Glossary of EMR/EHR

Medical Software Terms

 

ADSL (Asymmetric Digital Subscriber Line): A type of DSL that uses copper telephone lines to transmit data faster than a traditional modem. ADSL only works within short distances because it uses high frequencies with short signals.

Ambulatory care: is any medical care delivered on an outpatient basis.

ASP (Applications Service Provider): Application service provider is a business that provides computer based services to customers over a network.

ASP (Active Server Page): is dynamically generated web page with the use of ActiveX scripting, which executes on the server instead on the Web browser (HTML). The Server executes the file and generates an HTML formatted page for Search Engine Spiders or Web Browsers so it can be displayed properly.

BMI charts: BMI charts within EMR systems can manipulate data, perform calculations, and adapt to user preferences and patient characteristics, users may expect greater functionality from electronic BMI charts.

Capitated payments: Payment for healthcare services based on the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided.

Citrix Server: A server solution, similar to Microsoft Terminal Services that provides remote access to clients via the web or to dummy terminals in a network.

CCHIT: Acronym for Certification Commission for Healthcare Information Technology is the recognized certification authority for electronic health records and their networks, and an independent, voluntary, private-sector initiative.

Clearinghouse: A company that provides clearing and settlement services for medical financial transactions. Some of the more popular clearinghouses include Emdeon/WebMD, McKesson and THIN.

Client-Server: A network architecture which separates the client (often an application that uses a graphical user interface) from the server.

Computerized Patient Record (CPR): Also known as an EMR or EHR. A patient's past, present, and future clinical data stored in a server.

Computerized Physician Order Entry (CPOE): A system for physicians to electronically order labs, imaging and prescriptions

CPT Code: A nationally recognizable five-digit number used to represent a service provided by a healthcare provider.

Digital Imaging and Communications in Medicine (DICOM): A standard to define the connectivity and communication between medical imaging devices.

Drug Formulary Database: this EMR feature is used for electronic prescribing, electronic medical record (EMR), and computerized physician order entry (CPOE) systems to present formulary status to the provider while during the prescribing decision.

E/M level coding: Evaluation and Management level coding – documentation of each visit which identifies each service provided during an office visit.

EDI: Acronym for Electronic Data Interchange. Electronic communication between two parties, generally for the filing of electronic claims to payers.

EMR: Acronym for Electronic Medical Records. A computerized record of a patient's clinical, demographic and administrative data. Also known as a computer-based patient record (CPR) or electronic health record (EHR).

Electronic Eligibility: this EMR feature access a payer to deliver up-to-date insurance benefits eligibility information on patients.

Electronic Health Records (EHR): Patient health records including treatment history, medical test reports, and images stored in an electronic format that can be accessed by healthcare providers on a computer network 

Explanation of Benefits (EOB): A statement from the patient's insurance company that breaks down services rendered at time of doctor or hospital visit and amounts covered by insurance provider

Fee Schedule: A set maximum fee that an insurance company will pay a healthcare provider

Fee-for-service: A health insurance plan that allows policyholders to pay for any provider service, submit a claim to the insurance company, and get reimbursed if the service is covered by the insurance provider 

First DataBank: The leading provider of drug information. Provides context and integration information for healthcare of every type at every level.

Growth Chart: A feature for a Primary Care or EMR that can be used for pediatric patients. Age, height, weight, and head measurements can be entered over the patient's lifetime, and the feature creates a line graph. 

HCFA (CMS-1500 Form): The insurance claim form that a healthcare provider turns in to an insurance company

HIPAA: The Health Insurance Portability and Accountability Act of 1996, is a set of federal regulations which establishes national standards for health care information.

HL7 (Health Level 7): one of the American National Standards Institute accredited Standard Developing Organization (SDO) - Health Level 7 domain is the standards for electronic interchange of clinical, financial and administrative info among healthcare oriented computer systems. Is a not-for-profit volunteer organization. It develops specifications, most widely used is the messaging standard that enables disparate health care applications to exchange key sets of clinical and administrative data. It promotes the use of standards within and among healthcare organizations to increase the effectiveness and efficiency of healthcare delivery. It is an international community of healthcare subject matter experts and information scientists collaborating to create standards for the exchange, management and integration of electronic healthcare information.

Hybrid Record: Term used for when a provider uses a combination of paper and electronic medical records during the transition phase to EMR.

ICD-9: Internationally recognizable 3 to 5-digit code representing a medical diagnosis. Currently being replaced by the ICD-10 code.

IPA: Independent Physician Association or Independent Practice Association. Group of independent physicians that have joined together to negotiate contracts with payers, receive quantity discounts on products

Legacy System: Term used to describe an old system (usually hardware and software), ie. old medical billing software system.

MEDCIN: Clinical documentation nomenclature designed to provide E&M level coding assistance to providers through the use of an extensive database for documenting patient encounters.

National Provider Identifier (NPI): A unique number to define healthcare providers.

Picture Archive Communication System (PACS): Used by radiology and diagnostic imaging organizations to electronically manage information and images

Patient Portal: A secure web-based system that allows a patient to register for an appointment, schedule an appointment, request prescription refills, send and receive secure patient-physician messages, view lab results, pay their bills electronically, access physician directories.

Physician Practice Organization (PPO): An arrangement between insurers and healthcare providers where providers agree to a discounted fee-for-service in exchange for more patients

RAID (Redundant Array of Independent Disks): A way of storing the same data in different places on multiple hard disks. Often used on servers to provide redundancy in the event of a hard drive failure.

Remote Access: Data travels through a private, protected passage via the Internet, allowing healthcare providers to access from home or another practice location and allows EMR vendor to perform system maintenance off-site

SNOMED: (SNOMED CT) Systemized Nomenclature of Medicine Clinical Terms –
SNOMED CT is the universal health care terminology. It is comprehensive and covers procedures, diseases, and clinical data. SNOMED CT helps to structure and computerize the medical record. It allows for a consistent way of indexing, storing, retrieving and aggregating clinical data across sites of care (i.e. hospitals, doctors offices) and specialties. By standardizing the terminology, the variability in the way data is captured, encoded and used for clinical care of patients and research is reduced. Allows for more accurate reporting of data. It is currently available in English, Spanish and German.

SureScripts: Electronic exchange that links pharmacies and healthcare providers. Founded in 2001 by NACDS to make the prescribing process safer and more efficient

SQL: Structured Query Language – is a computer language aimed to store, manipulate and retrieve data stored in relational databases.

T1, T3 line: A high-speed internet connection provided via telephone lines often used by businesses needing internet connection speeds greater than DSL/Cable.

Terminal Services: Microsoft's method for remote administration tasks that delivers the Windows desktop and Windows-based applications to nearly any personal computing device, even devices that can't run Windows.

Thin Client: Also know as a “Dummy Terminal” is a network computer without a hard-drive which requires the constant connection to a server to operate.

UNIX: A network capable, multi-user operating system used for workstations and servers. Many old practice management, medical billing and EMR software were originally designed under the UNIX operating system.

UB-92 Form: Form designed for hospitals to file a medical claim with the patient's insurance carrier.

UPIN (Unique Physician Identification Number): Unique Identification number given to each healthcare provider. Frequently used in insurance billing and is currently being replaced by the NPI number.

XML (Extensible Markup Language): Used for defining data elements on a Web page and communication between two business systems. Example: Standard messaging system for and EMR to integrate with another software such as a practice management or drug formulary database.

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