Accredited Standards Committee X12 

A committee of the national Standards Institute that develops and maintains standards for the electronic exchange of business transactions

RIS

Radiology information system (RIS):

Ancillary system application in a hospital or physician’s office that generates clinical (radiological) information 

RFID

Radio frequency identification (RFID):

An automatic recognition technology that uses a device attached to an object to transmit data to a receiver and does not require direct contact. 

ANSI:

American National Standards Institute 

The organization that accredits all US standards development organizations to ensure that they are following due process in promulgating standards 

PHI

Protected health information (PHI):

individually identifiable health information held by a covered entity or business associate on behalf of the covered entity and which is protected through confidentiality integrity and availability measures required under the HIPAA regulations. 

ASTM

PMS

Practice management system (PMS):

Software designed to help medical practices run more smoothly and efficiently

POC

Point-of-care (POC) patient charting system:  

Guides the user in the necessary data to collect in the context of the specific patient at the location where the healthcare service is performed.  (Health Information Management Concepts, Principles, and Practice

 CDA

Clinical Document Architecture (CDA):HL7 electronic exchange model for clinical documents (such as discharge summaries and progress notes)

PACS

Picture archiving and communication system (PACS):

System that digitizes medical images

CCD

Continuity of Care Document (CCD): (Dustin) Document that is the result of harmonizing the ASTM INternational Continuity of Care Record (CCR) standard content for referrals with the HL7 CDA standard for document construction; now widely used in creating PHR’s (p960)

CCR

Continuity of Care Record (CCR):   Documentation of care delivery from one healthcare experience to another 

PHR

Personal health record (PHR):

An electronic or paper health record maintained and updated by an individual for himself or herself

DICOM

Digital Imaging and Communications in Medicine (DICOM):   A standard that promotes a digital image communications format and picture archive and communications systems for use with digital images

OC/RR

Order communication/results reporting (OC/RR):

 In hospitals, type of daa that may be directed to many of the applications that support CPOE and EMAR and other applications that have been relatively stand-alone applications. 

 EDI

Electronic data interchange (EDI)  the electronic transfer of information such as health claims transmitted electronically, in a standard format between trading partners. 

OLTP

Online/real-time transaction processing (OLTP):

The real-time processing of day-to-day business transactions from a database 

XML 

Extensible Markup Language (XML):    developed as a universal language to facilitate the storage and transmission of data published on the internet.  It is a standardized computer language that allows the interchange of data as structured text.

OLAP

Online analytical processing (OLAP): A data access architecture that allows the user to retrieve specific information from a large volume of data 

HL7

Health Level (HL7):  A standards development organization accredited by the American National Standards Institute that addresses issues at the seventh, or application, level of healthcare systems interconnections.

NLP

Natural language processing (NLP):

the extraction of unstructured or structured medical word data, which are then translated into diagnostic or procedural codes for clinical and administrative applications. 

 IEEE

Institute of Electrical and Electronics Engineers (IEEE) 1073:  A national organization that develops standards for hospital system interface transactions including links between critical care bedside instruments and clinical information systems. The IEEE 1073 was adopted as a federal health information Interoperability standard for electronic data exchange.   

NHIN

Nationwide health information network (NHIN):

Network envisioned by the government whereby health information may be exchange securely and seamlessly to authorized parties acrossthe country.

ISO

International Organization for Standardization (ISO):   A non-governmental global organization established in 1987 that provides more than 17,000 quality standards for nearly every business technology and industry sector.  

LHR

Legal health record (LHR)::

the “subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to legally permissible requests 

Logical Observation Identifiers Names and Codes (LOINC): A database protocol developed by the regenstrief institute for healthcare aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research

LIS

Laboratory information system (LIS):

System that in addition to producing lab results manages workload balancing supplies, inventories, medicare medical necessity checking, biling, public health reporting, and generates custom reports for clinical or quality management

HIMSS

Health Information Management and Systems Society (HIMSS):

A national membership association that provides leadership in healthcare for the management of technology, information and change 

NDC

National Drug Codes (NDC) Directory:  Codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few select over-the-counter products 

National Provider Identifier (NPI):  An eight-character alphanumeric identifier used to identify individual healthcare providers for Medicare billing purposes 

EBM

Evidence-based medicine (EBM):

Healthcare services based on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies 

PACS

Picture archiving and communication systems (PACS):  are computers or networks dedicated to the storage, retrieval, distribution, and presentation of medical images. Most common format is the DICOM standard. 

Semantic Clinical Drug (SCD):   is a subset of RxNorm for the ingredient plus strength and dose form.

Standard development organizations (SDOs):   A private or government agency involved in the development of healthcare informatics standards at a national or international level.

EMPI

Enterprise master patient index (EMPI):

An index that provides access to multiple repositories of information from overlapping patient populations that are maintained in separate systems and databases

ECRM

Enterprise (or electronic) content and records management (ECRM):

Systems that enable scanning and indexing of paper documents and other content in digital form.

Unified Medical Language System (UMLS):   A program initiated by the National Library of Medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions and their interrelationships 

EMAR

Electronic medication administration record (EMAR) system: 

system designed to prevent medication errors by checking a patient’s medication information against his or her bar-coded wristband 

CCHIT

Certification Commission for Health Information Technology (CCHIT): recognized certification body for electronic health records and their networks; a private, non-profit initative. 

EMR

Electronic medical record (EMR): 

an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization 

EHR

Electronic health record (EHR): 

 an electronic record of health-related information on an individual that conforms to nationally recognized standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization 

EDM

Electronic document management (EDM) system: 

a storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks

CPOE

Computerized provider order entry (CPOE):

 Systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindications, or other clinical decision support

COLD

computer output to laser disk (COLD):

technology that electronically stores the documents and distributes them with fax, email, Web, and traditional hard-copy print processes 

CDA

Clinical document architecture (CDA):  

HL7 electronic exchange model for clinical documents (such as discharge summaries and progress notes) 

CDS

Clinical decision support (CDS): 

 a special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions 

CDW

Clinical data warehouse (CDW): 

 a database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface 

Health Information Management and Systems Society (HIMSS):  A national membership association that provides leadership in healthcare for the management of technology, information and change 

Nationwide health information network (NHIN): Network envisioned by the government whereby health information may be exchange securely and seamlessly to authorized parties acrossthe country.

health Information Technology Standards Panel (HITSP):  This organization serves as a cooperative partnership between the public and private sectors for achieving a wide acceptance and usable standards; its specific mission is to enable and support widespread interoperability among healthcare software applications as they interact in a local, regional and NHIN for the U.S. 

Regional health information organizations (RHIOs):   An organization that manages the local deployment of systems promoting and facilitating the exchange of healthcare data within a national health information network 

Regional health information networks (RHINs):  System that links various healthcare information systems in a region together so that patients, healthcare institutions, and other entities can share clinical information 

bar-code medication administration record (BC-MAR) system: adds positive patient identification and drug information to EMAR to carry out automated reminders for the five rights of medication management.

Certification Commission for Healthcare Information Technology (CCHIT):  A recognized certification body for electronic health records and their networks; a private, non-profit initiative 

Clinical data repository (CDR):   A central database that focuses on clinical information