EMR Glossary for Health Care Providers

An EMR glossary of most of the relevant EMR, EHR, and healthcare definitions, abbreviations, and acronyms you will come across.

Use a secure network

There are several measures doctors and hospitals should take to secure EMR and be HIPAA compliant. One of the most effective is data encryption. Encryption technology protects EMRs while they are being transferred and ensures that only the intended recipients are able to view them. Also, all hospitals and health providers are required to have firewalls on their computer networks. Firewalls are a strong first line of defense for medical records security by blocking unwanted access to the computer networks used by EMR systems.

Finding the appropriate electronic medical record (EMR) and electronic health record (EHR) software for your practice can be a daunting task since most information sources out there utilize a myriad of EMR / EHR abbreviations and acronyms that further complicate the process. To help minimize this, we have compiled an EMR glossary of most of the relevant EMR, EHR, and healthcare definitions, abbreviations, and acronyms you will come across.


A

Access: A patient’s ability to obtain medical care, which is a function of the availability of healthcare services and cost.

ACO: Accountable Care Organization. A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization’s payment is tied to achieving health care quality goals and outcomes that result in cost savings.

Addendum: Text that is added to a document after it has been finalized.

AHRQ: Agency for Healthcare Research and Quality. The lead federal agency charged with improving the quality, safety, and efficiency of health care delivery in the United States. AHRQ supports health services research that will improve the quality of health care.

Allowed Charge: The amount that Medicare or another health insurer approves for payment to a physician, but due to co-pay or deductible usually does not match the total that a healthcare provider charges a patient. For instance, Medicare normally pays 80 percent of the approved charge and the beneficiary pays the remaining 20 percent.

Allowable Costs: Covered expenses within a given health plan reflecting elements of an institution’s costs, which is reimbursable under a payment formula. Both Medicare and Medicaid reimburse hospitals on the basis of only certain costs.

Ambulatory Care: Medical care provided on an outpatient basis.

ARRA: The American Recovery and Reinvestment Act. This 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) system. These incentive payments began in 2011. 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 ASP deploys, hosts and manages software from a centrally managed facility. 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” or “SaaS”.

Audit Trail: Security system report that tracks a user’s access, deletion or modification of data and the time at which each event happened. This includes user login, file access, other various activities, and whether any actual or attempted security violations occurred.

Authentication: The verification of the identity of a person or process for purposes of accessing medical records, whether they are stored on paper or digitally. In the case of computerized systems, this typically involves entering a combination of account numbers and passwords or other personal information so that the identity of the person using the computer is verified and access can be enabled.


B

Balance Billing: The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.

Bandwidth: A data transmission rate; the maximum amount of information (bytes/second) that can be transmitted along a connection, typically between a user’s computer and a central server accessed via the internet. A higher number is a faster connection, and connection speeds are typically referenced in terms of megabytes per second (thousands of characters per second) or gigabytes per second (millions of characters per second). For most individual users, the connection from their personal computer to the internet will be the limiting factor in how quickly they can access their medical records when online. Diagnostic images require far more bandwidth to transmit than simple reports.

Bar Code: A printed horizontal strip of vertical bars which represent decimal digits used for identification. Routinely used to tag diagnostic samples for processing and tracking. Bar codes are read by a bar code reader.

Behavioral Healthcare: An umbrella term that includes mental health, psychiatric, marriage and family counseling, or treatment for substance abuse.

Beneficiary: Individual who is eligible to use health insurance benefits.

Biometrics: 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.


C

CCHIT: Certification Commission for Healthcare Information Technology. An independent, non-governmental certification body for electronic medical records.

Central Data Repository. A central place where paper records or computer-based data are stored and maintained.

Chain of Trust Agreement. This is a contract used to extend the responsibility to protect health care data covered under HIPAA across a series of sub-contractual relationships.

CMS: Centers for Medicare and Medicaid Services. The Centers for Medicare and Medicaid Services is a federal agency within the U.S. Department of Health and Human Services which is responsible for administering Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), HIPAA and CLIA. CMS is responsible for oversight of HIPAA security standards.

COBRA: Consolidated Omnibus Budget Reconciliation Act. A federal law that provides, among other things, for continuation of health care benefits for employees whose employment has been terminated.

Coding: A mechanism for defining physicians’ and hospitals’ services in a standardized fashion. Coding provides universal definition and recognition of diagnoses, procedures and level of care.

Co-Insurance (coinsurance): A cost-sharing requirement under a health insurance policy that provides that the insured will assume a portion or percentage of the costs of covered services according to either a fixed percentage or fixed amount.

Computerized Patient Record (CPR): Casually used as meaning the same thing as an Electronic Medical record (EMR) or Electronic Health Record (EHR), but technically a single patient’s clinical data stored in a computer.

Co-Payment (Co-pay): A cost-sharing arrangement in which a health insurance plan enrollee pays a specified flat amount for a specific service. A Co-pay does not vary with the cost of the service and is usually a flat sum, unlike co-insurance that is based on a percentage of the cost.

Cost Sharing: Payment method where a person is required to pay some health costs in order to receive medical care. This includes deductibles, co-insurance and co-payments.

CPT (Current Procedural Technology) Code: A standardized five-digit number established and updated annually by the American Medical Association and used to represent a specific service provided by a health care provider. The purpose of CPT codes is to provide a uniform language that describes medical, surgical, and diagnostic services.

CAH (Consumer Assessment of Healthcare Hospital): A Critical Access Hospital is certified to receive cost-based reimbursement from Medicare in order to improve their financial position and reduce hospital closures that serve critical community needs.

CAHPS: Consumer Assessment of Healthcare Providers and Systems. The CAHPS surveys ask consumers and patients to report on their experiences with health care services in different settings. The surveys are a product of the Agency for Healthcare Research and Quality’s CAHPS program, which is a public-private initiative to develop and maintain standardized surveys of patients’ experiences.

Case Management: A method designed to effectively manage the specific health services needed by an individual.

Case Manager: A nurse, doctor, or social worker who works with patients, providers and insurers to coordinate delivery of healthcare services, typically from multiple providers.

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
.

Chart: A medical record

Chart Note: A document, written by a health care provider, which describes the details of a patient’s encounter. Sometimes referred to as a progress note.

CHIP: Children’s Health Insurance Program, also known as Children’s Medicaid.

Claim: A request by an individual (or his or her provider) to that individual’s insurance company to pay for healthcare services.

Claims Review: Healthcare claims are reviewed prior to reimbursement by an insurer.

Client/Server Architecture: A type of computer information system, in which a client program sends a request to a computer server. This system architecture usually implies that the server is located on site as opposed to the ASP (Application Server Provider) architecture, which accesses computer processes and data over the internet.

Clinical Guidelines: Clinical guidelines are protocols and 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.

CMS: Centers for Medicare and Medicaid Services. The Centers for Medicare and Medicaid Services is a federal agency within the U.S. Department of Health and Human Services which is responsible for administering Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), HIPAA and CLIA. CMS is responsible for oversight of HIPAA security standards.

CCR: Continuity of Care Record. The continuity of care record is a standardized electronic snapshot of a patient’s medical, insurance, and demographic information at any given point in time. While not all of the patient’s information is in the CCR, critical information is available that may be useful in referrals and emergencies.

CPR: Computerized Patient Record, Computer-Based Patient Record. Electronically maintained information about an individual’s lifetime record of health care from all specialties.

CPR: Customary, Prevailing, and Reasonable. Current method of paying healthcare providers under Medicare. Payment for a service is limited to the lowest of the following: the billed charge for the service; the physician’s customary charge for the service; or the prevailing charge for that service in the community. Similar to the Usual, Customary, and Reasonable system used by private insurers.

CY: Calendar Year


D

Data conversion: The conversion of data for use from one software to another.

Data Use Agreement (DUA): HIPAA Regulation states that a health care entity may use or disclose a “limited data set” if that entity obtains a data use agreement from the recipient of the data. Released data can be used only for research, public health or health care operations. DUAs must specify who is permitted to use or receive the limited data set and must require that appropriates security safeguards be used.

Deductibles: Annual amounts required to be paid by the insured under a health insurance plan before benefits become payable.

DES: Data Encryption Standard. A widely-used method of data encryption. DES is designed to allow transmission of data over communications networks or the internet between authorized users while maximizing security of the underlying data and preventing unauthorized viewing.

Data Integrity: Refers to the validity of data. A condition in which data has not been altered or destroyed in an unauthorized manner.

Data Mining: The process of analyzing or extracting data from a database to identify patterns or relationships.

Data Set: A group of data elements relevant for a particular use.

Data Structure: A way to store and organize data in order to facilitate access and modifications.

Database: A collection of information organized in such a way that a computer program can quickly select desired pieces of data.

DBMS: Database Management System. A set of computer programs for organizing the information in a database. A DBMS supports the structuring of the database in a standard format and provides tools for data input, verification, storage, retrieval, query, and manipulation.

DICOM: Digital Imaging and Communications in Medicine. A standard to aid the distribution and viewing of medical images, such as CT scans, MRIs, and ultrasound.

Dictation: The process by which a physician records his/her notes about a patient. This recording is intended for reproduction in written word (Transcription).

Digital Signature: Sometimes referred to as Advanced Electronic Signature. Digital signature takes the traditional hand-written signature and creates a digital image of the signature to eliminate the need to print and sign documents.

Document Imaging: Converting paper documents into an electronic format, typically through a scanning process.

Documentation: The process of recording information.

Document Management: A system involving scanning, categorizing and storing vital patient documents.

Drug Formulary: Lists of prescription drugs approved by a given health insurer. Health plans often restrict or limit the type and number of medicines allowed for full or partial reimbursement.


E

EDI: Electronic Data Interchange. A standardized format for data transmission which allows the automated exchange between different computer systems or organizations. In health care, insurance claims submission and payment relies on EDI.

EHR: Electronic Health Record. A computerized repository of information regarding the health of an individual. It is also a generic term for all electronic patient care systems. EHR’s imply a level of interoperability beyond the capability of an EMR (Electronic Medical Record), but are similar in terms of the information stored and the purpose for the system. Although technically incorrect, the terms EHR and EMR are often used casually in interchangeable fashion. Search for EHR software here. 

EMR: Electronic Medical Record. An electronic medical record (EMR) is a provider-based medical record that includes all health documentation for one person covering all services provided within one enterprise. Although technically incorrect, the terms EHR and EMR are often used casually in interchangeable fashion. Search for EMR software here.

The Difference Between EHR and EMR

EPO: Exclusive Provider Organization. An exclusive provider organization (EPO) is a type of managed care plan that combines features of HMOs and PPOs.

EPR: Electronic Patient Record. Medical information about an individual stored electronically. Same as a CPR, Computerized Patient Record.

Encryption: Process of converting messages or data into a form that cannot be read without decrypting or deciphering it. DES is one such commonly used system. Encryption allows sharing of sensitive or confidential information over the Internet with authorized users with a high degree of security. Encrypting sensitive data for transmission is considered by many now to be a standard component of ensuring HIPAA compliance.

e-Prescribing: Prescribing medication through computerized systems and transmitting the information electronically to participating pharmacies. It also enables health care providers and pharmacies to share information about a patient’s insurance eligibility and medication history.

EBM: Evidence Based Medicine. The integration of best research evidence with clinical expertise to aid in the diagnosis and management of patients.


F

FFS: Fee-For-Service. Typically references a Fee-For-Service Medicare Advantage health plan offered by a private insurance company under contract to the Medicare program. Medicare pays a set amount of money every month to the Private Fee-For-Service organization to arrange for health care coverage for enrolled beneficiaries.

FFY: Federal Fiscal Year.

Firewall: A computer or software system designed to prevent unauthorized access to or from a computer or computer network.

Formulary: A listing of prescription drugs established by a particular health plan which includes both brand name and generic drugs. It typically lists covered, preferred and lower cost drugs.

FQHC: Federally Qualified Health Center. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities.

FTE: Full-Time Equivalent.

FTP: File Transfer Program. Software used to transmit files across a network or over the Internet. Considered a relatively dated technology.

FY: Fiscal Year.


G

Group Insurance: Any insurance policy or health services contract by which groups of employees are covered under a single health insurance policy.

Group Practice: A group of persons licensed to practice medicine who share common overhead expenses, medical and other records, equipment, and professional staff.

GUI: Graphical User Interface. (Pronounced “gooey”). A program interface that takes advantage of the computer’s graphics capabilities to make the program easier to use. Well-designed graphical user interfaces can help expedite the software learning process.


H

Human Subject: Under HIPAA rules, this term refers to a living subject participating in research about whom directly or indirectly identifiable health information or data are obtained or created.

HHS: Federal Department of Health and Human Services.

HIE: Health Information Exchange. HIEs provide the capability to electronically move clinical information between multiple different health care computer systems while maintaining the integrity, confidentiality, privacy, and security of that information. The purpose of HIE development is to improve healthcare delivery by making all relevant information for a particular patient readily accessible by all healthcare providers.

HIPAA: Health Insurance Portability and Accountability Act of 1996. A federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. HIPAA also seeks to establish standardized mechanisms for electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.

HIT: Health Information Technology. Describes the comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers.

HITECH Act: The Health Information Technology for Economic and Clinical Health Act was created to stimulate the adoption of electronic health records (EHR) and supporting technology in the United States. President Obama signed HITECH into law on February 17, 2009 as part of the American Recovery and Reinvestment Act of 2009 (ARRA), an economic stimulus bill.

HITSP: Health Information Technology Standards Panel. HITSP is a cooperative public and private partnership whose goal is setting standards to enable and support widespread interoperability among health care software applications. The organization is comprised of healthcare providers, vendors, payers, consultants, government groups and others.

HL7: Health Level Seven. One of several standards developing organizations accredited by the American National Standards Institute (ANSI). HL7 develops an international set of open standards for data format and content that allows different health information systems to communicate with one another to improve healthcare delivery and improve workflow. HL7 is a not-for-profit, volunteer based organization.

HM: Health Maintenance (also referred to as Preventive Health Maintenance). A system of guidelines of tests or procedures that have proven value in disease prevention.

HMO: Health Maintenance Organization. HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. The members of an HMO, who pay monthly premiums as for other types of health insurance, are required to use participating or approved providers for all health services.

HOS: Health Outcomes Survey. The Medicare Health Outcomes Survey (HOS) is a patient reported outcomes measure used in Medicare managed care. The goal of the Medicare HOS program is to gather valid, reliable, and clinically meaningful health status data in the Medicare Advantage (MA) program for use in quality improvement activities, pay for performance, program oversight, public reporting, and improving health.  All managed care organizations with Medicare Advantage contracts must participate.

HRA: Health Reimbursement Arrangements. This is a savings account offered by employers where tax-deferred deposits can be made for medical expenses. Withdrawals from the HRA are tax-free if used to pay for qualified medical expenses. Health Savings Accounts (HSAs) for individuals are similar in purpose.

HSA: Health Savings Account. This is an individual savings account where tax-deferred deposits can be made for medical expenses. Withdrawals from the HSAs are tax-free if used to pay for qualified medical expenses. Health Reimbursement Arrangements (HRAs) are similar in purpose and can be offered by employers.

Hybrid Record: A provider’s use of a combination of paper and electronic medical records during the transition phase to EMR.


I

Information Technology (IT): This includes computer hardware and software, operating systems, Web-based information and applications, telephones and other telecommunications products, video equipment and multimedia products, information kiosks, and office products, such as photocopiers and fax machines.

ICD-9 or ICD-10: International Classification of Diseases. ICD is the standardized and highly detailed classification and coding of diseases and injuries, typically used in clinical settings and in the health insurance industry for determining coverage and payments allowed under a particular health plan.

Interoperability: The capability to provide successful communication between end-users across a mixed environment of different computer domains and networks, facilities, and enterprises. Typically used in referring to a long term goal of allowing interoperability, or easy exchange, of information between different electronic medical records systems.


K

Kiosk: Small computer workstations which allow information to be input. Patient kiosks are used for patients to input information into the system at a medical practice, usually through a workstation in the waiting room.


L

Legacy System: A system that is considered old and possibly outdated (e.g. old medical billing software system).

Legacy System Integration: The integration of data between a legacy system and some other software program, most commonly using HL7 standards.

Legend Drug: Drug that can only legally be obtained by prescription.

LEPR: Longitudinal Patient Record. This is an EHR that includes all healthcare information from all sources for one individual from birth onwards.

Lifetime Limit: A cap on the benefits paid under a health insurance policy.

LPPO: Local Preferred Provider Organization. A PPO is a type of Managed Care Organization offered under the federal Medicare Advantage program in which hospitals, physicians, and other health care providers offer health care at reduced rates to an insurer’s clients. PPOs may either be local (LPPOs) or regional (RPPOs).


M

MU: Meaningful Use. Meaningful use sets specific objectives that eligible professionals (EPs) and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services (CMS) Incentive Programs.

MA: Medicare Advantage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. These plans provide all Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

MAC: Medicare Administrative Contractor. MACs serve as Medicare providers’ primary point-of-contact for the receipt, processing and payment of claims.

MAO: Medicare Advantage Organization. A public or private organization licensed and under contract with the Centers for Medicare & Medicaid Services (CMS) to provide health care coverage to Medicare Eligible enrollees.

MCO: Managed Care Organization. A health care delivery system consisting of affiliated and/or owned hospitals, physicians and others which provide coordinated health services, typically on a capitated, or fixed fee per patient per month, basis. Examples include Health Maintenance Organizations (HMOs), Point of Service Plans (POSs), and Preferred Provider Organizations (PPOs).

Medical Informatics: The analysis of data about medical care services to improve decisions made by physicians and managers of health care organizations.

MMIS: Medical Management Information System. A computer system that allows payers to track health care expenditure and usage. It may also be referred to as Health Information System (HIS), Health Information Management (HIM) or Information System (IS).

MSA: Medical Savings Account. This is an individual savings account where tax-deferred deposits can be made for medical expenses. Withdrawals from the MSA are tax-free if used to pay for qualified medical expenses. MSAs have been replaced since 2003 by Health Savings Accounts (HSAs). Health Reimbursement Arrangements (HRAs) are similar in purpose and can be offered by employers.

Master Patient Index: An index referencing all patients known to particular organization.

Multi-Specialty Group: A group of doctors who represent various medical specialties and who work together in a group practice.


N

National Provider Identifier (NPI): A unique 8 digit number assigned to every health care provider and required by the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers.

Nationwide Health Information Network (NHIN): The nationwide health information network is a set of standards, services and policies that enable secure health information exchange over the Internet.

Non-Participating or Non-Plan Physician (or Provider): A healthcare provider that does not sign a contract to participate in a health plan. 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

ONC: Office of the National Coordinator for Health IT.  Group within the U.S. Department of Health and Human Services that is responsible, among other things, for promoting the development of a nationwide interoperable Health Information Technology (HIT) infrastructure, which includes EMRs, and consequently for supervising the certification process in order for an EMR system to qualify for federal payments.

ONC-ATCB: ONC-Authorized Testing and Certification Body. Organizations selected and authorized by the ONC to perform complete EHR and/or EHR module testing and certification. Certification by an ATCB will signify to eligible professionals, hospitals, and critical access hospitals that an EHR technology has the capabilities necessary to support their efforts to meet the goals and objectives of meaningful use.

OCR: Optical Character Recognition. OCR is recognition of printed or written characters by a computer. OCR systems are typically used in scanning paper-based medical records into electronic systems.

Open Access: Open access arrangements allow a health insurance member to see a participating provider without a referral from another doctor.

Outpatient Care: Healthcare provided to a person who is not bedridden. It is also called ambulatory care.


P

PACS: Picture Archiving and Communication System. An information system for the storage and distribution of digital radiology images over a networked environment that allows for instant access to images and reports.

PAHP: Prepaid Ambulatory Health Plan. A healthcare entity that provides medical services on a prepaid capitation, or per enrollee, basis and only provides outpatient medical care, as opposed to medical care requiring hospitalization.

Part A Medicare: Refers to the inpatient portion of benefits under the Medicare Program, covering hospital, home health, hospice, and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and co-payments.

Part B Medicare: Refers to the outpatient benefits of Medicare. Beneficiaries are responsible for monthly premiums, co-payments, deductibles, and balance billing.

Participating Provider: Any healthcare provider who has contracted with a particular health insurer.

Patient Liability: The total amount that an insured person is legally obligated to pay for a particular healthcare service. These may include co-payments, deductibles, as well as payments for uncovered services.

Patient Portal: Allows healthcare providers or insurers to provide a central website where patients can log in and view healthcare bulletins and messages from providers, as well as reviewing medical records or healthcare summaries.

Payer (usually Third Party Payer): The public or private organization that is responsible for payment for health care expenses, such as insurance companies.

PCP: Primary Care Physician. Typically a PCP provides routine healthcare and must approve referrals to specialists.

PFFS: Private Fee-For-Service. A Private Fee-For-Service plan is a Medicare Advantage health plan offered by a private insurance company under contract to the Medicare program. Beneficiaries may go to any eligible doctor or hospital anywhere in the U.S. that is willing to provide care and accepts the Private Fee-For-Service plan’s terms of payment.

PHI: Personal Health Information. Refers to medical history, test and laboratory results, insurance information and other data that is collected by a health care professional to identify an individual and determine medical care. This information is covered by HIPAA privacy protections and cannot be sold unless it is being used for public health activities or research.

PHO: Physician Hospital Organization. This is a joint healthcare provision effort of a group of physicians and one or more hospitals, which provides a single interface to health care insurers.

PHR: Personal Health Record. A PHR includes all healthcare information from all healthcare providers that have been used by a single patient. The information is typically gathered and maintained by the patient.

PIHP: Prepaid Inpatient Health Plan. Healthcare entity that provides medical services on a prepaid capitation, or per enrollee, basis and only provides inpatient medical care requiring hospitalization.

Point-of-Care-Testing (POCT): POCT refers to medical testing made while a health care provider is with a patient, without the need for samples to be sent to outside or remote laboratories, providing more immediate results.

PPO: Preferred Provider Organization. A PPO is a type of Managed Care Organization offered under the federal Medicare Advantage program in which hospitals, physicians, and other health care providers offer health care at reduced rates to an insurer’s clients. PPOs may either be local (LPPOs) or regional (RPPOs).

PQRI: Physician Quality Reporting Initiative. Initiative under which Medicare makes incentive payments to health care professionals who satisfactorily report data on quality measures for Medicare covered patients.

Pre-Authorization: Most group medical policies require that patients contact the insurer prior to a non-emergency hospitalization or surgery and receive authorization.

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.

Primary Care Network (PCN): A group of primary care physicians who share the risk of providing care to members of a particular health insurance plan.

Privacy: For purposes of the HIPAA Privacy Rule, privacy means an individual’s interest in limiting who has access to personal health care information.

Problem List: Diagnosis list of conditions and information regarding the health condition of a patient.

Protocols: Healthcare provider guidelines governing the specific medical care to be delivered for each disease or medical diagnosis.

PSO: Provider Sponsored Organization. Hospitals, physician groups, and other healthcare providers that are affiliated through common ownership or control.


Q

QIO: Quality Improvement Organization. The Medicare QIO program consists of a national network of fifty-three QIO’s that work with consumers, physicians, hospitals, and other health care providers to refine care delivery systems.


R

Referral: Most health insurers require a referral by the individual’s Primary Care Physician for certain procedures or visits to specialists.

RHIO: Regional Health Information Organization. The terms “RHIO” and “Health Information Exchange” or “HIE” are often used interchangeably. RHIO is a group of organizations with a business stake in improving the quality, safety and efficiency of health care delivery.

RPPO: Regional Preferred Provider Organization. A PPO is a type of Managed Care Organization offered under the federal Medicare Advantage program in which hospitals, physicians, and other health care providers offer health care at reduced rates to an insurer’s clients. PPOs may either me local (LPPOs) or regional (RPPOs) serving either a single state of larger area.


S

Subscriber: Person responsible for payment of premiums, or person whose employment is the basis for membership in a health plan.

SSO: Single sign-on. SSO is mechanism whereby a single action of user authentication and authorization can permit a user to access all computers and systems where he/she has access permission, without the need to enter multiple passwords.

SOAP: A commonly used format for medical documentation which helps to organize the information. SOAP is an acronym for S-Subjective, O-Objective, A-Assessment, P-Plan.

SAAS: Software as a Service. A software distribution model in which applications are hosted by a vendor or service provider and made available to customers over a network, typically the Internet.

Speech Recognition: The ability of a computer to understand the spoken word for the purpose of receiving commands and transforming speech into text. Many EMR systems allow the use of speech recognition for inputting clinical notes.

SureScripts: Electronic exchange that links pharmacies and health care providers. It was founded in 2001 by National Association of Chain Drug Stores (NACDS) to make the medication prescribing process safer and more efficient.

SNOMED CT: Systemized Nomenclature of Medicine Clinical. A computer-processable collection of medical terminology covering most areas of clinical information, such as diseases, findings, procedures, microorganisms, and pharmaceuticals. It provides a consistent way to index, store, retrieve, and aggregate clinical data and helps organize the content of medical records, reducing variability in the way data are captured and used.


T

Tablet: A tablet is a computer shaped in the form of a notebook and operated via touchscreen input rather than through traditional mouse and keyboard designs. Tablet PCs (such as the iPad) are gaining widespread acceptance as an easy means to input and retrieve clinical medical information.

Template: Often called a library or dictionary. Templates are pre-defined choices of pick-lists on a computer screen designed to streamline the documentation process by limiting the number of choices and effort required to input data.

TIN: Tax Identification Number. A number assigned to every individual and organization for purposes of filing tax records and returns. The TIN for individuals is the Social Security Number.

Transcription: The process by which medical transcriptionists convert physician’s dictation into written (typed) words.

Tier: A drug formulary tier determines how much, if any, co-payment or coinsurance someone must pay for a drug.

Touch Screen: An input device that allows user to interact with the computer by touching the display screen rather than by manipulating a mouse or using arrow keys on a keyboard.

Treatment: The provision of health care for an individual. HIPAA provides for the use and sharing of protected health information for treatment purposes without authorization.


U

Unstructured Data: Data which is not structured, such as free-text. The computer cannot automatically extract properties and relationships from unstructured data, so that meanings can be ambiguous or difficult to find.

Usual, Customary, and Reasonable: Common healthcare insurance terminology. Payment for a service is limited to the lowest of the following: the usual charge for that service in the community; the physician’s customary charge for the service; the reasonable charge for the service. Similar to the Customary, Prevailing, and Reasonable (CPR) system used by Medicare.


V

Vital Statistics: Information 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. An individual patient’s vital statistics in a health care setting may also refer simply to blood pressure, temperature, height and weight, etc.

Voice Recognition: The ability of a computer to understand the spoken word for the purpose of receiving commands and transforming speech into text. Many EMR systems allow the use of speech recognition for inputting clinical notes.

VPN: Virtual Private Network. A way to communicate securely to a corporate network over the internet using software installed on a computer.


W

Waiver of Authorization: Under HIPAA, a waiver of the requirement for authorization for use or disclosure of private health information may be obtained from the relevant Institutional Review Board (IRB) by a medical researcher under limited circumstances. An IRB is a board, committee, or other group formally designated by an institution to review research involving humans as subjects. A waiver of authorization can be approved only if specific criteria have been met.

WAN: Wide Area Network. A computer network that spans a larger geographical area than a LAN (Local Area Network).

Webinar: A lecture, presentation, workshop or seminar that is transmitted over the Web. Short for Web-based Seminar.

Wireless: A system employing no connecting wire between the transmitting and receiving stations. Typically these systems use an Ethernet compatible system known colloquially as Wi-Fi.

Workers’ Compensation: A state-mandated program providing insurance coverage for work-related injuries and disabilities.

Workflow: The specification or the automation of a work process during which documents, information or tasks are passed from one participant or system to another for action, according to a set of standardized rules.