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

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

Medical care provided on an outpatient basis.

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

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".

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.

The verification of the identity of a person or process.

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

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

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

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.

Medical record

A document, written by the clinician or provider, which describes the details of a patient’s encounter. Sometimes referred to as a progress note.

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.

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.

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.

Clinical guidelines are recommendations based on the latest available evidence for the appropriate treatment and care of a patient’s condition.

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

Clinical Practice Guidelines

Clinical Performance Measures

CPOE refers to the act of a clinician entering an order for patient services into an information system.

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

The purpose of CPT codes is to provide a uniform language that accurately describes medical, surgical, and diagnostic services.

The conversion of data from one software to another.

Data Encryption Standard (DES) is a widely-used method of data encryption using a private (secret) key.

Refers to the validity of data. A condition in which data has not been altered or destroyed in an unauthorized manner.

The process of analyzing or extracting data from a database to identify patterns or relationships.

A group of data elements relevant for a particular use.

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

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

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.

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.

The process by which a physician records his/her notes about a patient. This recording is intended for reproduction in written word (Transcription).

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.

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.

Converting paper documents into an electronic format usually through a scanning process.

The process of recording information.

Is a system involving scanning, categorizing and storing vital patient documents.

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.

Documentation guidelines for Evaluation and Management CPT codes from the Center for Medicare and Medicaid Services (formerly HCFA).

Electronic Data Interchange

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).

An electronic encounter form used for coding and billing.

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.

The function of this program is to move from hand-written and verbal orders to computer-based entry.

Same as a CPR – Computerized Patient Record.

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

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

Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise to aid in the diagnosis and management of patients.

Also called a Summary Screen or Patient Dashboard. This screen includes a summary of patient relevant information on one screen.

A fat client is a network computer with a hard disc drive, as opposed to a thin client which has no disc drive.

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

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.

File Transfer Program

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.

Service and support desk

HIPAA seeks to establish standardized mechanisms for electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.

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.

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.

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.

ICD is the classification and coding of diseases and injuries.

The application of computer technology to the management of information.

Integration allows for secure communication between enterprise applications.

The capability to provide successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.

Internet Service Provider

The development, installation, and implementation of computer systems and applications.

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.

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.

A system that is considered old and possibly out-dated.

The integration of data between a legacy system and some other software program most commonly using HL-7 standards.

Longitudinal Patient Record is an EHR that includes all healthcare information from all sources.

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.

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.

A system for communication among two or more computers.

OCR is recognition of printed or written characters by a computer.

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.

Allow patients and providers to communicate over the Internet in a secure environment.

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.

Personal Health Information

Preventive Health Maintenance – see Health Maintenance.

A PHR includes all healthcare information from all sources, compiled and maintained by the patient.

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.

Practice Management (billing) system.

Patient Medical Record Information

Practice Management System

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

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

A website considered as an entry point to other websites. Examples are a Patient Portal.

Diagnosis list

Clinical Guidelines

Also called a drop-down menu. These are a menu of commands or options that appears when you select an item with a mouse.

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.

The primary mechanism for retrieving information from a database and consists of questions presented to the database in a predefined format.

Radio Frequency Identification

Return on investment typically means measuring an increase in revenue, a decrease in expense or an avoidance of expense.

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

Is the effort to create a secure computing platform, designed so that agents (users or programs) can only perform actions that have been allowed.

A group of networked servers that are housed in one location.

(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.

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.

A format for medical documentation. SOAP is an acronym for S-Subjective, O-Objective,

A-Assessment, P-Plan.

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

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

The T1 carrier is a commonly used digital Internet connection line in the US supporting data rates of 1.544Mbits per second.

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.

Often called a library or dictionary. Templates are pre-defined choices of pick-lists designed to streamline the documentation process.

A thin client is a network computer without a hard disc drive, as opposed to a fat client which includes a disc drive.

The process by which medical transcriptionists convert physician's dictation into written (typed) words.

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

Data which is not structured such as free-text. The computer cannot automatically extract properties and relationships from unstructured data.

See Speech Recognition

A way to communicate through a dedicated server securely to a corporate network over the internet.

A computer network that spans a larger geographical area than a LAN (Local Area Network).

A lecture, presentation, workshop or seminar that is transmitted over the Web. Short for Web-based Seminar.

A website considered as an entry point to other websites.

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

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.