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