Automated Dispensing Cabinets
Computerized drug storage devices or cabinets that allow medications to be stored and dispensed near the point of care, while controlling and tracking drug distribution.
Adverse drug reaction
Agency for healthcare research and quality
One of the federal agencies within the Department of Health and Human Services. AHRQ's mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans.
American Medical Informatics Association
Ancillary services are supplemental services in the hospital setting, including laboratory, radiology, physical therapy, and inhalation therapy that are provided in conjunction with medical or hospital care.
American Recovery and Reinvestment Act
On February 17, 2009, Congress passed the American Recovery and Reinvestment Act of 2009 at the urging of President Barack Obama, who signed it into law 4 days later. A direct response to the economic crisis, the Recovery Act has 3 immediate goals:
- Create new jobs and save existing ones.
- Spur economic activity and invest in long-term growth.
- Foster unprecedented levels of accountability and transparency in government spending.
Bar-Coded Medication Administration
An electronic system that confirms patient ID and medication at the point of drug administration in an effort to avoid potentially harmful medication administration errors.
All the functionality of the new system will be implemented at the same time, instead of an incremental phased-in approach.
Best of breed
BoB EDISs are designed specifically for EDs and usually offer better workflow, content, and functionality. However, a BoB EDIS requires interfacing with the HIS and registration system to function properly.
“Build your own” approach
BYO system development requires many more IT resources and likely a longer development time than purchasing a packaged system, but there have been several very successful examples. In fact, many of the BoB EDISs were originally created in this way. Advantages include flexibility and customization, and they are much more likely to interface well with existing systems. However, depending on the resources available, this approach may result in a less robust system.
ASTM Continuity of Care Record (CCR)
An XML-based standard for the movement of “documents” between clinical applications. Furthermore, it responds to the need to organize and make transportable a set of basic information about a patient's healthcare that is accessible to clinicians and patients.
Continuity of care document
The result of a collaborative effort between the Health Level Seven (HL7) and American Society for Testing Materials (ASTM) to “harmonize” the data format between ASTM's continuity of care record (CCR) and HL7s clinical document architecture (CDA) specifications.
CCDS is a collaborative effort to identify a core set of human and mouse protein coding regions that are consistently annotated and of high quality. The long-term goal is to support convergence toward a standard set of gene annotations. The NCBI, Ensembl, and Sanger (Havana) annotation of the human reference genome (NCBI build 37.2) was analyzed to identify additional coding sequences (CDS) that are consistently annotated. CCDS data is available in the CCDS website and FTP site and will become available in the collaborators' genome and/or gene browser websites according to each browser's update cycle.
Certification commission for healthcare information technology
An independent, voluntary, private-sector initiative founded in 2005 to accelerate the adoption of robust, interoperable health information technology by creating a credible, efficient certification process. CCHIT is currently the only certifying body of its kind in the United States.
Clinical decision support
CDS systems (CDSS) assist the physician in applying new information to patient care and help to prevent medical errors and improve patient safety. Many of these systems include computer-based programs that analyze information entered by the physician and consider order sets, drug-drug interactions and patient allergies to inform clinical decisions.
Chief information officer
Clinical information systems
General term referring to IT implementations within healthcare settings that assist in medical care delivery.
Consolidated Digitalized Environment
Describes a “system of systems” where all information is ultimately recorded in digital format.
Centers for Medicare and Medicaid Services
Computer on wheels (also WOW)
Computerized provider order entry
Selection, entry, and transmittal of orders via a computerized system.
Current Procedural Terminology
CPT® is a registered trademark of the American Medical Association that refers to numeric codes that are assigned to every task and service provided by medical practitioners. The codes are used by insurers to determine the amount of reimbursement that a practitioner will receive from the insurer.
CQI is an approach to quality management that builds upon traditional quality assurance (QA) methods by emphasizing the organization and systems: it focuses on “process” rather than the individual; it recognizes both internal and external “customers”; it promotes the need for objective data to analyze and improve processes.
Department of Health and Human Services
A cabinet department of the US government with the goal of “improving the health, safety, and well-being of America.”
Discharge functions include the following: prescription writing (preferably electronically written and transmitted, even though they may frequently be printed); discharge education (information about the patient's condition) and instructions (how to care for the condition, as well as precautions, including what signs and symptoms should prompt a return); follow-up information, including referrals to specialists or back to PCPs; and detailed visit information (eg, medications that were prescribed and administered in the ED and related precautions).
Emergency department information system
Electronic health record systems designed specifically to manage data in support of Emergency Department patient care and operations.
A type of physician-patient electronic communication that is a two-way exchange of clinical information revolving around a particular clinical question or problem specific to the patient. It may be initiated by either the patient or the caregiver.
Electronic health record
EHR is an evolving concept referring to health information about individual patients that is stored in digital format with the capacity to share specified components across different healthcare settings.
EMR is often used interchangeably with EHR, but there is a slight difference in that the EMR is the legal patient record created in hospitals and ambulatory environments which serves as the data source for the EHR.
Electronic medical administration record
A system that automates the paper-based Medication Administration Record (MAR) process.
A strategic resource that aligns business and technology, leverages shared assets, builds internal and external partnerships, and optimizes the value of information technology services.
Computer technology in which physicians use handheld or personal computer devices to review drug and formulary coverage and transmit prescriptions to a printer, EMR, or pharmacy. ePrescribing software can be integrated with existing clinical information systems to allow access to patient-specific information to screen for drug interactions and allergies.
Evaluation and management
Medical billing is based on evaluation and management codes that classify the level of care that was provided.
The date/time when the system will officially be “switched on” for clinician use.
Graphical User Interface
Refers to a software interface designed to be more conducive to end user interactions. As opposed to legacy software systems dependent on text input alone.
Health Information Exchange
Commonly used interchangeably with RHIO. An HIE is a project or initiative focused around electronic data exchange between 2 or more organizations or stakeholders.
Healthcare Information and Management Systems Society
HIMSS is a nonprofit organization that focuses exclusively on providing global leadership for the optimal use of information technology and management systems to improve healthcare.
Health Insurance Portability and Accountability Act
Federal compliance requirements for the remote exchange of patient data using encrypted or secured Internet transmission.
Health Information Technology
Includes the use of electronic health records (EHRs) instead of paper medical records to maintain patient's health information.
The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. Subtitle D of the HITECH Act addresses the privacy and security concerns associated with the electronic transmission of health information, in part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules.
Healthcare information technology standards panel
Health Level Seven
A not-for-profit healthcare standards development organization that has developed a messaging standard for system interfaces in healthcare.
International Classification of Diseases, 10th revision
ICD is the international standard diagnostic classification for general epidemiological, health management purposes and clinical use. ICD-10 is an upgrade of the US developed clinical modification (ICD-9) of diagnosis and procedure codes. The DHHS and Center for Medicaid and Medicare Services (CMS) have required all healthcare providers and other entities to convert from ICD-9 to ICD-10 by October 1, 2013.
International Classification of Diseases, 9th revision
The ICD is used to provide a standard classification of diseases for the purpose of health records. The World Health Organization (WHO) assigns, publishes, and uses the ICD to classify diseases and to track mortality rates based on death certificates and other vital health records. Medical conditions and diseases are translated into a single format with the use of ICD codes. ICD-10 codes have 7 alphanumeric characters as opposed to ICD-9 (which has 5 numeric digits), and allow for increased granularity and accuracy of coding.
The installation and optimization of a clinical information system. Typically carried out over the course of several months, depending on the breadth of the clinical information system.
Data compliant with uniform data standards. Independent of any individual vendor's system allowing the free exchange of such data between any and all vendor information systems.
A technology often used for communication between electronics within provider facilities.
Also HIS (Hospital Information System) and CIS (Clinical Information System).
John Doe registrations
Assigning a medical record and account billing number to an unidentified patient.
A research body that provides a commercial source of comparative information. KLAS has been collecting end-user satisfaction information on the EDIS market for the last several years and is arguably the best source for head-to-head comparisons.
Logical observation identifiers names and codes
LOINC is a universal code system developed and maintained by the Regenstrief Institute for identifying laboratory and clinical observations.
A variety of goals set by the CMS to provide financial incentives for providers to most effectively use electronic medical records.
A feature common to many CISs used to facilitate patient and administration-related messages between hospital clinicians and staff.
Information stored by electronic medical records that provides a permanent electronic footprint to track all activity within the system.
Optical Character Recognition
Given an image representing printed text, determine the corresponding text. Scanning in picture of a written document and the computer converts it into usable text documentation.
Natural Language Processing
Computer understanding, analysis, manipulation, and/or generation of natural language. This can refer to anything from fairly simple string-manipulation tasks like stemming, or building concordances of natural language texts, to higher-level AI-like tasks like processing user queries in natural language.
Speech recognition (a subset of NLP)
Given a sound clip of a person or people speaking, determine the textual representation of the speech. This is the opposite of text to speech and is one of the extremely difficult problems colloquially termed “AI-complete” (see earlier). In natural speech there are hardly any pauses between successive words, and, thus, speech segmentation is a necessary subtask of speech recognition (see later). Note also that in most spoken languages, the sounds representing successive letters blend into each other in a process termed coarticulation, and so the conversion of the analog signal to discrete characters can be a very difficult process.
Office of the National Coordinator for Health Information Technology
ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. The position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009. ONC is organizationally located within the Office of the Secretary for the US Department of Health and Human Services (DHHS).
Picture archiving and communication system
The standard in radiology for digital information management. This standard is also commonplace in EDs. Web-based PACS viewers tend to have fewer features and slower performance, but are more easily deployed to multiple workstations.
The process of uniquely identifying a patient in the EDIS. This is distinct from formal registration which can be done at any time in the care process and usually in a separate hospital registration system. Patient entry may occur at triage or during a “greet” process whereby arriving patients are entered into the EDIS prior to a formal triage assessment. This process may enhance the identification of patients waiting to be seen and track the interval between arrival and triage.
Protected health information
Patient information that is HIPAA mandated for improved security for covered entities.
Personal health record
An electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment.
The process of continuously altering processes to improve performance.
Automatic notifications transferred to the ordering clinician by manually requesting a lookup of data.
Automatic notifications that interrupt the ordering clinician for an important patient alert.
A term used to describe a process for assigning a medical record and account billing number in the absence of full registration.
Root cause analysis
As opposed to approaching a problem by correcting the most obvious errors, root cause analysis seeks to uncover the core components of a problem. RCA is a class of problem-solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct, or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented. However, it is recognized that complete prevention of recurrence by one corrective action is not always possible. Conversely, there may be several effective measures (methods) that address the root cause of a problem. Thus, RCA is often considered to be an iterative process, and is frequently viewed as a tool of continuous improvement.
Request for information
RFIs are used to query system vendors for information and demonstrations about their system/product capabilities and features. RFIs remain the industry standard mechanism to formally obtain system information in a standardized way.
An automatic process for patient location tracking, following the patient in physical space through all phases of the visit.
Request for proposal
RFPs are used to query system vendors and/or consulting firms for proposals on their organization's qualifications and capabilities. An RFP is an opportunity to narrow the vendor options and is perhaps the first opportunity to consider the real cost of the system.
Regional health information organizations
RHIO is a group of organizations with a business stake in improving the quality, safety, and efficiency of healthcare delivery. These organizations are expected to be responsible for motivating integration and information exchange among stakeholders in their region's healthcare system.
Return on investment
The value return (eg, staff efficiency, patient safety, improved data management, workflow automation) on an information technology investment.
Sound-alike or look-alike drugs
A framework for communication between members of the healthcare team about a patient's condition.
Medical scribes are individuals, often premedical students, who are paired with a physician for the purpose of documenting the physician's encounter with the patient and gathering test results. Scribes do not obtain medical information directly from the patient nor are they involved in any way with patient care.
Systematized nomenclature of medicine-clinical terms
SNOMED is a comprehensive ontological system for clinical terms that was originally created by the College of American Pathologists and, as of April 2007, is now owned, maintained, and distributed by the International Health Terminology Standards Development Organization, a nonprofit association in Denmark.
AHRQ-developed Survey on Patient Safety.
Structured query language
A database computer language.
Super users have a deep understating of the product, at least for their particular role. They have completed additional training and are added as extra staff during the “Go-Live” and available for additional ad hoc point of service training thereafter. The qualities for a super user include: a willingness to commit the time necessary (with or perhaps without extra pay); ability to not only grasp a “user level” understanding of the product, but able to teach it in an effective way; understand their own role(s) in the ED well; and most importantly have credibility with the other ED staff.
Interfaces communicate data between disparate computer systems such as the EDIS, enterprise HIS, pharmacy, CPOE, PACS, and laboratory. These interfaces are vital to proper data ecology in the ED environment
A teamwork system developed by AHRQ and the Department of Defense to improve communication and teamwork skills among health professionals.
The process of determining the priority of patients' treatments based on the severity of their condition.
The sum of all interactions between the person and the EDIS, including all screens, input devices (eg, keyboards, mice, touch screens, ePens, etc), and output devices (eg, printers, CDs, etc).
Uniform Data Standard
Agreement to a standard definition and format for each data point across all users of healthcare data points (ie, last name, serum sodium level, insurance company, etc).
Workstation on wheels (also COW)