Chapter 11 Health Information Technologies

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Accredited Standards Committee X12 (ASC X12)

A committee accredited by ANSI responsible for the development and maintenance of EDI standards for many industries. The ASC "X12N" is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms


Reflects the fact that the organization has implemented all of the major components of technology, although there may be some available technology that is more specialized, costly, or time consuming to implement that has not yet been implemented

Alert fatigue

When an excessive number of alerts are used in an information system, users get tired of looking at the alerts and may ignore them

American Recovery and Reinvestment Act (ARRA)

The purposes of this act include the following: (1) To preserve and create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases


refers to statistical processing of data to reveal new information

Ancillary systems

Systems that serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR

Application service provider (ASP)

A third-party service company that delivers, manages, and remotely hosts standardized applications software via a network through an outsourcing contract based on fixed, monthly usage, or transaction-based pricing

ASTM International

An international organization whose purpose is to establish standards on materials, products, systems, and services


Device that analyzes the specimen

Automated drug dispensing machines

System that makes drugs available for patient care

Barcode medication administration record (BC-MAR)

System that uses barcoding technology for positive patient identification and drug information

Best of breed

A vendor strategy used when purchasing an EHR that refers to system applications that are considered the best in their class

Best of fit

A vendor strategy used when purchasing an EHR in which all the systems required by the healthcare facility are available from one vendor

Big data

Very large volume of data that offers greater reliability and validity

Billing system

Information system that generates a bill for healthcare services performed


the physical characteristics of users (such as fingerprints, voiceprints, retinal scans, iris traits) that systems store and use to authenticate identity before allowing the user access to a system

Business intelligence (BI)

the end product or goal of knowledge management

Certificate authority

An organization that verifies a person’s credentials and can revoke the certificate if the credentials are revoked


1. The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a specified set of requirements

Change control program

Assures that there is documented approval for the change to be made and evidence that all elements of implementation, testing, rollout, training, and such are performed

Charge capture

The process of collecting all services, procedures, and supplies provided during patient care

Chart conversion

An EHR implementation activity in which data from the paper chart are converted into electronic form

Chart tracking

A process that identifies the current location of a paper record or information

Chief medical informatics officer (CMIO)

A salaried physician (most often part time so that he or she retains credibility with other practicing physicians) who is heavily involved in policy development, workflow and process improvement, and ongoing maintenance of CDS and other systems requiring significant physician input


A request for payment for services, benefits, or costs by a hospital, physician or other provider that is submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider

Claim attachment

Any of a variety of hard-copy or electronic forms needed to process a claim in addition to the claim itself, such as a copy of the emergency department note

Claims data

Information required to be reported on a healthcare claim for service reimbursement

Claims status inquiry and response

Used to determine if a health plan has ended a claim for additional information or is processing the claim

Client/server system

System in which the healthcare organization has commercial software installed on servers housed and maintained within the organization itself, housed within the organization and managed by an outsourced company, or housed and maintained by a contractor for the healthcare organization

Clinical data repository (CDR)

A central database that focuses on clinical information

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

Clinical decision support (CDS)

The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts

Clinical decision support system (CDSS)

CDS that requires the combination of data from more than one sources and the ability to deliver the alert back to the appropriate system or systems

Clinical Document Architecture (CDA)

An HL7 XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes). The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from HL7, Integrating the Healthcare enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for Stage I Meaningful Use, and HITECH final rule. It is commonly referred to as Consolidate CDA or C-CDA

Clinical documentation system

System that supplies templates to the user to be completed primarily via point-and-click, drop-down, type-ahead, and other data entry tools

Clinical transformation

A fundamental change in how medicine is practiced using health IT systems to aid in diagnosis and treatment

Closed-loop medication management

Information systems used to provide patient safety when ordering and administering medications

Cloud computing

A practice that uses a vendor to archive data, and in some cases also provide application software, including an EHR, on multiple, disparate servers

Computerized provider order entry (CPOE)

Electronic prescribing systems that allow physicians to write prescriptions and transmit them electronically. These systems usually contain error prevention software that provides the user with prompts that warn against the possibility of drug interaction, allergy, or overdose and other relevant information


Open-source software that implements health exchange specifications; it enables discovery of where there may be information as well as directly retrieving it from the source

Consent directive

A process by which patients may opt in or opt out of having their data exchanged in the HIE

Consent management systems

Systems that help maintain patient preferences about who may have access to their health information

Consolidated Clinical Document Architecture (C-CDA)

HL7-created document templates

Continuity of care document (CCD)

The result of ASTM’s Continuity of Care Record standard content being represented and mapped into the HL7’s Clinical Document Architecture specifications to enable transmission of referral information between providers; also frequently adopted for personal health records

Continuity of care record (CCR)

Is a core data set of the most relevant administrative, demographic, and clinical information about a patient’s healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care


Medication should not be prescribed due to another medication or condition

Core measures

Standardized performance measures developed to improve the safety and quality of healthcare


The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions

Data conversion

The task of moving data from one data structure to another, usually at the time of a new system installation

Data dictionary

A descriptive list of the names, definitions, and attributes of data elements to be collected in an information system or database whose purpose is to standardize definitions and ensure consistent use

Data model

1. A picture or abstraction of real conditions used to describe the definitions of fields and records and their relationships in a database 2. A conceptual model of the information needed to support a business function or process

Data quality

The reliability and effectiveness of data for its intended uses in operations, decision making, and planning

Data Use and Reciprocal Support Agreement (DURSA)

A trust agreement entered into when exchanging information with other organizations using an agreed upon set of national standards, services, and policies developed in coordination with the Office of the National Coordinator for Health Information Technology

Diagnostic studies

All diagnostic services of any type, including history, physical examination, laboratory, x-ray or radiography, and others that are performed or ordered pertinent to the patient’s reasons for the encounter

Digital certificate

An electronic document that establishes a person’s online identity

Digital Imaging and Communications in Medicine (DICOM)

An ISO standard that promotes a digital image communications format and picture archive and communications systems for use with digital images

Direct Project

Launched in March 2010 to offer a simpler, standards-based way for participants to send authenticated, encrypted health information directly to known recipients over the internet

Discrete reportable transcription (DRT)

Transcription system that combines speech dictation with natural language processing

Document imaging

1. The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed; 2. The process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end-user

Drug knowledge database

A subscription service that provides current information about drugs and is accessible to users and CDS

Due diligence

The actions associated with making a good decision, including investigation of legal, technical, human, and financial predictions and ramifications of proposed endeavors with another party

eHealth Exchange

A group of federal agencies and non-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. Participating organizations mutually agree to support a common set of standards and specifications that enable the establishment of a secure, trusted, and interoperable connection among all participating Exchange organizations for the standardized flow of information

Electronic clinical quality measures (eCQM)

Electronic health record (EHR)

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

Eligibility verification

Verification that determines if a patient’s health plan will provide reimbursement for services to be performed, and sometimes prior-authorization management systems where a health plan requires review and approval of a procedure (or referral) prior to performing the service


Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system

End user

Persons who will use the system for their daily processes

e-Prescribing (e-RX)

When a prescription is written from the personal digital assistant and an electronic fax or an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy’s information system

e-Prescribing for Controlled Substances (EPCS)

Evidence-based medicine

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


Non face-to-face interaction between patient and provider

Federal Health IT Strategic Plan 2015-2020

Issued by the Office of the National Coordinator for Health Information Technology (ONC), this plan describes a vision of high-quality care, lower costs, healthy population, and engaged people and mission to improve the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most


First use of the system in actual practice

Health information exchange (HIE)

The exchange of health information electronically between providers and others with the same level of interoperability, such as labs and pharmacies

Health information organization (HIO)

An organization that supports, oversees, or governs the exchange of health-related information among organizations according to nationally recognized standards

Health Information Technology for Economic and Clinical Health (HITECH)

Legislation created to promote the adoption and meaningful use of health information technology in the United States. Subtitle D of the Act provides for additional privacy and security requirements that will develop and support electronic health information, facilitate information exchange, and strengthen monetary penalties. Signed into law on February 17, 2009, as part of ARRA (Public Law 111-5 2009)

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The federal legislation enacted to provide continuity of health coverage, control fraud, and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information; limits exclusion for pre-existing medical conditions, prohibits discrimination against employees and dependents based on health status, guarantees availability of health insurance to small employers, and guarantees renewability of insurance to all employees regardless of size; requires covered entities (most healthcare providers and organizations to transmit healthcare claims in a specific format and to develop, implement, and comply with the standards of the Privacy Rule and the Security Rule; and mandates that covered entities apply for and utilize national identifies in HIPAA transactions (Public Law 104-191 1996)

Health IT

Under HITECH, hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information (Public Law 111-5 2009)

Health Level Seven (HL7)

Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards-developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services

Health reform

Steps taken to make major policy changes in how providers are reimbursed for healthcare services

Hospital information system (HIS)

the comprehensive database containing all the clinical, administrative, financial, and demographic information about each patient served by a hospital

Identity management

Provides security functionality, including determining who (or what information system) is authorized to access information, authentication services, audit logging, encryption, and transmission controls

Identity matching algorithm

Rules established in an information system that predicts the probability that two or more patients in the database are the same patient

Identity proofing

Authentication credentials used to electronically sign prescriptions


Refers to technology having been installed, configured to meet the basic requirements of the healthcare organization, and demonstrated to users


Data processed into usable form


The zone between different computer systems across which users want to pass information (for example, a computer program written to exchange information between systems or the graphic display of an application program designed to make the program easier to use)


The capability of different information systems and software applications to communicate and exchange data

Issues management

Any issues that arise during the implementation are documented, brought to the attention of the vendor, and hopefully resolved, or escalated so that resolution is accomplished


Special form of input device geared more to people less familiar with computers


The information, understanding, and experience that gives individuals the power to make informed decisions

Laboratory information system (LIS)

Health information system that includes hardware; software; communications and network technologies; operational and cultural adaptations that people must make to use the technologies in performing diagnostic studies on various specimens collected from patients and to apply professional judgement in evaluating the quality of the data representing the results; policies and standards form the local organization in which the system is housed as well as accrediting and licensing bodies that must be followed for design of the technology and its use; and workflow and process designs assure the most efficient and effective use of the technology

Learning health system

The alignment of science, informatics, incentives, and culture for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience

Logical Observations, Identifiers, Names, and Codes (LOINC)

A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research that enable exchange and aggregation of electronic health data from many independent systems

Meaningful Use

A regulation that was issued by CMS on July 28, 2010, outlining an incentive program for professionals (EPs) eligible hospitals, and CAHs participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology

Meaningful Use (MU) program

A program managed by the Centers for Medicare and Medicaid Services. Meaningful Use uses certified electronic health record technology to: (1) Improve quality, safety, efficiency, and reduce health disparities; (2) Engage patients and family; (3) Improve care coordination, and population and public health; and (4) Maintain privacy and security of patient health information

Medical device integration

Connecting medical devices to the EHR

Medication five rights

The right drug, in the right dose, through the right route, at the right time, and to the right patient

Medication reconciliation

Process that monitors and confirms that the patient receives consistent dosing across all facility transfers, such as on admission, from nursing unit to surgery, and from surgery to ICU

Message format standards

Protocols that help ensure that data transmitted from one system to another remain comparable


Descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information. Metadata consist of both indexing terms and attributes. Data about data: for example, creation date, date sent, date received, last access date, last modification date

National Council for Prescription Drug Programs (NCPDP)

A not-for-profit ANSI-accredited standards development organization founded in 1977 that develops standards for exchanging prescription and payment information

National Drug Codes (NDC)

Codes that serve as product identifiers for human drugs, currently limited to prescription drugs and a few selected over-the-counter products

Natural language processing (NLP)

A technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems; branch of artificial intelligence

Nursing information system

System that manages the nursing department, including staffing, credentialing, training, budgeting, and other managerial functions

Office of the National Coordinator (ONC) for Health Information Technology

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 HITECH Act of 2009

Online analytical processing (OLAP)

A data access architecture that allows the user to retrieve specific information from a large volume of data

Online transaction processing (OLTP)

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

Operating rules

Rules that further explain the business requirements so their use is consistent across health plans


Reflects not only good adoption for all routine operations, but also an understanding and appropriate use of the technology’s features

Opt in/opt out

A type of HIE model that sets the default for health information of patients to be included automatically, but the patient can opt out completely

Patient acuity staffing

The number of nurses and other care providers is based on how sick the patient is

Patient financial system (PFS)

Information system that manages patient accounts

Patient portal

Information system that allows patient to log in to obtain information, register, and perform other functions

Patient safety

Preventing harm to patients, learning from errors, and building a culture of safety

Personal health record (PHR)

An electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care

Personalized medicine

Pharmacy information system

this system receives an order for a drug in a hospital, aids the hospital’s pharmacist in checking for contraindications, directs staff in compounding any drugs requiring special preparation, aids in dispensing the drug in the appropriate dose and for the appropriate route of administration, maintains inventory (documenting medications in stock using the National Drug Code, the terminology maintained by the Food and Drug Administration [FDA] for use in identifying FDA-approved drugs), supports staffing and budgeting, and performs other departmental operations

Physician champion

An individual who assists in communicating and educating medical staff in areas such as documentation procedures for accurate billing and appropriate EHR processes

Physician Quality Reporting System (PQRS)

An incentive payment system for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries; formerly known as the Physician Quality Reporting Initiative (PQRI)

Picture archiving and communications system (PACS)

An integrated computer system that obtains, stores, retrieves, and displays digital images (in healthcare, radiological images)

Point-of-care (POC) charting

A system whereby information is entered into the health record at the time and location of service


Windows into information systems

Power user

Users who are able to use technology to significantly improve their productivity

Primary care physician (PCP)

1. Physician who provides, supervises, and coordinates the healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan. Family and general practitioners, internists, pediatricians, and obstetricians and gynecologists are primary care physicians 2. The physician who makes the initial diagnosis of a patient’s medical condition

Prior authorization

Process of obtaining approval from a healthcare insurance company before receiving healthcare services


In healthcare, a detailed plan of care for a specific medical condition based on investigative studies; in medical research, a rule or procedure to be followed in a clinical trial; in a computer network, a rule or procedure used to address and ensure delivery of data


Physician, clinic, hospital, nursing home, or other healthcare entity (second party) that delivers healthcare services

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

Radiology information system (RIS)

Performs functions similar to LIS, receiving an order for a procedure, scheduling it, notifying hospital personnel or the patient if performed as an outpatient, tracking the performance of the procedure and its output, tracking preparation of the report, performing quality control, maintaining an inventory of equipment and supplies, and managing departmental staffing and budget

Record locator service (RLS)

A process that seeks information about where a patient, once identified, may have a health record available to the HIO

Registration-Admission, Discharge, Transfer (R-ADT)

A type of administrative information system that stores demographic information and performs functionality related to registration, admission, discharge, and transfer of patients within the organization


A collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison

Remittance advice

An explanation of payments (for example, claim denials) made by third-party payers

Requirements specification

Determining and documenting the detailed features and functions desired in the system in order to meet the organization’s specific goals

Results management

An EHR application that enables diagnostic study results (primarily lab results) to be both reviewed in a report format and the data within the reports to be processed

Revenue cycle management (RCM)

Refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services


A clinical drug nomenclature developed by the Food and Drug Administration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms


The NCPDP standard developed for electronically transmitting a prescription

Semantic interoperability

Mutual understanding of the meaning of data exchanged between information systems

Shared Nationwide Interoperability Roadmap

ONC’s three stage vision for interoperability; 2015-2017: Nationwide ability to send, receive, find, and use a common clinical data set; 2018-2020: Expand interoperable data, users, sophistication, and scale; 2021-2024: Broad-scale learning health systems

SMART goals

Statements that identify results that are: Specific, Measurable, Attainable, Relevant, and Time-based

Software as a Service (SaaS)

Arranged similar to an application service provider with generally less custom configuration ability and that offers a pay as you go model, where there is payment for only the actual time using the system; may be delivered via dedicated communications technology or cloud computing

Source systems

1. A system in which data was originally created 2. Independent information system application that contributes data to an EHR, including departmental clinical applications (for example laboratory information system, clinical pharmacy information system) and specialty clinical applications (for example, intensive care, cardiology, labor and delivery)

Speech dictation

Method of collecting information in an information system through spoken word

Steering committee

An overarching committee comprised of key stakeholders to health information systems in general, or less commonly, a steering committee will be convened for each specific health information system project and include only stakeholders associated with that project

Storage management

The process of determining on what type of media to store data, how rapidly data must be accessible, arranging for replication of storage for back up and disaster recovery, and where storage systems should be maintained

Structured data

Binary, machine-readable data in discrete fields; data able to be processed by the computer


No longer selling or supporting a product


Refers to all the components (technology, standards, people, policy, and process) that must work together to achieve a desired goal (interoperability)

System build

The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system; also known as system configuration

System configuration

The creation of data dictionaries, tables, decision support rules, templates for data entry, screen layouts, and reports used in a system; also known as system build

System integration

A translation process that hardwires the applications together in order to be able to interoperate and exchange data seamlessly across the different applications

Systems development lifecycle (SDLC)

A model used to represent the ongoing process of developing (or purchasing) information systems


A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment


A pattern used in computer-based patient records to capture data in a structured manner


As amended by HITECH, under HIPAA, the transmission of information between two parties to carry out financial or administrative activities related to health care. It includes the following types of information transmissions: (1) Health care claims or equivalent encounter information; (2) Health care payment and remittance advice; (3) Coordination of benefits; (4) Health care claim status; (5) Enrollment and disenrollment in a health plan; (6) Eligibility for a health plan; (7) Health plan premium payments; (8) Referral certification and authorization; (9) First report of injury; (10) Health plan premium payments; (11) Health care electronic funds transfers (EFT) and remittance advice; (12) Other transactions that the secretary may prescribe by regulation (45 CFR 160.103 2013)

Two-factor authentication

A signature type that includes at least two of the following three elements: something known, such as a password; something held, such as a token or digital certificate; and something that is personal, such as a biometric in the form of a fingerprint, retinal scan, or other

Unintended consequence

An unanticipated and undesired effect of implementing

Unstructured data

Nonbinary, human-readable data


As amended by HITECH, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information (45 CFR 160.103 2013)


Refers to the combination of quality and cost

Value-based purchasing (VBP)

CMS incentive plan that links payments more directly to the quality of care provided and rewards providers for delivering high-quality and efficient clinical care. It incorporates clinical process-of-care measures as well as measure from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey on how patients view their care experiences

Vendor selection

Formal process by a healthcare organization that is just starting to acquire health information systems or replacing entire set of components with new components; steps in the process include needs identification, requirements specification, requests for proposal (RFP), analysis of RFP responses, due diligence, and contract negotiation

Virtual private network (VPN)

An encrypted tunnel through the Internet that enables secure transmission of data

Web services architecture (WSA)

An architecture that utilizes web-based tools to permit communication among different software applications

Workstations on wheels (WOWs)

Notebook computers mounted on carts that can be moved through the facility by users

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