Glossary of Terms Relevant to Health Informatics
Agency for Healthcare Research and Quality (AHRQ)
The branch of the United States Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services.
American Recovery and Reinvestment Act of 2009 (ARRA)
The purposes of this act include:
- Preserve and create jobs and promote economic recovery.
- Assist those most impacted by the recession.
- Provide investments needed to increase economic efficiency by spurring technological advances in science and health.
- Invest in transportation, environmental protection, and other infrastructures that will provide long-term economic benefits.
- Stabilize state and local government budgets in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases.
Review of the health record for proper documentation and adherence to regulatory and accreditation standards.
Beacon Community Cooperative Agreement Program
This program demonstrates how health IT investments and meaningful use of EHRs advance the vision of patient-centered care, while achieving the three-part aim of better health, better care, and lower cost. The Office of the National Coordinator for Health IT (ONC) is providing $250 million over three years to 17 selected communities throughout the United States that have already made inroads in the development of secure, private, and accurate systems of EHR adoption and health information exchange.7
A field of study concerned with the broad range of issues in the management and use of biomedical information, including biomedical computing and the study of the nature of biomedical information itself. Formerly called medical informatics, the new name is intended to clarify that the domain encompasses biological and biomolecular informatics as well as clinical, imaging, and public health informatics.8 Biomedical informatics is the interdisciplinary field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making, motivated by efforts to improve human health.9 It’s the use of information technology for assimilating, gathering, organizing, analyzing, and presenting healthcare-related data to produce information for decision support to improve quality of care, decrease costs, enhance patient safety, and increase interoperability. Health information technology is the tool and information is the outcome.
The process of systematically investigating subjects related to the functioning of the human body.
Centers for Disease Control and Prevention (CDC)
A federal agency dedicated to protecting health and promoting quality of life through the prevention and control of disease, injury, and disability. Committed to programs that reduce the health and economic consequences of the leading causes of death and disability, thereby ensuring a long, productive, and healthy life for all people.
Centers for Medicare and Medicaid Services (CMS)
The Department of Health and Human Services (HHS) agency responsible for Medicare and parts of Medicaid. Historically, CMS has maintained the UB-92 institutional electronic media claims (EMC) format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.
Certification Commission for Healthcare Information Technology (CCHIT)
An independent voluntary private-sector initiative organized as a limited liability corporation that has been awarded a contract by HHS to develop, create prototypes for, and evaluate the certification criteria and inspection process for electronic health record (EHR) products.
Certified Health Data Analyst (CHDA)
AHIMA credential awarded to individuals who have demonstrated skills and expertise in health data analysis.
Certified in Healthcare Privacy and Security (CHPS)
AHIMA credential that recognizes advanced competency in designing, implementing, and administering comprehensive privacy and security protection programs in all types of healthcare organizations. Requires successful completion of the CHPS exam sponsored by AHIMA.
The process of gathering and examining data in order to help gain greater insight about patients.
Clinical Data Analytics
The process by which health information is captured, reviewed, and used to measure quality.
Clinical Decision Support
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 Document Architecture (CDA)
A Health Level Seven (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, and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for stage 1 of the “meaningful use” EHR Incentive Program and HITECH final rule. It is commonly referred to as Consolidate CDA or C-CDA.
Clinical Documentation Improvement (CDI)
The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes.
Clinical Documentation Improvement Plan
A program in which specialists concurrently review health records for incomplete documentation, prompting clinical staff to clarify ambiguity which allows coders to assign more concise disease classification codes.
Clinical Document Improvement Practitioner (CDIP)
AHIMA credential awarded to individuals who have achieved specialized skills in clinical documentation improvement.
A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement.
Commission on Accreditation of Health Informatics and Information Management Education (CAHIIM)
An independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality accreditation standards for health informatics and health information management educational programs.
Commission on Certification for Health Informatics and Information Management (CCHIIM)
An independent body within AHIMA that establishes and enforces standards for the certification and certification maintenance of health informatics and information management professionals.
Comparative Effectiveness Research (CER)
Research that generates and synthesizes evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.
Computer-Assisted Coding (CAC)
The process of extracting and translating dictated and then transcribed free-text data (or dictated and then computer-generated discrete data) into ICD-9-CM and CPT evaluation and management codes for billing and coding purposes.
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, overdose, and other relevant information.
Covered Entity (CE)
As amended by HITECH, a covered entity may be defined as a health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with a transaction covered by HITECH.
The science of examining raw data with the purpose of drawing conclusions about that information. This includes data mining, machine language, development of models, and statistical measurements. Analytics can be descriptive, predictive, or prescriptive.
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.
The overall management of the availability, usability, integrity, and security of the data employed in an organization or enterprise.9
Data mapping allows for connections between two systems. This connection allows for data initially captured for one purpose to be translated and used for another purpose. One system in a map is identified as the source while the other is the target. It is a process by which two distinct data models are created and a link between these models is defined. This process is used in data warehousing by which different data models are linked to each other using a defined set of methods to characterize the data in a specific definition. This definition can be any atomic unit, such as a unit of metadata or any other semantic. This data linking follows a set of standards, which depends on the domain value of the data model used. Data mapping serves as the initial step in data integration.
The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors.
The responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing, or otherwise making use of personal health information.
Decision Support System (DSS)
A computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision making tasks associated with non-routine and non-repetitive problems.
A set of statistical techniques used to describe data such as means, frequency distributions, and standard deviations; statistical information that describes the characteristics of a specified group or a population.
Enterprise Information Management (EIM)
Ensuring the value of information assets, requiring an organization-wide perspective of information management functions, calls for explicit structures, policies, processes, technology, and controls. EIM is the infrastructure and processes in place to ensure information is trustworthy and actionable.
Scientific discipline that is concerned with the cognitive, information-processing, and communication tasks of healthcare practice, education, and research, including the information science and technology to support these tasks.
Health Informatics and Information Management (HIIM)
Refers to the individuals responsible for the management of healthcare data and information in paper or electronic form and control the collection, access, use, exchange, and protection of the information through the application of health information technology.
Health Information Technology
A term that encompasses the technical roles that process health data and records, such as classification, abstracting, and retrieval.10 Under HITECH, health IT is defined as 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, healthcare entities or patients for the electronic creation, maintenance, access, or exchange of health information.
Healthcare Cost and Utilization Project (HCUP)
A family of databases and related software tools and products developed through a federal-state-industry partnership and sponsored by AHRQ. HCUP databases are derived from administrative data and contain encounter-level, clinical, and nonclinical information including all listed diagnoses and procedures, discharge status, patient demographics, and charges for all patients, regardless of payer, beginning in 1988.
Healthcare Effectiveness Data and Information Set (HEDIS)
A set of standard performance measures that can give an individual information about the quality of a health plan. One can find out about the quality of care, access, cost, and other measures to compared managed care plans. CMS collects HEDIS data for Medicare plans.
A field of study that focuses on the use of technology to improve access to, and utilization of, information.
Information Governance (IG)
The accountability framework and decision rights to achieve enterprise information management (EIM). IG is the responsibility of executive leadership for developing and driving the IG strategy throughout the organization. IG encompasses both data governance and information technology governance.
Information Technology Governance (ITG)
Led by the chief information officer (CIO), the process to ensure the effective evaluation, selection, prioritization, and funding of competing IT investments. ITG oversees the implementation of these investments and extracts business benefits.11
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
The coding classification system that will replace ICD-9-CM, Volumes 1 and 2, on October 1, 2015. ICD-10-CM is the United States’ clinical modification of the World Health Organization’s ICD-10. ICD-10-CM has a total of 21 chapters and contains significantly more codes than ICD-9-CM, providing the ability to code with a greater level of specificity.
International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS)
The coding classification system that will replace ICD-9-CM, Volume 3, on October 1, 2015. ICD-10-PCS has 16 sections and contains significantly more procedure codes than ICD-9-CM, providing the ability to code procedures with a greater level of specificity.
The capability of different information systems and software applications to communicate and exchange data.
An area of computer science that studies algorithms and computer programs that improve employee performance on some task by exposure to training or learning experience.
A field of information science concerned with the management of data and information used to diagnose, treat, cure, and prevent disease through the application of computers and computer technologies.12
Natural Language Processing (NLP)
A technology that converts human language (structured or unstructured) into data that can be translated and then manipulated by computer systems; a branch of artificial intelligence.
Office of the National Coordinator for Health Information Technology (ONC)
The principle 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 the National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the HITECH Act of 2009.
A process used to identify patterns that can be used to predict the odds of a particular outcome based on the observed data.
Mutual understanding of the meaning of data exchanged between 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.