EHR Glossary of Terms

Transcription

1 EHR Glossary of Terms American Recovery and Reinvestment Act of 2009 (ARRA): budget bill enacted by Congress and signed by President Obama on February 17, 2009 that was designed to provide an economic stimulus to the country. ARRA (also referred to as HITECH for the provisions dealing with EHR) created incentives for physician and hospital adoption of EHR while imposing additional security provisions beyond HIPAA to protect medical records from unauthorized disclosure. Application Service Provider (ASP): a third-party entity managing and distributing software-based services and solutions to customers over the internet from a central data center. Backup: to copy files to a second medium (e.g., a disk or tape) as a precaution in case the first medium fails. One of the cardinal rules in using computers is back up files regularly. Even the most reliable computer is apt to break down eventually. Many professionals recommend making two, or even three, backups of all files. To be especially safe, keep one backup in a different location from the others. Business Continuity Plan: a plan created that outlines what the practice s procedures will be in the case of an emergency. As practices become more dependent upon an EHR, the cost of a major failure or outage becomes quite large. A Business Continuity Plan will provide for recovery and resumption of operations in the event of a major outage. Card Scanner: a tool used to copy/capture information from driver s licenses, insurance cards, etc. and transfers the data to the patient s record in the EHR. Certification Commission for Healthcare Information Technology (CCHIT): a private nonprofit organization with the sole public mission of accelerating the adoption of robust, interoperable health information technology by creating a credible, efficient and impartial certification process. To date, CCHIT certification is the only widely recognized national certification procedure accepted as a national standard for EHR systems. Chart Conversion: the process of deciding and implementing the means to get data from the practice s paper charts into the new EHR. Client-Server Model: a dedicated server located at a physician s office that handles most of the software processing tasks, while less-powerful (typically older) computers in the practice can access and share files, programs and computing prowess with the server. OSMA EHR Glossary of Terms 5/15/09 Page 1

2 Clinical Decision Support: typically used when referring to a type of system that assists healthcare providers in making medical decisions. These types of systems typically require input of patient-specific clinical variables. Clinical Information: refers to data contained in the patient record. The data may include information such as problem lists, lab results, current medications, family history, patient identification, and insurance information. Clinical Information System (CIS): an information system which is oriented around the care delivery process, and that captures data, stores it and makes the data available to authorized persons for supporting care. The CIS includes clinical diagnostic results and clinical documentation, including nursing notes, progress notes, vital signs and intake and output. It also can involve clinical alerts and reminders. Consolidated Health Informatics (CHI): a federal initiative that requires federal agencies that engage in healthcare activities to adopt a common set of clinical, administrative, and messaging standards. Continuity of Care: the process by which the patient and the physician are cooperatively involved in ongoing healthcare management toward the goal of high-quality, cost-effective medical care. CORE Certification: voluntary national standards certification for health plans, providers, software systems vendors and clearinghouses by the Council for Affordable Quality Healthcare (CAQH). CORE certification addresses issues of interconnectivity in the eligibility and benefits determination area and the health care claims payment area. Desktop Computer: A computer designed to fit comfortably on top of a desk, typically with the monitor sitting on top of the computer. Docking Station: computer equipment that enables the user of a laptop to turn it into a personal computer (pc) utilizing a full keyboard and monitor. Document Imaging: creating an electronic image in a computer file from a paper document, typically through scanning. Document Scanner: an electronic device used for scanning paper medical records and converting them into an electronic medical record. EHR Standards of Excellence Program (EHR SOE): OSMA program established in March 2008 that provides OSMA members with physician-friendly contract terms as well as a discount from participating vendors on the purchase of an EHR. OSMA EHR Glossary of Terms 5/15/09 Page 2

3 Electronic Health Record (EHR): a patient-centric clinical record designed to give an overall view of the patient s clinical history. The term is often used to imply that the information system or systems providing data for the EHR should be interoperable among providers. Electronic Medical Record (EMR): a record of a patient s clinical history and information stored in an electronic format. The EMR data can be stored either at the physician s office site or remotely at a site controlled by an application service provider (ASP). e-prescribing (erx): the ability of a physician or other authorized health care provider to prescribe for patients by use of an online pharmaceutical program that can transmit the prescription electronically to the pharmacy, provide information to the physician on drug-todrug interactions and allergies, and give the patient educational information on the drug and its use. Hardware: devices to capture, process, and transmit data in an electronic form. Hardware includes such components as computers and network equipment. Health Information Technology (HIT): the acquisition, storage, retrieval, and use of electronic information in a health care setting. Health Information Technology for Economic and Clinical Health Act (HITECH): the healthcare portion of ARRA that provides $19 billion for health information technology and other incentives that support and promote the adoption of electronic health records (EHRs). Other provisions in HITECH increase the enforcement of laws and regulations governing the privacy and security of personal health information. Covered entities, such as physician offices, and their business associates will continue to have to comply with federal privacy and security standards as well as any state law requirements. Health Insurance Portability and Accountability Act (HIPAA): a federal statute governing, among other things, development of national health information data standards and privacy and security standards. Health Level Seven (HL7): One of the several standards-developing organizations (SDOs) accredited by the American National Standards Institute (ANSI) that operate in the healthcare area. HL7 s domain is clinical and administrative data. Implementation Plan: once a decision is made to purchase an EHR, this document is created to clarify objectives, assign tasks with deadlines, and charts progress in reaching goals and milestones to ensure success. Infrastructure: those elements of information and communications technology that support the use of electronic software, but do not include the software applications. This typically includes such support essentials as electrical power and HVAC, network OSMA EHR Glossary of Terms 5/15/09 Page 3

4 transport, backup and recovery, hardware and operating systems and operational processes and procedures. Integration: the process of ensuring all elements in an information system can communicate and can act as a uniform entity (e.g., the interaction of an office s practice management system, billing system and clinical records system). Integrated System: a system that combines both a practice management system with an EHR product; usually also includes e-prescribing, scanning capabilities, etc. Interface: a program designed to enable the exchange of data between two sources; enable software to connect one information system to another, to share certain data or outputs, to join systems to perform tasks seamlessly and without double entry of data. Internet: a worldwide system of computer networks that allows users to send and receive information among computers. Internet Service Provider (ISP): a company that offers its customers access to the Internet. The ISP connects to its customers using a data transmission technology appropriate for delivering Internet Protocol datagrams, such as dial-up, DSL, cable modem or dedicated high-speed interconnects. Interoperability: the capability of various systems to pass meaningful information between them (e.g., the ability of a hospital s EHR system to communicate with a physician s office EHR system). Kiosk: a free-standing self-service booth used in a physician s office to enable patients to register, view educational materials, etc. Laptop: a portable microcomputer small enough to rest on the user's lap. Maintenance Agreement: a legal document that outlines the maintenance schedule and associated costs for upkeep of hardware and/or software purchased from a vendor. Meaningful Use: the term, yet to be defined by the federal government, that will determine the success of a physician s or hospital s use of an EHR system and allow the drawing down of federal incentive dollars. There are three components of meaningful use in the federal stimulus bill (ARRA): 1) use of e-prescribing; 2) interconnectivity of the system; and 3) quality reporting. Medicare Improvements for Patients and Providers Act (MIPPA): federal statute that created new financial incentives to encourage Medicare physicians to adopt technology to allow them to order prescriptions electronically (e-prescribing). The goal of e-prescribing is to reduce medical errors and help physicians consider cost issues as they make prescribing decisions. Beginning in 2009, physicians could receive a 2 percent increase in OSMA EHR Glossary of Terms 5/15/09 Page 4

5 payments, phasing down to 0.5 percent in However, in 2014 and afterward, physicians that have not implemented e-prescribing will lose 2 percent of their payments. Modules: additional software packages that can be added to the EHR such as a laboratory information system, clinical information system, etc. There is normally an additional charge for the purchase of each module. Monthly Subscription Option: an option offered by EHR vendors that enables physicians to pay a monthly fee to the vendor to access the vendor s EHR product. By utilizing this option, the EHR vendor owns the software, not the physician. Needs Assessment: the process used to identify clinical and workflow needs in the physician s office. This process generates a document that describes the plan for success. Network: a set of connected computers that is able to communicate and share data or programs. Operating System: the software program that provides the commands and logic that operates the computer. Operational Capacity: an assessment of a practice s infrastructure preparedness to ensure technology adoption. Personal Computer (PC): a computer designed for the individual user. Personal Digital Assistant (PDA): a handheld computer loaded with personal productivity tools such as a calendar, address book, word processing, and spreadsheet functions. Personal Health Record (PHR): a health record maintained by the patient that incorporates clinical information from various providers. Phased Implementation: a stepped process, over a specific time period, of implementing a Practice Management and/or EHR product. Physician Quality Reporting Initiative (PQRI): The 2006 Tax Relief and Health Care Act (TRHCA) that required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries. MIPPA made the PQRI program permanent, but only authorized incentive payments through The 2009 PQRI consisted of 153 quality measures and 7 measures groups. Portal: a web site considered as an entry point to other web sites, often by being gthe search engine or providing access to a search engine. OSMA EHR Glossary of Terms 5/15/09 Page 5

6 Practice Management System (PMS): a system used in physicians offices that addresses workflow issues in all areas but clinical data, e.g., scheduling, billing, and collections. Protected Health Information (PHI): individually identifiable health information that is transmitted or maintained in any form except for individually identifiable health information in school or employment records. The physician office practice information to which federal rules governing use and disclosure apply is patient medical and billing records. Readiness Assessment: a review of workflow procedures in a physician s office that indicates what improvements to office workflow needs to be made prior to EHR implementation. Regional Health Information Organization (RHIO): an organization whose purpose is to support and promote the formation and operation of health information sharing organizations to support coordination of care and care delivery improvement among providers. Return on Investment (ROI): a measurement of success of a project; the percent of profit earned on an investment. Scalability: the ability of a system to expand, such as when a practice needs to add additional users. Server: a computer on a network that stores commonly used data or programs and makes those available on demand to clients on the network. Software: a computer program used to run an EHR application such as Windows, Internet Explorer, Macintosh. Software Licenses: contracts between a physician s office and a software vendor that allows the physician to use the software of the vendor. Typically, there is a fee associated with the use of each component of a software system. Speech/Voice Recognition: software that converts spoken word into written text. Tablet: a type of flat graphics computer using a stylus, digital pen, or fingertip instead of a keyboard or mouse. Technical Support/Help Desk: the customer service area of a software vendor designed to provide support to an office for questions about the use of the software. Templates: a form or pattern to capture data in a structured manner. Third Party Software: software created by programmers or publishers independent of the manufacturer of the hardware for which it is intended. OSMA EHR Glossary of Terms 5/15/09 Page 6

7 Upgrades: the process of updating a computer with the most recent information or software program. Virtual Private Network (VPN): a network of data lines that makes it possible to have secure sharing of public resources for the transmission of data. Webmaster: the person responsible for the designing, developing, marketing or maintaining a website. Workgroup for Electronic Data Interchange (WEDI): national group established to develop standards to facilitate the exchange of electronic healthcare information. Workflow: the study of how processes and functions are performed in an office setting. This document was developed for general informational purposes and may not include everything you need to know regarding your particular practice situation. Be advised that this information is current as of May 2009 and that laws and other references are subject to change. Users should consult a professional with expertise in this area with specific questions regarding this topic. Do not rely on this information as comprehensive or authoritative legal or other professional advice. OSMA EHR Glossary of Terms 5/15/09 Page 7