Digitization Dictionary: A Glossary to Guide Your EHR Selection Process
By Nancy Stafford
ARRA
American Reinvestment and Recovery Act: This is legislation designed to boost the economy of the United States. One emphasis is to develop a better health care system. As a portion of that focus, this act provides support for the development and use of electronic health records to ease the flow of patient information. Signed into law February 13, 2009, this act can be read in its entirety by clicking here.
Ambulatory Care: The care provided to a patient who is able to walk around, who is not bed ridden. It can be used for outpatient procedures as in ambulatory electrocardiogram.
Alerts: Computer generated updates and notices that are usually controlled in content and intent by the person who initially requested the notifications. For instance, a person using e-mail could ask the e-mail provider to send an alert to their electronic hand-held devise when an e-mail arrives.
Bandwidth: Usually relates to the speed of electronic transfer. The wider the bandwidth, the faster the transfer.
Bar Code: A visual representation of electronic data read by an optical scanning reader. These are the lines the clerk at a grocery store reads with the electronic wand that registered the price of the item and updates the store's inventory at the same time. They can be used in the health care setting a number of ways including verifying patient identity to reduce errors.
Certified: A health information exchange software, hardware, network or process that meets the national standards criteria as set by the Certification Commission for Healthcare Information Technology. Check the U.S. Department of Health and Human Services Web site for updates on the certification process. This is an ongoing, national effort at standardization.
CCHIT
Certification Commission for Healthcare Information Technology: Develops the minimum standards for the security and privacy of electronic health records and their transmission. It is responsible for the interoperability standards.
Chart Note: The notes, lab results and information a health care provider enters into a patient's chart. A chart can be either a paper folder full of files or an electronic summation of a patient's records.
Compliance: To conform or adhere to standards, rules or laws. In regards to health care, it is important that providers comply with HIPPA standards as well as making sure Medicare and Medicaid patients are assigned to the correct admission status.
Computerized Physician Order Entry (CPOE): Allows physicians to electronically enter any patient's orders. This reduces the possibility of communication, medication and treatment
errors. See www.cpoe.org for more information.
Department of Health and Human Services: This federal agency protects the health of U.S. citizens. It houses all the laws, regulations and grants for the use and expansion of electronic health records. It is the place to begin any search on electronic records.
EHR
Electronic Health Records: A tool for providers; the total personal health records maintained electronically by a medical provider that may be shared to authorized professionals. See: electronic medical record. These records may be accessed by medical professionals authorized by the individual. These records conform to national interoperability standards and may be used by any authorized professional anywhere. EHR may also refer to billing and scheduling electronically.
Electronic Signature: Any legally recognized electronic means that indicates the person signing agrees or intends to agree to the electronic document.
EMR
Electronic Medical Records: A tool for a provider; the total personal health records maintained electronically by a medical provider. See: electronic health record. This term usually refers to electronic records obtainable by one health organization. These records do not conform to the interoperability standards.
Encryption: A security measure to code or make difficult for unauthorized accessibility. Encryption of Electronic Health Records protects the patient's privacy.
Face Sheet: The first sheet in a patient's paper record containing the general information such as
name, date of birth, martial status, type of insurance, emergency contact, and any medical information the patient can self-report.
HIPAA
Health Information Portability and Accountability Act: The actual name is the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. It protects and sets the guidelines for storage, sharing and transporting a patient's personal and health information to any other person or organization. Every one who handles health records must follow these standards including health insurers, health facilities, health providers, data entry clerks, etc. To
read more, try this Web site.
HIE
Health Information Exchange: The electronic transfer of health information among organizations using nationally recognized standards of security and transmission. It is the process of sharing information.
HIO
Health Information Organization: These networks provide oversight of the nationally accepted standards of electronic health information transmission.
HIT
Health Information Technology: The use of computers, hardware and software, and electronic devices to store, transfer and use health information.
Health Information Organization: A governing body that monitors health information transmission, usually for standardization, security and privacy, by a group of health care users.
Informatics: The study of information processing, computer science.
Integrated EHR: This software would include office management tools such as billing and scheduling and the electronic health records software for patient management.
Interoperability: Electronic systems communicating with each other. An agreement as to the principles, policies and procedures as well as connectivity among electronic information exchange units.
Meaningful Use of Electronic Health Records: This is in the beginning stages of definition. The first meeting was held in June 2009, with public comments due at the end of June. Expect the rules and definitions to come late in 2009. Watch this site for updates.
Metrics: An efficient logical study and resolution of issues and problems.
Personal Health Records: The records of individuals to help them monitor their own health and health care. This information is managed, stored and controlled by the individual. This information would be useful to make more informed health decisions.
RHIO
Regional Heath Information Exchange: These governing networks monitor health information transmission among providers as defined by a geographic area. They are set up to improve community health information exchange.
Server: Can be either a physical computer or a computer system of programs that holds and services electronic information.
Standardization: Agreed upon requirements for EHR systems so that the various systems will be able to communicate with each other easily. Check hhs.gov for updates on the certification
process. This is a national ongoing effort at coordination.
Super Users/Users: Super users are the ultimate administrators of a computer system. They can block and unblock content and issue restraints. A user is one who is authorized to login to a system and perform certain authorized tasks.
Templates: Pre-made electronic forms that mirror basic office visit forms. They usually can be customized to a particular practice's needs.
Vendor: The company, organization or person that is hired to provide a service or product for compensation. For instance, a computer vendor would supply computers to a practice, while a medical vendor would supply surgical instruments to a practice.
Workflow: The path a task follows from the beginning to the end. For instance, a patient calls to schedule an appointment, the receptionist takes the message, records the appointment, and sends a reminder to the patient. Many software vendors do extensive workflow analyses on their healthcare clients in order to better serve their needs.
Resources:
http://hhs.gov/
www.centerforhit.org
http://csat.samhsa.gov/IDBSE/idb/modules/FINAL-CMS_SAMHSA_InteroperabilityConfPapers.pdf
www.cpoe.org
www.dictionary.com