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access levels  In electronic health records software, a security feature that limits access to information based on the type of information each user will need to view or modify.
acute care  Inpatient treatment for urgent problems.
administrative safeguards  Policies and procedures designed to protect electronic health information.
Administrative Simplification  HIPAA Title II rules on the uniform transfer of electronic health care data and privacy protection.
adverse drug event (ADE)  Side effect or complication from a medication.
adverse event  Patient harm resulting from health care treatment.
ambulatory care  Treatment provided without admission to a hospital, on an outpatient basis.
antivirus software  Software that scans for viruses and attempts to remove them.
application service provider (ASP)  An electronic health record model in which software and data are housed on an external company's servers or off-site from a medical practice, as opposed to a locally hosted model.
audit trails  Records of who has accessed a computer or network and the operations performed.
authentication  Confirmation of the identity of a computer user.
authorization  Permission to use and disclose information for uses other than TPO.
availability  Accessibility of systems for delivering, storing, and processing electronic protected health information.
business associates  Entity that works under a contract for a covered entity and is therefore subject to the CE's HIPAA policies and procedures.
chronic diseases  Prolonged conditions that rarely improve and often cannot be cured.
classification systems  Software systems that organize related terms into categories.
clearinghouses  Companies that process health information and execute electronic transactions.
clients  Computers that access a server through a network.
clinical guidelines  Recommended patient care based on the best available scientific evidence.
clinical templates  Structured progress notes that document patient encounters in an EHR.
clinical vocabularies  Common definitions of medical terms that minimize ambiguity.
computer-assisted coding  Software that automates part of the coding process.
computerized physician order entry (CPOE)  Application for health care providers to enter patient care orders.
confidentiality  Sharing of electronic PHI among authorized individuals or organizations only.
consumer-driven health plans (CDHPs)  Health plans with high deductibles, low premiums, and tax-free savings accounts.
content standards  Standards that specify the functional content of an information system.
continuity of care  Delivery of appropriate and consistent care over time.
covered entities (CEs)  Professionals and organizations that normally provide health care and electronically transmit PHI.
Current Procedural Terminology (CPT)  A coding classification system maintained by the American Medical Association for reporting medical services and procedures performed by physicians.
dashboard  A feature in Practice Partner that offers providers a convenient view of important information at a glance.
decision-support tool  Computer based program that make the latest clinical information available.
de-identified health information  Information that neither identifies nor provides a basis to identify an individual.
designated record set (DRS)  Information that includes PHI and is maintained by a covered entity.
desktop computer  Fixed, hardwired computer.
Digital Imaging and Communications in Medicine (DICOM)  Standards that enable electronic information exchange between imaging systems.
disclosure  Release of PHI to an outside provider or organization.
disease management (DM)  Systematic approach to improving health care for people with chronic diseases.
electronic health record (EHR)  A computerized lifelong health care record with data from all sources.
electronic medication administration records (e-MARs)  Electronic log with information about a medication order that enables electronic tracking of medication administration at the bedside.
electronic medical record (EMR)  A computerized record of one physician's encounters with a patient over time.
electronic prescribing  A computer based communication system that transmits prescriptions electronically.
electronic protected health information (ePHI)  PHI created, received, maintained, or transmitted in electronic form.
encryption  Process of converting data into an unreadable format.
evidence-based medicine  Medical care based on the latest and most accurate clinical research.
evaluation and management codes (E/M codes)  Procedure codes that are used to represent the processes a physician performs in determining the best course of treatment for a patient.
firewall  A software tool that examines traffic entering and leaving a computer network.
five rights  Five safety rules followed during the administration of medication—1. right patient; 2. right medication; 3. right dose; 4. right time; 5. right route of administration.
formulary  Pharmaceutical products and dosages deemed the best, most economical treatments.
Healthcare Common Procedure Coding System (HCPCS),
Level II
  
Classification codes for products, supplies, and certain services not included in Current Procedural Terminology (CPT).
health information exchange  An electronic network that securely moves clinical information among a variety of health information systems.
health information technology (HIT)  Technology that is used to record, store, and manage patient health care information.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)  Federal legislation the main purpose of which is to protect patient's private health information, ensure continuation of health care coverage, and uncover fraud and abuse.
Health Level Seven (HL7)  An electronic messaging standard used to send data from one application to another.
health plan  Insurance plan that provides or pays for medical care.
HIPAA Privacy Rule  HIPAA rule that provides protection for individually identifiable health information.
HIPAA Security Rule  HIPAA rule that protects the confidentiality, integrity, and availability of electronic health information.
hybrid conversions  Paper to electronic document conversion process that combines approaches.
incremental conversion  Gradual paper to electronic document conversion process.
Institute of Electrical and Electronics Engineers 1073 (IEEE1073)  A standard developed to provide communication among medical devices at a patient's bedside.
integrity  Authenticity, completeness, and reliability of electronic PHI.
International Classification of Diseases, Ninth Revision,
Clinical Modification
  
Internationally accepted rules for selecting and sequencing diagnosis codes in both the inpatient and the outpatient environments; standards that categorize diseases.
interoperable  Able to exchange electronic information and use the information in a meaningful way.
intrusion detection system (IDS)  A software tool that provides surveillance of a computer network.
laptop computer  Fully functioning portable computer.
locally hosted  EHR model in which hardware and software are housed onsite in a medical practice.
Logical Observation Identifiers Names and Codes (LOINC)  Universal terms and codes for electronic exchange of laboratory results and clinical observations.
Lookup  A feature in Practice Partner that provides different search options for locating a patient's record.
medical error  Adverse medical event that could have been prevented, such as an incorrectly filled prescription, a surgical mistake, and so on.
medical record  Chronological record generated during a patient's treatment.
Medicare Part D  Voluntary prescription drug benefit plan under Medicare.
Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA)
  
Federal legislation creating a prescription drug benefit plan that encourages electronic prescribing.
medication administration record (MAR)  Log with information about a medication order.
medication reconciliation  Process of obtaining and updating an accurate list of all of a patient's medications.
messaging standards  Electronic standards that allow data transfer to an electronic health record system.
minimum necessary standard  Required safeguards to protect PHI from being accidentally released.
National Council for Prescription Drug Program (NCPDP)  Code sets or standards for exchanging prescription information in the retail pharmacy environment.
Nationwide Health Information Network (NHIN)  Nationwide computer network facilitating the exchange of health care information.
network  Equipment that enables computers to exchange information electronically.
networked personal health record  PHR that transfers information to and from multiple health information systems.
Notice of Privacy Practices (NPP)  Document describing practices regarding use and disclosure of PHI.
order sets  Predefined groupings of standard orders for a condition, disease, or procedure.
Office of the National Coordinator for Health Information Technology (ONC)  The organization that serves as the recognized certification authority for electronic health records (EHR) and their networks.
outsourcing  The process of an organization contracting with an outside company for completion of all or part of a job.
passwords  Codes for gaining access to information on a computer or network.
patient portal  Website that allows patients to interact with provider or facility.
pay for performance (P4P)  The use of financial incentives to improve health care quality and efficiency.
personal digital assistants (PDA)  Handheld computer devices used to search for information, write prescriptions, and handle e-mail.
personal health record (PHR)  An individual's comprehensive record of health information.
physical safeguards  Mechanisms to protect electronic systems, equipment, and data.
picture archiving and communication system (PACS)  Electronic image management system.
point-of-care  Setting in which a physician makes decisions about a patient's illness and treatment.
progress notes  Notes about a patient's medical condition that are made during or after a physician-patient encounter.
protected health information (PHI)  Individually identifiable health information transmitted or maintained by electronic media.
providers  People or organizations that furnish, bill, or are paid for health care in the normal course of business.
regional health information organization (RHIO)  A group of health care organizations that share information.
role-based authorization  A tool that limits access to patient information based on the user's organizational role.
scanning  Method for electronically capturing text and images from paper documents.
server  Powerful computer that houses software applications and data.
SOAP  A widely used format for documenting patient encounters. It stands for Subjective, Objective, Assessment, and Plan.
standards  A set of commonly agreed on specifications.
Systematized Nomenclature of Medicine
Clinical Terms (SNOMED-CT)
  
Internationally recognized comprehensive clinical vocabulary of all terms used in medicine.
tablet computer  Portable computer with built-in handwriting and voice recognition software.
technical safeguards  Automated processes to protect and control access to data.
tethered  Information system attached to another information system.
total conversion  Paper to electronic document conversion method by an external company.
transition points  Times when patients move from one setting to another.
treatment, payment, and operations (TPO)  Conditions under which PHI can be released without patient consent.
Unified Medical Language System (UMLS)  Major thesaurus database of medical terms.
untethered  Information system not connected to another information system.
voice recognition  Method of entering information via a microphone connected to a computer.
Web View  A feature in Practice Partner that allows patients to view certain information from their chart via the Internet.
wired network  Network in which computers are connected via Ethernet cable.
wireless network  Network in which computers access servers without cables.
workstations  Hardware devices used to access the electronic health record and other software.







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