Health IT and Electronic Health Definitions

This glossary explains the meaning of key words and phrases that information technology (IT) and business professionals use when discussing health IT and related software products. You can find additional definitions by visiting WhatIs.com or using the search box below.

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A
accountable care organization (ACO)

An accountable care organization (ACO) is an association of hospitals, healthcare providers and insurers in which all parties voluntarily assume financial and medical responsibility for Medicare patients.
Allscripts

Allscripts is a vendor of electronic health record systems for physician practices, hospitals and healthcare systems.
ambulatory medical record (AMR)

An ambulatory medical record (AMR) is an electronically stored file of a patient’s outpatient medical records, which includes all surgeries and care that do not involve being admitted to a hospital.
American Health Information Management Association (AHIMA)

The American Health Information Management Association (AHIMA) is a professional organization that promotes the business and clinical uses of electronic and paper-based medical information.
American Medical Association (AMA)

The American Medical Association (AMA) is a physician group that works for healthcare reform and publishes a collection of medical journals.

athenahealth Inc.

athenahealth Inc. is a developer of cloud-based practice management, point-of-care mobile applications and electronic health record (EHR) systems for small to medium-sized (SMB) physician practices and hospitals.
Patient Protection and Affordable Care Act (PPACA, ACA or Obamacare)

The Patient Protection and Affordable Care Act (more commonly referred to as the Affordable Care Act, ACA or Obamacare) is a healthcare law passed by Congress in 2010 during the administration of President Barack Obama.
B
Bar Coded Medication Administration (BCMA)

Bar Coded Medication Administration (BCMA) is a hospital inventory control system that uses barcodes in the distribution of prescription medications with the goal of ensuring the patient is receiving the correct medication.
biomedical informatics

Biomedical informatics is the branch of health informatics that uses data to help clinicians, researchers and scientists improve human health and provide healthcare.
C
Centers for Disease Control and Prevention (CDC)

Promoting a healthy general public and sharing data about chronic diseases are main goals of the Centers for Disease Control and Prevention (CDC).
Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS) is the wing of the U.S. Department of Health and Human Services that runs healthcare reimbursement and health IT programs.
Cerner Corp.

Cerner Corp. is a public company in North Kansas City, Mo., that provides various health information technologies, ranging from medical devices to electronic health records (EHR) to hardware.
Chief Medical Information Officer (CMIO)

A Chief Medical Information Officer, or CMIO, essentially serves as the bridge between medical and IT departments at a healthcare organization.
clinical decision support system (CDSS)

A clinical decision support system (CDSS) is an application that analyzes data to help healthcare providers make decisions and improve patient care.
Clinical Document Architecture (CDA)

Clinical Document Architecture (CDA) is a markup standard created by Health Level 7 International (HL7) that defines the structure of discharge summaries, progress notes and other medical records.
clinical documentation

Clinical documentation (CD) is the creation of a digital or analog record detailing a medical treatment, medical trial or clinical test.
clinical informatics

Clinical informatics, also known as health informatics, is the study of how technology and data analytics can be used to improve patient care plans.
clinical trial

A clinical trial, also known as a clinical research study, is a protocol to evaluate the effects and efficacy of experimental medical treatments or behavioral interventions on health outcomes.
computer assisted coding system (CACS)

A computer assisted coding system (CACS) is medical software that reviews healthcare forms, including electronic health records, and assigns appropriate medical codes to its findings.
computerized physician order entry (CPOE)

Computerized physician order entry (CPOE), also known as computerized provider order entry or computerized practitioner order entry, refers to the process of a medical professional entering and sending medication orders and treatment instructions electronically via a computer application instead of on paper charts.
Continuity of Care Document (CCD)

A Continuity of Care Document (CCD) is an electronic, patient-specific document detailing a patient's medical history.
Continuity of Care Record (CCR)

The Continuity of Care Record, or CCR, provides a standardized way to create electronic snapshots about a patient's health information.
What is Change Healthcare?

Change Healthcare is a healthcare technology provider specializing in revenue cycle management, payment management and health information exchange solutions.
What is Current Procedural Terminology (CPT) code?

Current Procedural Terminology (CPT) is a medical code set that enables physicians and other healthcare providers to describe and report the medical, surgical, and diagnostic procedures and services they perform to government and private payers, researchers and other interested parties.
D
DICOM (Digital Imaging and Communications in Medicine)

DICOM (Digital Imaging and Communications in Medicine) is a standard protocol for the management and transmission of medical images and related data and is used in many healthcare facilities.
What is digital health (digital healthcare)?

Digital health, also known as digital healthcare, is the use of digital technologies in healthcare.
E
eClinicalWorks

eClinicalWorks is a Massachusetts-based company that sells electronic medical record (EMR), practice management (PM) and personal health record (PHR) software and services to reportedly more than 115,000 physicians and 70,000 facilities in the United States.
electronic intensive care unit (eICU)

An Electronic Intensive Care Unit (eICU) is a form or model of telemedicine where state-of-the-art technology is used to provide an additional layer of critical care service to patients.
electronic protected health information (ePHI)

Electronic protected health information (ePHI) is protected health information that is produced, saved, transferred or received in an electronic form.
enterprise master patient index (EMPI)

An enterprise master patient index (EMPI) is a database that is used to maintain consistent and accurate information about each patient registered by a healthcare organization.
Epic Systems

Epic Systems, also known simply as Epic, is one of the largest providers of health information technology, used primarily by large U.S. hospitals and health systems to access, organize, store and share electronic medical records.
What is an electronic health record (EHR)?

An electronic health record (EHR) is an individual's official health document that's shared among multiple facilities and agencies.
F
FDA (U.S. Food and Drug Administration)

The FDA (U.S. Food and Drug Administration) regulates the production and sale of food, medicine, health technology and cosmetic products. The FDA, also called the USFDA, approves drugs and medical devices for sale and recalls unsafe products.
fee-for-service (FFS)

Fee-for-service (FFS) is a payment model in which doctors, hospitals, and medical practices charge separately for each service they perform.
FHIR (Fast Healthcare Interoperability Resources)

Fast Healthcare Interoperability Resources (FHIR) is an interoperability standard for electronic exchange of healthcare information.
G
genomics

Genomics is the study of an organism's entire genome, including all its genes and how those genes interact with each other and their environment.
H
health informatics

Health informatics is the practice of acquiring, studying and managing health data and applying medical concepts in conjunction with health information technology systems to help clinicians provide better healthcare.
Health Information Exchange (HIE)

Health information exchange (HIE) is the electronic transmission of healthcare-related data among medical facilities, health information organizations -- companies that oversee and govern the exchange of this data -- and government agencies according to national standards.
Health IT (health information technology)

Health IT (health information technology) is the area of IT involving the design, development, creation, use and maintenance of information systems for the healthcare industry.
healthcare CIO (healthcare chief information officer)

A healthcare CIO (healthcare chief information officer) is an executive at a healthcare organization that oversees the operation of the information technology department and consults with other C-level personnel on technology-related needs and purchasing decisions.
HIMSS (Healthcare Information and Management Systems Society)

The Healthcare Information and Management Systems Society (HIMSS) is a nonprofit organization whose goal is to promote the best use of IT and management systems in the healthcare industry.
HIPAA (Health Insurance Portability and Accountability Act)

HIPAA (Health Insurance Portability and Accountability Act) is United States legislation that provides data privacy and security provisions for safeguarding medical information.
HL7 (Health Level Seven International)

HL7 (Health Level Seven International) is a set of standards, formats and definitions for exchanging and developing electronic health records (EHRs).
What is HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009?

The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 is legislation that was created to stimulate the adoption of electronic health records (EHR) and the supporting technology in the United States.
I
ICD-10 (International Classification of Diseases, 10th Revision)

The International Classification of Diseases, 10th Revision (ICD-10), is a global standard for classifying and coding mortality and morbidity data.
ICD-10-CM (Clinical Modification)

The ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures related to inpatient and outpatient medical care in the United States.
ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System)

The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) is an American adaptation of the World Health Organization's ICD-10 system, tailored for procedural coding in inpatient and hospital settings.
What is ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification)?

The International Classification of Diseases, Ninth Revision, Clinical Modification, also known simply as ICD-9-CM, is the U.S. healthcare system's adaptation of the World Health Organization's (WHO) ICD-9 standard list of six-character alphanumeric codes to describe medical diagnoses and procedures and to track diseases and mortality.
J
Joint Commission

The Joint Commission is an independent group that presently accredits 20,500 healthcare facilities in the United States by performing onsite evaluations.
L
laboratory information system (LIS)

A laboratory information system (LIS) is computer software that processes, stores and manages data from patient medical processes and tests.
legal health record (LHR)

A legal health record (LHR) refers to documentation about a patient's personal health information that is created by a healthcare organization or provider.
M
MACRA (Medicare Access and CHIP Reauthorization Act of 2015)

MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is U.S. healthcare legislation that provides a new framework for reimbursing clinicians who successfully demonstrate value over volume in patient care.
McKesson Corp.

McKesson Corp. is a provider of medicines, pharmaceutical supplies and health information technology including nursing automation, practice management, clinical decision support systems, secure online healthcare communication and electronic health records systems. Based in San Francisco, it is one of the largest providers of these services in the United States and has more than 32,000 employees.
Meaningful Use

In the context of health IT, meaningful use is a term used to define minimum U.S. government standards for electronic health records (EHR), outlining how clinical patient data should be exchanged between healthcare providers, between providers and insurers and between providers and patients.
meaningful use stage 3

Meaningful use stage 3 is the third phase of the federal incentive program that details requirements for the use of electronic health record systems by hospitals and eligible healthcare professionals. However, the new MACRA law will change the overall meaningful use program, which may eventually lessen stage 3's influence.
medical scribe

A medical scribe is a professional who specializes in documenting patient encounters in real time under the direction of a physician.
medical transcription (MT)

Medical transcription (MT) is the manual processing of voice reports dictated by physicians and other healthcare professionals into text format.
Meditech (Medical Information Technology Inc.)

Meditech (Medical Information Technology Inc.) is an electronic health record vendor that holds a 19% market share in the hospital industry, but faces intense competition.
mHealth (mobile health)

mHealth (mobile health) is a general term for the use of mobile phones and other wireless technology in medical care.
N
national provider identifier (NPI)

A national provider identifier (NPI) is a unique ten-digit identification number required by the Health Insurance Portability and Accountability Act (HIPAA) for covered healthcare providers in the United States.
O
ONC (Office of the National Coordinator for Health Information Technology)

The Office of the National Coordinator for Health Information Technology, abbreviated ONC, is an entity within the U.S. Department of Health and Human Services (HHS).
P
personal health record (PHR)

A personal health record (PHR) is an electronic summary of health information that a patient maintains control of themselves, as opposed to their healthcare provider.
pharmaceutical detailing

Pharmaceutical detailing is a 1:1 marketing technique pharmaceutical companies use to educate a physician about a vendor's products, hoping that the physician will prescribe the company's products more often.
PHI breach (protected health information breach)

A PHI breach is unauthorized access, use or disclosure of individually identifiable health information that is held or transmitted by a healthcare organization or its business associates.
point of care (POC) testing

Point of care testing (POC testing or POCT) is medical testing performed with the patient, outside of a laboratory setting. POC testing is also known as bedside testing, near-patient testing, remote testing, mobile testing and rapid diagnostics.
population health management (PHM)

Population health management (PHM) is a discipline within the healthcare industry that studies and facilitates care delivery across the general population or a group of individuals.
precision medicine (PM)

Precision medicine (PM) is a rapidly evolving development in healthcare in which physicians and other caregivers consider differences in genes, socioeconomic status and lifestyles when devising treatment regimens for patients.
problem list

A problem list is a document that states the most important health problems facing a patient such as nontransitive illnesses or diseases, injuries suffered by the patient, and anything else that has affected the patient or is currently ongoing with the patient.
Project Nightingale

Project Nightingale is a controversial partnership between Google and Ascension, the second largest health system in the United States. The partnership, which began in 2018, has provided Google with access to the medical records of over 50 million people.
What is PHI (protected or personal health information)?

Protected health information (PHI), also referred to as 'personal health information,' is the demographic information, medical histories, test and laboratory results, physical and mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care.
What is picture archiving and communication system (PACS)?

Picture archiving and communication system (PACS) is a medical imaging technology used primarily in healthcare organizations to securely store and digitally transmit electronic images and clinically relevant reports.
R
radiology information system (RIS)

A radiology information system (RIS) is a networked software system for managing medical imagery and associated data.
Regional Health Information Organization (RHIO)

A Regional Health Information Organization (RHIO) is a group of organizations within a specific area that share healthcare-related information electronically according to accepted healthcare information technology (HIT) standards.
registered health information technician (RHIT)

A registered health information technician (RHIT) is a certified professional who stores and verifies the accuracy and completeness of electronic health records.
remote patient monitoring (RPM)

Remote patient monitoring (RPM) is a subcategory of homecare telehealth that allows patients to use mobile medical devices or technology to gather patient-generated health data (PGHD) and send it to healthcare professionals.
revenue cycle management (RCM)

Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance to ensure proper identification, collection and management of revenues from patient services.
RHIA (Registered Health Information Administrator)

An RHIA, or registered health information administrator, is a certified professional who oversees the creation and use of patient health information, including analyzing that data.
S
SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms)

SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms) is a standardized, multilingual vocabulary of clinical terminology that is used by physicians and other health care providers for the electronic exchange of health information.
T
telehealth (telemedicine)

Telehealth, also referred to as telemedicine or e-medicine, is the remote delivery of healthcare services over the telecommunications infrastructure.
U
US Department of Health and Human Services (HHS)

The U.S. Department of Health and Human Services (HHS) is a cabinet-level agency in the executive branch of the federal government. Its mission is to enhance and protect the well-being of all Americans by providing effective health and human services and fostering advances in medicine, public health and social services.
V
value-based healthcare

Value-based healthcare, also known as value-based care, is a payment model that rewards healthcare providers for providing quality care to patients.
vendor neutral archive (VNA)

A vendor neutral archive (VNA) is a technology that stores medical images in a standard format and interface, making them accessible to healthcare professionals regardless of what proprietary system created the images.