Health IT and Electronic Health Definitions

This glossary explains the meaning of key words and phrases that information technology (IT) and business professionals use when discussing health IT and related software products. You can find additional definitions by visiting WhatIs.com or using the search box below.

  • A

    accountable care organization (ACO)

    An accountable care organization (ACO) is an association of hospitals, healthcare providers and insurers in which all parties voluntarily assume financial and medical responsibility for Medicare patients.

  • Agency for Healthcare Research and Quality (AHRQ)

    The Agency for Healthcare Research and Quality (AHRQ) is a U.S. government agency that functions as a part of the Department of Health & Human Services (HHS) to support research to help improve the quality of health care.

  • Allscripts

    Allscripts is a vendor of electronic health record systems for physician practices, hospitals and healthcare systems.

  • ambulatory medical record (AMR)

    An ambulatory medical record (AMR) is an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital.

  • American Health Information Management Association (AHIMA)

    The American Health Information Management Association (AHIMA) is a professional organization that promotes the business and clinical uses of electronic and paper-based medical information.

  • American Medical Association (AMA)

    The American Medical Association (AMA) is a physician group that works for healthcare reform and publishes a collection of medical journals.

  • athenahealth Inc.

    athenahealth Inc. is a developer of cloud-based practice management, point-of-care mobile applications and electronic health record (EHR) systems for small to medium-sized (SMB) physician practices and hospitals.

  • Patient Protection and Affordable Care Act (PPACA, ACA or Obamacare)

    The Patient Protection and Affordable Care Act (more commonly referred to as the Affordable Care Act, ACA or Obamacare) is a healthcare law passed by Congress in 2010 during the administration of President Barack Obama.

  • B

    Bar Coded Medication Administration (BCMA)

    Bar Coded Medication Administration (BCMA) is a hospital inventory control system that uses barcodes in the distribution of prescription medications with the goal of ensuring the patient is receiving the correct medication.

  • biomedical informatics

    Biomedical informatics is the branch of health informatics that uses data to help clinicians, researchers and scientists improve human health and provide healthcare.

  • C

    Centers for Disease Control and Prevention (CDC)

    Promoting a healthy general public and sharing data about chronic diseases are main goals of the Centers for Disease Control and Prevention (CDC).

  • Centers for Medicare & Medicaid Services (CMS)

    The Centers for Medicare & Medicaid Services (CMS) is the wing of the U.S. Department of Health and Human Services that runs healthcare reimbursement and health IT programs.

  • Cerner Corp.

    Cerner Corp. is a public company in North Kansas City, Mo., that provides various health information technologies, ranging from medical devices to electronic health records (EHR) to hardware.

  • Change Healthcare

    Change Healthcare is a healthcare technology provider of revenue cycle management, payment management and health information exchange (HIE) solutions.

  • clinical decision support system (CDSS)

    A clinical decision support system (CDSS) is an application that analyzes data to help healthcare providers make decisions and improve patient care.

  • Clinical Document Architecture (CDA)

    Clinical Document Architecture (CDA) is a markup standard created by Health Level 7 International (HL7) that defines the structure of discharge summaries, progress notes and other medical records.

  • clinical documentation (healthcare)

    Clinical documentation (CD) is the creation of a digital or analog record detailing a medical treatment, medical trial or clinical test.

  • clinical informatics

    Clinical informatics, also known as health informatics, is the study of how technology and data analytics can be used to improve patient care plans.

  • clinical trial

    A clinical trial, also known as a clinical research study, is a protocol to evaluate the effects and efficacy of experimental medical treatments or behavioral interventions on health outcomes.

  • CMIO (Chief Medical Information Officer)

    A Chief Medical Information Officer, or CMIO, essentially serves as the bridge between medical and IT departments at a health care organization. This person may also be referred to as the director of medical informatics or health informatics.

  • common working file (CWF)

    A common working file (CWF) is a tool used by the Centers for Medicare & Medicaid Services (CMS) to maintain national Medicare records for individual beneficiaries enrolled in the program.

  • computer assisted coding system (CACS)

    A computer assisted coding system (CACS) is medical software that reviews healthcare forms, including electronic health records, and assigns appropriate medical codes to its findings.

  • computerized physician order entry (CPOE)

    Computerized physician order entry (CPOE), also known as computerized provider order entry or computerized practitioner order entry, refers to the process of a medical professional entering and sending medication orders and treatment instructions electronically via a computer application instead of on paper charts.

  • Consolidated Health Informatics (CHI)

    The Consolidated Health Informatics (CHI) initiative refers to a collaborative effort to create and adopt health informatics standards to be used by federal departments such as the Department of Health & Human Services and the Department of Veterans Affairs.

  • Continuity of Care Document (CCD)

    The Continuity of Care Document (CCD) is an electronic document exchange standard for sharing patient summary information.

  • Continuity of Care Record (CCR)

    The Continuity of Care Record, or CCR, is a standard for the creation of electronic summaries of patient health. Its aim is to improve the quality of health care and to reduce medical errors by making current information readily available to physicians.

  • Current Procedural Terminology (CPT) code

    Current Procedural Terminology (CPT) codes are a uniform medical code set maintained and copyrighted by the American Medical Association and used to describe medical, surgical and diagnostic services.

  • D

    DICOM (Digital Imaging and Communications in Medicine)

    DICOM (Digital Imaging and Communications in Medicine) is a standard protocol for the management and transmission of medical images and related data and is used in many healthcare facilities.

  • digital health (digital healthcare)

    Digital health, or digital healthcare, is a broad, multidisciplinary concept that includes concepts from an intersection between technology and healthcare.

  • E

    e-prescribing (electronic prescribing)

    E-prescribing, or electronic prescribing is a technology framework that allows physicians and other medical practitioners to write and send prescriptions to a participating pharmacy electronically instead of using handwritten or faxed notes or calling in prescriptions.

  • eClinicalWorks

    eClinicalWorks is a Massachusetts-based company that sells electronic medical record (EMR), practice management (PM) and personal health record (PHR) software and services to reportedly more than 115,000 physicians and 70,000 facilities in the United States.

  • EHR implementation plan

    An electronic health record (EHR) implementation plan is a comprehensive set of strategies and steps used by a health care organization when preparing for and executing the adoption of an electronic-based health care system.

  • electronic health record (EHR)

    An electronic health record (EHR) is an individual's official health document that is shared among multiple facilities and agencies.

  • electronic intensive care unit (eICU)

    An Electronic Intensive Care Unit (eICU) is a form or model of telemedicine where state-of-the-art technology is used to provide an additional layer of critical care service to patients.

  • electronic protected health information (ePHI)

    Electronic protected health information (ePHI) is protected health information (PHI) that is produced, saved, transferred or received in an electronic form. In the United States, ePHI management is covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule.

  • enterprise master patient index (EMPI)

    An enterprise master patient index (EMPI) is a database that is used to maintain consistent and accurate information about each patient registered by a healthcare organization.

  • Epic Systems

    Epic Systems is one of the largest providers of health information technology, used primarily by large U.S. hospitals and health systems to access, organize, store and share electronic medical records.

  • F

    FDA (U.S. Food and Drug Administration)

    The FDA (U.S. Food and Drug Administration) regulates the production and sale of food, medicine, health technology and cosmetic products. The FDA, also called the USFDA, approves drugs and medical devices for sale and recalls unsafe products.

  • fee-for-service (FFS)

    Fee-for-service (FFS) is a payment model in which doctors, hospitals, and medical practices charge separately for each service they perform.

  • FHIR (Fast Healthcare Interoperability Resources)

    Fast Healthcare Interoperability Resources (FHIR) is an interoperability standard for electronic exchange of healthcare information.

  • G

    genomics

    Genomics is the study of human genes and chromosomes.

  • H

    health informatics

    Health informatics is the practice of acquiring, studying and managing health data and applying medical concepts in conjunction with health information technology systems to help clinicians provide better healthcare.

  • Health Information Exchange (HIE)

    Health information exchange (HIE) is the electronic transmission of healthcare-related data among medical facilities, health information organizations -- companies that oversee and govern the exchange of this data -- and government agencies according to national standards.

  • Health IT (health information technology)

    Health IT (health information technology) is the area of IT involving the design, development, creation, use and maintenance of information systems for the healthcare industry.

  • Healthcare CIO (healthcare chief information officer)

    A healthcare CIO is a healthcare executive with an influence over technology purchasing and other IT business decisions.

  • HIMSS (Healthcare Information and Management Systems Society)

    The Healthcare Information and Management Systems Society (HIMSS) is a nonprofit organization whose goal is to promote the best use of IT and management systems in the healthcare industry.

  • HIPAA (Health Insurance Portability and Accountability Act)

    HIPAA (Health Insurance Portability and Accountability Act) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

  • HIPAA disaster recovery plan

    A HIPAA disaster recovery plan is a document that specifies the resources, actions, personnel and data that are required to protect and reinstate healthcare information in the event of a fire, vandalism, natural disaster or system failure. 

  • HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009

    The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 is legislation that was created to stimulate the adoption of electronic health records (EHR) and the supporting technology in the United States.

  • HL7 (Health Level Seven International)

    HL7 (Health Level Seven International) is a set of standards, formats and definitions for exchanging and developing electronic health records (EHRs).

  • hybrid health record (HHR)

    A hybrid health record (HHR) is documentation of an individual's health information that is tracked in multiple formats and stored in multiple places. Today, the majority of health records in the United States are considered to be hybrid.

  • I

    ICD-10 (International Classification of Diseases, Tenth Revision)

    The International Classification of Diseases, Tenth Edition (ICD-10), is a clinical cataloging system that went into effect for the U.S. healthcare industry on Oct. 1, 2015, after a series of lengthy delays.

  • ICD-10-CM (Clinical Modification)

    The ICD-10-CM (Clinical Modification) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.

  • ICD-10-PCS

    The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) is a U.S. cataloging system for procedural codes that track various health interventions taken by medical professionals.

  • ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification)

    ICD-9-CM is the current medical coding standard used in hospitals in the United States. It is scheduled to be replaced by ICD-10 by Oct. 1, 2015.

  • J

    Joint Commission

    The Joint Commission is an independent group that presently accredits 20,500 healthcare facilities in the United States by performing onsite evaluations.

  • K

    Kinect

    Kinect is Microsoft’s motion gaming system for the Xbox 360. The system provides a natural user interface (NUI) that allows users to interact intuitively and without any intermediary device, such as a controller.

  • L

    laboratory information system

    A laboratory information system (LIS) is software that collects, stores and produces reports from medical test data.

  • legal health record

    A legal health record is the record of patient health that is created by a health care organization for its own business record. It is also the record that is produced upon request from patients or legal services.

  • M

    MACRA (Medicare Access and CHIP Reauthorization Act of 2015)

    MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is U.S. healthcare legislation that provides a new framework for reimbursing clinicians who successfully demonstrate value over volume in patient care.

  • Maintenance Management Information System (MMIS)

    Maintenance Management Information System (MMIS) is a mechanized claims processing and information retrieval system for Medicaid that's required by the federal government.

  • McKesson Corp.

    McKesson Corp. is a provider of medicines, pharmaceutical supplies and health information technology including nursing automation, practice management, clinical decision support systems, secure online healthcare communication and electronic health records systems. Based in San Francisco, it is one of the largest providers of these services in the United States and has more than 32,000 employees.

  • Meaningful Use

    In the context of health IT, meaningful use is a term used to define minimum U.S. government standards for electronic health records (EHR), outlining how clinical patient data should be exchanged between healthcare providers, between providers and insurers and between providers and patients.

  • meaningful use attestation

    Meaningful use attestation, in a health information technology (HIT) context, is a process that documents that an organization or individual has successfully demonstrated meaningful use and is successfully fulfilling the requirements for electronic health records (EHR) and related technology.

  • meaningful use stage 1

    Meaningful use stage 1 is the first phase of the United States federal government's meaningful use incentive program, which details the requirements for the use of electronic health record (EHR) systems by hospitals and eligible health care professionals.

  • meaningful use stage 2

    Meaningful use stage 2 is the second phase of the meaningful use incentive program that details the second phase of requirements for the use of electronic health record (EHR) systems by hospitals and eligible health care providers.

  • meaningful use stage 3

    Meaningful use stage 3 is the third phase of the federal incentive program that details requirements for the use of electronic health record systems by hospitals and eligible healthcare professionals. However, the new MACRA law will change the overall meaningful use program, which may eventually lessen stage 3's influence.

  • medical scribe

    A medical scribe is a healthcare employee that assists medical professionals with documenting patients' medical histories.

  • medical transcription (MT)

    Medical transcription (MT) is the manual processing of voice reports dictated by physicians and other healthcare professionals into text format.

  • Meditech (Medical Information Technology Inc.)

    Meditech (Medical Information Technology Inc.) is an electronic health record vendor that holds a 19% market share in the hospital industry, but faces intense competition.

  • mHealth (mobile health)

    mHealth (mobile health) is a general term for the use of mobile phones and other wireless technology in medical care.

  • N

    national provider identifier (NPI)

    A national provider identifier (NPI) is a unique ten-digit identification number required by HIPAA for covered healthcare providers in the United States.

  • Nationwide Health Information Network (NHIN)

    The Nationwide Health Information Network (NHIN) is a set of standards, services and policies that enable secure health information exchange (HIE) over the Internet.

  • O

    Office for Civil Rights (OCR)

    The Office for Civil Rights (OCR) is an organization within the U.S. Department of Health & Human Services (HHS),

  • ONC (Office of the National Coordinator for Health Information Technology)

    The Office of the National Coordinator for Health Information Technology, abbreviated ONC, is an entity within the U.S. Department of Health and Human Services (HHS).

  • P

    PACS (picture archiving and communication system)

    PACS (picture archiving and communication system) is a medical imaging technology used primarily in healthcare organizations to securely store and digitally transmit electronic images and clinically-relevant reports.

  • personal health record (PHR)

    A personal health record (PHR) is a collection of health-related information that is documented and maintained by the individual it pertains to.

  • pharmaceutical detailing

    Pharmaceutical detailing is a 1:1 marketing technique pharmaceutical companies use to educate a physician about a vendor's products, hoping that the physician will prescribe the company's products more often.

  • PHI breach (protected health information breach)

    A PHI breach is unauthorized access, use or disclosure of individually identifiable health information that is held or transmitted by a healthcare organization or its business associates.

  • point of care (POC) testing

    Point of care (POC) testing is medical testing that is performed outside of a laboratory setting. Common examples of POC test tools include blood glucose monitors, thermometers, home pregnancy tests and rapid strep tests.

  • population health management (PHM)

    Population health management (PHM) is a discipline within the healthcare industry that studies and facilitates care delivery across the general population or a group of individuals.

  • precision medicine (PM)

    Precision medicine (PM) is a rapidly evolving development in healthcare in which physicians and other caregivers consider differences in genes, socioeconomic status and lifestyles when devising treatment regimens for patients.

  • problem list

    A problem list is a document that states the most important health problems facing a patient such as nontransitive illnesses or diseases, injuries suffered by the patient, and anything else that has affected the patient or is currently ongoing with the patient.

  • Project Nightingale

    Project Nightingale is a controversial partnership between Google and Ascension, the second largest health system in the United States. The partnership, which began in 2018, has provided Google with access to the medical records of over 50 million people.

  • protected health information (PHI) or personal health information

    Protected health information (PHI), also referred to as personal health information, is the demographic information, medical histories, test and laboratory results, mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care.

  • R

    Radiology Information System (RIS)

    A RIS is the traditional core software system for electronically managing medical images, scheduling and billing in hospital radiology departments and physician practices.

  • Regional Health Information Organization (RHIO)

    A Regional Health Information Organization (RHIO) is a group of organizations within a specific area that share healthcare-related information electronically according to accepted healthcare information technology (HIT) standards.

  • registered health information technician (RHIT)

    A registered health information technician (RHIT) is a certified professional who stores and verifies the accuracy and completeness of electronic health records.

  • remote patient monitoring (RPM)

    Remote patient monitoring (RPM) is a subcategory of homecare telehealth that allows patients to use mobile medical devices or technology to gather patient-generated health data (PGHD) and send it to healthcare professionals.

  • revenue cycle management (RCM)

    Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.

  • RHIA (Registered Health Information Administrator)

    An RHIA, or registered health information administrator, is a certified professional who oversees the creation and use of patient health information, including analyzing that data.

  • S

    serious reportable event (SRE)

    A serious reportable event (SRE) is an incident involving death or serious harm to a patient resulting from a lapse or error in a healthcare facility. The National Quality Forum (NQF) coined the term to refer to "preventable, serious, and unambiguous adverse events that should never occur.”

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

    SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms) is a standardized, multilingual vocabulary of clinical terminology that is used by physicians and other health care providers for the electronic exchange of clinical health information.

  • T

    telemedicine (telehealth)

    Telemedicine is the remote delivery of healthcare services, such as health assessments or consultations, over the telecommunications infrastructure.

  • U

    US Department of Health and Human Services (HHS)

    The U.S. Department of Health and Human Services (HHS) is a cabinet-level agency in the executive branch of the federal government. Its mission is to enhance and protect the well-being of all Americans by providing effective health and human services and fostering advances in medicine, public health and social services.

  • V

    value-based healthcare

    Value-based healthcare, also known as value-based care, is a payment model that rewards healthcare providers for providing quality care to patients.

  • vendor neutral archive (VNA)

    A vendor neutral archive (VNA) is a technology that stores medical images in a standard format and interface, making them accessible to healthcare professionals regardless of what proprietary system created the images.

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