Health Information Technology Terminology

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Accountable Care Organization (ACO)

An Accountable Care Organization is a voluntary entity established by the ACA law (Obamacare) in which organizations can contract to provide care for a set number of patients. Agreements specify that payments to providers are based at least partially on the health outcomes of the patients, not just for delivering services.

Acuity

Refers to the level of disease severity in a patient, group of patients, or clinical care area. It defines how much medical care is needed for the condition or patient. It is sometimes used in the context of an acuity score, which compiles different data to arrive at a number to better understand how to care for a patient.

Administrative Rights

Refers to a set of permissions that allows a user to access or change protected functions on a computer, operating system, or application. This access allows the user to install or update software or make configuration changes among other things. A clinical user usually won’t have administrative rights, but an IT analyst will.

Alert Fatigue

For users of clinical technology, improperly configured systems can present false warnings, leading users to mentally tune them out over time. The danger is that a real warning will eventually appear, but be ignored

Ambulatory System

Refers to systems that care for patients in a non-hospital setting, such as a Primary Care Clinic. When someone is “Ambulatory”, we say they are up and about, as opposed to in a hospital bed.

Automated Dispensing Units

In a Healthcare facility, these are the systems used to physically secure medical supplies and medications in vending machine-like devices that require a user ID and password to access. The units also track the clinical administration of supplies and medications, as well as assisting with inventory management. The leading providers of the technology are Omnicell and Pyxis.

AVS – After Visit Summary

Written instructions given to patients after a medical visit. Usually contains what you were seen for, medications and orders placed, and what to do after the visit. Can be printed or transmitted to a patient portal.

Bar Code Administration

A barcode system that works much like those in retail, except that a caregiver uses a handheld reader to verify the patient and medication to provide extra security against dosing the wrong medication or amount, or getting the wrong patient.

Bidirectional Interface

In healthcare, an interface that communicates to and from a set of technical systems. An example is a Lab order system in which orders may be placed from an integrated medical records system, as well as placed from another system that needs to also send and receive order information. The Lab will then send back results from that original order to the EMR.

BLOB server

Stands for Binary Large Object. A physical server that stores large amounts of data, usually media files such as scanned images. An EMR can display the images without needing to be the source of storage.

Blue Button Initiative

Blue Button is an effort by the Federal ONC division to support patients’ ability to download copies of their health records. The idea is to encourage portability, accuracy, and completeness of health records.

Case Mix Index

A value which is assigned to a group of patients based on how acute their care needs are. EMRs provide the data points for calculation, and the outcome is a calculated payment for services by Medicare and Medicaid.

Centers For Medicare & Medicaid (CMS)

CMS is the Federal agency that administers and governs the Medicare and Medicaid programs. They have wide-ranging authority to set rules, policies, and standards for clinical practices as well as for healthcare technology data and processes.

Change Control

Refers to a system of IT governance where representatives from many departments meet regularly to approve or deny proposed changes to IT systems. Anyone who is wanting to make major changes to software, network setup, etc needs to present their proposed changes to the team to be sure there are no conflicts or unforeseen side effects.

Chief Information Officer (CIO)

An executive level position in a technology organization. This person is the ultimate authority over most operational and personnel issues in the department. Hospitals and large healthcare technology companies will usually have a CIO and a CMIO.

Chief Medical Information Officer (CMIO)

A CMIO is a physician who serves as a liaison between the physician community and a technology department in a healthcare organization. The CMIO has a voice in what technologies are adopted and how they are used, and works closely with the CIO, directors of nursing, and technical managers.

Citrix

Citrix is a large American company that provides products to support application implementation via servers, cloud-based tools, and software as a service. The practical application in a healthcare IT department is that many programs are installed and hosted on Citrix servers, and then accessed from a web browser or program shortcut on many computers and other devices as opposed to having the applications installed on those many devices.

Clinical Applications Analyst

A clinical applications analyst implements, configures, and supports specific clinical software programs for healthcare organizations or vendors. They typically work closely with clinical users to make sure the software meets the needs for documentation and efficient patient care. The clinical applications analyst will usually be involved in testing, documentation, and at least some training.

Clinical Decision Support System

A clinical decision support system is a software module or program that provides relevant patient specific information to guide the clinician in delivery of care. An example would be a reminder to a doctor to order the clinically recommended eye exam for every patient who is has type 2 diabetes. The doctor would see this reminder on a screen in their EHR as soon as they open the chart of a patient that meets the criteria.
Medication interaction checking is another example of clinical decision support.

Clinical Document Architecture

Clinical Document Architecture is a data structure developed by the Health Level Seven organization to define how specific medical information (such as medication lists and progress notes) should be structured. Because it follows a uniform standard, many different vendors and systems can use it to exchange data among them. It is formatted using XML (Extensible Markup Language).

Clinical Documentation Improvement

A skill and a job position that has to do with best practices for documenting everything clinical that gets entered into an electronic system. A clinical documentation improvement specialist guides other clinicians to ensure data is entered into systems to meet regulatory guidelines.

Clinical Episode/Encounter

An episode of care is a grouping of more than one encounter. A pregnancy is an episode that has many encounters as the mom-to-be has her OB visits. A round of chemo treatments for a cancer patient is also an episode.

Clinical Informatics

Clinical Informatics involves the use of information technology to deliver and manage healthcare services. It places emphasis on accurate clinical documentation, decision support, and the use of reports to help improve patient outcomes.

Clinical Workflow

Refers to the steps that are performed in a clinical setting, such as an office visit or a patient admission. In the context of IT, staff will relate the workflow steps to functions in an electronic system, looking for ways to improve efficiencies and capture data correctly.

CMIO (Chief Medical Information Officer)

Chief Medical Informatics Officer. A high-level executive in a healthcare organization who provides leadership of an organization’s IT strategy, specifically relating to clinical impact. Will hold MD or other physician level credentials.

CMS – Centers for Medicare and Medicaid Services

The Centers for Medicare & Medicaid Services is a large Federal agency that regulates many aspects of Healthcare and Healthcare IT. Founded in 1965, it employs about 4,100 people and is funded by taxation. It provides oversight for more than 6,000 healthcare facilities, and has the authority to shut down or levy fines against organizations. In 2017, CMS paid about $709 billion in medical benefits.

Comorbidities

Chronic medical conditions that accompany or are otherwise associated with a primary diagnosis. For example, a patient with Diabetes may have comorbidities of sleep apnea and cardiovascular disease.

Computer Assisted Coding System

Computer assisted coding is the use of technology that analyzes clinical documentation to assist with correct medical coding for billing purposes. For example, a progress note on a patient visit for diabetes may or may not have the appropriate documentation for a complex case. Computer assisted coding can help point out issues in documentation that are likely to cause problems with billing.

Continuity Of Care Document

An electronic synopsis of a patient’s medical record that can be downloaded and transmitted to various other clinical systems using an agreed-to standard among vendors.

CPOE – Computerized Physician Order Entry

Computerized Physician Order Entry is the process of entering orders electronically instead of in paper charts. Advantages include 1) the ability to see orders without needing to view a paper record, 2) ability to check for duplicate orders, 3) ability to review order history and compare results over time, 4) ability to check for adverse interactions.

Current Procedural Terminology (CPT) Code

CPT is a set of medical codes used to identify procedures and clinical visits. Whereas ICD codes identify diagnoses, CPT codes identify the specific procedures that are ordered and performed by clinicians, as well as various medical visits. For example, the procedure code for an appendectomy is 44950. For a new patient physical exam, there is a range of codes from 99381 to 99387. CPT codes are primary used to support billing functions.

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Data Warehouse

A large database collection of records from various locations that is used to run complex reports and statistical analysis over time. Insurance companies and Healthcare organizations store millions of patient records in data warehouses over long periods.

Date of Service

Usually abbreviated to “DOS”, this is when a patient was seen. It is critical for billing purposes, as well as considering when orders were placed. Even if a physician completes documentation after the visit, the date of service stays the same.

Decision Support System

A technology solution designed to provide useful information in making organizational decisions. A clinical report on a population of patients would be the outcome of a decision support system.

DICOM

Digital Imaging and Communications in Medicine – a protocol to format the transmission of medical images, such as MRIs and ultrasounds. Used in radiology systems.

Disaster Recovery

Refers to a comprehensive plan, drills, and technical tools to prepare for a major events such as natural disasters, data breaches, terrorism, or system failures. Designed to protect IT systems during these events. During a disaster recovery drill, a production system will be brought offline to run through disaster scenarios.

Discrete Data

In the context of a Healthcare IT implementation, discrete data refers to the concept of recording data into distinct fields in the smallest unit possible, as opposed to entering multiple entries into free-text fields that are hard to retrieve by queries and reports.

E-Prescribing

The process to electronically prescribe medications from a provider’s EHR to pharmacies using a electronic prescribing service. This process replaces hand-written prescriptions in most cases. The leading e-prescribing supplier is Surescripts.

E-Visit

An e-visit is an electronic exchange between a patient and healthcare provider. It can be done through questionnaires via an online portal where a patient submits concerns that are replied to by a provider. An e-visit is not the same as telehealth visit, which is done in real-time through video.

Electronic Claim

An electronic claim is a paperless transmission from a clinical system to a insurance payer to reimburse for medical services on a patient. Electronic systems typically send large batches of claims at defined intervals. The sending system has reports to confirm the successful receipt of claims by the receiving systems and to check for errors.

Electronic Signature

An electronic signature is a digital authentication that verifies the identity of an individual for legal and medical purposes. For example, when a physician signs into an electronic health records system with a user ID and password, that physician can then sign medication orders with the click of a button because their identity has already been verified by logging in. A electronic fingerprint reading or other digital authentication can also serve as an electronic signature.

Electronic Health Record (EHR)

The official electronic record for an individual that is shared among multiple platforms and organizations. It is commonly used to describe a software platform that is implemented to perform functions of an electronic medical records system plus more comprehensive information shared from other systems. The current trend is to refer to enterprise wide systems as EHRs. Some of the largest EHR systems are Cerner, Epic, and MEDITECH.

Electronic Intensive Care Unit (eICU)

eICU is a support model that provides ancillary monitoring of ICU patients from a remote location. It involves the use of video cameras, audio monitoring, and vital sign monitoring to provide an additional layer of support to the clinical staff working within the ICU. It’s important to note that eICU does not replace clinical staff in the ICU. The remote eICU clinicians are called intensivists and are licensed RNs.

Electronic Medical Record (EMR)

The official electronic record contained in a single electronic system. It is commonly used to describe a software platform that is implemented in a healthcare setting to perform functions of clinical documentation, order entry, clinical analysis, scheduling, and more.

Enterprise Master Patient Index (EMPI)

An EMPI is a database used in a healthcare organization to maintain complete and accurate data on all patients. Each patient is assigned a unique identifier (the master patient index) to facilitate indexing of records. This also allows the data to be referenced by systems outside of the healthcare organization, and assists with patient matching from various connected systems.

Fee For Service

The typical payment model for Healthcare in the US where Healthcare providers and facilities are paid for individual services such as lab tests and surgeries as opposed to flat-fee or outcomes based price structures. This model is frequently criticized as the reason for high costs, and various entities are always experimenting with alternative options, such as accountable care organizations.

FHIR

Pronounced “fire” – stands for Fast Healthcare Interoperability Resources. It is a communication standard developed by the Health Level Seven (HL7) organization to facilitate electronic sharing of clinical data across EMRs, devices, health information exchanges, and more.

Flat File Database

A flat file database is a database that stores data within plain text files. the text fields for the data items are separated by characters like commas or the pipe symbol |.
The main difference in this type of data structure is that it is not a relational database where every table shares at least one field with another table, making it easier to link and reference data.

Formulary

A defined database of medications used as a standard for placing orders in electronic systems as well as defining coverage by insurance companies. A formulary is typically imported into a electronic health record system at regular intervals.

Front Office/Back Office

In a clinic setting, refers to specific functions and personnel. Front office staff perform check-ins, scheduling, and calling patients. Back office staff are Medical Assistants and other clinicians who interact with patients clinically.

FTP – File Transfer Protocol

FTP stands for File Transfer Protocol. It is a method by which systems or users move files from one computer to another over a network. A file will usually be transferred from a folder location on one computer to a folder on another computer. In the past, FTP functions were done via DOS commands. There are now many commercial and free software programs that support FTP on Windows, Apple, and Linux platforms.

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H&P (History and Physical)

Describes the documentation of pertinent medical history, as well as a physical exam on a patient. It begins with the patient’s “story” on why they are seeking care. The history portion includes previous conditions and surgeries, as well as the condition they are currently seeking treatment for. Then a complete physical examination is performed, which includes both objective and subjective information.

Health Information Exchange (HIE)

A Health Information Exchange is a community based technology system that allows various healthcare organizations to share clinical data across systems that are not otherwise connected. Numerous systems transmit clinical messages to manage populations of patients and to look for patterns in medication dispenses.

HEDIS (Healthcare Effectiveness Data and Information Set)

HEDIS is a widely used measurement tool of clinical performance measures for healthcare, developed and maintained by the National Committee for Quality Assurance (NCQA). It measures almost 100 data points across these six disciplines: Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Risk Adjusted Utilization, Health Plan Descriptive Information, Measures Collected Using Electronic Clinical Systems.

HIMSS

The Healthcare Information and Management Systems Society. A non-profit organization that advocates for the advancement of Healthcare IT. They publish articles, hold trade conferences, and oversee several Health IT certifications. himss.org

HIPAA

The Health Insurance Portability and Accountability Act of 1996 provides oversight of how patient data is exchanged and protected. It also provides some insurance protection for people who change or lose jobs.

HL7 (Health Level Seven)

Health Level Seven is a messaging standard to govern the formatting, transmission, and display of clinical data in healthcare. Competing and complementary systems use the same standard to share  clinical data using HL7.

HPI – History of Present Illness

A documentation of the development of a patient’s current medical condition. A chronological description from when the symptoms and conditions appeared up to the current time. It included some or all of these components: location, quality, severity, duration, timing, context, modifying factors, signs & symptoms.

ICD-10

The International Classification of Disease 10th revision is a system of coding medical conditions and diseases. Established by the World Health Organization, it was implemented in October 2015 to replace the previous version, ICD-9. ICD-10 allows for very detailed descriptions of conditions. An example is E11.9, which is “Type 2 Diabetes Mellitus without complications”.

ICD-11

ICD-11 is the next major version of medical coding that is being developed by the WHO. The draft version of ICD-11 was released in May 2012. The World Health Assembly will meet in May 2019 to rule on official endorsement. Assuming that happens on schedule, the earliest date when the code set can be used will be January 2022.

Index (Database Reference)

A database structure that facilitates quick retrieval of data from a database. In more simple terms, may refer to a unique identifier for every item in a table. For example, a database table of patients may have a unique column value that serves to index the values.

Interface Engine

A specialized server and software solution used to format, translate, and communicate healthcare related data to and from other systems using various protocols, with HL7 being the most frequently used. The interface engine is the “traffic cop” of most data that is transmitted throughout a healthcare organization.

Interoperability

Refers to an expectation that electronic health systems and other technologies should be able to easily exchange data among each other regardless of location or technical platform. This requires that data is shared using common standards, such as HL7.

Joint Commission

The Joint Commission is a non-profit organization that accredits healthcare organizations in the US. Established in 1951, the organization provided accreditation to over 20,000 healthcare facilities which include hospitals, nursing homes, surgery centers, and home health agencies. The Joint Commission is not a governmental organization, but carries a high level of authority and credibility. An unfavorable survey on a facility by Joint Commission can be very detrimental to a healthcare organization.

Laboratory Information System

A laboratory information system is a software platform that manages and stores data for a clinical laboratory. Orders from physicians in hospitals and clinics are typically transmitted electronically or faxed to lab systems. The orders are then processed by lab technicians, who then enter the results into the LIS. The LIS then transmits the results back to the ordering provider electronically, or by fax if the provider is not on a EHR system. In some cases, the LIS can send results directly back to patients.

Legacy System

Legacy System A concept in IT referring to an older system that could be considered for replacement by newer technology. In a Healthcare system, we may have a homegrown product that has been in place for many years, and does not send data to other systems. When a project team meets, they may say something like “We need to replace our legacy registration system with something that interfaces to the rest of our organization”.

Legal Medical Record

A healthcare facility may have various systems which contain parts of the patients’ medical record, and some may not be updated in a timely manner. Those partial systems contain useful information, but can’t be relied on as the legal medical record. An organization will define one system as the legal system, such as Epic or Cerner. May also be called the “source of truth”.

LOINC (Logical Observation Identifiers Names and Codes)

LOINC is a database structure and standard for identifying clinical lab observations. It is used by medical coders and billing to process lab results, as well as in health information exchanges. An example of a LOINC code is: 4635-9: Free Hemoglobin [Mass/volume] in Serum.

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MACRA (Medicare Access And Chip Reauthorization Act)

Medicare Access and CHIP Reauthorization Act of 2015 is a US law that changes the way that Medicare rewards clinicians for value over volume, and streamlines other CMS quality programs. It measures patient-reported outcomes and functional statuses, and patient experiences. It also reissues Medicare ID cards that have a new identifier which replaces using social security numbers.

MAR – Medication Administration Record

Documentation that is done when the patient actually gets a medication into their body as opposed to just the writing of the medication order. Many times a physician writes a medication or, and a nurse administers and documents the med. There can be many administrations tied to a single medication order. If the order is for Tylenol 325 mg every 6 hours, then the nurse documents on the MAR each time that medication is given.

Master Patient Index (MPI)

A master data source that identifies patients across various entities or organizations. If two hospitals merge, and each has a different format for their MRNs, they need a master ID to tie the two different ID formats together. The MPI becomes that “tiebreaker” between more than one medical record number.

Meaningful Use

A regulatory component of the HITECH Act of 2009, which established guidelines for the meaningful use of electronic medical records systems. Designed to push providers towards using EMRs to their full capacity. Financial incentives were given to providers who comply through 2015. Future incentives turned into penalties in October 2016 for not complying.

Medical Device Integration

Medical device integration allows for clinical data to be transmitted between medical devices and software platforms such as EHRs. Examples of integrated devices are IV pumps, glucose monitors, blood pressure monitors, and life-supporting ventilators. Devices can use several different communication standards, including HL7 and ISO/IEEE 11073. Devices may be tethered to a network via a network cable or may transmit over a wireless network. The more patient critical devices use a hardwired connection. Consumer wearables such as FitBits don’t technically qualify as medical devices but can be tied to a patient portal in order to send information to a physician.

MRN – Medical Record Number

A unique numeric value assigned to a given patient in an electronic medical records system, as well as many other clinical systems. This number usually stays with the patient indefinitely. Some older systems allow an alpha-numeric format.

NDC – National Drug Codes

NDCs are 10 or 11 digit numbers uniquely assigned to every over-the-counter and prescribed medication. For example, the NDC for Tylenol Extra Strength is 50090-0005-0. The codes are divided into three sections. The first section is the manufacturer or distributor. The second section is the product itself. The third section is the commercial package size.

National Health Service (NHS)

The NHS is the publicly funded healthcare system of the United Kingdom, covering citizens of England, Scotland, Wales, and Northern Ireland. It provides free and low-cost lifetime healthcare to over 54 million people, paid for mainly by taxation.

National Provider Identifier (NPI)

NPI National Provider Identifier is a unique 10 digit ID required by Federal healthcare governing authorities. All physician and physician assistant level providers have an NPI. It is required for placing orders, and is used in e-prescribing systems. Healthcare entities may also have an NPI.

OASIS Data Set

OASIS data (The Outcome and ASsessment Information Set) is a clinical documentation structure developed by CMS and the Robert Wood Johnson Foundation for the home health clinical setting. It is not used in any other clinical area. OASIS has many questions that assess patient functional status, information on falls and other risks, psychological status, hospital admissions, and more.

ONC (Office Of The National Coordinator For Health Information Technology)

The Office of the National Coordinator for Health Information Technology is a Federal Agency created in 2004 to oversee the implementation of technology in healthcare nationally. They were heavily involved in the implementation of the online healthcare exchange website and program. Their public facing website is healthit.gov.

Open Notes Initiative

Open Notes is non-governmental initiative that encourages physicians to allow patients to see the progress notes that get entered into electronic health records (EHR) systems during medical visits. Traditionally, this part of the medical record has not been released to patients unless they specifically ask for it. The idea is to provide more transparency and encourage patients to be more involved in their own care.

PACS

Picture Archiving and Communication System. An electronic system for storing, transmitting, and presenting medical images such as X-Rays and MRIs. A PACS system is used in the radiology department of a healthcare organization, and the PACS administrator is the individual who supports the technologies.

Patient Portal

A web-based application that allows patients to view portions of their medical records. It also usually provides the ability for patients to request or book appointments and communicate with their care providers who have implemented it with an electronic health records system. Most patient portals are implemented along with electronic health records systems in healthcare organizations.

Patient Protection And Affordable Care Act

This law is more commonly referred to as the Affordable Care Act, or Obamacare. Signed in 2010, it is a wide-ranging effort to get most Americans on health insurance plans and provide methods to improve the quality of care and patient outcomes. Components of the law that related to healthcare technology are accountable care organizations and the expansion of health information exchanges. In December 2018, a federal judge in Texas issued a ruling that the entire law is unconstitutional because the individual mandate portion had been previously invalidated.

PHI – Protected Health Information

Stands for Protected Health Information. Personal info about patients that allows them to be personally identified. Usually includes demographics such as name, address, phone, SSN, etc. Transmission of this info is Federally protected and regulated, and violations for transmitting PHI inappropriately can be severe.

PHQ-2 or PHQ-9

PHQ stands for patient health questionnaire, and the 2 or 9 has to do with the number of specific questions that are asked of patients concerning their mental well-being. The questionnaire is used as a screening tool for depression.
The first question asks, “over the past two weeks, how often have you been bothered by any of the following problems?” Little interest or pleasure in doing thingsFeeling down, depressed, or hopeless. If the patient responds that they have experienced these feelings in the first two questions, then they are directed to answer seven more questions.

Physician Champion

A Physician Champion is physician in a healthcare organization who has chosen to take on the role of liaison between a group of clinical users and the technical staff who implements technology. It usually does not explicitly carry a high level of authority like the CMIO. The physician champion may help with technical and configuration activities that are usually done by IT analysts.

Point of Care Test

A test or reading that is initiated and resulted at the same place and near the same time where the patient is being seen. Glucose readings, strep tests, pregnancy test, and some urine collections are examples of POCTs.

Population Health Management

Population Management is coordinated effort among healthcare providers, patients, and other entities to focus healthcare delivery on the outcomes of patients, not just on delivering services. The participating parties may sign agreements to care for a fixed number of patients (at least in the thousands) for a set duration, with payments to providers being based on the overall health of the patients.

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Protocol Orders

Protocol Orders are orders that can be administered by non-physician clinicians according to a pre-defined set of guidelines that line up with their clinical qualifications. An example would be “when fever is above 101F, RN to give 350 mg of Tylenol”. Protocol orders streamline the delivery of care in certain clinical settings such as hospital inpatient stays.

Radiology Information System (RIS)

The software system for managing radiology procedures and images, as well as the information connected to the images such as text results. A radiology system is usually used in conjunction with a PACS system.

Real Time Eligibility

Real time eligibility (RTE) is a technology solution that allows electronic health records systems to retrieve up to date insurance information on patients. Registration staff will trigger a query from their EHR system that sends patient information to an insurance company or a third party data provider. That system will then quickly return a verification that confirms the patient’s insurance status.

Relational Database

A database which has tables that are linked to each other using indexes. This configuration facilitates speed and performance as well as the ability to perform complex queries to modify and report on the entire data set. Access to the database is done using structured query language (SQL).

Release of Information

When an entity or person outside of a healthcare facility requests medical information on a patient,  organizations need to follow specific guidelines and laws to be sure that the request is legally authorized, and that the correct information is provided to the entity or person. The policies and technology to support this is release of information. A common form of release of information (ROI) is a lawyer’s request for records on a patient.

Remote Desktop Protocol (RDP)

Remote Desktop Protocol is a Windows software program that enables a user to connect remotely to another computer in order to view and control that computer. The connecting user can see the remote computer screen as if they were sitting at that computer. RDP has been built into Windows operating systems since version XP.

Remote Patient Monitoring

Remote patient monitoring involves the use of technology to collect clinical data on patients located outside of a clinical setting. It is used to help manage chronic and complex conditions such as diabetes and congestive heart failure. The patient uses devices that report clinical readings an vital signs back to clinicians electronically. For example, a patient may have a blood pressure monitor, glucose reader, and weight scale that are all configured to send readings back to clinicians through a mobile data connection.

Risk for Readmission

A measure for how likely a patient is to be readmitted to the hospital for a condition that should have been fully resolved in a previous encounter. Hospitals in particular use a readmission risk score in an attempt to reduce readmissions. Federal agencies and rating organizations report hospital readmission rates to the public.

RxNorm

RXNorm is a database of medications maintained by the National Library of Medicine. It serves as a reference point for drug names and vocabulary used in clinical systems for interaction checking software. Each medication name, dose and strength is given a unique RxNorm name. For example, a 325mg tablet of Tylenol has a different name from a 500mg tablet of Tylenol.

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SBAR

SBAR is an acronym for Situation, Background, Assessment, Recommendation. It is a communication tool used to help with efficient reporting of routine tasks or unforeseen problems. It was created by the Navy, but has been adopted by many industries, such as healthcare and technology.

Scope of Care

The definition of what a healthcare practitioner is permitted to do in keeping with their professional license. For example, a nurse can administer medications, but usually orders for medications are written by a MD, Nurse Practitioner, or Physician Assistant.

Service Level Agreement

A written set of rules that defines the commitment between providers of technology and the customers they serve. An example SLA item might say something like “All critical IT issues will be responded to by the help desk within 15 minutes“.

SNOMED

SNOMED (Systematized Nomenclature of Medicine-Clinical Terms) is a standard for mapping clinical terminology in electronic systems to make it easier to associate with diagnoses. SNOMED is used by many electronic health systems to facilitate interoperability.

SOAP Note

SOAP Stands for Subjective, Objective, Assessment, and Plan. It is a format that physicians use to document visits in progress notes, usually in an electronic medical records system.

Subject Matter Expert (SME)

A SME is a person who has specific and relevant knowledge about how detailed tasks are carried out in their day-to-day job. They serve as a liaison between non-technical and technical users to help define how technology should be used in their area of expertise. They usually don’t carry any extra authority in this position, but their input is valued by clinical and technical staff.

SQL – Structured Query Language

SQL is a language used to view and change data within a relational database. The main SQL functions are built around commands to select, insert, modify, and delete data. SQL is fairly easy to learn, as it uses an English-like syntax to access data. An example would be something like
Select first_name from patients_table where DOB > “01-01-2001“. This query would show the first names of all patients who have a birth data after January 01, 2001.

System of Record (or Source of Truth)

Hospitals have many IT systems that share data with each other. For each data set (medications, users, orders, patients), the organization must define which system is to be considered if there is a data discrepancy between more than one system. That system “wins” for whatever data is in question at a given time.

Telemedicine (Telehealth)

Telemedicine is the use of video technology by healthcare providers to treat and/or diagnose patients. In most settings, a telemedicine visit is performed for routine or low level visits such as rashes, cold symptoms, or minor injuries. There is a large focus on using the technology in rural areas where access to healthcare provider can be a challenge. There have been challenges on how to get insurance policies to pay for these visits, but some of those issues have been worked out, and the adoption of telemedicine is growing quickly.

Twenty-First Century Cures Act

The 21st Century Cures Act of 2016 allocated $6.3 billion for research, healthcare quality improvement, the opioid crisis, the FDA drug approval process, and some technology components. The healthcare technology part supports improved connection between EHR systems, better ability for patients to access their medical records electronically, and a reduction in the amount of clinical documentation required by physicians.

Value-Based Healthcare (Value Based Purchasing)

An initiative from CMS that pays hospitals and other organization payments in part for the quality of care they provide to Medicare beneficiaries, measured by patient outcomes as opposed to just paying for the services delivered. This is a departure from the traditional fee-for-service model that dominates most of healthcare in America.

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Summary
Article Name
Health Information Technology Terminology
Description
Health Information Technology terminology and glossary. Over 100 Healthcare IT terms, definitions, & references. Includes practical applications for Healthcare IT.
Author
HealthcareITSkills.com
HealthcareITSkills.com
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