Fundamentals of HIT
|ARRA||An economic stimulus package enacted by the 111th United States Congress in February 2009. The Act of Congress was based largely on proposals made by President Barack Obama and was intended to provide a stimulus to the U.S. economy in the wake of the economic downturn. The measures are nominally worth $787 billion.|
|Ambulatory Surgical Center||A place other than a hospital that does outpatient surgery. You may stay for only a few hours and no more than one night.|
|Capitation||A health insurance payment mechanism in which a fixed amount is paid per person to cover services; a fixed, per capita (per head) payment.|
|Backward Compatibility||Capability of an information system to work with earlier versions. Important consideration in working with legacy systems.|
|802.11x||A wireless networking standard ratified by the IEEE in late 1999 and supported by the largest wireless local area network (WLAN) vendors. Also known as Wi-Fi. 802.11b has data transfer rates of 11Mbs. 802.11g (newer standard has rates of 54 Mbs).|
|Best of breed||Information technology strategy where the best products are adopted, irrespective of their ability to be integrated.|
|CDR||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.|
|Bandwith||A measure of how much information can be transmitted at once through a communication medium, such as a telephone line, fiber-optic cable, or radio frequency. Usually reported in Megabits per second (Mbps).|
|Allowed Charge||This is the amount Medicare approves for payment to a physician, but may not match the amount the physician gets paid by Medicare (due to co-pay or deductibles) and usually does not match what the physician charges patients. Medicare normally pays 80 percent of the approved charge and the beneficiary pays the remaining 20 percent. The allowed charge for a nonparticipating physician is 95 percent of that for a participating physician. Non-participating physicians may bill beneficiaries for an additional amount above the allowed charge. The CMS intermediary in each state publishes these rates.|
|Anti-kickback statutes||Prohibits certain solicitations or receipt of remuneration and the offer or payment of certain remuneration. It has generally been applied to broker-style arrangements, whereby an individual offers remuneration to another individual for the purpose of recommending or referring an individual for the furnishing or arranging for an item or service.|
|ASP||Hosts applications on servers in ASP data centers to allow users to get connected and use applications as if they were located in the client's own site. An ASP handles maintenance and upgrades to lower the total cost of ownership (TCO) for clients, while minimizing the risks and costs of keeping highly skilled IT talents.|
|ANSI X12 Standard||This is a standard format used for transmitting business data, developed by the Data Interchange Standards Association. The parties who exchange EDI transmissions are referred to as trading partners. Data that is transmitted often includes what would usually be contained in a typical business document or form.|
|Accreditation||An evaluative process in which a healthcare organization undergoes an examination of its policies, procedures and performance by an external organization ("accrediting body") to ensure that it is meeting predetermined criteria. It usually involves both on- and off-site surveys.|
|AMIA||The first professional group to issue guidelines for physician-patient e-mail. Dedicated to promoting the effective organization, analysis, management, and use of information in health care in support of patient care, public health, teaching, research, administration, and related policy.|
|Alerts||An automated warning system within an EHR system that provides clinical alerts, preventive health maintenance information, medication interactions, etc., to users.|
|Acute Care||A pattern of healthcare in which a patient is treated for immediate and severe episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Unlike chronic care, acute care is often necessary for only a short time.|
|Access Point||Radio-based device that provides users of wireless devices with access to a local area network (LAN).|
|ADT||Usually a hospital database containing patient admission and discharge data. Often a source of patient demographics through HL7 interface.|
|Admission Date||The date the patient was admitted for inpatient care, outpatient service, or start of care. For an admission notice for hospice care, enter the effective date of election of hospice benefits.|
|Ancillary Services||Professional services by a hospital or other inpatient facility. These may include x-ray, drug, laboratory, or other services.|
|CCR||It is intended to foster and improve continuity of patient care, to reduce medical errors, and to assure at least a minimum standard of health information transportability when a patient is referred or transferred to, or is otherwise seen by, another provider.|
|CCHIT||A voluntary, private-sector organization launched in 2004 to certify health information technology (HIT) products such as electronic health records and the networks over which they interoperate|
|AHIMA||A community of professionals engaged in health information management, providing support to members and strengthening the industry and profession.|
|Advance Directives||A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.|
|Access||The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care. Efforts to improve access often focus on providing/improving health coverage.|
|Adverse Event||An injury to a patient resulting from a medical intervention. As regards clinical studies, adverse events are any adverse changes in health or "side-effects" that occur in a person who participates in a clinical trial while the patient is receiving the treatment (study medication, application of the study device, etc.) or within a pre-specified period of time after their treatment has been completed.|
|Ambulatory Care||Health services provided without patient admission or overnight stay. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading provided that the patient remains at the facility less than 24 hours. Also called outpatient care.|
|AHRQ||Federal government agency within HHS that, among other things, maintains the National Guideline Clearinghouse of clinical guidelines.|
|ALOS||Refers to the average length of stay per inpatient hospital visit. The figure is typically calculated for both commercial and Medicare patient populations.|
|CDC||The U.S. government agency at the forefront of public health efforts to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats. The CDC is one of 13 major operating components of the Department of Health and Human Services.|
|ASTM CCR Standard||A patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or EMR systems, allowing easy interoperability between otherwise disparate entities.|
|Biometric / Biometric identifier||Physical characteristic (e.g., fingerprint) of a computer user used to provide authentication. Confidentiality laws and HIPAA privacy rules refer to biometric identifiers.|
|CDSS|| This is a critical component of any EMR|
system. Its focus is to aid the care-giver in the
care decision making process by monitoring
relevant information and producing alerts or
reminders when certain events occur.
|CDT|| A code set with descriptive terms developed|
and updated by the American Dental Associ-
ation (ADA) for reporting dental services and
procedures to dental benefit plans. Many of
the codes are published by CMS as HCPCS
D-codes under arrangement with the ADA.
|CIS|| This term is sometimes used interchange-|
ably with EMR. Typically covers: *Pathology
and radiology order entry and results report-
ing; *Medication prescribing, supply and ad-
ministration; Clinical work lists; Problem
lists; Clinical notes; and Decision support.
|CMO|| Executive with responsibility for leading the|
medical affairs of a healthcare provider orga-
nization (may have multiple other names).
|CPOE|| A computer application that allows a physi-|
cian's orders for diagnostic and treatment ser-
vices (such as medications, laboratory, and
other tests) to be entered electronically in-
stead of being recorded on order sheets or
|CPT|| A uniform coding system that consists of|
descriptive terms and identifying codes that
are used primarily to identify medical services
and procedures furnished by providers and is
maintained by the AMA.
|CPU|| Primary area of electronic circuitry in a|
computer where processing takes place.
|Capitation|| A health insurance payment mechanism in|
which a fixed amount is paid per person to
cover services; a fixed, per capita (per head)
|ANSI||The U.S. standards organization that es-|
tablishes procedures for the development and
coordination of voluntary standards. Also ac-
credits various standards-setting committees,
and monitors their compliance with the open
rule-making process. HIPAA prescribes that
mandated standards be developed by accred-
ited bodies whenever practical.
|Change management|| Process of overcoming resistance to change|
and promoting adoption (of EHR). Change
management strategies are often incentive-
based, behavioral norm-based, sanction-
based, or adoption based.
|Claim|| An itemized statement of health care ser-|
vices and their costs provided by a hospital,
physician's office or other health care facility.
Claims are submitted to the plan by either
the plan member or the provider for payment
of the costs incurred.
|Claim Form||An application for payment of benefits under a health care plan.|
|Clearinghouse|| A service providing connectivity between|
healthcare providers and payers (HMOs, in-
surers, government entities such asMedicare).
They translate and reformat claims according
to the specifications by payers and re-transmit
them to their original destination. They may
also add edit functions to check the validity
and completeness of the claims.
|Clinical Messaging|| Secure transmission of health informa-|
tion messages; often accomplished through
provider and/or patient portals.
|DICOM|| The industry standard for transferral and|
storage of diagnostic images from medical
modalities such as radiology, cardiology, etc.
This standard enables digital communication
between diagnostic equipment and systems
from various manufacturers.
|DBMS|| A set of computer programs for organizing|
the information in a database. These pro-
grams support the structuring of the database
in a standard format and provides tools for
data input, verification, storage, retrieval,
query, and manipulation.
|Cost/Benefit Analysis||Compares costs to tangible, financial bene-fits of an investment. Benefits and costs are|
often expressed in money terms, and are ad-
justed for the time value of money, so that
all flows of benefits and flows of project costs
over time (which tend to occur at different
points in time) are expressed on a common
basis in terms of their "present value."
|DRG|| A classification system that groups patients|
according to diagnosis, type of treatment, age
and other relevant criteria for the purposes of
payment to hospitals.
|Data Mining|| Analyzing information in a database using|
tools that look for trends or anomalies with-
out knowledge of the data's meaning. Mining
a clinical database may produce new insights
on outcomes, alternate treatments, or effects
of treatment on different races and genders.
|DSL|| A technology for delivering high-bandwidth|
service (Internet or data) over ordinary cop-
per telephone lines.
|Data Repository|| A database acting as an information storage|
facility. Although often used synonymously
with data warehouse, a repository does not
have the analysis or querying capabilities of a
|Data Dictionary|| A list that describes the specifications and|
locations of all data contained in a system.
|Data Storage|| Requirements to store data, applications,|
backup, multimedia, etc., on a storage
medium (disk, tape, CD, DVD, etc.). Ex-
pressed in Megabytes, Gigabytes, Terabytes,
|Data Synchronization|| The process of sending updates between|
a mobile computing device and a personal
computer or application server in order to
keep both sets of files synchronized. Some-
times called "hot syncing." Sometimes spelled
|Data warehouse|| A large database that stores information|
like a data repository but goes a step fur-
ther, allowing users to access data to perform
research oriented analysis.
|De-identified Data|| Health care information from which indi-|
vidual identifying information (as specified
by HIPAA) has been stripped.
|Database|| An aggregation of records or other data|
that is updateable. These are used to manage
and archive large amounts of information.
|Digital Certificate|| Type of digital signature that binds the|
identity of an individual with a public key in
an asymmetric encryption technology.
|Digital Signature|| Sometimes referred to as Advanced Elec-|
tronic Signature. Takes the traditional hand-
written signature and creates a digital image
of the signature to eliminate the need to print
and sign documents.
|Database Server|| A computer that stores data centrally for|
network users. It often uses client/server
software to distribute the processing of data
among itself and other workstations on the
|Drug Formulary|| A list of preferred pharmaceutical products|
that health plans, working with pharmacists
and physicians, have developed to encourage
greater efficiency in the dispensing of prescrip-
tion drugs without sacrificing quality.
|EDC|| The use of electronic technology to gather|
and collect data, especially in the context of
clinical trials. Allows data to be aggregated,
sorted, shared, and searched more easily than
paper-based records. May be Web-based, use
handheld computers, etc.
|EDI||Standardized electronic format for business|
transactions sent from one computer to an-
other computer system. Consists of strings
of data in a pre-arranged accepted format by
both sending and receiving computer systems.
Also includes electronic claims submission,
electronic remittance notices and electronic
eligibility checks, etc.
|EHR||A real time patient health record or any|
other information relating to the past, present
or future physical and mental health, or con-
dition of a patient which resides in computers
which capture, transmit, receive, store, re-
trieve, link, and manipulate multimedia data
for the primary purpose of providing health
care and health-related services.
|EMR||A computer-based patient medical record|
that facilitates: *access of patient data by
clinical staff at any given location; *accurate
and complete claims processing by insurance
companies; *building automated checks for
drug and allergy interactions; *clinical notes;
prescriptions; scheduling; *sending to and
viewing by labs.
|EOB|| A form sent to the enrollee after a claim|
for payment has been processed by the health
plan. The form explains the action taken on
that claim. This explanation usually includes
the amount paid, the benefits available, rea-
sons for denying payment, or the claims ap-
|Ethernet|| Probably the most commonly used stan-|
dard for local area network (LAN) architec-
ture. It supports data transfer rates of up to
10 megabits per second, although newer sys-
tems support transfer rates of 100 Mbps and
1 gigabit (1,000 megabits) per second.
|Encryption|| The use of an algorithmic process to trans-|
form data into a form in which there is a low
probability of assigning meaning without use
of a confidential process or key.
|Evidence Based Medicine|| The use of evidence (scientific information)|
and clinical expertise to make clinical deci-
sions regarding the effectiveness of a specific
treatment or diagnostic test, how well it works
in comparison to other treatments or tests,
and what, if any, risks are associated with a
therapy or test.
|Enterprise-Wide Network|| A network in which all computers in the|
various facilities of an organization (e.g., a
health care system) are connected.
|Fat Client|| In a client/server system, a client that per-|
forms most of the necessary data processing
itself, rather than relying on the server.
|Federal Qualified|| An HMO meeting certain federal qualifica-|
tions under Title XIII of the Public Health
|Fee Schedule|| A complete listing of fees used by the plans|
to pay providers.
|Firewall|| A system that secures a network, shield-|
ing it from access by unauthorized users. It
can be implemented in software, hardware or
a combination of both. In addition to pre-
venting unrestricted access into a network, it
can also restrict data from flowing out of a
|Fee for service payment|| A payment method in which the insurer will|
reimburse the member or provider directly for
each covered medical expense (professional
service, laboratory, x-ray, injections, etc.).
|Flow process chart|| Tool for describing and analyzing the steps|
and their flow in a process.
|File Server|| A computer dedicated to managing the flow|
of information among networked computers
and used as a storage location for data and
applications shared by network users.
|Gantt Chart|| Project management chart displaying|
project tasks and bars indicating duration and
|Go-Live|| Moment in time at which a new information|
system is turned on for production use.
|HCPCS|| A uniform method for providers to report|
professional services, procedures, and sup-
plies. Includes CPT codes (Level I) and na-
tional alphanumeric codes (Level II).
|HIE|| The movement of healthcare information|
electronically across organizations within a
region or community. Provides the capability
to electronically move clinical information be-
tween disparate healthcare information sys-
tems while maintaining the meaning of the
information being exchanged.
|HHS|| The United States government's principal|
agency for protecting the health of all Amer-
icans and providing essential human services,
especially for those who are least able to help
|HEDIS|| A set of standardized performance mea-|
sures, used in NCQA accreditations, designed
to ensure that purchasers and consumers have
the information they need to reliably com-
pare the performance of managed health care
|HIMSS|| The healthcare industry's membership or-|
ganization exclusively focused on providing
leadership for the optimal use of healthcare
information technology and management sys-
tems for the betterment of human health.
|HIPAA||A federal health benefits law effective July|
1, 1997 that protects people who change jobs,
are self-employed or who have pre-existing
medical conditions. Standardizes an ap-
proach to the continuation of health care ben-
efits for individuals and members of small
group health plans and establishes parity be-
tween the benefits extended to these individ-
uals and those benefits offered to employees
in large group plans.
|HMO|| A type of managed-care organization that|
provides health care coverage through con-
tracts with specific health care providers.
Such organizations may restrict coverage to
only those services and providers that have
|HITSP||With the American National Standards In-|
stitute (ANSI), this organization of 18 inde-
pendent entities serves as a cooperative part-
nership between the public and private sectors
for the purpose of achieving a widely accepted
and useful set of standards specifically to en-
able and support widespread interoperabil-
ity among healthcare software applications,
as they will interact in a local, regional and
national health information network for the
|ICD|| Classification system that groups related|
disease terms; used throughout the world for
reporting mortality data and some morbidity
data; ICD-9-CMis the clinical modification of
the 9th edition used in the U.S. for reimburse-
ment coding of diagnoses (most other parts of
the world are using the 10th edition, ICD-10)
|HL7|| One of several accredited standards (spec-|
ifications or protocols) established by ANSI
(American National Standards Institute) for
clinical and administrative data. Compliant
systems improve the ability for interoperabil-
ity and exchange of electronic data.
|IP|| Set of rules to exchange messages over the|
Internet. It has the task of delivering distin-
guished protocol datagrams (packets) from
the source host to the destination host solely
based on their addresses.