Glossary of EHR Terms - iSALUS

Glossary of EHR Terms

Ambulatory Electronic Health Records are designed for environments in which access from a variety of locations is required. This technology allows for remote access on multiple devices, including smartphones and tablet computers.

Chartered in 2005, the American Health Information Community (AHIC) was designed to advise the federal government on the implementation of health information technology. The overarching goal of the AIHC is to ensure the complete security of all electronic medical records by 2014.

Commonly referred to as the Stimulus, the American Recovery and Reinvestment Act of 2009 was passed in response to an economic recession that left a large number of Americans unemployed. When it was passed, the economic stimulus totaled $787 billion. This funding was appropriated for a variety of programs aimed at stimulating the economy, including infrastructure, education and clean energy. Several tax incentives were also added to provide relief for struggling individuals and businesses.

Formerly referred to as the Health Care Financing Administration, the Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for administering such programs as Medicare, Medicaid and the State Children's Health Insurance Program. CMS is also charged with the task of administering standards set by HIPAA, as well as ensuring that all standards for long-term care (otherwise known as nursing homes or assisted-living facilities) are met.

In the NPRM for the Electronic Health Record Incentive Program, CMS proposes clinical decision support to be defined as health information technology functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care.

Clinical Quality Measures are defined in the CMS NPRM for the Electronic Health Record Incentive Program to consist of measures of processes, experience, and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient centered, equitable, and timely care.

Originally, Electronic Health Records were stored with the help of onsite technology. In recent years, cloud-based EHRs have enabled medical professionals to access necessary information from remote locations. The result is greater flexibility on the part of health care providers, and thus, improved service for patients.

Continuity of Care Document (CCD) is a standard created by HL7 Clinical Document Architecture for the use of exchanging patient health summary records and contains data that is defined by ASTM Continuity of Care Record (CCR).

The ASTM Continuity of Care Record is a standard specification developed for the electronic sharing of patient health summary records.

CPOE refers to the electronic entry of medical instructions. Under CPOE, an order is entered electronically and then passed along to the appropriate staff members. This system is considered advantageous because it can reduce miscommunications related to poor handwriting or other circumstances.

An EHR is a digital document that contains information related to the health of a patient or group of patients. Such information may include patient demographics, notes from past checkups, immunization history, lab test results and billing status. The EHR automates and streamlines the clinician's workflow. It has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. An Electronic Health Record can be shared with multiple health care providers and is typically accessible from remote locations.

Often confused with Electronic Health Records, EMR consists of computerized documents created and used by a single health care institution. While records may be shared among multiple departments in a given practice, other providers do not retain access to this information.

HIE involves the mobilization of health care information that was previously limited to paper documents. This mobilization may take place at a single facility or across a large network of practices. Those in favor of HIE believe that the system will ensure improved safety, efficiency and cost efficacy.

An integral part of the 2009 American Recovery and Reinvestment Act, HITECH centered on the adoption of health information technology. The United States Congress appropriated $26 billion towards the implementation of a nationwide network for EHR.

The majority of HITECH centers on standards for EHR. However, an incentive was also established to encourage practices across the nation to adopt EHR. Under the HITECH EHR Incentive Program Timeline, eligible professionals and hospitals who can demonstrate the meaningful use of electronic health records (EHR); to establish standards, implementation specifications, and certification criteria for EHRs; protecting privacy and security of health information can be awarded up to $2 billion in funding.

HIMSS is a non-profit organization dedicated to the effective use of information technology in health care. The premise of this organization is that, with the help of IT and management systems, the quality and affordability of health care systems can be simultaneously improved.

The rapid adoption of health information technology in the 1990s led to a number of pressing privacy concerns. HIPAA's goal was to address these issues. The legislation set up a number of minimum privacy standards, the most significant of which may have been a requirement forcing practices to provide patients with records upon request.

Commissioned by the Office of the National Coordinator for Health Information Technology, HITSP was created in 2005 to simplify a vast set of health information technology standards that, until then, was getting more complicated every year. HITSIP's mission is to coordinate the public and private sector so that interoperability between software applications is possible.

Much as the HITSP works to improve interoperability in the United States, HL7 aims for interoperability on a national level. This non-profit organization offers a basic framework for the storage, sharing and retrieval of EHR and EMR. It also provides standards to ensure that the electronic systems of all participating bodies are run efficiently and effectively.

Launched in 1997 by a group of radiologists and information technology specialists, the IHE initiative is dedicated to improving the information technology systems related to health care. Although the international organization is limited by a relative lack of funding, it has made progress in three areas: patient-ID binding, device-enterprise communication and point-of-care technology.

Interoperability refers to the ability of highly diverse health care systems to work together as a cohesive unit (or interoperate). When a high level of interoperability is maintained, multiple systems are able to exchange essential information and then effectively utilize it without compromising the needs or privacy of patients.

KLAS Enterprises is a research firm focused on objective measurements of vendor performance in the health care sector. The independently owned and operated organization works with more than 4,500 hospitals as well as 3,000 doctors and practices.

The 2009 American Recovery and Reinvestment Act (also known as the Stimulus) uses the term “meaningful use” to identify individuals, practices and hospitals utilizing EHR technology in a way that allows for measurements of significant quality and quantity. Participating bodies successfully meeting meaningful use requirements may be awarded with monetary incentives.

MU Stage 1 is the criteria documented in the IFR that begins in 2011 and 2012, and continues to be applicable for all payment years until update by future rule making.

MU Stage 2 criteria are an expanded set of goals for meaningful use to apply in 2013 and 2014. The criteria are to be proposed for rulemaking by end of 2011.

MU Stage 3 criteria are an expanded set of goals for meaningful use to apply in 2015. The criteria are to be proposed for rulemaking by end of 2013.

The NHIN consists of a set of standards regulating the exchange of health care information over the internet. The initiative aims to establish what it refers to as a "network of networks" including practices, government agencies, pharmacies, laboratories, insurance providers and other entities essential to the delivery of quality health care.

An NPRM is a proposed rule which must be put forth before a final rule can be published. It represents the plan or intention for the rule and solicits public comment. After the public comments are reviewed, and any modifications to the proposed rule are made, a final rule is then published. The final rule is then codified in the Code of Federal Regulations.

Located within the Department of Health and Humans Services, the ONC promotes the adoption of health information technology while supporting those practices and hospitals aiming to implement IT systems. Incentives are then provided for health care organizations successfully meeting meaningful use standards. The ONC is formally a part of the Office of the Secretary of the U.S. Department of Health and Human Services (HHS).

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