health information technology terms assignment

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Healthcare IT Skills, Health Information Technology Career Advice

Health Information Technology Terminology

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Accountable Care Organization (ACO)

An Accountable Care Organization is a voluntary entity established by the ACA law (Obamacare) in which organizations can contract to provide care for a set number of patients. Agreements specify that payments to providers are based at least partially on the health outcomes of the patients, not just for delivering services.

Refers to the level of disease severity in a patient, group of patients, or clinical care area. It defines how much medical care is needed for the condition or patient. It is sometimes used in the context of an acuity score, which compiles different data to arrive at a number to better understand how to care for a patient.

Administrative Rights

Refers to a set of permissions that allows a user to access or change protected functions on a computer, operating system, or application. This access allows the user to install or update software or make configuration changes among other things. A clinical user usually won’t have administrative rights, but an IT analyst will.

Alert Fatigue

For users of clinical technology, improperly configured systems can present false warnings, leading users to mentally tune them out over time. The danger is that a real warning will eventually appear, but be ignored

Ambulatory System

Refers to systems that care for patients in a non-hospital setting, such as a Primary Care Clinic. When someone is “Ambulatory”, we say they are up and about, as opposed to in a hospital bed.

Automated Dispensing Units

In a Healthcare facility, these are the systems used to physically secure medical supplies and medications in vending machine-like devices that require a user ID and password to access. The units also track the clinical administration of supplies and medications, as well as assisting with inventory management. The leading providers of the technology are Omnicell and Pyxis.

AVS – After Visit Summary

Written instructions given to patients after a medical visit. Usually contains what you were seen for, medications and orders placed, and what to do after the visit. Can be printed or transmitted to a patient portal.

Bar Code Administration

A barcode system that works much like those in retail, except that a caregiver uses a handheld reader to verify the patient and medication to provide extra security against dosing the wrong medication or amount, or getting the wrong patient.

Bidirectional Interface

In healthcare, an interface that communicates to and from a set of technical systems. An example is a Lab order system in which orders may be placed from an integrated medical records system, as well as placed from another system that needs to also send and receive order information. The Lab will then send back results from that original order to the EMR.

BLOB Storage Server

Stands for Binary Large Object. A physical server that functions as a repository for large amounts of data, usually media files such as scanned images. An EMR can display the images without needing to be the source of storage.

Blue Button Initiative

Blue Button is an effort by the Federal ONC division to support patients’ ability to download copies of their health records. The idea is to encourage portability, accuracy, and completeness of health records.

Case Mix Index

A value which is assigned to a group of patients based on how acute their care needs are. EMRs provide the data points for calculation, and the outcome is a calculated payment for services by Medicare and Medicaid.

Centers For Medicare & Medicaid (CMS)

CMS is the Federal agency that administers and governs the Medicare and Medicaid programs. They have wide-ranging authority to set rules, policies, and standards for clinical practices as well as for healthcare technology data and processes.

Change Control

Refers to a system of IT governance where representatives from many departments meet regularly to approve or deny proposed changes to IT systems. Anyone who is wanting to make major changes to software, network setup, etc needs to present their proposed changes to the team to be sure there are no conflicts or unforeseen side effects.

Chief Information Officer (CIO)

An executive level position in a technology organization. This person is the ultimate authority over most operational and personnel issues in the department. Hospitals and large healthcare technology companies will usually have a CIO and a CMIO.

Chief Medical Information Officer (CMIO)

A CMIO is a physician who serves as a liaison between the physician community and a technology department in a healthcare organization. The CMIO has a voice in what technologies are adopted and how they are used, and works closely with the CIO, directors of nursing, and technical managers.

Citrix is a large American company that provides products to support application implementation via servers, cloud-based tools, and software as a service. The practical application in a healthcare IT department is that many programs are installed and hosted on Citrix servers, and then accessed from a web browser or program shortcut on many computers and other devices as opposed to having the applications installed on those many devices.

Clinical Applications Analyst

A clinical applications analyst implements, configures, and supports specific clinical software programs for healthcare organizations or vendors. They typically work closely with clinical users to make sure the software meets the needs for documentation and efficient patient care. The clinical applications analyst will usually be involved in testing, documentation, and at least some training.

Clinical Decision Support System

A clinical decision support system is a software module or program that provides relevant patient specific information to guide the clinician in delivery of care. An example would be a reminder to a doctor to order the clinically recommended eye exam for every patient who is has type 2 diabetes. The doctor would see this reminder on a screen in their EHR as soon as they open the chart of a patient that meets the criteria. Medication interaction checking is another example of clinical decision support.

Clinical Document Architecture

Clinical Document Architecture is a data structure developed by the Health Level Seven organization to define how specific medical information (such as medication lists and progress notes) should be structured. Because it follows a uniform standard, many different vendors and systems can use it to exchange data among them. It is formatted using XML (Extensible Markup Language).

Clinical Documentation Improvement

A skill and a job position that has to do with best practices for documenting everything clinical that gets entered into an electronic system. A clinical documentation improvement specialist guides other clinicians to ensure data is entered into systems to meet regulatory guidelines.

Clinical Episode/Encounter

An episode of care is a grouping of more than one encounter. A pregnancy is an episode that has many encounters as the mom-to-be has her OB visits. A round of chemo treatments for a cancer patient is also an episode.

Clinical Informatics

Clinical Informatics involves the use of information technology to deliver and manage healthcare services. It places emphasis on accurate clinical documentation, decision support, and the use of reports to help improve patient outcomes.

Clinical Workflow

Refers to the steps that are performed in a clinical setting, such as an office visit or a patient admission. In the context of IT, staff will relate the workflow steps to functions in an electronic system, looking for ways to improve efficiencies and capture data correctly.

CMIO (Chief Medical Information Officer)

Chief Medical Informatics Officer. A high-level executive in a healthcare organization who provides leadership of an organization’s IT strategy, specifically relating to clinical impact. Will hold MD or other physician level credentials.

CMS – Centers for Medicare and Medicaid Services

The Centers for Medicare & Medicaid Services is a large Federal agency that regulates many aspects of Healthcare and Healthcare IT. Founded in 1965, it employs about 4,100 people and is funded by taxation. It provides oversight for more than 6,000 healthcare facilities, and has the authority to shut down or levy fines against organizations. In 2017, CMS paid about $709 billion in medical benefits.

Comorbidities

Chronic medical conditions that accompany or are otherwise associated with a primary diagnosis. For example, a patient with Diabetes may have comorbidities of sleep apnea and cardiovascular disease.

Computer Assisted Coding System

Computer assisted coding is the use of technology that analyzes clinical documentation to assist with correct medical coding for billing purposes. For example, a progress note on a patient visit for diabetes may or may not have the appropriate documentation for a complex case. Computer assisted coding can help point out issues in documentation that are likely to cause problems with billing.

Continuity Of Care Document

An electronic synopsis of a patient’s medical record that can be downloaded and transmitted to various other clinical systems using an agreed-to standard among vendors.

CPOE – Computerized Physician Order Entry

Computerized Physician Order Entry is the process of entering orders electronically instead of in paper charts. Advantages include 1) the ability to see orders without needing to view a paper record, 2) ability to check for duplicate orders, 3) ability to review order history and compare results over time, 4) ability to check for adverse interactions.

Current Procedural Terminology (CPT) Code

CPT is a set of medical codes used to identify procedures and clinical visits. Whereas ICD codes identify diagnoses, CPT codes identify the specific procedures that are ordered and performed by clinicians, as well as various medical visits. For example, the procedure code for an appendectomy is 44950. For a new patient physical exam, there is a range of codes from 99381 to 99387. CPT codes are primary used to support billing functions.

Data Warehouse

A large database collection of records from various locations that is used to run complex reports and statistical analysis over time. Insurance companies and Healthcare organizations store millions of patient records in data warehouses over long periods.

Date of Service

Usually abbreviated to “DOS”, this is when a patient was seen. It is critical for billing purposes, as well as considering when orders were placed. Even if a physician completes documentation after the visit, the date of service stays the same.

Decision Support System

A technology solution designed to provide useful information in making organizational decisions. A clinical report on a population of patients would be the outcome of a decision support system.

Digital Imaging and Communications in Medicine – a protocol to format the transmission of medical images, such as MRIs and ultrasounds. Used in radiology systems.

Disaster Recovery

Refers to a comprehensive plan, drills, and technical tools to prepare for a major events such as natural disasters, data breaches, terrorism, or system failures. Designed to protect IT systems during these events. During a disaster recovery drill, a production system will be brought offline to run through disaster scenarios.

Discrete Data

In the context of a Healthcare IT implementation, discrete data refers to the concept of recording data into distinct fields in the smallest unit possible, as opposed to entering multiple entries into free-text fields that are hard to retrieve by queries and reports.

E-Prescribing

The process to electronically prescribe medications from a provider’s EHR to pharmacies using a electronic prescribing service . This process replaces hand-written prescriptions in most cases. The leading e-prescribing supplier is Surescripts.

An e-visit is an electronic exchange between a patient and healthcare provider. It can be done through questionnaires via an online portal where a patient submits concerns that are replied to by a provider. An e-visit is not the same as telehealth visit, which is done in real-time through video.

Electronic Claim

An electronic claim is a paperless transmission from a clinical system to a insurance payer to reimburse for medical services on a patient. Electronic systems typically send large batches of claims at defined intervals. The sending system has reports to confirm the successful receipt of claims by the receiving systems and to check for errors.

Electronic Signature

An electronic signature is a digital authentication that verifies the identity of an individual for legal and medical purposes. For example, when a physician signs into an electronic health records system with a user ID and password, that physician can then sign medication orders with the click of a button because their identity has already been verified by logging in. A electronic fingerprint reading or other digital authentication can also serve as an electronic signature.

Electronic Health Record (EHR)

The official electronic record for an individual that is shared among multiple platforms and organizations. It is commonly used to describe a software platform that is implemented to perform functions of an electronic medical records system plus more comprehensive information shared from other systems. The current trend is to refer to enterprise wide systems as EHRs. Some of the largest EHR systems are Cerner, Epic, and MEDITECH.

Electronic Intensive Care Unit (eICU)

eICU is a support model that provides ancillary monitoring of ICU patients from a remote location. It involves the use of video cameras, audio monitoring, and vital sign monitoring to provide an additional layer of support to the clinical staff working within the ICU. It’s important to note that eICU does not replace clinical staff in the ICU. The remote eICU clinicians are called intensivists and are licensed RNs.

Electronic Medical Record (EMR)

The official electronic record contained in a single electronic system. It is commonly used to describe a software platform that is implemented in a healthcare setting to perform functions of clinical documentation, order entry, clinical analysis, scheduling, and more.

Enterprise Master Patient Index (EMPI)

An EMPI is a database used in a healthcare organization to maintain complete and accurate data on all patients. Each patient is assigned a unique identifier (the master patient index) to facilitate indexing of records. This also allows the data to be referenced by systems outside of the healthcare organization, and assists with patient matching from various connected systems.

Fee For Service

The typical payment model for Healthcare in the US where Healthcare providers and facilities are paid for individual services such as lab tests and surgeries as opposed to flat-fee or outcomes based price structures. This model is frequently criticized as the reason for high costs, and various entities are always experimenting with alternative options, such as accountable care organizations.

Pronounced “fire” – stands for Fast Healthcare Interoperability Resources. It is a communication standard developed by the Health Level Seven (HL7) organization to facilitate electronic sharing of clinical data across EMRs, devices, health information exchanges, and more.

Flat File Database

A flat file database is a database that stores data within plain text files. the text fields for the data items are separated by characters like commas or the pipe symbol |. The main difference in this type of data structure is that it is not a relational database where every table shares at least one field with another table, making it easier to link and reference data.

A defined database of medications used as a standard for placing orders in electronic systems as well as defining coverage by insurance companies. A formulary is typically imported into a electronic health record system at regular intervals.

Front Office/Back Office

In a clinic setting, refers to specific functions and personnel. Front office staff perform check-ins, scheduling, and calling patients. Back office staff are Medical Assistants and other clinicians who interact with patients clinically.

FTP – File Transfer Protocol

FTP stands for File Transfer Protocol. It is a method by which systems or users move files from one computer to another over a network. A file will usually be transferred from a folder location on one computer to a folder on another computer. In the past, FTP functions were done via DOS commands. There are now many commercial and free software programs that support FTP on Windows, Apple, and Linux platforms.

H&P (History and Physical)

Describes the documentation of pertinent medical history, as well as a physical exam on a patient. It begins with the patient’s “story” on why they are seeking care. The history portion includes previous conditions and surgeries, as well as the condition they are currently seeking treatment for. Then a complete physical examination is performed, which includes both objective and subjective information.

Health Information Exchange (HIE)

A Health Information Exchange is a community based technology system that allows various healthcare organizations to share clinical data across systems that are not otherwise connected. Numerous systems transmit clinical messages to manage populations of patients and to look for patterns in medication dispenses.

HEDIS (Healthcare Effectiveness Data and Information Set)

HEDIS is a widely used measurement tool of clinical performance measures for healthcare, developed and maintained by the National Committee for Quality Assurance (NCQA). It measures almost 100 data points across these six disciplines: Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Risk Adjusted Utilization, Health Plan Descriptive Information, Measures Collected Using Electronic Clinical Systems.

The Healthcare Information and Management Systems Society. A non-profit organization that advocates for the advancement of Healthcare IT. They publish articles, hold trade conferences, and oversee several Health IT certifications. himss.org

The Health Insurance Portability and Accountability Act of 1996 provides oversight of how patient data is exchanged and protected. Examples of HIPAA violations are the inappropriate viewing or sharing of patient information by healthcare workers, and unsafe handling of printed or electronic health information. It also provides some insurance protection for people who change or lose jobs.

HL7 (Health Level Seven)

Health Level Seven is a messaging standard that governs the formatting, transmission, and display of clinical data in healthcare. Competing and complementary systems use the same standard to share clinical data using HL7.

HPI – History of Present Illness

A documentation of the development of a patient’s current medical condition. A chronological description from when the symptoms and conditions appeared up to the current time. It included some or all of these components: location, quality, severity, duration, timing, context, modifying factors, signs & symptoms.

The International Classification of Disease 10th revision is a system of coding medical conditions and diseases. Established by the World Health Organization, it was implemented in October 2015 to replace the previous version, ICD-9. ICD-10 allows for very detailed descriptions of conditions. An example is E11.9, which is “Type 2 Diabetes Mellitus without complications”.

ICD-11 is the next major version of medical coding that is being developed by the WHO. The draft version of ICD-11 was released in May 2012. The new code set goes into effect on January 2022.

Index (Database Reference)

A database structure that facilitates quick retrieval of data from a database. In more simple terms, may refer to a unique identifier for every item in a table. For example, a database table of patients may have a unique column value that serves to index the values.

Interface Engine

A specialized server and software solution used to format, translate, and communicate healthcare related data to and from other systems using various protocols, with HL7 being the most frequently used. The interface engine is the “traffic cop” of most data that is transmitted throughout a healthcare organization.

Interoperability

Refers to an expectation that electronic health systems and other technologies should be able to easily exchange data among each other regardless of location or technical platform. This requires that data is shared using common standards, such as HL7.

Joint Commission

The Joint Commission is a non-profit organization that accredits healthcare organizations in the US. Established in 1951, the organization provided accreditation to over 20,000 healthcare facilities which include hospitals, nursing homes, surgery centers, and home health agencies. The Joint Commission is not a governmental organization, but carries a high level of authority and credibility. An unfavorable survey on a facility by Joint Commission can be very detrimental to a healthcare organization.

Laboratory Information System

A laboratory information system is a software platform that manages and stores data for a clinical laboratory. Orders from physicians in hospitals and clinics are typically transmitted electronically or faxed to lab systems. The orders are then processed by lab technicians, who then enter the results into the LIS. The LIS then transmits the results back to the ordering provider electronically, or by fax if the provider is not on a EHR system. In some cases, the LIS can send results directly back to patients.

Leapfrog Group

The Leapfrog Group is a non-profit patient safety and quality ratings firm that grades healthcare organizations in the areas of quality and patient safety. They provide easy to understand hospital safety letter grades that carry significant consequences. A hospital’s Leapfrog score can generate enough good or bad media attention to make the difference between success and failure.

Legacy System

Legacy System A concept in IT referring to an older system that could be considered for replacement by newer technology. In a Healthcare system, we may have a homegrown product that has been in place for many years, and does not send data to other systems. When a project team meets, they may say something like “We need to replace our legacy registration system with something that interfaces to the rest of our organization”.

Legal Medical Record

A healthcare facility may have various systems which contain parts of the patients’ medical record, and some may not be updated in a timely manner. Those partial systems contain useful information, but can’t be relied on as the legal medical record. An organization will define one system as the legal system, such as Epic or Cerner. May also be called the “source of truth”.

LOINC (Logical Observation Identifiers Names and Codes)

LOINC is a database structure and standard for identifying clinical lab observations. It is used by medical coders and billing to process lab results, as well as in health information exchanges. An example of a LOINC code is: 4635-9: Free Hemoglobin [Mass/volume] in Serum.

MACRA (Medicare Access And Chip Reauthorization Act)

Medicare Access and CHIP Reauthorization Act of 2015 is a US law that changes the way that Medicare rewards clinicians for value over volume, and streamlines other CMS quality programs. It measures patient-reported outcomes and functional statuses, and patient experiences. It also reissues Medicare ID cards that have a new identifier which replaces using social security numbers.

MAR – Medication Administration Record

Documentation that is done when the patient actually gets a medication into their body as opposed to just the writing of the medication order. Many times a physician writes a medication or, and a nurse administers and documents the med. There can be many administrations tied to a single medication order. If the order is for Tylenol 325 mg every 6 hours, then the nurse documents on the MAR each time that medication is given.

Master Patient Index (MPI)

A master data source that identifies patients across various entities or organizations. If two hospitals merge, and each has a different format for their MRNs, they need a master ID to tie the two different ID formats together. The MPI becomes that “tiebreaker” between more than one medical record number.

Meaningful Use

A regulatory component of the HITECH Act of 2009, which established guidelines for the meaningful use of electronic medical records systems. Designed to push providers towards using EMRs to their full capacity. Financial incentives were given to providers who comply through 2015. Future incentives turned into penalties in October 2016 for not complying.

Medical Device Integration

Medical device integration allows for clinical data to be transmitted between medical devices and software platforms such as EHRs. Examples of integrated devices are IV pumps, glucose monitors, blood pressure monitors, and life-supporting ventilators. Devices can use several different communication standards, including HL7 and ISO/IEEE 11073. Devices may be tethered to a network via a network cable or may transmit over a wireless network. The more patient critical devices use a hardwired connection. Consumer wearables such as FitBits don’t technically qualify as medical devices but can be tied to a patient portal in order to send information to a physician.

MRN – Medical Record Number

A unique numeric value assigned to a given patient in an electronic medical records system, as well as many other clinical systems. This number usually stays with the patient indefinitely. Some older systems allow an alpha-numeric format.

NDC – National Drug Codes

NDCs are 10 or 11 digit numbers uniquely assigned to every over-the-counter and prescribed medication. For example, the NDC for Tylenol Extra Strength is 50090-0005-0. The codes are divided into three sections. The first section is the manufacturer or distributor. The second section is the product itself. The third section is the commercial package size.

National Health Service (NHS)

The NHS is the publicly funded healthcare system of the United Kingdom, covering citizens of England, Scotland, Wales, and Northern Ireland. It provides free and low-cost lifetime healthcare to over 54 million people, paid for mainly by taxation.

National Provider Identifier (NPI)

NPI National Provider Identifier is a unique 10 digit ID required by Federal healthcare governing authorities. All physician and physician assistant level providers have an NPI. It is required for placing orders, and is used in e-prescribing systems. Healthcare entities may also have an NPI.

OASIS Data Set

OASIS data (The O utcome and AS sessment I nformation S et) is a clinical documentation structure developed by CMS and the Robert Wood Johnson Foundation for the home health clinical setting. It is not used in any other clinical area. OASIS has many questions that assess patient functional status, information on falls and other risks, psychological status, hospital admissions, and more.

ONC (Office Of The National Coordinator For Health Information Technology)

The Office of the National Coordinator for Health Information Technology is a Federal Agency created in 2004 to oversee the implementation of technology in healthcare nationally. They were heavily involved in the implementation of the online healthcare exchange website and program. Their public facing website is healthit.gov .

Open Notes Initiative

Open Notes is non-governmental initiative that encourages physicians to allow patients to see the progress notes that get entered into electronic health records (EHR) systems during medical visits. Traditionally, this part of the medical record has not been released to patients unless they specifically ask for it. The idea is to provide more transparency and encourage patients to be more involved in their own care.

Picture Archiving and Communication System. An electronic system for storing, transmitting, and presenting medical images such as X-Rays and MRIs. A PACS system is used in the radiology department of a healthcare organization, and the PACS administrator is the individual who supports the technologies.

Patient Portal

A web-based application that allows patients to view portions of their medical records. It also usually provides the ability for patients to request or book appointments and communicate with their care providers who have implemented it with an electronic health records system. Most patient portals are implemented along with electronic health records systems in healthcare organizations.

Patient Protection And Affordable Care Act

This law is more commonly referred to as the Affordable Care Act, or Obamacare. Signed in 2010, it is a wide-ranging effort to get most Americans on health insurance plans and provide methods to improve the quality of care and patient outcomes. Components of the law that related to healthcare technology are accountable care organizations and the expansion of health information exchanges . In December 2018, a federal judge in Texas issued a ruling that the entire law is unconstitutional because the individual mandate portion had been previously invalidated.

PHI – Protected Health Information

Stands for Protected Health Information. Personal info about patients that allows them to be personally identified. Usually includes demographics such as name, address, phone, SSN, etc. Transmission of this info is Federally protected and regulated, and violations for transmitting PHI inappropriately can be severe.

PHQ-2 or PHQ-9

PHQ stands for patient health questionnaire, and the 2 or 9 has to do with the number of specific questions that are asked of patients concerning their mental well-being. The questionnaire is used as a screening tool for depression. The first question asks, “over the past two weeks, how often have you been bothered by any of the following problems?” Little interest or pleasure in doing things … Feeling down, depressed, or hopeless . If the patient responds that they have experienced these feelings in the first two questions, then they are directed to answer seven more questions.

Physician Champion

A Physician Champion is physician in a healthcare organization who has chosen to take on the role of liaison between a group of clinical users and the technical staff who implements technology. It usually does not explicitly carry a high level of authority like the CMIO. The physician champion may help with technical and configuration activities that are usually done by IT analysts.

Point of Care Test

A test or reading that is initiated and resulted at the same place and near the same time where the patient is being seen. Glucose readings, strep tests, pregnancy test, and some urine collections are examples of POCTs.

Population Health Management

Population Management is coordinated effort among healthcare providers, patients, and other entities to focus healthcare delivery on the outcomes of patients, not just on delivering services. The participating parties may sign agreements to care for a fixed number of patients (at least in the thousands) for a set duration, with payments to providers being based on the overall health of the patients.

Protocol Orders

Protocol Orders are orders that can be administered by non-physician clinicians according to a pre-defined set of guidelines that line up with their clinical qualifications. An example would be “when fever is above 101F, RN to give 350 mg of Tylenol”. Protocol orders streamline the delivery of care in certain clinical settings such as hospital inpatient stays.

Radiology Information System (RIS)

The software system for managing radiology procedures and images, as well as the information connected to the images such as text results. A radiology system is usually used in conjunction with a PACS system.

Real Time Eligibility

Real time eligibility (RTE) is a technology solution that allows electronic health records systems to retrieve up to date insurance information on patients. Registration staff will trigger a query from their EHR system that sends patient information to an insurance company or a third party data provider. That system will then quickly return a verification that confirms the patient’s insurance status.

Relational Database

A database which has tables that are linked to each other using indexes. This configuration facilitates speed and performance as well as the ability to perform complex queries to modify and report on the entire data set. Access to the database is done using structured query language (SQL).

Release of Information

When an entity or person outside of a healthcare facility requests medical information on a patient,  organizations need to follow specific guidelines and laws to be sure that the request is legally authorized, and that the correct information is provided to the entity or person. The policies and technology to support this is release of information. A common form of release of information (ROI) is a lawyer’s request for records on a patient.

Remote Desktop Protocol (RDP)

Remote Desktop Protocol is a Windows software program that enables a user to connect remotely to another computer in order to view and control that computer. The connecting user can see the remote computer screen as if they were sitting at that computer. RDP has been built into Windows operating systems since version XP.

Remote Patient Monitoring

Remote patient monitoring involves the use of technology to collect clinical data on patients located outside of a clinical setting. It is used to help manage chronic and complex conditions such as diabetes and congestive heart failure. The patient uses devices that report clinical readings an vital signs back to clinicians electronically. For example, a patient may have a blood pressure monitor, glucose reader, and weight scale that are all configured to send readings back to clinicians through a mobile data connection.

Risk for Readmission

A measure for how likely a patient is to be readmitted to the hospital for a condition that should have been fully resolved in a previous encounter. Hospitals in particular use a readmission risk score in an attempt to reduce readmissions. Federal agencies and rating organizations report hospital readmission rates to the public.

RXNorm is a database of medications maintained by the National Library of Medicine. It serves as a reference point for drug names and vocabulary used in clinical systems for interaction checking software. Each medication name, dose and strength is given a unique RxNorm name. For example, a 325mg tablet of Tylenol has a different name from a 500mg tablet of Tylenol.

SBAR is an acronym for S ituation, B ackground, A ssessment, R ecommendation. It is a communication tool used to help with efficient reporting of routine tasks or unforeseen problems. It was created by the Navy, but has been adopted by many industries, such as healthcare and technology.

Scope of Care

The definition of what a healthcare practitioner is permitted to do in keeping with their professional license. For example, a nurse can administer medications, but usually orders for medications are written by a MD, Nurse Practitioner, or Physician Assistant.

Service Level Agreement

A written set of rules that defines the commitment between providers of technology and the customers they serve. An example SLA item might say something like “A ll critical IT issues will be responded to by the help desk within 15 minutes “.

SNOMED (Systematized Nomenclature of Medicine-Clinical Terms) is a standard for mapping clinical terminology in electronic systems to make it easier to associate with diagnoses. SNOMED is used by many electronic health systems to facilitate interoperability.

SOAP Stands for Subjective, Objective, Assessment, and Plan. It is a format that physicians use to document visits in progress notes, usually in an electronic medical records system.

Subject Matter Expert (SME)

A SME is a person who has specific and relevant knowledge about how detailed tasks are carried out in their day-to-day job. They serve as a liaison between non-technical and technical users to help define how technology should be used in their area of expertise. They usually don’t carry any extra authority in this position, but their input is valued by clinical and technical staff.

SQL – Structured Query Language

SQL is a language used to view and change data within a relational database. The main SQL functions are built around commands to select, insert, modify, and delete data. SQL is fairly easy to learn, as it uses an English-like syntax to access data. An example would be something like “ Select first_name from patients_table where DOB > “01-01-2001 “. This query would show the first names of all patients who have a birth data after January 01, 2001.

System of Record (or Source of Truth)

Hospitals have many IT systems that share data with each other. For each data set (medications, users, orders, patients), the organization must define which system is to be considered if there is a data discrepancy between more than one system. That system “wins” for whatever data is in question at a given time.

Telemedicine (Telehealth)

Telemedicine is the use of video technology by healthcare providers to treat and/or diagnose patients. In most settings, a telemedicine visit is performed for routine or low level visits such as rashes, cold symptoms, or minor injuries. There is a large focus on using the technology in rural areas where access to healthcare provider can be a challenge. There have been challenges on how to get insurance policies to pay for these visits, but some of those issues have been worked out, and the adoption of telemedicine is growing quickly.

Twenty-First Century Cures Act

The 21st Century Cures Act of 2016 allocated $6.3 billion for research, healthcare quality improvement, the opioid crisis, the FDA drug approval process, and some technology components. The healthcare technology part supports improved connection between EHR systems, better ability for patients to access their medical records electronically, and a reduction in the amount of clinical documentation required by physicians.

Value-Based Healthcare (Value Based Purchasing)

An initiative from CMS that pays hospitals and other organization payments in part for the quality of care they provide to Medicare beneficiaries, measured by patient outcomes as opposed to just paying for the services delivered. This is a departure from the traditional fee-for-service model that dominates most of healthcare in America.

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Your Guide to Health Information Technology Terminology

It’s no secret that health information technology is revolutionizing the world of health care — producing dramatic changes both in the ways that physicians and institutions practice health care and in the ways that patients (now increasingly regarded as “consumers”) experience it.

Meanwhile, health information technology terminology — the vocabulary we use to define, describe and communicate about these changes — is also evolving at a rapid pace. From EHRs and HIPAA to the rise of health informatics, the conversation about health care today includes important new health information technology terms (and acronyms!), some of which did not even exist as recently as a decade ago.

This glossary covers some of the key terms that you’ll want to be familiar with — whether you are a health care consumer or someone who is interested in pursuing some of the new health informatics career opportunities .

Health Information Technology Terminology

Founded in 1928 to improve the quality of health records, the American Health Information Management Association describes itself as “the premier association of health information management (HIM) professionals worldwide,” serving 52 affiliated state associations and more than 103,000 health information professionals. It strives to play a leadership role in the effective management of health data and medical records needed to deliver quality healthcare to the public and is a respected authority for rigorous professional education and training.

The American Medical Informatics Association is a professional scientific association focused on “transforming health care through trusted science, education and the practice of informatics.” Connecting a broad community of professionals and students interested in informatics, it strives to be a resource for informaticians and — through education, training, accreditation, and certification — to support the current and next generation of informatics professionals.

The mission of the American Nursing Informatics Association is “to advance nursing informatics through education, research and practice in all roles and settings.” Founded in 1992, it describes nursing informatics as a specialty that “integrates nursing science, computer science and information science to manage and communicate data, information, knowledge, and wisdom in nursing and informatics practice.”

Biomedical Informatics

AMIA defines biomedical informatics as “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.”  

Centers for Disease Control and Prevention (CDC)

This federal agency is 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 federal Department of Health and Human Services (HHS) agency responsible for Medicare and parts of Medicaid. CMS is also responsible for certain aspects of the Health Insurance Portability & Accountability Act (HIPAA).

Certified Health Data Analyst (CHDA)

The AHIMA credential awarded to individuals who have demonstrated skills and expertise in health data analysis.

Certified in Healthcare Privacy and Security (CHPS)

The 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.               

Chief Medical Information/Informatics Officer (CMIO)

In hospitals or health systems, a physician charged with helping to assure the success of clinical information systems, representing a clinician’s perspective, and participating in system selection, implementation, evaluation and user training.

Clinical Decision Support

According to HealthIT.gov, clinical decision support (CDS) “provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.” In practice, it encompasses a variety of tools to enhance health care decision-making, including computerized alerts and reminders to both health care providers and patients; focused patient data reports and summaries; diagnostic support and contextually relevant reference information, etc.

Clinical Informatics 

Clinical Informatics is synonymous with health informatics (see entry below), according to the Healthcare Information and Management Systems Society and other sources. HIMSS defines the discipline as promoting “the understanding, integration, and application of information technology in health care settings.”

Clinical Documentation Improvement (CDI)

Clinical documentation improvement is a specialty that involves creating and administering accurate, timely health care records to ensure improved patient outcomes, data quality, and accurate reimbursement. According to SearchHealthIT.com , some health care facilities employ CDI specialists to ensure that each patient’s clinical documentation is comprehensive and up to date.

Connected Health

Connected Health describes the use of technology to facilitate intelligent communication and insights that drive better and more integrated health care services. According to Partners HealthCare Connected Health , some of the goals and benefits include:

• Engaging patients and providers for productive participation
• Empowering individuals to self-manage their health and wellness
• Achieving clinical workflow efficiencies and minimizing disruption from new programs
• Ensuring regulatory and privacy compliance

Data Analytics

The systematic use of data to obtain new insights and drive fact-based decision making for patient care outcomes as well as clinical and operational improvements. The types of data being utilized include:

• Claims and cost data
• Pharmaceutical data, research and development data
• Clinical data collected from electronic medical records
• Data on patient behavior and preferences

Data Stewardship

Data stewardship encompasses the responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing or otherwise making use of personal health information.

The explicit agreement from a patient to allow another party to view the data contained in his or her electronic health record.

eHealth Initiative

The eHealth Initiative is an independent, nonprofit organization that engages doctors and patients to standardize and reform the use of health information technology (HIT) to improve patient care in the U.S. One of its main objectives is the advocacy of electronic prescribing, or e-prescribing.

Electronic Health Record (EHR)

EHRs offer a complete real-time record of a person’s medical history that is easily accessible by health providers (and increasingly, by patients). In addition to being a comprehensive record of an individual’s health care, the documentation inside EHRs supports the functions of billing, quality management, outcome reporting and public health disease surveillance and reporting. EHR is sometimes used interchangeably with EMR (electronic medical record).

Electronic prescribing

Also, called e-prescribing, this describes technological advances that allow doctors and other medical practitioners to write and securely send prescriptions to a patient’s pharmacy electronically instead of using handwritten prescriptions, faxes, and phones. Industry leader Surescripts reports that it processed 1.41 billion e-prescriptions in 2015 (a figure that has doubled since 2012) and that more than 75% of all prescriptions are now handled electronically.

Health Informatics

The U.S. National Library of Medicine defines health informatics (also called medical informatics) as the interdisciplinary study of the design, development, adoption, and application of IT-based innovations in health care services delivery, management, and planning. According to AHIMA , there are four major focus research areas in informatics education:

• Medical/Bio-Informatics — physician- and research-based; attracts medical students
• Nursing Informatics — Clinical- and research-based; attracts nursing students
• Public Health Informatics — public health- and bio surveillance-based; attracts public health students
• Applied Informatics — addresses the flow of medical information in an electronic environment and covers process, policy and technological solutions; attracts health information management students

[RELATED]  What is Health Informatics? [Definition + Jobs and Salary Information] >>

Health Information Exchange (HIE)

Health information exchange, used as both a noun and a verb, focuses on utilizing technology to share health care information (including patient records). Health providers use HIE to deliver safer and more timely, efficient and effective patient care; public health officials leverage larger data sets to analyze the health of patient populations.

Health information management  (HIM)

The practice of acquiring, analyzing and protecting digital and traditional medical information vital to providing quality patient care. HIM involves a combination of business, science and information technology ( AHIMA ). Working in a diverse set of roles that include accurately and securely managing patients’ medical data, HIM professionals affect the quality of patient information and patient care at every touch point in the healthcare delivery cycle.

[RELATED]  How Health Informatics is Shaping Future of Health Information Management >>

Health Information Technology (HIT)

According to AHIMA , “Professionals who work in HIT are focused on the technical side of managing health information, working with software and hardware used to manage and store patient data. HIT professionals are usually from information technology backgrounds and provide support for EHRs and other systems HIM professionals use to secure health information.”

HIMSS (Healthcare Information and Management Systems Society)

The Healthcare Information and Management Systems Society ( HIMSS ) is a nonprofit organization whose goal is to promote the best use of information technology and management systems in the healthcare industry. Founded in 1961, HIMSS provides a forum for collaboration among the various stakeholders in health care IT, using advocacy, education , and collaboration to further its mission.

HIPAA (Health Insurance Portability and Accountability Act)

A federal law designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers. It is also intended to prevent fraud and abuse and to help protect employees and their families from losing health insurance coverage after a job change or loss.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was enacted to promote the adoption and meaningful use of health information technology. It includes multiple provisions related to the expanded use of electronic medical records, privacy protocols (HIPAA), structures for Medicare and Medicaid reimbursement, and an ever-evolving set of rules and systems seeking to incentivize providers to deliver the highest quality care. Its adoption has also dramatically increased the demand for skilled labor in the healthcare IT industry .

Information Governance

Information governance (IG) programs are being adopted by healthcare organizations as part of their commitment to managing information as a valued strategic asset. AHIMA reports that IG programs:

• Contribute to safety and quality of care, population health, operational effectiveness and cost-reduction initiatives
• Serve the dual purpose of optimizing the ability to extract clinical and business value from healthcare information while simultaneously meeting compliance needs and mitigating risk

Internet of Medical Things (IoMT)

Named after the IoT (Internet of Things), IoMT refers to the ever-growing array of medical devices and applications that connect to health care IT systems through online computer networks.

Interoperability

According to HIMSS, interoperability describes the extent to which systems and devices can exchange data and interpret that shared data. For two systems to be interoperable, they must be able to exchange data and subsequently present that data in a way that can be understood by a user. In practical terms, it often refers to the ability of providers — for example, a patient’s primary care physician as well a specialist at another office or a doctor providing care in a hospital setting — to easily and securely access patient histories and other medical information without waiting for paper copies of health records to be sent. It also means empowering patients to utilize patient portals to access information about their own care.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) governs the payment methodologies for physicians and other providers seeking federal reimbursement for services to patients insured under Medicare and Medicaid.

Meaningful Use

Meaningful Use refers to a program administered by the federal Centers for Medicare & Medicaid Services (CMS) that uses a system of financial awards and penalties to incentivize quality care and the most efficient use of electronic health records.  

Medicare and Medicaid EHR Incentive Programs

As a part of the HITECH Act of 2009, Congress created programs within Medicare and Medicaid to pay incentive payments to hospitals and physicians to promote adoption and use of healthcare IT methodology. The program reduces payments to health care providers who underperform relative to the evolving set of standards.

Short for “mobile health,” this term refers to the use of mobile phones, tablets and other wireless technology in health care , often to educate consumers about preventive health care services. It can also be used for disease surveillance, treatment support, tracking of epidemic outbreaks and chronic disease management. The nonprofit mHealth Alliance is advocating for increased use of mHealth in the developing world.

Nursing Informatics

Nursing informatics is described by the American Nursing Informatics Association (ANIA, see above) as “a specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage and communicate data, information, knowledge, and wisdom in nursing practice.”

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.

Precision Medicine

The National Institutes of Health (NIH) defines precision medicine as: An emerging approach for disease treatment and prevention that considers individual variability in genes, environment, and lifestyle.

Patient Engagement

Many health care organizations are now employing strategies to better educate patients about their conditions and involve them more fully in making decisions about their care — due to emerging evidence that people who are actively involved in their health care tend to have better outcomes and in some cases lower costs. Information technology is at the heart of patient engagement — enabling patients and families to e-connect with health care providers through secure channels and making possible such innovations as wearable apps that generate data (blood pressure readouts, glucose monitoring for diabetics, etc.) that is useful to both patients and their physicians.

Public Health Informatics

The systematic application of information and computer sciences to public health practice, research, and learning. This discipline, which integrates public health with information technology, is considered the key to unlocking the potential of information systems to improve the health of the populations throughout the world.

Security of data and health records is paramount in the health care industry. Ransomware (malicious software that blocks access to a victim’s data until a ransom is paid) has been used by hackers to extort payments from hospitals and health care organizations (including England’s National Health Service). This “Health Care and Ransomware” article from SecurityIntelligence.com discusses the ongoing threat and outlines steps health care security professionals can take to minimize the risk.

Remote patient monitoring (RPM)

According to the Center for Connected Health Policy , remote patient monitoring uses digital technologies to collect medical and other forms of health data from individuals in one location and electronically transmit that information securely to health care providers in a different location for assessment and recommendations. In practice, it enables a patient to use a mobile medical device to perform a routine test and send the test data to a health care professional in real time. Frequently used with the elderly and the chronically ill, RPM technology includes daily monitoring devices such as glucose meters for patients with diabetes and heart or blood pressure monitors for patients receiving cardiac care.

  Telehealth or Telemedicine

The growing use of telecommunications systems, video conferencing and other technology to conduct medical consultations or treatments from a distance. This quickly growing sector has provided increased access to residents in rural areas and those with limited physical access to medical services.

Telesurgery

Also known as remote surgery, telesurgery refers to capabilities that enable a doctor to perform surgery on a patient when they are not physically in the same location by using robotics and other advanced technologies.

Education and Career Opportunities

Staying up to date on the latest health information technology terminology is one way to position yourself for potential career opportunities in the fast-evolving field. Another is to explore the possibility of advancing your education with professional certification or by earning a master’s degree in health informatics.

[RELATED]  How to Choose the Best Health Informatics Degree Program >>

The University of San Diego is helping to train the next generation of health informatics leaders and innovators through its Master of Science in Health Care Informatics online degree program . The convenient online format enables you to continue working full-time while earning your degree in just 24 months — putting you on the path to new opportunities and earning potential.

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The newest edition of the HIMSS bestselling Dictionary of Health Information Technology Terms, Acronyms, and Organizations has been developed and curated by subject matter experts from across the healthcare industry. The fifth edition of this dictionary serves as a quick and accessible reference for healthcare executives, health information technology professionals and students to better navigate the ever-growing health IT landscape.

This valuable resource includes more than 3,400 entries. Updated definitions of terms for the information technology and clinical, medical and nursing informatics fields are included. This edition also features an acronyms list with cross references to current definitions, word-search capability (e-book version only), and a list of health IT-related associations and organizations, including mission statements and web addresses. Academic and certification credentials are incorporated as well.

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A cheatsheet for 25 health IT terms

A straightforward guide to some of the hottest terms in health IT.

1. Actionable data: Data points that are immediately available and useful to the situation at hand. For healthcare, this tends to mean patient data, useful without analysis to clinicians, payers and the patients themselves.

2. Breach: The illegal access of a health organization's information, data breaches have proliferated in recent years. There have been 1,140 health data breaches alone since 2009, according to ProPublica.

3. Clinical decision software: Built-in evidence-based software that helps providers make clinical decisions for their patients.

4. Data center: The physician location where an organization's data is stored. Many are stored off-site in data warehouses or centers.

5. E-prescription: Converting from the traditional paper, e-prescriptions are sent across systems from providers to pharmacies for patients to pick up without the phone calls, lost paper prescriptions or possible fraud.

6. EHR: Electronic health records are the digital storage of a patient's medical information in a documented format, able to be exchanged and accessible from multiple locations on a practice's EHR platform.

7. Encryption: Data encryption is the codifying of information into an unreadable state using algorithms or ciphers. It plays a key role in the secure transmission of information, particularly patient data.

8. HIE: Health information exchanges are slowly but steadily inching their way into the market.

9. HL7: A set of international standards for the sharing, exchange, integration and retrieval of healthcare information, they are dictated by Health Level 7, an international organization. The standards include best practices to enhance clinical management and practice.

10. Home monitoring: The use of technology to remotely monitor a patient's information from their home to enhance the patient's comfort and reduce costs.

11. ICD-10: The abbreviation for the International Codex of Diseases, 10th edition. The deadline for implementation of the code system for classifying treatments and medical conditions in the U.S. falls on Oct. 1, 2015, although it has been delayed several times.

12. Interoperability: The ability of information systems to exchange information. Interoperability has long been a problem in health systems, but the ONC has set a deadline of 2017 for national interoperability.

13. Meaningful use: A set of standards measuring how a provider is using an EHR system and its functionality. Many providers and organizations have protested that the regulations are too burdensome, and the rate of attestation has lagged.

14. mHealth: An abbreviation for mobile health, the term for all mobile devices and apps that allow patients and providers to monitor health information. It is a rapidly growing sector for both patients and providers.

15. ONC: The Office of the National Coordinator of Health Information Technology, a federal agency that regulates and standardizes health technology for use in the U.S. It was founded in 2004 when the medical industry began to incorporate digital record-keeping.

16. Opensource: A type of coding that allows for free redistribution, have a source code, allow for derived works and must be technology neutral, according to the Opensource Initiative. Many EHRs are developed on opensource codes, which reduces licensing costs.

17. Portal: An access point to an online system. The term is frequently applies to patient potals, an access interface tool where patients can access their medical records and log into a healthcare organization's system to make appointments, manage prescriptions and ask questions, among other functions.

18. Predictive analytics: The use of datasets to make predictions about the health of an individual or group of individuals. It has been touted as a way to reduce costs by preventing hospital admissions once a patient's condition worsens.

19. Remote monitoring: Similar to home monitoring but more widely defined, remote monitoring can apply to a patient anywhere. Remote monitoring tools are used in hospitals, as in the case of smart beds or smart monitors. Frequently, remote monitoring tools send alerts to a nurse station if patient's condition worsens, reducing the need for close personal monitoring.

20. SaaS: An abbreviation for Software-as-a-Service, a licensing model that consists of a developer hosting a software service and licensing it to a client over a monthly subscription method.

21. SSO: An abbreviation for single sign-on, a system on which a provider can log in once and then is able to access the system from any device in a service area. It has streamlined workflow and cut down on documentation time, eliminating the number of times a provider has to log into a system.

22. System architecture: An overarching term to refer to the way an information system is built. Architecture varies from system to system and defines the way it is maintained.

23. Telehealth/telemedicine: The use of telepresence or video conferencing to conduct medical consultations or treatments from a distance. It is a quickly growing sector and has provided access to many rural residents with limited physical access to medical services.

24. Vendor: A term for a company that sells and maintains an IT system. It can refer to EHR vendors, general platform vendors or a variety of other IT management companies, but a vendor-healthcare organization relationship has become a central one to the operation of the medical industry.

25. Wearable: Any portable device that can be worn to collect medical information, such as pacemakers, pedometers or smartphones. More and more Americans are using mobile devices to collect health data, and providers are facing the question of how to collect and use this data in the most efficient way possible.

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Health information technology.

Maxwell Y. Jen ; Connor C. Kerndt ; Scott J. Korvek .

Affiliations

Last Update: June 20, 2023 .

• Definition/Introduction

Health information technology (HIT) is the hardware, software, and systems that comprise the input, transmission, use, extraction, and analysis of information in the healthcare sector. The end-users of this technology include not only patients, physicians, and other front-line healthcare providers, but also medical researchers, healthcare insurance companies, public health agencies, regulatory and quality assurance entities, pharmaceutical and medical device corporations, and various levels of government. Because these entities assume a huge range of roles and have such varied needs and goals, the technology and systems that underlie HIT are, at the societal scale, critical to the delivery and advancement of healthcare. [1] [2] [3]

• Issues of Concern

Functions and Goals of Healthcare Information Technology

The push for the development of HIT was borne from the belief that HIT would improve accountability, patient and population health outcomes, and healthcare delivery efficiencies while augmenting the ongoing effort to decrease healthcare costs. [4] [5] [6] [7]

Increased Accountability

By digitizing healthcare data, HIT improves the ease with which the data can be abstracted and reviewed by medical centers, governmental agencies, and other interested entities. Previously, with paper records, data was frequently uninterpretable, illegible, lost, and/or incomplete. As a result, the analysis and insights that could be derived were limited. With HIT, not only is data digitized, but can also be automatically sorted, structured, and presented in ways (i.e., dashboard, graphs, figures) that provide meaningful real-time actionable insights. For instance, the NEDOCS score is a real-time measure of emergency department (ED) overcrowding. This is important to patient care as overcrowding has been linked to poorer patient care outcomes as well as poorer patient satisfaction. The NEDOCS score requires real-time variables (e.g., number of ED patients, the number of critical care patients, number of inpatient beds, etc.) for accurate calculation. With HIT, the required inputs can be automatically determined and thus, a minute-to-minute NEDOCS score can be calculated and thus hold administrators responsible not only for developing and implementing surge plans in the setting of overcrowding but also developing long-term, evidence-based plans for hospital staffing or expansion.

Improved Patient and Population Health Outcomes

Tools and applications can be built into HIT systems to address safety and outcome issues within patient care and population health. One prominent example is computerized physician order entry (CPOE). A product of HIT advances, CPOE has been touted as a major tool in the movement towards better patient care. In fact, in 2001, the Institute of Medicine, recognizing the importance of digital rather than written orders, called for the universal adoption of CPOE within all US healthcare institutions by 2010. Traditional paper orders carry multiple risks: writing an inappropriate dosage, writing for a medication to which a patient is allergic, and illegibility, to name a few. With appropriate programming, a HIT can flag these potential errors at the time of order entry, thereby decreasing medication errors, a major contributor to morbidity. On the population level, HIT tools range from biosurveillance (i.e., early warning systems for infectious disease outbreaks) to routine health screening reminders to chronic disease monitoring to medical research. One of the most prominent examples of HIT detection of disease in recent memory was the outbreak of lead poisoning caused by the Flint water crisis of 2014 to 2015 in Flint, Michigan. Due to a water supply switch, the citizens of Flint, Michigan began suffering from a variety of maladies; however, for more than a year, public officials denied any issues with the water supply stating that it was safe for public consumption. A study performed by Dr. Mona Hanna-Attisha, utilizing electronic medical record data (EMR) combined with geographic information software (GIS) concluded that the Flint water supply was heavily contaminated with lead and had resulted in thousands of cases of lead poisoning. Her findings directly lead to the first acknowledgments of the lead poisoning as well as subsequent state and federal measures to address the crisis.

Better Healthcare Delivery Efficiencies

In addition to patient-care benefits, HIT is also thought to improve the efficiency of delivering healthcare services. Some of the smaller yet still meaningful changes included improved coordination and scheduling of care and decreased administrative bureaucracy. However, improved communication through HIT systems is hoped to have an even more meaningful impact. One of the challenges of delivering healthcare efficiently is having necessary data in-hand at the right time. Because healthcare in the United States is largely fractured between competing groups of healthcare systems, private practice specialists, and hospitals, information such as test results and medical histories is often not transmitted between these entities in an efficient and timely manner. As a result, when a patient seeks services outside of his or her primary healthcare system, requests for information must be processed, and tests repeated to determine the appropriate service to deliver. In the previous era of paper records, this challenge was even greater as information even within the patient’s own medical system had to be retrieved from a file archive. With EMRs now widespread, data within an organization can now be retrieved from an electronic data warehouse instantaneously. Unfortunately, data transfer across systems has remained a challenge; EMRs across the various providers generally cannot send information electronically. Currently, efforts are underway to build out robust healthcare information exchange (HIE) networks to facilitate the retrieval of patient information generated at another provider or health system independently of the specific home EHR platform or vendor. In another step advancing this cause, the healthcare standards organization Health Level Seven International (HL7) in 2014 proposed Fast Healthcare Interoperability Resources (FHIR), a proposed set of software and programming standards that would standardize EMR and associated HIT software for the purpose of universal interoperability.   Outside the hospital, health insurance companies can also take advantage of these systems to improve their practices. With digitally transmitted data comes faster and more complete processing of claims. Furthermore, HIT-software can now analyze claims data which improves actuarial calculations, comparisons of cost-effectiveness between institutions, and also helps to better detect cases of healthcare insurance fraud.

Decreased Healthcare Costs

One of the most important issues of modern times, rising healthcare costs threaten to undermine the national economy (currently, more than $1 of every $6 in the United States (US) economy is spent on healthcare) as well as other societal priorities such as education, military, and social services. Though not a cure-all, HIT is thought to decrease costs via all the methods described above: increased operational efficiencies, improved patient safety, and better chronic disease management. According to a 2005 RAND Corp. analysis, the savings achieved in improved operational efficiencies alone could amount to $77 billion annually. [8] [9]

Cost of Implementation

The primary challenge towards full adoption of HIT is the astronomical implementation cost. For EMR systems alone, such as those sold by the companies EPIC and Cerner Corp, can cost a small-to-medium-d hospital tens of millions of dollars, which may be unaffordable. The subsequent workflow changes, personnel training, associated software applications, and hospital infrastructure upgrades (e.g., additional computer and computer accessory purchases, Wi-Fi expansion, IT department expansion) represent additional costs. The subsequent learning curve leads to decreased productivity, at least temporarily which can result in decreased revenues following the expensive purchase.

Technologic Iatrogenesis

Though HIT may solve many problems, it will likely give rise to a new generation of problems. For example, data security, a smaller issue when healthcare organizations were primarily using paper charts because the amount of data one could steal was limited by how much one could physically carry without getting caught, becomes a very significant issue in a world in which corporate data breaches happen on a regular basis. At least one high-profile case of a hospital data breach occurred in February of 2016 when Hollywood Presbyterian Hospital in Hollywood, California became the victim of a ransomware attack. Its EMR and computer systems were locked down by hackers who would only release the lockdown if a ransom was paid. Since all hospital operations run through the EMR, for example, labs, billing, medical records, communications, this digital attack posed a life-threatening risk to the hospital’s patients. Another new problem that has arisen as a result of HIT is the decrease in productivity. Studies have demonstrated that working through an EMR is slower than with paper and pen. Additionally, the EMRs, in general, have typically succumbed to the problem of flashing too many warnings, many of them irrelevant similar to the problem of cardiac monitors giving too many false alarms. The general lack of specificity characterizing both the EMR warnings and cardiac monitors both slows workflow and also increases the tendency to ignore warnings even when they are relevant.

• Clinical Significance

Health Information Technology plays a role in improving health outcomes, quality of care, and the health care experience of patients, for example:

• Allows access up-to-date evidence-based clinical guidelines and resources
• Improves quality of care and patient safety
• Assists patients in health maintenance
• Coordinates care with multiple providers
• Assists in sharing of clinical information
• Relieves providers of paper-based referral process that burden practices and organizations.
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Disclosure: Maxwell Jen declares no relevant financial relationships with ineligible companies.

Disclosure: Connor Kerndt declares no relevant financial relationships with ineligible companies.

Disclosure: Scott Korvek declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Jen MY, Kerndt CC, Korvek SJ. Health Information Technology. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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HIMSS Dictionary of Health Information and Technology Terms, Acronyms and Organizations

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This significantly expanded and newest edition of the bestselling HIMSS Dictionary of Health Information and Technology Terms, Acronyms and Organizations has been developed and extensively reviewed by a robust team of industry experts. The fifth edition of this dictionary serves as a quick reference for students, health information and technology (IT) professionals, and healthcare executives to better navigate the ever-growing health IT field.

This valuable resource includes more than 3,400 definitions, organizations, credentials, acronyms and references. Definitions of terms for the health IT, medical and nursing informatics fields are updated and included. This fifth edition also includes an acronyms list with cross references to current definitions and a list of health IT-related associations and organizations, including contact information, mission statements and web addresses. Academic and professional certification credentials are also included.

As a mission driven non-profit, HIMSS offers a unique depth and breadth of expertise in health innovation, public policy, workforce development, research and analytics to advise global leaders, stakeholders and influencers on best practices in health information and technology. Through our innovation companies, HIMSS delivers key insights, education and engaging events to healthcare providers, governments and market suppliers, ensuring they have the right information at the point of decision.

As an association, HIMSS encompasses more than 72,000 individual members and 630 corporate members. We partner with hundreds of providers, academic institutions and health services organizations on strategic initiatives that leverage innovative information and technology. Together, we work to improve health, access and the quality and cost-effectiveness of healthcare.

HIMSS Vision

Better health through information and technology.

HIMSS Mission

Globally, lead endeavors optimizing health engagements and care outcomes through information and technology.

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Health Information Technology

Health information technology (health IT) involves the processing, storage, and exchange of health information in an electronic environment. Widespread use of health IT within the health care industry will improve the quality of health care, prevent medical errors, reduce health care costs, increase administrative efficiencies, decrease paperwork, and expand access to affordable health care. It is imperative that the privacy and security of electronic health information be ensured as this information is maintained and transmitted electronically.

Cloud Computing

With the proliferation and widespread adoption of cloud computing solutions, HIPAA covered entities and business associates are questioning whether and how they can take advantage of cloud computing while complying with regulations protecting the privacy and security of electronic protected health information (ePHI). HHS has developed guidance to assist such entities, including cloud services providers (CSPs), in understanding their HIPAA obligations .

HIPAA Privacy Components of the Privacy and Security Toolkit

The materials below are the HIPAA privacy components of the Privacy and Security Toolkit developed in conjunction with the Office of the National Coordinator. The Privacy and Security Toolkit implements the principles in The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information (Privacy and Security Framework). These guidance documents discuss how the Privacy Rule can facilitate the electronic exchange of health information.

• Privacy and Security Framework: Correction Principle and FAQs
• Privacy and Security Framework: Openness and Transparency Principle and FAQs
• Privacy and Security Framework: Individual Choice Principle and FAQs
• Privacy and Security Framework: Collection, Use, and Disclosure Limitation Principle and FAQs
• Privacy and Security Framework: Safeguards Principle and FAQs
• Privacy and Security Framework: Accountability Principle and FAQs

Learn more about the Privacy and Security Framework and view other documents in the Privacy and Security Toolkit, as well as other health information technology resources.

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