Electronic Health Records Acronyms & Definitions a guide to EHR Alphabet Soup
The transition to Electronic Health Records is complicated enough, but when you consider the unending acronyms and complicated terminology it can all add up to overwhelming. ASI complied a dictionary of sorts to help you muddle through the EHR alphabet soup.
AAC- Average Allowable Cost (of certified EHR Technology) Charges for health care services and/or supplies for which insurance benefits are available. In general, costs of services not considered to be reasonable or necessary to the proper provision of health services are excluded from allowable costs. Allowable costs vary across insurance companies. AIU- Adopt, Implement, Upgrade (certified EHR Technology) Adopt-acquiring, purchasing or securing access to certified EHR technology Implement- Installing or commencing utilization of certified EHR technology capable of meeting meaningful use requirements Upgrade- Expanding the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from exiting EHR technology to certified EHR technology per the EHR certification criteria published by the Office of the national Coordinator of Health Information Technology (ONC). ANSI- American National Standards Institute a private nonprofit organization that coordinates developments of standards for medical and other devices, services, and personnel in the United States and represents the UnitedStates in matters related to international standardization. ARRA- American Recovery and Reinvestment Act of 2009 Economic stimulus package enacted by the 111th Congress of the United States. ATL- Accredited Testing Laboratory in the ONC HIT Certification Program ATLs test products against the standards and certification criteria identified by the secretary of the Office of the National Coordinator for Health Information technology CAH- Critical Access Hospital Rural primary care hospital CAHPS- Consumer Assessment of Healthcare Providers and Systems a series of patient surveys rating health care experiences in the United States. CAHPS- Consumer Assessment of Healthcare Providers and Systems a series of patient surveys rating health care experiences in the United States.
CCD- Continuity of Care Document An XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange. CDC- Centers for Disease Control and Prevention The US agency charged with tracking and investigating public health trends and is a part of the US Public Health Services (PHS) under the Department of Health and Human Services (HHS). It publishes key health information, including weekly data on all deaths and diseases reported in the US and travelers’ health advisories. The CDC also fields special rapid-response teams to halt epidemic diseases CDS- Clinical Support Decision CDS provides a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools. CEHRT- Certified EHR Technology The Office of the National Coordinator for Health Information Technology (ONC) Certification Program provides a defined process to ensure that Electronic Health Record (EHR) technologies meet the adopted standards and certification criteria to help providers and hospitals achieve Meaningful Use (MU) objectives and measures established by the Centers for Medicare and Medicaid Services (CMS). CFR- Code of Federal Regulations The codification of the general and permanent rules and regulations (sometimes called administrative law) published in the Federal Register by the executive departments and agencies of the federal government of the United States. CGD- Certification Guidance Document The CGD serves as a guide for ONC to evaluate applications for recognized certification body status and provides the information a body would need to apply for and obtain such status.
CHIP- Children’s Health Insurance Program A medical coverage source for individuals under age 19 whose parents earn too much income to qualify for Medicaid, but not enough to pay for private coverage. CHIPRA- Children’s Health Insurance Program Reauthorization Act of 2009 On February 4, 2009, President Barack Obama signed the Children’s Health Insurance Reauthorization Act of 2009, expanding the healthcare program to an additional 4 million children and pregnant women, including for the first time legal immigrants without a waiting period. CHPL- Certified HIT Product List The authoritative, comprehensive listing of certified Complete EHRs and EHR Module(s). EPs and EHs must use the CHPL to identify the CEHRT they possess and generate a matching CMS EHR Certification ID as part of the meaningful use attestation process. CMS- Centers for Medicare & Medicaid Services An agency within the US Department of Health & Human Services. In addition to Medicare and Medicaid, CMS oversees the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments (CLIA), among other services. CPOE- Computerized Physicians Order Entry (Also sometimes referred to as Computerized Provider Order Entry or Computerized Provider Order Management ) is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. CQM- Clinical Quality Measure Tools that help measure and track the quality of health care services provided by eligible professionals, eligible hospitals and critical access hospitals (CAHs) within our health care system. CY- Calendar Year The period of 365 days starting from the first day in January and running through the last day December.
EH- Eligible Hospital Eligible Hospital under the Medicare EHR Incentive Program: “Subsection (d) hospitals” that are paid under the Inpatient Prospective Payment System (IPPS), Critical Access Hospitals ( CAHs), Medicare Advantage (MA-Affiliated) Hospitals Eligible Hospital under the Medicaid EHR Incentive Program: Acute care hospitals with at least 10% Medicaid patient volume and Children’s hospitals (no Medicaid patient volume requirements) EHR- Electronic Health Record A digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users EP- Eligible Professional 1. Medicare physicians (Doctor of Medicine, Doctor of Osteopathy, Doctor of Pediatric Medicine, Doctor of Optometry, Doctor of Oral Surgery, Doctor of Dental Medicine, Doctor of Chiropractic ) 2. Practitioners (Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant), Certified Nurse Midwife, Clinical Social Worker, Psychologist, Registered Dietician, Nutrition Professional, Audiologists) 3. Therapists (Physical Therapist, Occupational Therapist, Qualified Speech-Language Therapist) EPO- Exclusive Provider Organization A network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers. FACA- Federal Advisory Committee Act A United States federal law, which governs the behavior of federal advisory committees. In particular, it has special emphasis on open meetings, chartering, public involvement, and reporting. FFP- Federal Financial Participation Federal matching funds for State expenditures for assistance payments for certain social services, and State medical and medical insurance expenditures.
FFS- Fee-For-Service Occurs when doctors and other health care providers receive a fee for each service such as an office visit, test, procedure, or other health care service. FFY- Federal Fiscal Year The accounting period for the federal government which begins October 1 and ends September 30. For example fiscal year 2014 began on Oct. , 2013 and ended Sept. 30, 2014 FIPS- Federal Information Processing Standards Publically announced standardizations developed by the United States federal government for use in computer systems by all non-military government agencies and by government contractors. FQHC- Federally Qualified Health Center All organizations that are receiving grants under Section 330 of the Public Health Service Act are FQHCs. They must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors. FTE- Full-Time Equivalent The number of total hours worked divided by the maximum number of compensable hours in a full-time schedule as defined by law FY- Fiscal Year A period used for calculating annual financial statements in businesses and other organizations. HEDIS- Healthcare Effectiveness Data and Information Set A widely used set of performance measures in the managed care industry that measure performance on important dimensions of care and service, developed and maintained by the National Committee for Quality Assurance (NCQA). HHS- Department of Health and Human Services The United States government’s principal agency for “protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.”
HIE- Health Information Exchange The electronic movement of health-related information among organizations according to nationally recognized standards HIPAA- Health Insurance Portability and Accountability Act of 1996 The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs. HIT- Health Information Technology The area of IT involving the design, development, creation, use and maintenance of information systems for the healthcare industry HITECH- Health Information Technology for Economic and Clinical Health A federal act that was part of the American Recovery and Reinvestment Act of 2009. It promotes the adoption and meaningful use of health information technology. HITPC- Health Information Technology Policy Committee A federal committee created by the American Recovery and Reinvestment Act of 2009 (ARRA) that advises the National Coordinator for Health IT on the creation of a nationwide health IT infrastructure. HITSCHIT- Standards Committee Federally established committee that recommends to the National Coordinator standards, implementation specifications, and certification criteria for the electronic exchange and use of health information HL7- Health Level Seven A set of international standards for transfer of clinical and administrative data between hospital information systems. HMO- Health Maintenance Organization A health insurance organization to which subscribers pay a predetermined fee in return for a range of medical services from physicians and healthcare workers registered with the organization.
HOS- Health Outcomes Survey A patient-reported outcomes measure used in Medicare managed care. The goal of the program is to gather valid and reliable clinically meaningful data for targeting quality improvement activities and resources; monitoring health plan performance and rewarding top-performing health plans; helping beneficiaries make informed health care choices; and advancing the science of functional health outcomes measurement. HPSA- Health Professional Shortage Area These areas are designated by HRSA as having shortages of primary medical care, dental or mental health providers and may be geographic, demographic or institutional HRSA- Health Resource and Services Administration The primary Federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable IAPD- Implementation Advance Planning Document Document by which States obtain approval for Federal financial participation in Health Information technology implementation ICD-10-CM- International Classification of Diseases, 10th Revision, Clinical Modification The standard diagnostic tool for epidemiology, health management and clinical purposes ICD-10-PCS- International Classification of Diseases, 10th Revision, Procedure Coding System A seven character alphanumeric code structure that provides a unique code for all substantially different procedures, and allows new procedures to be easily incorporated as new codes ICD-9-CM- International Classification of Diseases, 9th Revision, Clinical Modification The official system of assigning codes to diagnoses and procedures associated with hospital utilization in the US. ICR- Information Collection Requirement A set of documents that describe reporting, record keeping, survey, or other information collection requirements imposed on the public by any federal agency
IHS- Indian Health Service U.S. Department of Health and Human Services agency providing healthcare to Native Americans and Alaskan Natives IPA- Independent Practice Association An association of independent physicians, or other organization that contracts with independent physicians, and provides services to managed care organizations on a negotiated per capita rate, flat retainer fee, or negotiated fee-for-service basis IT- Information Technology The study or use of systems (especially computers and telecommunications) for storing, retrieving, and sending information LOINC- Logical Observation Identifiers Names and Codes A database and universal standard for identifying medical laboratory observations MA- Medicare Advantage A type of Medicare health plan offered by a private company that contracts with Medicare to provide all Part A and Part B benefits. MAC- Medicare Administrative Contractor Used by CMS to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. MAO- Medicare Advantage Organization Organizations that are contracted by private companies to provide both Part A and Part B benefits of Medicare, these include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans MCO- Managed Care Organization An organization that combines the functions of health insurance, delivery of care, and administration. They have contacts with health care providers and medical facilities to provide care for members at reduced costs.
MMIS- Medicaid Management Information Systems An integrated group of procedures and computer processing operations. The objectives of this system includes the Title XIX program control and administrative costs; service to recipients, and providers and inquires operations of claims control and computer capabilities; and management reporting for planning and control. MSA- Medical Savings Account Tax-deferred deposits can be made for medical expenses into this savings account coupled with a high-deductible health plan. Withdraws from an MSA go toward paying the deductible expenses in a given year for most forms of health care, disability, dental care, vision care and long term care. MU- Meaningful Use Using certified electronic health record technology to: Improve quality, safety efficiency and reduce health disparities, engage patients and families, improve care coordination and population and public health, and maintain privacy and security of patient health information MU Stage 1- Meaningful Use Stage 1 Initial stage of proving meaningful use, Stage 1 began in 2011 with the main objective of data capture and sharing. This stage was to be completed no later than 2014 to qualify for the Medicare and Medicaid HER Incentive Program MU Stage 2- Meaningful Use Stage 2 Following Completion of Stage 1, providers will be required to meet Stage two objectives in 2014 over a 3 month reporting period. These objectives aim to advance clinical processes. NAAC- Net Average Allowable Cost (of certified EHR technology) Capped at $25,000, this is the reasonable costs for a provider to spend on the purchase of certified EHR technology NCPDP- National Council for Prescription Drug Programs Not-for-profit, multi-stakeholder forum for developing and promoting pharmacy services industry standards and business solutions that improve patient safety and health outcomes, while also decreasing costs.
NCQA- National Committee for Quality Assurance Non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of healthcare organizations through voluntary accreditation programs for individual physicians, health plans, and medical groups. NCVHS- National Committee on Vital and Health Statistics Established by Congress to serve as an advisory body to the Department of Health and Human Services on health data, statistics and national health information policy. It fulfills important review and advisory functions relative to health data and statistical problems of interest, stimulates or conducts studies of such problems and makes proposals for improvement of the Nation’s health statistics and information systems NIST- National Institute of Standards and Technology The federal technology agency that works with industry to develop and apply technology, measurement, and standards. NLM- National Library of Medicine Located on the campus of National Institute of Health in Bethesda, Maryland, it supports and conducts research, development, and training in health information technology. NPI- National Provider Identifier A unique 10 digit identification number issued to health care providers in the US by CMS, used by Medicare services and commercial healthcare insurers NPRM- Notice of Proposed Rulemaking A public notice issued by law when one of the independent agencies of the US government wishes to add, remove or change a rule or regulation as part of the rulemaking process. NVLAP- National Voluntary Laboratory Accreditation Program NIST program in the USA which provides an unbiased third-party test and evaluation program to accredit laboratories in their respective fields OCR- Office for Civil Rights Office in the department of Health and Human services, the OCR helps to protect citizens from discrimination in certain health care and social service programs.
OMB- Office of Management and Budget Office that serves the President of the United States in implementing his vision across the Executive Branch through the following processes: Budget development, management, coordination and review of federal regulations and agencies, legislative clearance and coordination of agency communications with Congress, Executive Orders and Presidential Memoranda. ONC- Office of the National Coordinator for Health Information Technology A resource to the entire health system to support the adoption of health information technology and the promotion of nationwide health information exchange to improve healthcare. ONC-AAONC-Approved Accreditor in the ONC HIT Certification Program Accredits certification bodies for the ONC HIT Certification Program, and oversees the ONC-Authorized Certification Bodies (ONC-ACBs). ONC-ACBONC -Authorized Certification Body in the ONC HIT Certification Program Certifies EHR products that have been successfully tested by an Accredited Testing Laboratory (ATL) against the certification criteria adopted by the Secretary ONC-ATCBONC-Authorized Testing and Certification Body in the Temporary Certification Program The ONC established a Temporary Certification Program for HIT to provide a way for organizations to become authorized by the National Coordinator to certify and test EHR technology. It was replaced by the ONC HIT Certification Program on October 4, 2012. ONC-ATCBs certified and tested HER technology in the TCP. PAHP- Prepaid Ambulatory Health Plan A non-comprehensive prepaid health plan that provides only certain outpatient services, such as dental services or outpatient behavioral health care. PAHPs provide no inpatient services and are paid on an at-risk or capitulated basis.
PCP- Permanent Certification Program Replaced the Temporary Certification Program, it was established in 2011 to certify EHR technology. PFFS- Private Fee-For-Service A type of Medicare Advantage Plan (Part C)offered by a private insurance company PHO- Physician Hospital Organization A vehicle that enables hospitals and physicians to work cooperatively toward accomplishing several objectives developing improved methods of health care delivery; overseeing integration of physicians and hospitals into health delivery networks; assisting in voluntary group formation; and collecting, analyzing and disseminating information. PHS- Public Health Service Overseen by the Surgeon General, the PHS Commissioned Corps is a diverse team of more than 6,500 highly qualified, public health professionals. These men and women fill essential public health leadership and clinical service roles with the Nation’s Federal Government agencies. PHSA- Public Health Service Act The act clearly established the federal government’s quarantine authority for the first time. It gave the United States Public Health Service responsibility for preventing the introduction, transmission and spread of communicable diseases from foreign countries into the United States. PIHP- Prepaid Impatient Heath Plan A prepaid inpatient health plan that provides less than comprehensive services on an at-risk or other than state plan reimbursement basis; and provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services POS- Place of Service Indicated by two-digit codes placed on health care professional claims to indicate the setting in which a service was provided.
PPO- Preferred Provider Organization A type of Medicare Advantage Plan offered by private insurance companies in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network. PQRI- Physician Quality Reporting Initiative A reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. PSO- Provider Sponsored Organization A managed care contacting and delivering organization consisting of a group of doctors, hospitals and other health care providers who accept full risk for beneficiaries’ lives. Therefore, they provide its services in return for a fixed payment per month for each Medicare beneficiary assigned to it. REST- Representational State Transfer An abstraction of the architecture of the World Wide Web; more precisely, REST is an architectural style consisting of a coordinated set of architectural constraints applied to components, connectors, and data elements, within a distributed hypermedia system RFA- Regulatory Flexibility Act Requires federal agencies to review regulations for their impact on small businesses and consider less burdensome alternatives RHC- Rural Health Clinic A federally qualified health clinic certified to receive special Medicare and Medicaid reimbursement they must be located within non-urban rural areas that have health care shortage designations. RHQDAPU- Reporting Hospital Quality Data for Annual Payment Update Originally mandated in the Medicare Prescription Drug, Improvement, and Modernization Act it authorized CMS to pay hospitals that successfully report designated quality measures a higher annual update to their payment rates.
RPPO- Regional Preferred Provider Organization A preferred provider health insurance plan that is set by Medicare and serves one of 26 regions. RPPOs are available through a private insurance company contracted with Medicare. They have their own network of doctors and hospitals. Individuals are allowed to use out-of-network providers for covered services, but usually for a higher cost. SAMHSA- Substance Abuse and Mental Health Services Administration The agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. SMHP- State Medicaid Health Information Technology Plan provides State Medicaid Agencies (SMAs) and CMS with a common understanding of the activities the SMA will be engaged in over the next 5 years relative to implementing Section 4201 Medicaid provisions of the American Recovery and Reinvestment Act (ARRA). SNOMED-CT- Systematized Nomenclature of Medicine - Clinical Terms a comprehensive clinical terminology, SNOMED CT is one of a suite of designated standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information and is also a required standard in interoperability specifications of the U.S. Healthcare Information Technology Standards Panel. SOAP- Simple Object Access Protocol a protocol specification for exchanging structured information in the implementation of web services in computer networks. TCP- Temporary Certification Program The Office of the National Coordinator for Health Information Technology (ONC) established a Temporary Certification Program (TCP) for Health Information Technology (Health IT) to provide a way for organizations to become authorized by the National Coordinator to certify and test Electronic Health Record (EHR) technology. With the launch of the ONC HIT Certification Program, the TCP sunset on October 4, 2012.
TIN- Tax Identification Number an identifying number used for tax purposes in the United States. It is also known as a Tax Identification Number or Federal Taxpayer Identification Number. A TIN may be assigned by the Social Security Administration or by the Internal Revenue Service (IRS) UCUM- Unified Code for Units of Measure a code system intended to include all units of measures being contemporarily used in international science, engineering, and business. The purpose is to facilitate unambiguous electronic communication of quantities together with their units. UMLS- Unified Medical Language System The UMLS is a set of files and software that brings together many health and biomedical vocabularies and standards to enable interoperability between computer systems, used to enhance or develop applications, including electronic health record technology. XML- eXtensible Markup Language defines a set of rules for encoding documents in a format which is both human-readable and machine-readable.
For additional information on this publication or how ASI can assist your organization in meeting EHR requirements contact:
Lauren Taylor Public Relations 205-322-6197 ext. 413 [email protected]