Glossary of Terms

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Clinical Decision Support (CDS)

Computer-based clinical decision support (CDS) is defined as software that makes relevant information available for clinical decision-making. CDS ranges from electronically available clinical data (e.g. information from a clinical laboratory system and information from a disease registry), to electronic full-text journal and textbook access, to evidence-based clinical guidelines, to systems that provide patient and situation specific advice (e.g., EKG interpretation, and drug-to-drug interaction checking).

Computerized Provider Order Entry (CPOE)

A computer application that allows a physician's orders for diagnostic and treatment services (such as medications, laboratory, and other tests) to be entered electronically instead of being recorded on order sheets or prescription pads. The computer compares the order against standards for dosing, checks for allergies or interactions with other medications, and warns the physician about potential problems.

Consent

Permission that is not required, but may be obtained from an individual prior to using or disclosing that individual's personal health information.

  • No-Consent Model – does not require any agreement on the part of the patient to participate in an HIE.
  • Opt-Out Model – allows for a pre-determined set of data to be automatically included in an HIE, but a patient may still deny access to information in the exchange.
  • Opt-Out With Exceptions Model – allows a patient's personal health information to be made available in an exchange, but enables the patient to selectively exclude data from an HIE, limit information to specific providers, or limit exchange of information for specific purposes.
  • Opt-In Model – required patients to specifically affirm their desire to have their data made available for exchange within an HIE.
  • Opt-In With Restrictions Model – allows patients to make all of some defined amount of their data available for electronic exchange.

Electronic Health Record (EHR)

An electronic health record (EHR) is a longitudinal record of patient health information generated by one or more encounters in any care delivery setting. The EHR automates and streamlines the clinical workflow.

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 one health care organization.

Electronic Prescribing (e-Prescribing)

A type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage, and transmit prescriptions to a printer or a local pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physician access to patient specific information to screen for drug interactions and allergies.

Enterprise Architecture

A strategic resource that aligns business and technology, leverages shared assets, builds internal and external partnerships, and optimizes the value of information technology services.

Health Information Exchange (HIE)

A health information exchange (HIE) electronically moves health information among disparate healthcare information systems. Texas law defines an HIE as an organization that:

  • (A) assists in the transmission or receipt of health-related information among organizations transmitting or receiving the information according to nationally recognized standards and under an express written agreement;
  • (B) as a primary business function, compiles or organizes health-related information that is designed to be securely transmitted by the organization among physicians, health care providers, or entities within a region, state, community, or hospital system; or
  • (C) assists in the transmission or receipt of electronic health-related information among physicians, health care providers, or entities within:
    • (i) a hospital system;
    • (ii) a physician organization;
    • (iii) a health care collaborative, as defined by Section 848.001, Insurance Code;
    • (iv) an accountable care organization participating in the Pioneer Model under the initiative by the Innovation Center of the Centers for Medicare and Medicaid Services; or
    • (v) an accountable care organization participating in the Medicare shared savings program under 42 U.S.C. Section 1395jjj.

Health Information Service Provider (HISP)

An organization that provides RHIOs, HIOs, or individual health care providers with technical services, including software, hardware, support services and clinical/quality services that facilitate the secure exchange and use of health information, including, measurement and reporting of health information.

Health Information Technology (HIT)

Health information technology (Health IT) is the use of computers and computer programs to store, protect, retrieve, and transfer clinical, administrative, and financial information electronically within health care settings.

Health Information Technology for Economic and Clinical Health Act (HITECH)

The $19 billion Health Information Technology for Economic and Clinical Health Act, contained in the American Recovery and Reinvestment Act of 2009, funds a number of national health information initiatives.

Health Insurance Portability and Accountability Act (HIPAA)

The HIPAA Privacy Rule regulates protected health information (PHI) held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the use and disclosure of PHI needed for patient care and other important purposes. The Security Rule specifies a series of administrative, physical, and technical safeguards for covered entities to use to assure the confidentiality, integrity, and availability of electronic PHI.

Health IT Regional Extension Centers (RECs)

The Texas Regional Extension Centers (TXREC) are funded by a grant from the ONC to promote the adoption, implementation, and meaningful use of Electronic Health Records (EHR) in primary care provider practices. The four Texas RECs have collaborated extensively with one another. They have also partnered with the Texas Medical Association, Texas Osteopathic Medical Association, and other professional and trade associations to reach out to Texas medical professionals and inform them about the opportunities that EHRs present to their practices, REC services available, and current Centers for Medicare and Medicaid Services (CMS) incentive programs.

Interoperability

The ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities.

Master Patient Index (MPI)

A database program that collects a patient's various hospital identification numbers, e.g. from the blood lab, radiology department, and admissions, and keeps them under a single, enterprise-wide identification number.

Medicaid Eligibility and Health Information Services

The electronic health record that will be provided to all Texas Medicaid recipients through a magnetic stripe card as part of phase one of the Medicaid HIE created in HB 1218, 81st legislative session.

Office of the National Coordinator (ONC)

A federal government office (part of U.S. Department of Health and Human Services, or HHS) that oversees and encourages the development of a national, interoperable (compatible) health information technology system to improve the quality and efficiency of health care.

Personal Health Record (PHR)

An electronic record of health-related information about an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

Regional Health Information Organization (RHIO)

A health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community.

Texas Health and Human Services Commission (HHSC)

HHSC oversees the operations of the health and human services system, provides administrative oversight of Texas health and human services programs, and provides direct administration of some programs.

Texas Health Services Authority (THSA)

Created by the Texas Legislature through HB 1066 (80R, 2007) as a non-profit, public-private partnership to promote health information technology and health information exchange in the state. The Texas Legislature, through SB 203 (84R, 2015), recently directed the THSA to continue as a public-private partnership through September 1, 2021, at which time the THSA will transition to a fully private entity.

See also:
icon Defining Key HIT Terms

April 28, 2008
National Alliance for Health Information Technology Report to the ONC