Affordable Care Act - Mandates comprehensive health insurance reform; some of the provisions of this
law include prohibiting the denial of coverage based on pre-existing conditions, preventing insurance
companies from rescinding coverage when someone gets sick, eliminating lifetime limits or caps on
insurance coverage, appealing insurance company decisions, providing free preventive care, getting
tough on health care fraud, and extending the amount of time parents can cover their adult children on
their own insurance policies; many more provisions are in place today and more will roll outthrough
2014
American Recovery and Reinvestment Act 2009 (ARRA) - Consists of 3 major goals: create and save jobs,
spur economic activity and invest in long-term growth, and support accountability and transparency in
recovery spending
Authorization - Required for any lease of patient PHI; consists of specific elements that make it legal and
appropriate to release information
Business associate - An organization or individual who provides specific services to a covered entity
involving the use or disclosure of PHI; for example, an off-site storage company that houses EMR data
Centers for Medicare and Medicaid Services (CMS) - Federal agency charged with administration of the
Medicare and Medicaid programs, as well as the Children's Health Insurance Program; operating division
of the Department of Health and Human Service (HHS)
Certification Commission for Health Information Technology (CCHIT) - Established to evaluate and
approve EHR and EMR systems; to participate in incentive programs for EHR adoption and use, facilities
must use a certified EHR or EMR product
Computer on Wheels (COW) - Most often refers to a laptop computer that sits on a cart with wheels
that can be rolled from patient room to patient room and facilitates real time documentation or charting
of patient care; often called COWs
Computerized Provider Order Entry (CPOE) - Allows providers to order prescription medication,
including IV therapies, laboratory tests, imaging studies, rehabilitation services, dietary requirements in
the inpatient environment
,Conditions of Participation (CoPs) - Specific practices that CMS mandates for facilities to follow if they
treat patients covered under Medicare or Medicaid; similar to the Joint Commission's accreditation
requirements
Continuity of Care Document (CCD) - The widely-accepted and federally-mandated document for sharing
patient health information across facilities; replaced the CCR and CDA, which were earlier attempts at
addressing the continuity of patient care between facilities
Continuity of Care Record (CCR) - An early form of a document developed to make communication
about patients' course of care available across facilities; CCD replaced it
Covered entities - Providers who transmit PHI in an electronic format, health plans, and health care
clearing houses
Credentialing - Process used to document a provider's education, licensure, and qualifications in order
to allow for the assignment of privileges to practice in a hospital or health care system
Current Procedural Terminology (CPT) - A nomenclature or naming system the American Medical
Association (AMA) publishes and maintains; allows providers to code for services provided and submit
bills for reimbursement
Database - Organized collection of pieces of information or data; electronic version of file cabinets with
folders and files; the term generally refers to data collected and stored in an electronic environment
Digitize - Transform information from a paper-based document into an electronic format; some systems
use document scanning that includes Optical Character Recognition (OCR) capabilities, which transforms
a scanned document from a static image to a searchable document
Discharge summary - Report written by the provider when a patient is being discharged from inpatient
care; summarizes the patient's chief compliant or why they were admitted to the hospital, diagnostic
test results and other findings, treatments administered and how the patient responded to them;
outlines recommendations for continued care and follow up, as well as dietary, medication and activity
instructions; the provider must sign the final copy in the record before the record can be marked
complete
, Electronic health record (EHR) - While this term is generic, its use denotes a system-wide record that
involves inputs from many systems and is used across a diverse environment of care with multiple
location; although not strictly defined as such, EHR often refers to the electronic records in a hospital or
integrated health care delivery system
EHR technology - Refers to the conceptual EHR, including the basic structure, functionally, and expected
outcomes users expect from any system identified as being an electronic health or medical records
system
Electronic medical record (EMR) - Another generic term for a digitized medical record; this term has
evolved to most often refer to the single, standalone records system that providers' offices and other
smaller outpatient settings' use; the term EMR is most often used in reference to the electronic records
used by providers in their private practice and outpatient settings; many EMRs can exchange data with
larger hospital-based EHR systems through the use of a Continuity of Care Document (CCD)
ePrescribing - Functionality that allows providers to prescribe medications to patients and send the
prescription to the patient's pharmacy where it will process and be ready for pickup when the patient
arrives; similar to CPOE from the inpatient environment in that clinical checking and alert provide
important safety measures for protecting patients
Fully-integrated EHR - Functionality that has replaced paper records entirely; few hospitals or health
care systems in the U.S. have achieved this yet, but many are moving in this direction
Health Information Management (HIM) Department - Department responsible for the care and
management of all patient information; as electronic records began to replace paper-based records,
HIM professionals became key players in the transition to the EHR or EMR system; previously known as
the medical records department
Health Information Technology - General use of computers and related devices to manage the day-to-
day functions in a health care environment
HIPAA - Legislation that protects employees' insurance coverage when they are between jobs; people
today are more familiar with what was formerly called Title II, or the Administrative Simplification
provisions of HIPAA; Title II established national standards that apply to electronic transaction involving
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