Acronyms
ADC – Automated dispensing cabinet, for Pharmacy
ADL -activities of daily living
ASC – Advanced Surgical Center
ASTM – American Society for Testing and Materials
ATCB – ONC Authorized Testing and Certification Body
BAA – Business Associate Agreement, required of third parties when providers share records with them (a BAA is NOT required from postal carriers)
CAH – Critical Access Hospitals (paid based on cost, not diagnosis)
CCD – Continuity of Care Document, an XML-based standard
CMS – Center for Medicare and Medicaid Services, a division of HHS
CPOE – Computerized Physician Order Entry: Lab, Rad and Pharmacy
CPT – Current Procedural Terminology
CSW – Clinical Social Worker
EDIS – Emergency department IS
eMAR – an electronic medication administration record, for Pharmacy, using barcode scanners at several points in the process
EPHI – Electronic Protected Health Information; Electronically transmitted or stored information
ERISA – Employee Retirement Income Security Act of 1974
Health Records:
EMR – Electronic Medical Records, usually in a stand-alone situation like a doctor’s office; an electronic version of the paper record.
EHR – Electronic Health Records are a collection of patient or population health information. One patient’s records from multiple sources and providers collectively are her EHR.
EPR – same as EHR
PHR – Personal Health Record, an electronic record maintained by the individual
HCPCS – Healthcare Common Procedure Coding System – https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Coding_System
HHS – Department of Health and Human Services, the federal colossus
HITSP – Healthcare Information Technology Standards Panel
Information Systems
EDIS
Pharmacy IS
Radiology IS
Lab IS (LIS)
IRB – Institutional Review Board
MAR – Medication Administration Record, for Pharmacy (cf. eMAR)
MOU – Memorandum of Understanding, or MOA, Memorandum of Agreement
NPI – National Provider Identifier
OCR – Office for Civil Rights
ONC – Office of the National Coordinator for Health Information Technologies
PACS – Picture Archiving and Communication System
PERT (chart) – Program Evaluation and Review Technique
Physician portal – a view into HIS/EMR/EHR; unlike CPOE it’s for notes, not orders; allows electronic signatures
PPACA or ACA – Patient Protection and Affordable Care Act
PPS – Prospective Payment System (payment based on diagnosis, not cost), a Medicare Part A system
RECs – HIT Regional Extension Centers
Surgical Process
Surgical summary report – short, for immediate reference during postop
Cold feed – how the report above is sent; there is no ACK confirming receipt
Operative record – complete, detailed account, dictated
SNF – Skilled Nursing Facility
TPO – Treatments, payments and operations
Suffixes
-osis – condition or disease
-itis – inflammation – Arthritis is inflammation
-algia – pain
-crine – secreting, as in endocrine
-blast – an immature or forming condition
-ology – study of
Terminology
Barium contrast – a video using injected barium to make objects show clearly
Echocardiogram – a video view of the heart
Electronic signature – a scanned copy of a signature on paper
Data Security – technical and procedural methods to control and manage confidential information.
Digital signature – a product of hashing and encryption with full legal legitimacy
Health Information
De-identified Health Information
Individually Identifiable Health Information
Archived Health Information
Demographic Health Information
Informed Consent – the conversation between patient and physician re. medical procedure being performed, reasons for it, benefits of it and risks.
Interface Engine – a “translator” that sits between multiple systems and reformats data for those systems
Nursing home vs. assisted living
Perioperative IS – the info system that manages patients in surgery
Privacy – “the individual’s right to control disclosure”
Specialty Hospital provides treatment for specific issues such as burns, cancer or women’s care
Thinning – reducing a patient’s chart when it gets too big to handle. Thinned records are sent to central medical records area.
Types of Plans
A Preferred Provider Organization (PPO) offers discounted services at in-network providers only.
A Health Maintenance Organization (HMO) provides services for a fixed, prepaid amount.
Types of IT in Medicine
Clinical IT – handling prescriptions, lab tests, images, medical procedures
Infrastructure IT – handling networks and major services
Financial IT – handling billing and finances
Administrative IT – handling staffing and operations IT
Types of Data
Images
Numbers
Text
Signals – tracking from an instrument, e.g. EEG or EKG