The following Glossary discusses terms and acronyms that you may find on our website, or during your search for the proper EMR.

AAC Average Allowable Cost (of certified EHR technology)
Addendum Text that is added to a document after it has been finalized.
AIU Adopt, Implement, Upgrade (certified EHR technology)
Alerts Pop-ups or reminders. An automated warning system such a clinical alerts, preventive health maintenance, medication interactions etc.
Ambulatory Care Medical care provided on an outpatient basis.
Annotator A system function that allows an explanatory note or diagram to be added to an image.
(ARRA) The American Recovery and Reinvestment Act The American Recovery and Reinvestment Act authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “Meaningful Users” of an electronic health record (EHR). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the “Meaningful Use” definition or they will be subject to financial penalties under Medicare.
Application Service Provider
An Application Service Provider (ASP) is a third party entity that deploys, hosts and manages software from a centrally managed host facility (offsite). Applications are delivered over networks (WAN, Internet) on a subscription fee/rental basis. This model is also been referred to as “software-as-a-service”.
Audit Trail Security system that tracks a user’s access, deletion or modification of data. The term used in healthcare information security refers to a chronological record of system resource usage. This includes user login, file access, other various activities, and whether any actual or attempted security violations occurred, legitimate or unauthorized.
Authentication The verification of the identity of a person or process.
Bandwidth A data transmission rate; the maximum amount of information (bits/second) that can be transmitted along a channel.
Bar Code A printed horizontal strip of vertical bars which represent decimal digits used for identification. Bar codes must be read by a bar code reader.
Biometrics Biometrics are automated methods of recognizing a person based on a physiological characteristic such as fingerprints, retina, voice etc.
Browser Short for Web browser, a software application used to locate and display Web pages.
CAH Critical Access Hospital
CAHPS Consumer Assessment of Healthcare Providers and Systems
Case Management A process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize the outcome.
CCN CMS Certification Number
(CDR) Clinical Data Repository A real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. It is optimized to allow clinicians to retrieve data for a single patient rather than to identify a population of patients with common characteristics or to facilitate the management of a specific clinical department.
(CDSS) Clinical Decision support system A clinical decision support system (CDSS) is software designed to aid clinicians in decision making by matching individual patient characteristics to computerized knowledge bases for the purpose of generating patient-specific assessments or recommendations.
CFR Code of Federal Regulations
Chart Medical record
Chart Note A document, written by the clinician or provider, which describes the details of a patient’s encounter. Sometimes referred to as a progress note.
CHIP Children’s Health Insurance Program
CHIPA Children’s Health Insurance Program Reauthorization Act of 2009
Client/Server architecture An information-transmission arrangement, in which a client program sends a request to a server. When the server receives the request, it disconnects from the client and processes the request. When the request is processed, the server reconnects to the client program and the information is transferred to the client. This usually implies that the server is located on site as opposed to the ASP (Application Server Provider) architecture.
Clinical Guidelines (Protocols) Clinical guidelines are recommendations based on the latest available evidence for the appropriate treatment and care of a patient’s condition.
Clinical messaging Communication of clinical information within the electronic medical record to other healthcare personnel.
CMS Centers for Medicare & Medicaid Services
CPG Clinical Practice Guidelines
CPM Clinical Performance Measures
(CPOE) Computerized Provider Order Entry CPOE refers to the act of a clinician entering an order for patient services into an information system.
(CPR) Computerized Patient Record, Computer-Based Patient Record Electronically maintained information about an individual’s lifetime health status and healthcare from all specialties.
(CPT) Current Procedural Terminology The purpose of CPT codes is to provide a uniform language that accurately describes medical, surgical, and diagnostic services.
CY Calendar Year
Data conversion The conversion of data from one software to another.
(DES) Data Encryption Standard Data Encryption Standard (DES) is a widely-used method of data encryption using a private (secret) key.
Data Integrity Refers to the validity of data. A condition in which data has not been altered or destroyed in an unauthorized manner.
Data Mining The process of analyzing or extracting data from a database to identify patterns or relationships.
Data Set A group of data elements relevant for a particular use.
Data Structure A way to store and organize data in order to facilitate access and modifications.
Database A collection of information organized in such a way that a computer program can quickly select desired pieces of data.
(DBMS) Database management system A set of computer programs for organizing the information in a database. A DBMS supports the structuring of the database in a standard format and provides tools for data input, verification, storage, retrieval, query, and manipulation.
(DICOM) Digital Imaging and Communications in Medicine Digital Imaging and Communications in Medicine (DICOM) is a standard to aid the distribution and viewing of medical images, such as CT scans, MRIs, and ultrasound.
Dictation The process by which a physician records his/her notes about a patient. This recording is intended for reproduction in written word (Transcription).
Digital Signature Sometimes referred to as Advanced Electronic Signature. Digital signature takes the traditional hand-written signature and creates a digital image of the signature to eliminate the need to print and sign documents.
Discrete Data A set of data is said to be discrete if the values belonging to it are distinct and separate, (i.e. they can be counted). Discrete data is more easily reportable as opposed to non-discrete or unstructured data.
Document Imaging Converting paper documents into an electronic format usually through a scanning process.
Documentation The process of recording information.
Document Management Is a system involving scanning, categorizing and storing vital patient documents.
(DOQ-IT) Doctors Office Quality Information Technology DOQ-IT is a two-year special study that is designed to improve quality of care, patient safety, and efficiency for services provided to Medicare beneficiaries by promoting the adoption of EHR’s and Information Technology (IT) in primary care physician offices.
(E & M Coding) Evaluation and Management Coding Documentation guidelines for Evaluation and Management CPT codes from the Center for Medicare and Medicaid Services (formerly HCFA).
Economic Stimulus A situation where the government changes its fiscal policy of spending and taxation in order to bolster and revive an economy that is in a recession. By spending money on state and federal infrastructure, the government hopes to provide jobs, and jump-start the failing economy.
EDI Electronic Data Interchange
(EHR) Electronic Health Record An electronic repository of information regarding the health of an individual. It is also a generic term for all electronic patient care systems. E HR’s imply a level of interoperability beyond the capability of an EMR (Electronic Medical Record).
Electronic Superbill An electronic encounter form used for coding and billing.
(EMR) Electronic Medical Record Electronic Medical record has a level of sophistication beyond a document management system. An EMR is a provider-based medical record that includes all health documentation for one person covering all services provided within an enterprise.
(EOE) Electronic Order Entry The function of this program is to move from hand-written and verbal orders to computer-based entry.
EP Eligible Professional
EPO Exclusive Provider Organization
(EPR) Electronic Patient Record Same as a CPR – Computerized Patient Record.
Encryption Process of converting messages or data into a form that cannot be read without decrypting or deciphering it.
e-Prescribing Prescribing medication through an automated data-entry process and transmitting the information to participating pharmacies.
(EBM) Evidence based medicine Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise to aid in the diagnosis and management of patients.
FACA Federal Advisory Committee Act
Face Sheet Also called a Summary Screen or Patient Dashboard. This screen includes a summary of patient relevant information on one screen.
Fat Client (Thick Client) A fat client is a network computer with a hard disc drive, as opposed to a thin client which has no disc drive.
FFP Federal Financial Participation
FFS Fee-For-Service
FFY Federal Fiscal Year
Firewall A system designed to prevent unauthorized access to or from a private computer network.
Formulary A listing of prescription drugs established by a particular health plan which includes both Brand name and Generic drugs. It serves to suggest covered, preferred and lower cost drugs.
FQHC Federally Qualified Health Center
FTE Full-Time Equivalent
FTP File Transfer Program
FY Fiscal Year
(GUI) Graphical User Interface Abbreviated GUI .A program interface that takes advantage of the computer’s graphics capabilities to make the program easier to use. Well-designed graphical user interfaces can help expedite the software learning process.
HEDIS Healthcare Effectiveness Data and Information Set
Help Desk Service and support desk
HHS Department of Health and Human Services
HIE Health Information Exchange
(HIPAA) Health Insurance Portability and Accountability Act of 1996 HIPAA seeks to establish standardized mechanisms for electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.
(HIT) Health Information Technology Provides the umbrella framework to describe the comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers.
(HITECH Act) The Health Information Technology for Economic and Clinical Health Act Legislation created to stimulate the adoption of electronic health records (EHR) and supporting technology in the United States. President Obama signed HITECH into law on February 17, 2009 as part of the American Recovery and Reinvestment Act of 2009 (ARRA), an economic stimulus bill.
(HL7) Health Level 7 Formed in the United States in 1987, HL7 has the goal of developing an international set of open standards for data format and content that allows different health information systems to easily and effectively communicate with one another.
(HM) Health Maintenance Health Maintenance, also referred to as Preventive Health Maintenance is a system of guidelines (recommended schedules) of tests or procedures that have proven value in disease prevention.
HMO Health Maintenance Organization
HOS Health Outcomes Survey
Hot Keys One- or two-keystroke command that switches the user to a different program or function within a software program. Hot keys are useful to expedite movement within a software program.
HPSA Health Professional Shortage Area
HRSA Health Resource and Services Administration
IAPD Implementation Advance Planning Document
(ICD-9 or ICD-10) International Classification of Diseases ICD is the classification and coding of diseases and injuries.
ICR Information Collection Requirement
IHS Indian Health Service
Informatics The application of computer technology to the management of information.
IPA Independent Practice Association
Integration Integration allows for secure communication between enterprise applications.
Interoperability The capability to provide successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.
ISP Internet Service Provider
(IT) Information Technology The development, installation, and implementation of computer systems and applications.
Kiosk Small computer workstations which allow information to be input. Patient kiosks are used for patients to input information into the system at the medical practice, usually input through a workstation in the waiting room.
(LAN) Local Area Network A LAN supplies networking capability to a group of computers in close proximity to each other such as in an office building, a school, or a home.
Legacy System A system that is considered old and possibly out-dated.
Legacy System Integration The integration of data between a legacy system and some other software program most commonly using HL-7 standards.
(LEPR) Longitudinal Patient Record Longitudinal Patient Record is an EHR that includes all healthcare information from all sources.
MA Medicare Advantage
MAC Medicare Administrative Contractor
Macro A symbol, name or key (macro key) that represents a list of commands, actions, keystrokes or blocks of text. When the macro key code is typed, the program carries out the instructions of the macro. Users create macros to save time by replacing often-used, series of strokes (blocks of text) with quick macro key codes.
MAO Medicare Advantage Organization
MCO Managed Care Organization
Meaningful Use A set of standards enforced by the American Recovery and Reinvestment Act in addition to HIPAA standards and regulations.
MEDCIN® MEDCIN® is a medical terminology engine and a registered trademark of MediComp Systems. MEDCIN® includes more than 250,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. MEDCIN® contains medical relationships through multiple clinical hierarchies for each Medcin term.
MITA Medicaid Information Technology Architecture
MMIS Medicaid Management Information Systems
MSA Medical Savings Account
NAAC Net Average Allowable Cost (of certified EHR technology)
NCQA National Committee for Quality Assurance
NCVHS National Committee on Vital and Health Statistics
Network A system for communication among two or more computers.
NPI National Provider Identifier
NPRM Notice of Proposed Rulemaking
(OCR) Optical Character Recognition OCR is recognition of printed or written characters by a computer.
ONC Office of the National Coordinator for Health Information Technology
(PACS) Picture Archiving and Communication System An information system for the storage and distribution of digital radiology images over a networked environment that allows for instant access to images and reports.
PAHP Prepaid Ambulatory Health Plan
PAPD Planning Advance Planning Document
Patient Portal Allow patients and providers to communicate over the Internet in a secure environment.
(PDA) Personal Desk Assistant or Personal Digital Assistant. PDA is a hand-held device with a multitude of uses such as scheduling appointments on a calendar, creating to-do lists, storing libraries of medical information, viewing patient specific data . PDA allow for mobility. They are also referred to as palmtops, hand-held computers and pocket computers.
PFFS Private Fee-For-Service
PHI Personal Health Information
PHM Preventive Health Maintenance – see Health Maintenance.
PHO Physician Hospital Organization
(PHR) Personal Health Record A PHR includes all healthcare information from all sources, compiled and maintained by the patient.
PHS Public Health Service
PHSA Public Health Service Act
PIHP Prepaid Inpatient Health Plan
Platform The basic technology of a computer system’s hardware and software that defines how a computer is operated and determines what other kinds of software can be used.
PM Practice Management (billing) system.
PMRI Patient Medical Record Information
PMS Practice Management System
Point and Click Allowing the activation of commands by moving the cursor over certain areas or icons and clicking a pointing device.
Point-of-Care POC refers to the time while with the patient, either bedside or during an encounter.
Portal A website considered as an entry point to other websites. Examples are a Patient Portal.
POS Place of Service
PPO Preferred Provider Organization
PQRI Physician Quality Reporting Initiative
Problem List Diagnosis list
Protocols Clinical Guidelines
PSO Provider Sponsored Organization
Pull Down Menu Also called a drop-down menu. These are a menu of commands or options that appears when you select an item with a mouse.
(QIO) Quality Improvement Organization The Medicare QIO program consists of a national network of fifty-three QIO’s found in each state responsible to work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems. They are associated with the DOQ-IT program.
Query The primary mechanism for retrieving information from a database and consists of questions presented to the database in a predefined format.
(REC) Regional Extension Center Offer technical assistance, guidance and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of Electronic Health Records (EHRs). The consistent, nationwide adoption and use of secure EHRs will ultimately enhance the quality and value of health care.
(RCM) Revenue Cycle Management Administrative duties, clinical and financial, that facilitate the collection of all revenues for the provision of care. The cycle is initiated at the time of appointment setting or registration and concludes with the posting of payments and adjustments, ultimately zero balancing that patient account.
RFID Radio Frequency Identification
RHC Rural Health Clinic
RHQDAPU Reporting Hospital Quality Data for Annual Payment Update
(ROI) Return on Investment Return on investment typically means measuring an increase in revenue, a decrease in expense or an avoidance of expense.
RPPO Regional Preferred Provider Organization
Scalable Refers to how well a hardware or software system can adapt to increased demands.
Security Is the effort to create a secure computing platform, designed so that agents (users or programs) can only perform actions that have been allowed.
Server Farm A group of networked servers that are housed in one location.
Single sign-on (SSO) is 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, without the need to enter multiple passwords.
SMHP State Medicaid Health Information Technology Plan
SNOMED CT® – Systematized Nomenclature of Medicine – Clinical Terms SNOMED CT ® is a clinical, health care terminology and infrastructure. SNOMED CT ® contains over 366,170 health care concepts with unique meanings and formal logic-based definitions organized into hierarchies.
SOAP note format A format for medical documentation. SOAP is an acronym for S-Subjective, O-Objective, A-Assessment, P-Plan.
Speech Recognition The ability of a computer to understand the spoken word for the purpose of receiving commands and transforming speech into text.
Stimulus An act meant to arouse action.
Structured Data Structured data is managed by technology that allows for querying and reporting against predetermined data types and understood relationships.
T1 Line The T1 carrier is a commonly used digital Internet connection line in the US supporting data rates of 1.544Mbits per second.
Tablet pc A tablet pc is a computer shaped in the form of a notebook except it has the capabilities of being written on through the use of digitizing tablet technology or a touch screen. A user can use a stylus and operate the computer without having to have a keyboard or mouse.
Template Often called a library or dictionary. Templates are pre-defined choices of pick-lists designed to streamline the documentation process.
Thin Client A thin client is a network computer without a hard disc drive, as opposed to a fat client which includes a disc drive.
TIN Tax Identification Number
Transcription The process by which medical transcriptionists convert physician’s dictation into written (typed) words.
Touch Screen An input device that allows user to interact with the computer by touching the display screen.
Unstructured Data Data which is not structured such as free-text. The computer cannot automatically extract properties and relationships from unstructured data.
Voice Recognition See Speech Recognition
(VPN) Virtual Private Network A way to communicate through a dedicated server securely to a corporate network over the internet.
(WAN) Wide Area Network A computer network that spans a larger geographical area than a LAN (Local Area Network).
Webinar A lecture, presentation, workshop or seminar that is transmitted over the Web. Short for Web-based Seminar.
Web Portal A website considered as an entry point to other websites.
Wireless A system employing no connecting wire between the transmitting and receiving stations.
Workflow The automation of a process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules.

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