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McWilliams School of Biomedical Informatics at UTHealth Houston

Are we speaking the same language?

Understanding terminology can be one of the most daunting parts of learning about a new topic. This page provides an introduction to some of the most commonly used terms in Health Informatics.

What does that term mean?

• Clinical Analytics: The process of gathering and examining data in order to help gain greater insight about patients.1

• Clinical Decision-Support System: A computer-based system that assists a professional who must decide what actions to take in a given clinical setting, such as physicians or nurses making decisions about patient care.2

• Computer-Based Physician Order Entry (CPOE):  A clinical information system that allows clinicians to record patient-specific orders (tests, treatments, management plans, and the like) for communication to other patient care team members and to other information systems. Sometimes called provider order entry or practitioner order entry.2

Health Information Management (HIM): The practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care.2

• Health Information Technology for Economic and Clinical Health (HITECH) Act: A government act to enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure the workforce is properly trained and equipped to be meaningful users of EHRs.2

• Health Insurance Portability and Accountability Act [of 1996] (HIPAA): A government act to reduce fraud and abuse in health care.2

• Health Level 7 (HL7): An ad hoc standards group formed to develop standards for exchange of health care data between independent computer applications.2

• Interoperability: The ability for systems to exchange data and operate in a coordinated, seamless manner.2

• Meaningful Use: A tiered set of objectives related to the ARRA Medicare and Medicaid EHR incentive programs. Meaningful Use criteria must be met by eligible professionals and hospitals if they are to collect financial rewards for the implementation of qualified, certified EHRs to achieve health and efficiency goals.2

• Personal/Protected Health Information (PHI): Information about patients that is protected from inappropriate disclosure under the privacy and security mandates of the Health Insurance Portability and Accountability Act of 1996 and subsequent related legislation.2

• Telehealth: The use of telecommunications and electronic information to support long-distance clinical healthcare.2

What does that term mean? - Health Records

• Electronic Health Record (EHR): A digital version of a patient's paper chart that can be created and used by multiple healthcare organizations.4

• Electronic Medical Record (EMR): A digital version of a patient's paper chart from one medical practice.4

• Health Information Exchange (HIE): A network that allows a group of healthcare organizations and a patient to securely share medical information.4

• Medical Application: An electronic program used primarily by medical professionals in the care of patients.

• Patient Portal: A PHR that is integrated with an EMR or EHR; also called a patient gateway.3

• Personal Health Application (PHA): An electronic program used primarily by healthcare consumers to manage health. May connect to PHRs and ultimately to providers.5

• Personal Health Record (PHR): A collection of an individual's health information, usually in electronic format, managed by that individual. May integrate with EMRs and/or EHRs.

• Personally-Controlled Health Record (PCHR): A subtype of PHR that is completely controlled by the healthcare consumer, who may choose to share some of the information with providers.6

Mapping health record concepts

References

1AMIA Glossary of Acronyms and Terms Commonly Used in Informatics - http://www.amia.org/glossary

2Britto, M. T., Jimison, H. B., Munafo, J. K., Wissman, J., Rogers, M. L., & Hersh, W. (2009). Usability testing finds problems for novice users of pediatric portals. Journal of the American Medical Informatics Association : JAMIA,16(5), 660-9. doi: 10.1197/jamia.M3154

3Office of the National Coordinator for Health Information Technology - http://www.healthit.gov

4Siek, K. A., Khan, D. U., Ross, S. E., Haverhals, L. M., Meyers, J., & Cali, S. R. (2011). Designing a personal health application for older adults to manage medications: a comprehensive case study. Journal of Medical Systems, 5(5), 1099-121. doi: 10.1007/s10916-011-9719-9

5Weitzman, E. R., Kaci, L., & Mandl, K. D. (2009). Acceptability of a personally controlled health record in a community-based setting: implications for policy and design. Journal of Medical Internet Research, 11(2), e14. doi: 10.2196/jmir.1187