Electronic Health Record Medical Glossary
The American Recovery and Reinvestment Act (ARRA) of 2009 is an economic stimulus package that plans to invest $59 billion in healthcare initiatives, including $19 billion in health information technology. ARRA has three main goals: to create new jobs, spur economic activity and create accountability and transparency in government spending.
CCHIT stands for the Certification Commission for Health Information Technology. It is a non-governmental certification body for EHRs. Currently, CCHIT certified EHRs have not been certified by the federal government for incentive eligibility. CCHIT will be one of multiple avenues to HITECH stimulus incentives.
Continuity of Care Document (CCD)
A Continuity of Care Document is a standardized record, or summary, of patient care. This uniform way of presenting patient health information is designed to enhance continuity of care, reduce medical errors, and ensure transferability of relevant health information when a patient is referred to, transferred to or seen by another provider.
To ensure that each record may be shared with other doctors, a uniform format is necessary. The format used by CCDs is XML. Format is the main difference between CCDs and CCRs, which use HL7 format.
Continuity of Care Record (CCR)
A Continuity of Care Record is a standardized record of patient care much like a CCD. CCR differs from CCD in that the standard format used is HL7. As is the case with CCDs, a consistent format allows for the dissemination of health records to the appropriate healthcare professionals. Presenting patient health information in a homogenized way is thought to enhance continuity of care, reduce medical errors, and ensure transferability of relevant health information when a patient is referred to, transferred to or seen by another provider.
CMS, or the Centers for Medicare and Medicaid Services is a federal agency that administers and regulates Medicare and works in conjunction with state governments to administer Medicaid and other state controlled insurance programs.
Cloud Computing is a web-based way of storing and accessing data that improves performance by calling on a group of servers, hosting sites and networks across which information is stored. With cloud computing, users access the systems through a web-browser.
CPOE, or computerized physician order entry, describes the process of digitally entering order forms for pharmacies, laboratories and radiology specialists in digital format. As is the case with EHRs in general, this digitization reduces errors and increases efficiency.
CPT Codes, or Current Procedural Terminology codes, describe medical, surgical and diagnostic procedures. The American Medical Association publishes this code to communicate uniform information to physicians, diagnostic technicians and insurance payers.
EHR, or electronic health record, is broader. EHRs aggregate an individual’s EMRs across multiple medical practices within a community, region, state or beyond. EHRs include charting, scheduling, e-prescribing, lab integration, and personal health record systems for patients with a focus on interoperability.
EMR, or electronic medical record, is all information in electronic format pertaining to an individual’s inpatient and outpatient care, treatment and prescriptions at a specific medical practice. Doctors use an EMR to replace traditional paper charting and record systems in their practice.
E-Prescribing, or electronic prescribing, is a process in which a prescription is sent directly from a point of care to a pharmacy. The process of sending and filling scripts is less error prone and more efficient thus improving care and reducing costs.
HHS stands for the US Department of Health and Human services which is the federal agency that directs and manages the ONCHIT as well as the Centers for Medicare and Medicaid Services.
Health Informatics is the intersection of computer science, information processing and healthcare. It is concerned with the optimization, organization, retrieval and storage of digital medical information.
HIT, or health information technology (HIT) refers to the use of information technology in the management and dissemination of health information from patients to providers and insurers. HIT is commonly viewed as the most promising manner of improving care, reducing costs and reforming healthcare delivery.
The Health Information Technology for Economic and Clinical Health Act (HITECH Act) is the piece of legislation in the ARRA that designates $19 billion to providers and hospitals who demonstrate ‘meaningful use’ of electronic health records.
Of the $19 billion provisioned by the HITECH Act, each provider who demonstrates 'meaningful use' of an EHR system is eligible for up to $44,000 in Medicare bonus incentives and up to $65,000 in Medicaid bonus incentives. HITECH payments will be made over a five year period from 2011 to 2015.
ICD-9 Codes classify diseases or signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ICD is short for the International Statistical Classification of Diseases and Related Health Problems. ICD codes are published by the World Health Organization and are used worldwide for insurance reimbursement and statistics.
Informatics is a broad field of study encompassing the science of information processing and the engineering of information systems.
Laboratory Integration allows a provider to send and receive lab work within their EHR system.
Meaningful Use is set of standards for determining eligibility for Medicare and Medicaid incentive payments. The specifics of the meaningful use standards are being published in the summer of 2010.
Medical Chart is a repository for all medical information concerning a patient. In an EHR, this location becomes digitized allowing for its secure and instantaneous transfer from one point of care to another.
The Office of the National Coordinator for Health Information and Technology (ONCHIT) is the body charged with the organization and implementation of health information technology under HITECH. ONCHIT is also responsible for defining ‘meaningful use’ as it pertains to Medicare and Medicaid incentives.
Patient Management is the process of monitoring and updating patient chart notes, summaries, messages, appointments, lab results, prescriptions and immunization records. Electronic health records are designed to collect and display this information in a comprehensive way allowing for better care.
PQRI, or Physician Quality Reporting Initiative is a set of reports meant to be sent in annually to the CMS for an incentive payment. PQRI is designed to measure the quality of professional services rendered to Medicare beneficiaries.
PHR, or personal health record, includes pertinent information from the patient’s EHR and is controlled by the patient. Those who add information to a PHR include health plans, medical clinics, physicians and the patient.
Practice Management is a term that is commonly used to refer to the billing process. A practice management software program generally has a scheduler, a document upload section, a patient account information page and the ability to send and follow up on insurance claims.
Regional Extension Center
Regional Extension Centers offer technical support, guidance and information for medical practices making the switch to an EMR. Over 70 non-profit RECs across the country have received grant money from the HITECH Act to support at least 100,000 primary care providers adopt an EMR, achieve meaningful use and participate in nationwide health information exchange.
Secure Messaging is an integral feature of an EHR that allows healthcare professionals to send messages containing or referring to sensitive medical information. Traditional email is not considered secure enough to send or receive medical information under HIPAA.
A Superbill is a visit summary statement meant to be submitted to an insurance payer for reimbursement. A superbill contains demographic and visit specific information such as name, date of service, ICD-9 codes, CPT codes and provider information.
Templates are a set of potential chart note comments organized around a chief complaint. An easily accessible set of comments is designed to facilitate the charting process while the provider is in front of patients. Templates are meant to be used in tandem with free form text entry necessary for a provider to capture the nuances of a particular visit.
Web-based systems are software programs that allow users access via an internet connection. This differs from a traditional software program in that all data is remotely stored. Users benefit from the host’s expertise and specialization in internet infrastructure to provide enhanced stability, security and accessibility to the user.