EMR Glossary for Physicians

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 may come across.


Access Rights

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

Access is also about user rights that determine who is authorized to access a protected network resource. Access rights determine who interacts with a resource, such as a user’s access rights determine whether a user can read or write to a file, or how many users may be authorized to access a resource. Access rights can be limited to specific categories and users.

Access rights can also be defined on a per-action basis: for example, an access right might be based on a resource’s existence or whether it is currently in use.

Access rights are defined on a per-resource basis, with access rights for a particular resource differing from access rights for other resources.


Accountable Care Organizations give coordinated care for chronic disease management, and work towards enhancing the quality of care patients receive. The payment for these health care providers is tied to achieving health care quality goals and outcomes that result in cost savings.

The ACO concept originated in 2010 as part of the Patient Protection and Affordable Care Act of 2010. Accountable Care Organizations are health care providers that come together to form a network, and deliver healthcare services to Medicare patients. The Affordable Care Act established ACOs as a way to promote healthcare quality, improve patient outcomes, and reduce costs. ACOs encourage care coordination and population health management.

The Centers for Medicare and Medicaid Services (CMS) determines if an organization is an ACO by reviewing its financial, operational, and clinical performance. ACOs are accountable for the quality of care they provide. ACOs must operate with a financial arrangement that meets CMS.


Text that is added to a document after it has been finalized. An addendum typically is used when more information is included in documentation than was originally included. An addendum explains or clarifies material that was not originally included. An addendum can also serve as a record of what was originally included in the original document.


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.

AHRQ is responsible for providing grants, contracts, and other types of financial assistance to researchers working on health topics.

AHRQ is also charged with assuring that the quality of research funded by the U.S. Department of Health and Human Services improves over time. AHRQ has specific responsibilities for assuring that federal research is conducted in a way that protects human subjects and that research results are communicated effectively to the public.

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.

Allowed costs refer to the costs that Medicare allows to be reflected in the Medicare cost report. Allowed costs are determined by Medicare and are based on the type of service or procedure furnished. The allowable cost is the amount that Medicare allows as a charge to a beneficiary, and payment for the allowed medical procedure/service may include the allowed amount by Medicare plus the patient’s coinsurance/copayment.

Allowed costs are determined by Medicare each year by reviewing the medical/professional journal articles, national organizations, professional associations, and other relevant sources.

Allowed Charge

The amount that Medicare or another health insurer approves for a payment to a physician, but due to copay 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.

The allowed charge Medicare is the amount that Medicare allows a hospital to charge for a service or an item. It includes administrative or facility charges, but not the cost of actually performing the service.

The allowed charge is set by Medicare each year and applies to all Medicare patients. It excludes payments for coinsurance, deductibles, and copayments, which patients must pay.

The allowed charge is set by Medicare each year and applies to all Medicare patients. It excludes payments for coinsurance, deductibles, and copayments, which patients must pay.

Ambulatory Care

An ambulatory care facility (ACH), often shortened to ambulatory care facility, or ambulatory care center, refers to medical care provided on an outpatient basis.

It is a medical facility that offers medical care to patients for illnesses and minor surgical procedures. Patients are usually treated in outpatient settings that do not require them to be admitted to the hospital.

Services at an ACH are usually entirely independent from services in a hospital, usually including the treatment of minor wounds, cuts, and bruises. ACHs usually offer less sophisticated and less intensive care than hospitals. ACH patients are usually treated in outpatient clinics, which may require them to do some paperwork or some work with a medical assistant.


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.


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 has also been referred to as “software-as-a-service” or “SaaS”. An ASP is a company that provides an application over the Internet.

Think of an ASP as a “renter” of an application. An ASP rents an application from a company like Microsoft or Oracle, then hosts that application on its servers and makes it available on the Internet.

The ASP does not develop, maintain, or market the application — it merely provides Internet access and a place to store company data. ASPs generally charge a subscription fee per user or per site, or they may charge a monthly fee per database.

Pricing depends on the kind of application being hosted, as well as the kind of access you want.

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.


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.


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.

When a health care provider bills an individual or third party for the cost of a service rendered after the primary insurer’s payment, it’s known as Balance billing.

Balance billing is the practice of charging a patient, or the person who paid the bill, for the difference between what the primary insurer reimbursed the health care provider and what the health care provider claims was the actual balance. Typically, the primary insurer is Medicare, Medicaid, or TRICARE.


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. Barcodes 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. Behavioral healthcare represents a broad range of interventions in the prevention, diagnosis, and treatment of mental health, substance-abuse, and developmental disabilities.

Behavioral healthcare includes behavioral counseling; referral to other services, such as family support or substance abuse treatment; and medication management.


An individual who is eligible to use health insurance benefits.


Automated methods of recognizing a person based on a physiological characteristic such as fingerprints, retina, voice, etc.


Short for Web browser, a software application used to locate and display Web pages.


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. The Consumer Assessment of Healthcare Hospital (CAH) survey is a type of patient satisfaction survey that hospitals, clinics, and other providers use to measure their patients’ perception of care. The CAH survey has two parts: a series of questions that ask patients to assess their experience, and prompts for a specific rating between 1 and 10.

Healthcare providers use these surveys to measure their patients’ overall satisfaction with care they have received, identify any areas for improvement, and identify best practices. CAH surveys also provide healthcare providers with consistent, comparable data on which to base their quality improvement efforts.


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.


Certification Commission for Healthcare Information Technology. An independent, non-governmental certification body for electronic medical records. CCHIT is a nonprofit organization established to standardize the certification process for electronic health records (EHR). The organization also provides guidance for EHR technology, interoperability, and security.

CCHIT certification is awarded based on the requirements outlined in the CCHIT Certification Criteria, and test results are validated by the CCHIT Validation Committee. The goal of the organization is to “introduce transparency into the EHR certification program,” according to the CCHIT website.


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.


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. The Clinical Data Repository (CDR) is also a software application that allows clinicians to store their data and view patient records.

The CDR allows clinicians to store information such as patient demographics, medications, lab results, and diagnostic images. Key features of the CDR include the ability to customize templates for clinicians, the ability to export data out to a file, and the ability to have multiple users sign into the application.

The CDR allows clinicians to securely share patient information with other clinicians.

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. A chain of trust agreement is a form used by employers to transfer electronic signatures electronically and is HIPAA-compliant(The Health Insurance Portability and Accountability Act of 1996).

The HIPAA chain of trust agreement is a form that employers fill out and require their employees to fill out.

The HIPAA chain of trust agreement requires employees to complete this certificate to confirm that they understand the HIPAA regulations. Employees are required to sign the document with a certified signature. Also, employers must present the documentation that they received certifying that the employees have signed the form.

Employers are required to keep this documentation on file for 10 years.


A medical record.

Chart Note

A document, written by a healthcare provider, which describes the details of a patient’s encounter. Sometimes referred to as a progress note.


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


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.


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.

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. The co-insurance rate is most often used in the event of a claim made against the insured party. The co-insurance rate is an actuarial value (AV), which is used to calculate the percentage of a loss that the insured party will cover.

For example, the co-insurance rate may be 70% of the claim amount, so that the policyholder pays 70% of the claim amount, and the insurance carrier pays the remaining 30%.

The co-insurance rate is calculated through actuarial calculation, which estimates the likelihood of a loss occurring. The chance of a loss occurring is based on the statistical likelihood of the claim occurring.

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.


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. The Consolidated Omnibus Budget Reconciliation Act of 1985, also known as the COBRA Act, is a piece of United States federal legislation.

COBRA was a landmark reform, which fundamentally transformed the U.S. healthcare system, extending the reach of employer-provided health insurance to individuals. Passed in 1985, COBRA was the first major federal law to mandate that a company’s health insurance plan must provide continued coverage to employees and their dependents, regardless of the company’s financial condition, when the employee leaves or is terminated.

COBRA offers a safety net for workers left jobless. It provides a way to keep health coverage when an individual’s employment is terminated.


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.

Computerized Patient Record (CPR)

Casually used to mean 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.

Cost Sharing

Payment method where a person is required to pay some health costs in order to receive medical care. This includes deductibles, coinsurance and copayments.

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.

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 healthcare provider. The purpose of CPT codes is to provide a uniform language that describes medical, surgical, and diagnostic services. The CPT Code system is the most widely used financial billing system for healthcare practitioners in the United States and in other countries.

CPT is a four-character (4), two-digit (2), two-letter (2), 2-digit (2), 3-letter (2) (i.e., two-digit, two-letter, two-digit, two- or three-letter) code that identifies the procedure or service that is being performed or provided.


Calendar Year.


Data Conversion

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

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.

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 appropriate security safeguards be used.


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


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.


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


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.


Digital Imaging and Communications in Medicine is a medical imaging standard developed based on the experience with digital medical images. DICOM was created in an effort to standardize and improve medical image communications. A standard to aid the distribution and viewing of medical images, such as CT scans, MRIs, and ultrasound.

Digital medical images, or DICOM images, are images or electronic representations of medical images created, transmitted, or received through medical imaging devices, such as x-ray machines, CT scanners, and MRIs.

DICOM was developed by two medical standards organizations – the International Organization for Standardization (ISO) and the International Electrotechnical Commission (IEC). DICOM uses a series of standards that secure transmission of medical images.


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.

Document Management

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


The process of recording information.

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.



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. For more about how physicians can e-prescribe, our guide can help!


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


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.


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. If you are searching for EHR software, we can help!


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. We’ve curated a quick read for you on how EHR & EMR are different.


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.


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


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



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.


Federal Fiscal Year.


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


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.


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.


Full-Time Equivalent.


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


Fiscal Year.


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.


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.



Federal Department of Health and Human Services.


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.


Health Insurance Portability and Accountability Act of 1996. HIPAA is a federal law created to improve the efficiency and effectiveness of the healthcare system in the United States. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted on March 23, 1996. The act established national standards to protect sensitive healthcare information, such as a person’s medical history, from unauthorized use.

HIPAA’s standards for data security and privacy are designed to encourage healthcare providers to provide better care and to participate in healthcare administrative activities.

HIPAA standards include requirements that medical providers and entities use secure electronic formats for electronic transactions with patients, healthcare providers, or healthcare payers. 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.


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


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.


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 healthcare software applications. The organization is composed of healthcare providers, vendors, payers, consultants, government groups and others.


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.


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


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.


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.


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.

A HRA is a plan that allows the employer to pay some or all of the cost of an employee’s or dependent’s medical expenses. HRAs are “self-funded” plans. In other words, they don’t pay for eligible expenses from the plan’s assets. Instead, the employer makes payments from the business’ profits. HRAs help employees pay for the cost of their medical care by allowing for pre-tax payroll deductions.

HRAs differ from HSAs and FSAs in that they do not allow employees to pay for medical expenses with pre-tax dollars. HRAs are portable, which means that employees can roll over unused funds from year to year.


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.

The money that is deposited into an HSA is invested and grows tax-free, while the money you withdraw to pay for any qualified medical expenses is tax-free.

The account holder has an “account balance” in their HSA, which is the difference between the amount of contributions made and the amount invested in the account. HSA account holders contribute their own money to the account, which is invested in mutual funds. Employers can pay either some or all of the HSA contributions, depending on the plan.

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.

Hybrid Record

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


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.

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.


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.

Interoperability is the ability of electronic systems and software to share information with each other.

Electronic medical and health records (EHRs) are an important pillar of interoperability. EHRs enable health care providers to share health data electronically and share patient information securely.

HIPAA, the Health Insurance Portability and Accountability Act of 1996, created the requirements for the electronic sharing of patient records. With HIPAA, electronic health records (EHRs) became an important healthcare technology, allowing patient health records to be managed and exchanged electronically.

EHRs give providers, patients, and payers the ability to share patient information.



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.


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

Drugs that can only legally be obtained by prescription.


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. Health insurance lifetime limit is a limit set by an insurance plan on the maximum amount of lifetime benefits you will receive.

A lifetime limit on medical benefits is where the health insurance company defines and sets a maximum dollar amount of lifetime benefits you can receive. Once you reach the maximum, the coverage stops.

A lifetime limit is not the same thing as an out-of-pocket maximum (OOPM), which is the maximum amount you must have in out-of-pocket expenses over your lifetime before your plan starts paying 100% of the costs.

A lifetime limit is usually set at a lower level than the OOPM. A lifetime limit is an amount that an insurance company has set.


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).



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).


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


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.

Master Patient Index

An index referencing all patients known to a particular organization.


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).

An MCO is an association of health care providers that come together to provide health care services to a group.

An MCO typically contracts with a health insurer to provide health care services to a group of individuals who are members of that MCO. An MCO may also be known as a carrier or managed care provider.

An MCO’s primary function is to control the cost of healthcare for its group. To that end, it typically contracts with a panel of physicians, hospitals, and other providers. MCOs usually provide services at a discounted rate.

MCOs are typically managed and owned by insurance companies.

Medical Informatics

The analysis of data about medical care services to improve decisions made by physicians and managers of healthcare organizations.


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).


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.


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. Meaningful use is an electronic health record (EHR) incentive program (2009–2015) created by the United States Department of Health and Human Services (HHS), originally launched in 2011 to encourage the adoption of EHRs in the United States.

Meaningful use program is part of the American Recovery and Reinvestment Act of 2009 (ARRA). The act includes provisions that allocated $33 billion to incentives for various health IT initiatives, including $15 billion for EHR incentive payments, in return for eligible providers adopting EHRs and achieving specified objectives, as listed by the Centers for Medicare and Medicaid Services.

Multi-Specialty Group

A group of doctors who represent various medical specialties and who work together in a group practice.


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.



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.


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-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.

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.



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.


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 copayments.

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.


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


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.


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.


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.


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. A Personal Health Record (PHR) is a digital record that can incorporate health records, medical history, personal health information, and dietary information.

A PHR is typically created and maintained by an individual for use by the person and, if shared with others, by those persons.

PHRs can be created and accessed on a personal computer, tablet, or smartphone and can include such information as the medication an individual is taking, allergies, immunizations, and information regarding personal medical history.

A PHR can include information from many sources including healthcare providers, pharmacies, laboratories, and hospitals.


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.


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).


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.


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 is 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.


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.


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


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



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.



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


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.


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 be local (LPPOs) or regional (RPPOs) serving either a single state or a larger area.



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.


Systematized 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.


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

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.


Single sign-on. SSO is a 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.


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


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.



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.


Often called a library or dictionary. Templates are predefined 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.


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


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.

Touch Screen

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


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


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


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.


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.


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


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.


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


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


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.


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.