Health IT Glossary
Application Service Provider (ASP)
ASP software products are web-based applications that do not require a physician to own or maintain a server. The software and database contents (patient data) are remotely stored, backed-up, serviced and upgraded by the vendor. Typically, ASP products reduce start-up costs because the physician does not have to purchase a server or hire technical support. However, if internet service is out or slow, the practice will not be able to access the electronic health record (EHR) applications.
A copy of EHR data stored, generally off-site, as a disaster recovery precaution.
Clinical Data Repository (CDR)
Database optimized to process day-to-day EHR transactions.
Clinical Data Warehouse (CDW)
Database optimized to analyze data from an EHR.
Clinical Decision Support (CDS)
Reminders and alerts generated from EHR data.
Computerized Provider Order Entry (CPOE)
Software used by physicians to electronically submit requests for diagnostic exams/tests and receive test results. Can be used in an inpatient setting or an outpatient setting, assuming the clinical departments conducting the exams/tests are capable of transmitting electronic messages to the physician’s system.
Continuity of Care Document (CCD)
HL7 standard transmission format for CCR documents.
Continuity of Care Record (CCR)
Standard data content recommended for referrals by ASTM.
CPT Category I Codes
AMA’s list of clinical procedures used for administrative documentation and billing. There are more than 8,000 codes in the CPT dictionary. See CPT Codes for more information.
CPT Category II Codes
AMA’s list of codes to track Physician Consortium performance measures. See CPT Codes for more information.
CPT Category III Codes
AMA’s list of temporary codes for tracking and reporting of new and emerging technologies. Payment for these codes is at the discretion of the payor.
Data mining (not illustrated)
Analytical process to identify patterns from a large amount of data.
System that records a voice file in digital format for electronic storing.
Drug Knowledge Base (DKB)
Reference continuously updated with new drug information.
System that enables faxes to be transmitted directly to or from a computer.
A "store and forward" system that sends messages over a network.
System, including CDS, that transmits prescriptions to retail pharmacies.
Electronic Health Record (EHR) and Electronic Medical Record (EMR)
A record consisting of an individual’s history of health status and medical care.
EHR vs. EMR
There are many definitions of EHR and EMR, and the terms are frequently used interchangeably.
EMRs may not be interoperable outside of the “home” enterprise (i.e. with other EMRs). The term EHR implies a level of interoperability with other EMRs. The implication of “health” rather than “medical” record in the term EHR is that it is a longitudinal record across time and providers. The EHR is generally not considered “owned” by any one physician because the information is not generally sourced by a single provider.
Electronic prescribing (ePrescribing or eRx)
Software that allows for prescriptions to be transmitted electronically to the pharmacy’s computer system. Other functions of ePrescribing may include patient eligibility verification with health plan, copay information, formulary data, medication history, “fill” status and medication alerts. Electronic prescribing may be part of an EHR application or a stand-alone software system.
Some pharmacies are not set up to receive electronic prescription information. In this case, some EHR vendors will convert the electronic information received from a physician to a paper form to be faxed by a third party service to the pharmacy.
Security system that inspects messages being sent/received from a computer.
Security system that controls access among computers or networks.
Health Information Exchange (HIE)
Organization that provides seamless exchange of data among different organizations agreeing to participate.
Health Information Technology (Health IT)
The software and infrastructure used in the clinical practice of medicine to support documentation, storage and exchange of patient data. Examples include EHRs, ePrescribing and CPOE.
Human-Computer Interface (HCI)
A computer (a.k.a. client) used primarily to enter data into another computer (see server) to be processed and to retrieve data after processing.
The ability of clinical or patient data to transfer between providers in various settings and their various software packages. If a physician’s EMR is not interoperable, physicians would only be able to access information within their own EMR application’s database.
Laboratory Information System (LIS)
System that manages a lab and generates lab test results.
Local Area Network (LAN)
Connectivity provided through cabling (or wireless technology, see WLAN), generally within a relatively small geographic area, such as an office or medical center complex.
Logical Observation Identifiers Names and Codes (LOINC)
The universal identifiers/language for lab testing and results. There are approximately 32,000 terms in LOINC.
National Health Information Network (NHIN)
The infrastructure that would be used to connect local and regional networks to provide access to all medical history for a patient nationwide. Without the infrastructure, each medical record is “standalone” at each provider and information exchange is significantly limited. There are several prototypes currently being developed with grants from the ONC.
Note: The model of information exchange is a “network of networks” where patient information is consolidated only when clinicians request the information. The model is not likely to be a centralized database of medical history stored at a single location.
Pay for Performance (P4P)
Pay for performance programs are incentive programs that provide monetary bonuses or non-financial benefits to physician practices that make progress in achieving or attaining specific quality and/or efficiency (cost of care) benchmarks or standards that are established by the program.
Pay for use
Some health payors will reward physicians for adopting health IT such as ePrescribing or EHRs. These programs are less common than Pay for performance.
Personal Health Record (PHR)
Application within an HER, or separate from an EHR, that enables the patient to maintain personal health information. The PHR includes data such as critical current health and medical history information. It also includes information that is tracked by the patient such as personal health maintenance and over-the-counter medications. For example, it would include daily tracking of insulin levels for diabetics.
Picture Archiving and Communication System (PACS)
Digital record of X-rays and other images.
Point of Care (PoC)
Generally implies use of an EHR as data are captured; may refer specifically to use of templates that are software tools that direct the capture of structured, context-sensitive data.
Point of access to a disparate computer system (e.g., at hospital) or the internet.
Practice Management System (PMS)
The software used by physicians for scheduling, registration, billing and receivables management. Many EMR vendors also offer practice management systems that are fully integrated with the clinical EHR software. If the EMR vendor does not offer a practice management system or the practice does not want to change systems, it is important to understand how the practice management system and EHR will interface so patient information is consistent between the two systems.
Regional Health Information Organization (RHIO)
RHIOs provide the organizational and technical infrastructure to exchange data among health care providers in a geographic region.
Compilation of a specific set of data, often for subsequent analysis.
System that captures an image of a document for storing in a computer.
A computer dedicated to running one or more software applications.
The part of a computer system that retains data.
Structured data (not illustrated)
Data that can be processed by a computer, as compared to documents that may only be viewed from a computer.
Systematized Nomenclature of Medicine (SNOMED)
A map of clinical concepts with standard descriptive terms. SNOMED currently has approximately 355,000 concepts and is the core terminology for EMRs.
Narrative information and images made viewable but not able to be processed in formulas by a computer.
Wide Area Network (WAN)
Connectivity provided through various types of telephone services, such as frame relay, T1 (trunk) lines, etc.
Wireless Local Area Network (WLAN)
Connectivity provided through radio frequency or other wireless technology, usually in relatively close proximity (although wide area wireless is now available).