Domain 5: Information Technologies
Health Information Technology
Technology is integrated into the organizational management of health care information.
Abbreviation | Full Name | Function |
|---|---|---|
EHR | Electronic Health Records | A computerized version of a patient’s health record; includes both preventive and medical information; maintained by multiple providers; designed to be interoperable |
EMR | Electronic Medical Records | A computerized version of a patient’s health record; medical information; maintained by a single provider and is not interoperable |
CPOE | Computerized Physician Order Entry | Electronic orders for: ePrescriptions, imaging, and lab work |
CDSS | Clinical Documentation Support System | Add-on software to an EHR; connects physician with evidence-based, peer-reviewed data, and innovation |
HIE | Health Information Exchange | State-wide, regional, or nation-wide electronic systems to exchange patient records when more than one provider is involved in care |
RIO or RHIO | Regional (Health) Information Organization | Local area, city, or regional system enabling the sharing of patient information between providers |
LOINC | Logical Observation Identifiers Names and Codes | Computerized collection of lab tests and their results |
N/A | RxNorm | Standardized nomenclature for clinical drugs |
PACS | Picture Archiving and Communication Systems | Stores digital, radiologic images |
CAC | Computer-Assisted Coding | Software programs, such as 3M, Dolbey, and M*Modal. These programs scan physician documentation and determine appropriate codes. |
PMS | Practice Management Software | Programs used to collate patient demographic information and coding determinations then used to create and electronically submit claims |
N/A | Encoder | Software used to support the manual coding process electronically. |
N/A | Grouper | Software used to help determine the accurate DRG assignment for a specific patient encounter in a hospital |