Glossary of Terms
Addendum
Text that is added to a document after it has been finalized.
Alerts
Pop-ups or reminders. An automated warning system such a clinical alerts, preventive health maintenance, medication interactions etc.
Ambulatory Care
Medical care provided on an outpatient basis.
Annotator
A system function that allows an explanatory note or diagram to be added to an image.
Application Service Provider
An Application Service Provider (ASP) is a third party entity that deploys, hosts and manages software from a centrally managed host facility (offsite). 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".
Audit Trail
Security system that tracks a user’s access, deletion or modification of data. The term used in healthcare information security refers to a chronological record of system resource usage. This includes user login, file access, other various activities, and whether any actual or attempted security violations occurred, legitimate or unauthorized.
Authentication
The verification of the identity of a person or process.
Bandwidth
A data transmission rate; the maximum amount of information (bits/second) that can be transmitted along a channel.
Bar Code
A printed horizontal strip of vertical bars which represent decimal digits used for identification. Bar codes must be read by a bar code reader.
Biometrics
Biometrics are 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.
Case Management
A process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize the outcome.
Client/Server architecture
An information-transmission arrangement, in which a client program sends a request to a server. When the server receives the request, it disconnects from the client and processes the request. When the request is processed, the server reconnects to the client program and the information is transferred to the client. This usually implies that the server is located on site as opposed to the ASP (Application Server Provider) architecture.
Clinical Data Repository
A real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. It is optimized to allow clinicians to retrieve data for a single patient rather than to identify a population of patients with common characteristics or to facilitate the management of a specific clinical department.
Clinical Decision support system (CDSS)
A clinical decision support system (CDSS) is software designed to aid clinicians in decision making by matching individual patient characteristics to computerized knowledge bases for the purpose of generating patient-specific assessments or recommendations.
Clinical Guidelines (Protocols)
Clinical guidelines are recommendations based on the latest available evidence for the appropriate treatment and care of a patient’s condition.
CPOE
Computerized Provider Order Entry - CPOE refers to the act of a clinician entering an order for patient services into an information system.
Computerized Patient Record, Computer-Based Patient Record
Electronically maintained information about an individual's lifetime health status and healthcare from all specialties.
Current Procedural Terminology (CPT)
The purpose of CPT codes is to provide a uniform language that accurately describes medical, surgical, and diagnostic services.
DICOM
Digital Imaging and Communications in Medicine (DICOM) is a standard to aid the distribution and viewing of medical images, such as CT scans, MRIs, and ultrasound.
DOQ-IT
Doctors Office Quality Information Technology - is a two-year special study that is designed to improve quality of care, patient safety, and efficiency for services provided to Medicare beneficiaries by promoting the adoption of EHR’s and Information Technology (IT) in primary care physician offices.
Evaluation and Management Coding (E&M)
Documentation guidelines for Evaluation and Management CPT codes from the Center for Medicare and Medicaid Services (formerly HCFA).
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA seeks to establish standardized mechanisms for electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.
HL7
Formed in the United States in 1987, HL7 has the goal of developing an international set of open standards for data format and content that allows different health information systems to easily and effectively communicate with one another.
Health Maintenance
Health Maintenance, also referred to as Preventive Health Maintenance is a system of guidelines (recommended schedules) of tests or procedures that have proven value in disease prevention.
Interoperability
The capability to provide successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.
PHR
A Personal Health Record includes all healthcare information from all sources, compiled and maintained by the patient.
QIO
The Medicare QIO program consists of a national network of fifty-three QIO’s found in each state responsible to work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems. They are associated with the DOQ-IT program
Thin Client
A thin client is a network computer without a hard disc drive, as opposed to a fat client which includes a disc drive.
Workflow
The automation of a process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules.