set of problems that a person visits his clinical care provider, it is considered a new episode. Within that episode the patient will have one or many encounters with his clinical care providers till the treatment for that episode is complete. Even before the resolution of an episode, the person may have a new episode that is considered as a distinctly separate event altogether. Thus, there may be none, one or several ongoing active episodes. All resolved episodes are considered inactive. Hence they become part of the patient's past history. A notable point here is that all chronic diseases are considered active and may never get resolved during the life-time of the person, e.g., diabetes mellitus, hypertension, etc.
EPR: Broadly defined, a personal health record is the documentation of any form of patient information– including medical history, medicines, allergies, visit history, or vaccinations–that patients themselves may view, carry, amend, annotate, or maintain. Today, when we refer to PHRs, we typically mean an online personal health record–which may variously be referred to as an ePHR, an Internet PHR, an Internet medical record, or a consumer Internet Medical Record (CIMR). Generally, such records are maintained in a secure and confidential environment, allowing only the individual, or people authorized by the individual, to access the medical information. Not all electronic PHRs are Internet PHRs. PC-based PHRs may be set up to capture medical information offline.
Evidence Based Medicine: Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise to aid in the diagnosis and management of patients.
[ F ]
Family History: A list of the patient’s family medical history including the chronic medical problems of parents, siblings, grandparents, etc.
FHIR: Fast Health Interoperable Resources, the newest version from HL7 org for messaging.
Formatting and Protocol Standards: Data exchange standards which are needed between CPR systems, as well as CPT and other provider systems, to ensure uniformity in methods for data collection, data storage and data presentation. Proactive providers are current in their knowledge of these standards and work to ensure their information systems conform to the standards.
Formulary: An approved list of prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. In HMOs, physicians are often required to prescribe from the formulary. See also Drug Formulary.
[ G ]
Growth Chart: A feature for a Primary Care or EMR that can be used for pediatric patients. Age, height, weight, and head measurements can be entered over the patient's lifetime, and the feature creates a line graph.
[ H ]
Health Care Operations: Institutional activities that is necessary to maintain and monitor the operations of the institution. Examples include but are not limited to: conducting quality assessment and improvement activities; developing clinical guidelines; case management; reviewing the competence or qualifications of health care professionals; education and training of students, trainees and practitioners; fraud and abuse programs; business planning and management; and customer service. Under the HIPAA Privacy Rule, these are allowable uses and disclosures of identifiable information “without specific authorization.” Research is not considered part of health care operations.
Health Care, Healthcare: Care, services, and supplies related to the health of an individual. Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, among other services. Healthcare also includes the sale and dispensing of prescription drugs or devices.
Health Information: Information in any form (oral, written or otherwise) that relates to the past, present or future physical or mental health of an individual. That information could be created or received by a health care provider, a health plan, a public health authority, an employer, a general health insurer, a school, a university or a health care clearinghouse.
Health Level Seven (HL7): A data interchange protocol for health care computer applications that simplifies the ability of different vendor-supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products. The organization is one of the American National Standards Institute accredited Standard Developing Organization (SDO) - Health Level 7 domain is the standards for electronic interchange of clinical, financial and administrative info among healthcare oriented computer systems. Is a not-for-profit volunteer organization. It develops specifications, most widely used is the messaging standard that enables disparate health care applications to exchange key sets of clinical and administrative data. It promotes the use of standards within and among healthcare organizations to increase the effectiveness and efficiency of healthcare delivery. It is an international community of healthcare subject matter experts and information scientists collaborating to create standards for the exchange, management and integration of electronic healthcare information.
Health: The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.
Healthcare provider: A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities. An individual health care provider may be a health care professional, an allied health professional, a community health worker, any or other person trained and knowledgeable in medicine, nursing or other allied health professions, or public/community health workers like , ASHA, ANM, midwives, paramedical staff, OT/lab/radio-diagnostic technicians, etc. An institution will include hospitals, clinics, primary care centers and other service delivery points of health care individual clinics, polyclinics, diagnostic centers, etc., i.e., any place where a medical record is generated during a patient-care provider encounter (in conformance to CEA 2010 – please refer to Clinical Establishment item above). It must be noted that any person solely performing non-clinical work is not a care provider.
Healthcare Service Provider (HSP): see Healthcare provider
History of Present Illness (HPI): The HPI is the history of the patient’s chief complaint.
Human Subject: Refers to a living subject participating in research about whom directly or indirectly identifiable health information or data are obtained or created.
Hybrid Record: Term used for when a provider uses a combination of paper and electronic medical records during the transition phase to EMR.
[ I ]
IOD: Information Object Definition, pertains to DICOM
Independent Software Vendor (ISV): A company specializing in making or selling software products that runs on one or more computer hardware or operating system platforms.
Immunization: A complete list of all immunizations that the patient has had.
Informatics: The application of computer technology to the management of information.
Integration: Integration allows for secure communication between enterprise applications.
Interface: A means of communication between two computer systems, two software applications or two modules. Real time interface is a key element in healthcare information systems due to the need to access patient care information and financial information instantaneously and comprehensively. Such real time communication is the key to managing health care in a cost effective manner because it provides the necessary decision-making information for clinicians, providers, other stakeholders, etc.
International Classification of Diseases: This is the universal coding method used to document the incidence of disease, injury, mortality and illness. A diagnosis and procedure classification system designed to facilitate collection of uniform and comparable health information. The ICD-9-CM was issued in 1979. This system is used to group patients into DRGs, prepare hospital and physician billings and prepare cost reports. Classification of disease by diagnosis codified into six-digit numbers. See also coding.
International Health Terminology Standards Development Organization (IHTSDO): Denmark-based organization that maintains and licenses SNOMED codes worldwide.
Interoperability: The capability to provide successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.
ISP: Internet Service Provider
ISV (Independent Software Vendor): An independent software vendor (ISV) is a company specializing in making or selling software, designed for mass or niche markets. This typically applies for application-specific or embedded software, from other software producers.
[ J ]
J-Codes: A subset of the HCPCS Level II code set with a high-order value of “J” that has been used to identify certain drugs and other items.
[ L ]
LAN (Local Area Network): A LAN supplies networking capability to a group of computers in close proximity to each other such as in an office building, a school, or a home.
Legacy System Integration: The integration of data between a legacy system and some other software program most commonly using HL-7 standards.
Legacy Systems: Computer applications, both hardware and software, which have been inherited through previous acquisition and installation. Most often, these systems run business applications that are not integrated with each other. Newer systems which stress open design and distributed processing capacity are gradually replacing such systems.
Length of Stay (LOS): The duration of an episode of care for a covered person. The number of days an individual stays in a hospital or inpatient facility. May also be reviewed as Average Length of Stay (ALOS).
LEPR (Longitudinal Patient Record): Longitudinal Patient Record is an EHR that includes all healthcare information from all sources.
[ M ]
Management Information System (MIS): The common term for the computer hardware and software that provides the support of managing the plan.
Master Patient / Member Index: An index or file with a unique identifier for each patient or member that serves as a key to a patient’s or member’s health record.
Maximum Defined Data Set: All of the required data elements for a particular standard based on a specific implementation specification. An entity creating a transaction is free to include whatever data any receiver might want or need. The recipient is free to ignore any portion of the data that is not needed to conduct their part of the associated business transaction, unless the inessential data is needed for coordination of benefits.
MCI: Medical Council of India
Medical Code Sets: Codes that characterize a medical condition or treatment. These code sets are usually maintained by professional societies and public health organizations. Compare to administrative code sets.
Medical Informatics: Medical informatics is the systematic study, or science, of the identification, collection, storage, communication, retrieval, and analysis of data about medical care services to improve decisions made by physicians and managers of health care organizations. Medical informatics will be as important to physicians and medical managers as the rules of financial accounting are to auditors.
Medical Management Information System (MMIS): A data system that allows payers and purchasers to track health care expenditure and utilization patterns. It may also be referred to as Health Information System (HIS), Health Information Management (HIM) or Information System (IS). See also Electronic Medical Record (EMR).
Metadata and Date Standard (MDDS) – A set of data elements and their specification for use in certain domain, such as health, e-governance.
MIMS: Monthly Index of Medical Specialties
Minimum Data Set: The minimum set of data elements that must be captured, stored, made available for retrieval, presentation, relay and sharing by an EHR system. It comprises of all of the essential data elements required for implementation. An entity creating a transaction must include the mandatory data elements at all times and is free to exclude optional data elements. The entity is free to additionally include whatever other data elements that any receiver might want or need. The recipient is free to ignore any portion of the data that is not mandatory and is further free to ignore any other portion of the data that is not needed to conduct their part of the associated transaction, unless required by sender, intermediaries or receiver. This minimum data set represents the most common data, and system designers are at liberty to add to it as they deem necessary to enrich or enhance their EHR systems.
Modifier: Additional character of a code added to an existing code that is used to help in extending or localization of the existing code.
[ N ]
NANDA: North American Nursing Diagnosis Association
National Council for Prescription Drug Programs: An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry.
NEMA: The National Electrical Manufacturers Association (NEMA) is the association of electrical equipment and medical imaging manufacturers, founded in 1926 and headquartered in Rosslyn, Virginia.
Non-Participating Physician (or Provider): A provider, doctor or hospital that does not sign a contract to participate in a health plan, usually which requires reduced rates from the provider. In the Medicare Program, this refers to providers who are therefore not obligated to accept assignment on all Medicare claims. In commercial plans, non-participating providers are also called out of network providers or out of plan providers. If a beneficiary receives service from an out of network provider, the health plan (other than Medicare) will pay for the service at a reduced rate or will not pay at all.
[ O ]
Open Access: A term describing a member’s ability to self-refer for specialty care. Open access arrangements allow a member to see a participating provider without a referral from another doctor. Health plan members’ abilities, rights or invitation to self refer for specialty care. Also called Open Panel.
openEHR: openEHR is an open standard specification in health informatics that describes the management and storage, retrieval and exchange of health data in electronic health records (EHRs). In openEHR, all health data for a person is stored in a "one lifetime", vendor-independent, person-centered EHR. Maintained by the openEHR Foundation, these are based on a combination of years of European and Australian research and development into EHRs and new paradigms, including what has become known as the archetype methodology for specification of content and include information and service models for the EHR, demographics, clinical workflow and archetypes. They are designed to be the basis of a medico-legally sound, distributed, versioned EHR infrastructure.
OR: Operating Room – synonymous to OT as below
OT: Operation Theatre
OTC: Over the counter (drugs). Refers to those drugs that are available off the shelf without any prescription or advice from a registered medical practitioner
Outcome: A clinical outcome is the “change in the health of an individual, group of people or population which is attributable to an intervention or series of interventions”. (Taken from: Frommer, Michael; Rubin, George; Lyle, David (1992)."The NSW Health Outcomes program". New South Wales Public Health Bulletin 3: 135. doi:10.1071/NB92067)
Outpatient Care: Care given a person who is not bedridden. It is also called ambulatory care. Many surgeries and treatments are now provided on an outpatient basis, while previously they had been considered reason for inpatient hospitalization. Some say this is the fastest growing segment of healthcare.
[ P ]
Participating Physician: A primary care physician in practice in the payer’s managed care service area who has entered into a contract.
Past History: A list of a patient’s past health problems, surgeries and specialists.
Patient Demographics: All patient’s pertinent information such as first and last name, SSN, DOB, insurance, etc.
Patient Portal: A secure web-based system that allows a patient to register for an appointment, schedule an appointment, request prescription refills, send and receive secure patient-physician messages, view lab results, pay their bills electronically, access physician directories.
Patient: A person who is under medical care or treatment
PC Based: A program designed to run on an individual PC. This typically means data is not shared in real time among other PCs (users).
PCP: Primary care physician who often acts as the primary gatekeeper in health plans. That is, often the PCP must approval referrals to specialists. Particularly in HMOs and some PPOs, all members must choose or are assigned a PCP.
PHR: A personal health record or PHR is typically a health record that is initiated and maintained by an individual. An ideal PHR would provide a complete and accurate summary of the health and medical history of an individual by gathering data from many sources and making this information accessible online.
Picture Archive Communication System (PACS): Used by radiology and diagnostic imaging organizations to electronically manage information and images
Practice Parameters, Practice Guidelines: Systematically developed statements to standardize care and to assist in practitioner and patient decisions about the appropriate health care for specific circumstances. Practice guidelines are usually developed through a process that combines scientific evidence of effectiveness with expert opinion. Practice guidelines are also referred to as clinical criteria, protocols, algorithms, review criteria, and guidelines. The American Medical Association defines practice parameters as strategies for patient management, developed to assist physicians in clinical decision-making. Practice parameters may also be referred to as practice options, practice guidelines, practice policies, or practice standards.
Prescription Drug: Drug that the law says can only be obtained by prescription.
Primary Care Physician: A “generalist” such as a family practitioner, pediatrician, internist, or obstetrician. In a managed care organization, a primary care physician is accountable for the total health services of enrollees including referrals, procedures and hospitalization. Also see Primary Care Provider.
Primary Care Provider: The provider that serves as the initial interface between the member and the medical care system. The PCP is usually a physician, selected by the member upon enrollment, who is trained in one of the primary care specialties who treats and is responsible for coordinating the treatment of members assigned to his/her plan.
Primary Care: Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians who are often referred to as primary care practitioners or PCPs. Professional and related services administered by an internist, family practitioner, obstetrician-gynecologist or pediatrician in an ambulatory setting, with referral to secondary care specialists, as necessary.
Principal Diagnosis: The medical condition that is ultimately determined to have caused a patient’s admission to the hospital. The principal diagnosis is used to assign every patient to a diagnosis related group. This diagnosis may differ from the admitting and major diagnoses.
Privacy Standards: The Privacy standards restrict the use & disclosure of individually identifiable health information. Privacy standard applies to all protected health information may it is in physical or electronic form.
Privacy: Privacy means an individual’s interest in limiting who has access to personal health care information. Specific patient authorization is required for use and disclosure of clinical notes. As per Fernando & Dawson, 2009, privacy is control of access to private information avoiding certain kinds of embarrassment and can be shared or not shared with others; Only authorized (by the patient) people can view the recorded data or part thereof
Progress Note: The documentation of a patient visit or encounter including all or part of the SOAP format.
Protected health information (PHI): Any individually identifiable information whether oral or recorded in any form or medium that is created, or received by a health care provider, health plan or health care Healthcare provider and relates to past, present, or future physical or mental health conditions of an individual; the provision of health care to the individual; or past, present, or future payment for health care to an individual.
[ R ]
Real Time: The instantaneous sharing of data among a user group. It is common to a client/server database configuration.
Reference Model (RM):
Referral: Some insurance companies require that on specific plans a referral must be obtained for certain procedures or visits to specialists. The referral is acquired by the primary care physician (PCP) by contacting the insurance company by phone or mail. This is a request for the service. The referral consists of an authorization code, a number of visits allowed (if applicable) and an expiration date.
Referring Provider: is the provider that referred the patient to a specialist or for a specific procedure.
Regenstrief: The Regenstrief Institute is an international non-profit medical research organization associated with Indiana University. It produces and maintains LOINC codes.
Relational Database: A database program that stores data in a manner similar to Excel, with the difference being the data elements are related (linked) to each other.
Remote Access: Data travels through a private, protected passage via the Internet, allowing healthcare providers to access from home or another practice location and allows EMR vendor to perform system maintenance off-site
Rendering/Performing Provider: The provider actually treating the patient.
Roles and Access Levels: The role and access level of the user needs to be determined and set by the system administrator. The role determines the access level. While roles may be such as system administrator, medical doctor, registered nurse, medical student, medical assistant, nurse assistant, ancillary nurse, health worker, Anganwadi worker (grass-root health worker), etc., the access levels may include viewing only, viewing/adding/editing only, viewing/adding/editing/deleting, all allowed etc. These need to be set out clearly in the SOP of the facility.
ROS (Review of Systems): A series of questions related to the system(s) that the patient is having complaints about (i.e. respiratory for cold symptoms).
RxNorm: RxNorm is the name of a US-specific terminology in medicine that contains all medications available on US market; it provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software.
[ S ]
Secondary Care: Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologist, urologists, dermatologists). In the U.S., however, there has been a trend toward self-referral by patients for these services, rather than referral by primary care providers. This is quite different from the practice in England, for example, where all patients must first seek care from primary care providers and are then referred to secondary and/or tertiary providers, as needed.
Security Standards: The Security Standards require measures to protect the confidentiality, integrity and availability of e-PHI while it’s being stored & exchanged. The security standard applies to all electronic PHI.
Security: This refers to the methods and techniques adopted to protect privacy and are a defense mechanism from any attack (Hong et al., 2004)
SNOMED: Systemized Nomenclature of Medicine Clinical Terms is the universal health care terminology. It is comprehensive and covers procedures, diseases, and clinical data. SNOMED CT helps to structure and computerize the medical record. It allows for a consistent way of indexing, storing, retrieving and aggregating clinical data across sites of care (i.e. hospitals, doctors offices) and specialties. By standardizing the terminology, the variability in the way data is captured, encoded and used for clinical care of patients and research is reduced. Allows for more accurate reporting of data. It is currently available in English, Spanish and German.
Social History: A description of a patient’s social habits and history including marital status, alcohol and drug use and exercise habits.
Solo Practice, Solo Practitioner: A physician who practices alone or with others but does not pool income or expenses. This form of practice is becoming increasingly less common as physicians band together for contracting, overhead costs and risk sharing.
SOP: Standard operating procedures or protocols
SQL: Structured Query Language – is a computer language aimed to store, manipulate and retrieve data stored in relational databases.
SDO: Standards Development Organization – an organization responsible for development and maintenance of a standard or several, usually run on a not-for-profit basis.
Subjective: Section in a progress note where a patient’s account of their current problem is documented. Consists of chief complaint, HPI and ROS.
Sx: Abbreviation for symptoms
[ T ]
T1, T3 line: A high-speed internet connection provided via telephone lines often used by businesses needing internet connection speeds greater than DSL/Cable.
Therapeutic Alternatives: Strong Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Drug Formulary.
TPA: Third Party Administrator
Treatment Episode: The period of treatment between admission and discharge from a modality, e.g., inpatient, residential, partial hospitalization, and outpatient, or the period of time between the first procedure and last procedure on an outpatient basis for a given diagnosis. Many healthcare statistics and profiles use this unit as a base for comparisons.
Treatment: The provision of health care by one or more health care providers. Treatment includes any consultation, referral or other exchanges of information to manage a patient’s care.
[ V ]
Vital Statistics: Statistics relating to births (natality), deaths (mortality), marriages, health, and disease (morbidity). Vital statistics for the United States are published by the National Center for Health Statistics.
Vital statistics can be obtained from CDC, state health departments, county health departments and other agencies. An individual patient’s vital statistics in a health care setting may also refer simply to blood pressure, temperature, height and weight, etc.
VPN: Virtual Private Network – A VPN “tunnel” is a secure connection, typically firewall to firewall that provides for remote access to your data server.
[ W ]
WADO: Web Access to DICOM Object Service.
WHO: The World Health Organization is a specialized agency of the United Nations that is concerned with international public health.
XML (Extensible Markup Language): Used for defining data elements on a Web page and communication between two business systems. Example: Standard messaging system for and EMR to integrate with another software such as a practice management or drug formulary database.