Cmt Ehr Glossary Of Terms

Front 1

Addendum

Back 1

Text that is added to a document after it has been finalized.

Front 2

Alerts

Back 2

Pop-ups or reminders. An automated warning system such as clinical alerts, preventive health maintenance, medication interactions etc.

Front 3

Ambulatory Care

Back 3

Medical care provided on an outpatient basis.

Front 4

Annotator

Back 4

A system function that allows an explanatory note or diagram to be added to an image.

Front 5

ASP
(Application Service Provider)

Back 5

Third-party entity that deploys, hosts and manages software from a centrally managed host facility (offsite). "Software-as-a-service" model.

Front 6

Audit Trail

Back 6

Security system that tracks a user's access, deletion, or modification of data. Chronological record of system resource usage.

Front 7

Authentication

Back 7

The verification of the identity of a person or process.

Front 8

Bandwidth

Back 8

A data transmission rate; the maximum amount of information (bits/second) that can be transmitted along a channel.

Front 9

Bar Code

Back 9

A printed horizontal strip of vertical bars which represent decimal digits used for identification.

Front 10

Biometrics

Back 10

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

Front 11

Browser

Back 11

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

Front 12

Case Management

Back 12

Process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize outcome.

Front 13

Chart

Back 13

Medical Record

Front 14

Chart Note

Back 14

Document written by clinician or provider describing details of a patient's encounter (progress note).

Front 15

Client/Server architecture

Back 15

Information-transmission arrangement in which client program sends a request to a server. Request received, server disconnects and processes, reconnects and sends info to client.

Front 16

Clinical Data Repository (CDR)

Back 16

A real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. Clinicians can retrieve data for a single patient instead of an entire population.

Front 17

Clinical Decision support system (CDSS)

Back 17

Software designed to match individual patient characteristics to knowledge bases to generate patient-specific assessments/recommendations.

Front 18

Clinical Guidelines (Protocols)

Back 18

Recommendations based on latest available evidence for appropriate treatment and care of patient's condition.

Front 19

Clinical messaging

Back 19

Communication of clinical information within the electronic medical record to other healthcare personnel

Front 20

CPG

Back 20

Clinical Practice Guidelines

Front 21

CPM

Back 21

Clinical Performance Measures

Front 22

CPOE (Computerized Provider Order Entry), CPOE

Back 22

Act of clinician entering an order for patient services into an information system., Computerized provider order entry

Front 23

CPR (Computerized Patient Record, Computer-Based Patient Record)

Back 23

Electronically maintained information about an individual's lifetime health status and healthcare from all specialties.

Front 24

CPT (Current Procedural Terminology), CPT

Back 24

CPT codes provide a uniform language that accurately describes medical, surgical, and diagnostic services., Current Procedural Terminology

Front 25

Data conversion

Back 25

Conversion of data from one software to another.

Front 26

Data Encryption Standard (DES)

Back 26

Widely-used method of data encryption using a private (secret) key.

Front 27

Data Integrity

Back 27

Validity of data. Data has not been altered, or destroyed in an unauthorized manner.

Front 28

Data Mining

Back 28

A group of data elements relevant for a particular use.

Front 29

Data Structure

Back 29

A way to store and organize data in order to facilitate access and modifications.

Front 30

Database

Back 30

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

Front 31

Database management system (DBMS)

Back 31

Set of computer programs for organizing the information in a database.

Front 32

DICOM (Digital Imaging and Communications in Medicine

Back 32

Standard to aid the distribution and viewing of medical images, such as CT scans, MRIs, and ultrasound.

Front 33

Dictation

Back 33

Process by which a physician records his/her notes about a patient. Recording is intended for reproduction in written word.

Front 34

Digital Signature

Back 34

Advanced Electronic Signature. A hand-written signature used to create a digital image to use in signing documents.

Front 35

Discrete Data

Back 35

Values belonging to the data are distinct and separate. Date is more easily reportable as opposed to nondiscrete or unstructured data.

Front 36

Document Imaging

Back 36

Converting paper documents into an electronic format through scanning process.

Front 37

Documentation

Back 37

Process of recording information

Front 38

Document Management

Back 38

System involving scanning, categorizing, and storing vital patient documents.

Front 39

DOQ-IT (Doctors Office Quality Information Technology)

Back 39

2-year special study designed to improve quality of care, patient safety, and efficiency for services provided to Medicare beneficiaries by promoting adoption of EHR's and IT in primary physician offices.

Front 40

E & M Coding (Evaluation and Management Coding)

Back 40

Documentation guidelines from Center for Medicare and Medicaid Services.

Front 41

EDI

Back 41

Electronic Data Interchange

Front 42

EHR (Electronic Health Record), EHR

Back 42

Electronic repository of information regarding the health of an individual., Electronic health record

Front 43

Electronic Superbill

Back 43

Electronic encounter form for coding and billing.

Front 44

EMR (Electronic Medical Record), EMR

Back 44

Provider-based medical record that includes all health documentation for one person covering all services provided within an enterprise., Electronic medical record

Front 45

EOE (Electronic Order Entry)

Back 45

Program moves hand-written and verbal orders to computer-based entry.

Front 46

EPR (Electronic Patient Record)

Back 46

Computerized Patient Record.

Front 47

Encryption

Back 47

Process of converting messages or data into a form that cannot be read without decrypting or deciphering it.

Front 48

e-Prescribing

Back 48

Prescribing medication through an automated data-entry process and transmitting to participating pharmacies.

Front 49

Evidence based medicine (EBM)

Back 49

Integration of best research evidence with clinical expertise to aid in the diagnosis and management of patients.

Front 50

Face Sheet

Back 50

Summary Screen or Patient Dashboard.

Front 51

Fat Client

Back 51

Network computer with a hard disc drive as opposed to a thin client wit no disc drive.

Front 52

Firewall

Back 52

System designed to prevent unauthorized access to or from a private computer network.

Front 53

Formulary

Back 53

Listing of prescription drugs established by a particular drug plan including both Brand name and Generic drugs.

Front 54

FTP

Back 54

File Transfer Program

Front 55

Graphical User Interface (GUI)

Back 55

Program interface that takes advantage of the computer's graphics capabilities to make the program easier to use.

Front 56

Help Desk

Back 56

Service and support desk.

Front 57

HIPAA (Health Insurance Portability and Accountability Act)

Back 57

Standardized mechanism for electronic data interchange (EDI), security, confidentiality of healthcare-related data.

Front 58

HL7 (Health Level 7), HL7

Back 58

Goal of developing international set of open standards for data format and content that allows different health information systems to easily and effectively communicate., Health level system

Front 59

Hot Keys

Back 59

One- or two keystroke command that switches the user to a different program.

Front 60

HM (Health Maintenance)

Back 60

Preventive Health Maintenance--system of guidelines of tests and procedures that have proven value in disease prevention.

Front 61

ICD-9 or ICD-10 (International Classification of Diseases)

Back 61

Classification and coding of diseases and injuries.

Front 62

Informatics

Back 62

Application of computer technology to the management of information.

Front 63

Integration

Back 63

Allows for secure communication between enterprise applications.

Front 64

Interoperability

Back 64

Successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.

Front 65

ISP

Back 65

Internet Service Provider

Front 66

IT (Information Technology)

Back 66

Development, installation, and implementation of computer systems and applications.

Front 67

Kiosk

Back 67

Small computer workstations which allow information to be input.

Front 68

LAN (Local Area Network)

Back 68

Supplies networking capability to a group of computers in close proximity to each other.

Front 69

Legacy System

Back 69

System considered old and possibly out-dated.

Front 70

Legacy System Integration

Back 70

Integration of data between a legacy system and some other software program most commonly using Hl-7 standards.

Front 71

LEPR (Longitudinal Patient Record)

Back 71

EHR that includes all healthcare information from all sources.

Front 72

Macro

Back 72

Symbol, name, or key (Macro key) that represents a list of commands, actions, keystrokes or blocks or text.

Front 73

Network

Back 73

System for communication among two or more computers

Front 74

OCR (Optical Character Recognition)

Back 74

Recognition of printed or written characters by a computer.

Front 75

PACS (Picture Archiving and Communication System), PACS

Back 75

System for storage and distribution of digital radiology images over a networked environment., Picture archiving and communications systems

Front 76

Patient Portal

Back 76

Allows patients and providers to communicate over the internet in a secure environment.

Front 77

PDA (Personal Desk Assistant or Personal Digital Assistant)

Back 77

Hand-held device with multitude of uses allowing for mobility.

Front 78

PHI

Back 78

Protected health information

Front 79

PHM

Back 79

Preventive Health Maintenance

Front 80

PHR (Personal Health Record), PHR

Back 80

Includes all healthcare information from all sources, compiled and maintained by the patient., Patient health record

Front 81

Platform

Back 81

Basic technology of a computer system's hardware and software that defines how a computer is operated and determines what software can be used.

Front 82

PM

Back 82

Practice Management (biling) system

Front 83

PMRI

Back 83

Patient Medical Record Information

Front 84

PMS

Back 84

Practice Management System

Front 85

Point and Click

Back 85

Allowing activation of commands by moving the cursor over certain areas or icons and clicking a pointing device.

Front 86

Point-of-Care

Back 86

Refers to time while with the patient, either bedside or during an encounter.

Front 87

Portal

Back 87

Website considered as an entry point to other websites.

Front 88

Problem list

Back 88

Diagnosis list.

Front 89

Protocols

Back 89

Clinical Guidelines

Front 90

Pull Down Menu

Back 90

Drop-down menu of commands or options that appear when you select an item with a mouse.

Front 91

QIO (Quality Improvement Organization), QIO

Back 91

Medicare QIO program. Associated with DOQ-IT program. Work to refine care delivery systems., Quality Information Organization (Formerly PRO - Peer Review Organization

Front 92

Query

Back 92

Primary mechanism for retrieving information from a database.

Front 93

RFID

Back 93

Radio Frequency Identification

Front 94

ROI (Return on Investment), ROI

Back 94

Measuring an increase in revenue, a decrease in expense or an avoidance of expense., Return on investment

Front 95

Scalable

Back 95

How well a hardware or software system can adapt to increased demands.

Front 96

Security

Back 96

Effort to create a secure computing platform designed so the agents can only perform actions that have been allowed.

Front 97

Server Farm

Back 97

Group of networked servers housed in one location.

Front 98

Single sign-on (SSO)

Back 98

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.

Front 99

SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms)

Back 99

Clinical, health care terminology and infrastructure.

Front 100

SOAP note format

Back 100

A format for medical documentation, subject, objective, assessment, plan

Front 101

Speech Recognition

Back 101

Ability of a computer to understand the spoken word for the purpose of receiving commands and transforming speech into text.

Front 102

Structured Data

Back 102

Data managed by technology that allows for querying and reporting against predetermined data types and understood relationships.

Front 103

T1 Line

Back 103

T1 carrier is a commonly used digital internet connection line in the US supporting date rates of 1.544 MBits per second.

Front 104

Tablet PC

Back 104

computer shaped in the form of a notebook. User can use a stylus to operate the computer without having to have a keyboard or mouse.

Front 105

Template

Back 105

Often called library or dictionary. Pre-defined choices of pick-lists designed to streamline the documentation process.

Front 106

Thin client

Back 106

computer network without a hard drive.

Front 107

Transcription

Back 107

Process by which medical transcriptionists convert physician's dictation into written words.

Front 108

Touch screen

Back 108

An input device that allows the user to interact with the computer by touching the display screen.

Front 109

Unstructured data

Back 109

Data such as free-text. Computer cannot automatically extract properties and relationships.

Front 110

Voice Recognition

Back 110

See Speech Recognition.

Front 111

Way to communicate through a dedicated server securely to a corporate network over the internet., Virtual private network

Back 111

Way to communicate through a dedicated server securely to a corporate network over the internet., Virtual private network

Front 112

WAN (Wide Area Network)

Back 112

Computer network that spans a larger geographical area than a LAN

Front 113

Webinar

Back 113

Lecture, presentation, workshop, or seminar that is transmitted over the Web.

Front 114

Web Portal

Back 114

Website considered as an entry point to other websites.

Front 115

Wireless

Back 115

A system employing no connecting wire between the transmitting and receiving stations.

Front 116

Workflow

Back 116

Automation of a process, in whole or in part, during which documents, information or tasks are passed from one participant to another for action according to a set of procedureal rules.