Glossary
The following are medical and computer terms used in this book with their definitions. Terms specific to this book begin with the phrase, "In this book, . . ."
abnormal: A description for diagnostic findings, including
clinical laboratory test results, meaning deviating from the normal. See
“diagnostic findings”.
access to care: The
ability of the patient to obtain the type of care needed at the time
necessary.
access: To store or retrieve data from a storage device such as a disk or magnetic tape. To provide the capability to initiate an automated service on a system.
ACR/NEMA: American College of Radiology and the
National Electrical Manufacturers Association. This relationship was formed in
1982 to develop the DICOM standard for medical imaging. See “DICOM”.
actionable
information: Data that can be used
by its receiver to immediately analyze and resolve a problem.
active window: A window is a rectangular box on the screen.
The active window is the one currently being used, which appears on top of
other windows.
activities of daily
living: Activities usually
performed in the course of a normal day of a person to meet basic needs, such
as eating, toileting, dressing, bathing, teeth brushing and grooming. While a
patient is in the hospital, nurses are responsible for insuring they occur.
activity: See “care activity”.
acuity: Intensity of nursing care required to meet
the needs of a patient; higher acuity usually requires longer and more frequent
nurse visits and more supplies and equipment.
acupuncture: A technique that relies on piercing parts of
the body with needles to treat disease or relieve pain.
acute care: Short term care, as opposed to long-term,
“chronic”, care.
acute illness: Illness characterized by symptoms that are
of relatively short duration, are usually severe, and affect the functioning of
the patient in all dimensions; not “chronic”.
addendum: An appendage to an existing document that
contains supplemental information. The parent document remains in place and its
content is altered by the addendum. For example, a clarification or correction
to an interpretation of an anatomic pathology specimen might produce an
addendum.
administration of
medication: The process whereby a
prescribed medication is given to a patient by one of several routes—oral,
inhalation, topical or parenteral.
admission: The formal acceptance by a hospital of a
patient who is to be provided room, board, and continuous nursing services in
an area of the hospital where patients generally stay at least overnight.
admitting
diagnosis: A statement of the
provisional condition given as the basis for admission to the hospital for
study.
admitting
physician: The physician who admits
the patient to the hospital.
ADT (admission,
discharge and transfer system): A
clinical system for recording admissions to a hospital, discharges from a
hospital and transfers within a hospital and maintains the hospital census.
advance directive: Written instructions a patient has prepared
for medical personnel to inform them of the patient’s wishes for treatments and
care when the patient is incapacitated, especially regarding life-sustaining
treatment if the patient’s condition becomes irreversible. An advance directive
is a legal document prepared when the individual is competent and able to make
decisions.
advice nurse: A nurse who takes patient phone calls and advises the patient on
medical conditions according to protocol;
the advice nurse informs the patient when self care is appropriate and
when a patient needs to come in and when the patient does not.
Agency for Health
Care Policy and Research (AHCPR):
An agency of the U.S. Department of Health and Human Services whose
mission is to enhance the quality, appropriateness, and effectiveness of health
care services and access to these services. AHCPR has developed clinical
practice guidelines based upon “evidence-based medicine”.
agent: In this book, a way of categorizing and separating out a
set of code and tables, interfaces between systems, databases, and user
interfaces (possibly all spread across a number of different software systems),
and administrative and operational procedures of employees implementing a
business policy, so that the business policy could be implemented and changed
by the people responsible for the business policy instead of relying totally on
technical staff to do so.
aggregation: For databases, a relationship where one
entity (engine) is “a part of” another entity (e.g., car).
AHCPR clinical
practice guidelines (AHCPR National Guideline Database): A set of clinical practice guides for
various diseases available on-line on the Internet. Each set of guidelines has
several versions: Clinical Practice
Guidelines, Quick Reference Guides for Clinicians, and Consumer Guides.
Examples of conditions for which there are guidelines are “acute pain
management”, “urinary incontinence”, and “pressure ulcers in adults”.
alarm: A notification message for an abnormal
result, panic result, or other result of a caregiver order that the caregiver
wants to be notified about.
alert: A notification message describing a patient
put in by one caregiver to later inform other caregivers. More urgent messages are
alerts and less urgent messages are reminders.
algorithm: A generic procedure consisting of a finite
sequence of well-defined steps (instructions) for producing one or more outputs
from a set of inputs. For example, a set of instructions on how to generically
draw a graph with its axes on the screen.
allergy: A state of hypersensitivity induced by
exposure to a particular antigen (allergen) resulting in harmful immunologic
reactions on subsequent exposure.
alliance
organizations: Healthcare
organizations that HMOs contract with to share hospital space or medical office
facilities.
alternate delivery
systems: Health services provided
as a less expensive substitute for care as an inpatient in a hospital. Examples
within general health services include skilled and intermediary nursing
facilities, hospice programs, and home health care.
alternative
medicine: Acupuncture, naturopathy,
care given by chiropractors or osteopaths, and other approaches to medical
diagnosis and therapy that have not been developed by use of generally accepted
scientific methods. Also called “complementary medicine”.
ambiguous allergy: An allergy that is not clear cut (e.g., the
allergy is not confirmed, the benefit of the substance causing the allergy
outweighs its allergic side effects, the substance causing the allergic
reaction only causes the reaction some of the time).
American Medical
Association (AMA): A partnership of
physicians and their professional associations dedicated to promoting the art
and science of medicine and the betterment of public health.
ANSI (American National Standards Institute): A group that publishes many computing standards. The U.S. representative is the ISO (International Standards Organization). For example, ANSI has standards for COBOL and C.
ANSI ASC X12N: A federally mandated EDI format to be used
by providers and payers who electronically transmit claims and related
transactions to the federal government.
ASC stands for Accredited Standards Committee. The mandated version of ANSI ASC X12N is Version 4010.
ANSI Health
Informatics Standards Planning Panel (HISPP): The primary organization working to coordinate healthcare
standards being developed by other standard development organizations
analog: A flow of information where things
change smoothly and have an infinite number of values, as opposed to “digital”.
analysis: The determination of the total effects of any addition, change or deletion to a project to the other aspects of the project (e.g., requiring a user to remember a status code could divert the caregiver’s attention away from patient care).
analytic disease
prediction: In this book, disease prediction based upon
a patient having a known risk factor for a disease (e.g., smoking increasing
the risk of lung cancer, a severe knee injury increasing the risk of
osteoarthritis and knee replacement, the presence of the BRCA1 or BRCA2 genes
increasing the risk of breast cancer) or protective factors against that
disease. Analytic disease prediction is based upon analytic epidemiology
studies. See “disease prediction”, “risk factor” and “analytic epidemiology”.
analytic
epidemiology: A branch of epidemiology identifying
the causations of diseases, also referred to as etiology. See “etiology”.
anatomic pathology: An ancillary department that determines if
tissues are in fact abnormal or diseased. Anatomic pathology deals with wet
specimens, tissues, anything out of the body (a piece of bone, skin tissue,
muscle, blood vessel, bullet). Anatomic pathology includes surgical pathology,
cytology (study of cells), histology (microscopic structure of tissues) and
autopsy (multiple body parts). Cytology deals with smears: vaginal, sputum,
semen--fluids with cellular material.
ancillary
department: Departments providing
services for patients or services for departments providing direct medical care.
For example, this may include the following: laboratory, x-ray, physical
therapy, injections, pharmacy, optical sales and hearing center.
Andover Working
Group for Interoperability: A
group of companies formed to build upon healthcare standards set up by the
Hewlett-Packard Company. The principal standards supported are HL7, DICOM, ASTM
for clinical lab data interchange, EDIFACT for healthcare data interchange,
HTML for information on the Internet, and IEEE P1073 for medical device
communication with computer systems.
angiography: X-ray with contrast material injected into
blood showing arteries and veins.
application: A set of files (or databases), programs,
equipment, and procedures to support a set of related functions suited to the
user’s organizational needs. Such functions may be related to a business,
entertainment, science or engineering organizational need.
application
database: Any database that is not meant to be used by all automated
systems in an organization, containing data specific to a single automated
system or to a set of related automated systems. See “corporate database”.
application service
provider: “A company that offers
individuals or enterprises access over the Internet to application and related
services that would otherwise have to be located in their own personal or
enterprise computers . . . on a rental, pay-as-you-use basis.” (From http://www.whatis.com/ .
appointment: A scheduled outpatient meeting between a
patient and a caregiver. Also, sometimes patients are also scheduled with a
room, equipment, a class, etc. Making appointments minimizes wait time for
patients and optimizes utilization of resources.
appointment clerk: A person who takes member phone calls and
who may schedule an appointment.
arbitration: A dispute resolution process involving a
hearing outside of court. The arbitrators, who are supposed to be neutral, hear
a complaint and resolve the dispute. The resolution is final and binding to all
parties.
architecture: See “system architecture”.
archive: Archiving
is the process of long-term storage and organization of data and documents. An
archive is an off-line storage of patient data or other information, in a way
that ensures the possibility to restore them on-line when needed.
Arden Syntax: Standards for defining and sharing medical
knowledge bases
aspects:
Modular units of code that describe a recurring property within a
software system that can be defined once and used wherever needed in the
software system, possibly in different objects, applications, or computer
systems.
aspect-oriented
programming: A programming paradigm providing modular
units of code called aspects that can be used across objects, applications or
computer systems.
ASCII: American Standard Code for Information
Exchange: ASCII is a 7 bit code with an
8th bit used for parity (ISO-7 code) used for defining displayable
and non-displayable characters.
assessment: A clinician’s interpretation of the subjective and objective findings, including any tests, x-rays or procedures that are performed and thus an appraisal or evaluation of a patient’s condition, based upon clinical and laboratory data, medical history, and the patient’s account of symptoms.
association: For databases, a relationship existing
between instances of entities (e.g., a company has a number of offices, a
person works for a company).
association
class: Data to describe a formal
association (e.g., to describe a contract between an employee and employer).
ASTM (the American
Society for Testing and Materials):
A not-for-profit organization that provides a forum for members of
various groups to meet on common ground and write standards for materials,
products, systems and services.
ASTM E1384: ASTM standards for the content and
structure of the Computer-Based Patient Record.
ASTM’s E31.12
Subcommittee: An ASTM group meeting
on standards for healthcare.
asynchronous
communication: Irregularly timed
communication where each character is sent independently. Synchronization of
the clock of the receiver generally is achieved by adding start and/or stop
bits to each character transmitted. See “synchronous”.
Asynchronous
Transfer Mode (ATM): A standard for
a packet-switched broadband network architecture that allows data, voice and
multimedia transmission on the same line.
attending
physician: A physician directly
responsible for the care of an inpatient.
audit: An official examination and methodical
review of the medical record in all aspects of medical care, based upon
established standards, usually done by trained medical staff unaffiliated with
the healthcare organization.
audit trail: Computerized recording of transactions,
the resources, or medical records, that were accessed and the identity of the
user.
authentication: (1) computer science: In a
computer system or network, the process of verifying that a person,
organization, process or device seeking access to a computer system or network is
who or what it claims to be; authorization of a person signing on to a system
is often done at the time the person enters a user name and password. (2)
medicine: Proof of authorship of a medical record entry, such as by a “digital
signature”.
authorization: (1) computer science: In a computer system
or network, the determination by a security service of what access rights, if
any, a person, organization, process or device seeking access has to a given
device, application, process or information resource; (2) medicine: To use or
disclose health information.
automated patient
medical record: Patient medical
records available over a network.
automated speech
recognition (ASR) access: Access to
computers through hardware and software to support interpretation of human
speech into text. Same technology as “interactive voice recognition (IVR)”.
back up: The process of copying important software,
data or documents onto some other media (magnetic tape, floppy disks, etc.) to
guard against its loss should anything happen to the original.
Balanced Scorecard:
A management technique for measuring the future financial health of an
organization or the financial benefits of a
project. It does this by not only using financial figures to predict the
future, but also by looking at positive aspects of an organization that would
predict the financial health of the organization in the future.
bandwidth: The amount of information that can be handled by a device or system, usually measured in baud rate or bps. Also the range of frequencies that can be passed through a communication channel.
bar code: An array of rectangular marks and spaces
in a predetermined pattern. Usually used for automatic product identification.
batch processing: A mode of data processing where programs are
put into queues to be processed off-line and where there is no user
interaction.
baud: When transmitting data, the number of times
the medium’s “state” changes per second. A 2400 baud modem changes the signal
it sends on the phone line 2400 times per second. Since each change in state
can correspond to multiple bits, the actual bit rate of data may exceed the
baud rate.
benefits: The services payable under a specific payer
plan.
benign: Not malignant; not recurrent; favorable for
recovery.
best practice
guideline: A guideline for treating
a medical condition that is based upon the best current scientific research,
that produces the best outcome.
binary number: A number expressed in base 2. Internally, it
is shown as a series of 1’s and/or 0’s and internally in the computer as on or
off switches.
biometrics: The utilization of an anatomical or
behavioral characteristic in order to verify the identity of an
individual; an “authentication”
technique.
bit: Short for “binary digit”. A 0 or 1, on or
off. Computers use bits in combination
to represent data, numbers, characters.
bitmap: A pattern consisting of rows and columns of
dots, or bits in memory, that correspond to pixels on a screen.
black box: With regard to computer software systems,
everything seen by the users of the system.
"Black box" is often used to describe testing, where
"black box" testing is done without a knowledge of the internal
workings of the system. See "white box" and "internal
workings".
bps (bits per
second): The speed at which bits are
transmitted over a communications medium. This speed may exceed the baud rate.
blood pressure: The pressure exerted by the circulating
volume of blood on the walls of the arteries, veins, and chambers of the heart.
Systolic pressure is the highest level of blood pressure, which is the pressure
exerted in the aorta and large arteries during systolic contraction of the left
ventricle. Diastolic pressure is the minimum level of blood pressure, which
occurs between contractions of the heart. A typical value for a young adult is
120 mm Hg during systole and 70 mm Hg during diastole.
board-certified: A physician or other healthcare professional
who has passed a test given by their national specialty organization.
body surface area: The total area of skin on the entire or a
particular part of the body, which is sometimes used in determining dosages of
medications. Formulas exist based upon sex, height, weight, build. Body surface
area is important in determining pediatric dosages, in determining the extent of
burns and in determining radiation doses.
book: The act of making an appointment and
recording it in a schedule.
border: A box around an object on a screen to
mark its boundary.
bottleneck: A system component that limits the
performance of an automated system. Such components include disk subsystems,
memory, CPU’s/processors, networks, buses, operating systems, databases, and
transaction or application software.
brand-name: See “trade-name”.
broadband: Transmission facilities with a bandwidth
greater than those for voice grade facilities.
broadness: In this book, a description for a software
system that is built to handle initial automation as well as the current
non-automated environment.
browser: A tool that provides an Internet Web user
interface to access HTML pages.
business analysis:
A process which identifies the changes to be accomplished by a project or phase
in terms of a mission, objectives and business requirements for the project or
phase.
business policy: A policy to be applied throughout an
organization via changes to workflows, systems and data kept for organizational
business reasons.
business process
reengineering (BPR): Means the same
thing as reengineering.
business
requirement: A required
characteristic of an organization at the end of a project.
button: In a graphical user interface (GUI), an
object on the screen that the user can select, either by a mouse click or by an
equivalent keyboard operation, sending a command to an application to trigger a
specified action such as the start of a particular process.
byte: Eight bits forming a meaningful unit. It may
represent an ASCII character or some other coded meaning to the computer. A
computer’s memory size is measured in megabytes where 1 megabyte is equal to
1,048,576 bytes.
C: A programming language developed in 1972 by Dennis Richie and Brian Kernighan of AT&T.
C++: An object-oriented extension of the C
language developed by Bjarne Stroustrup of AT&T - Bell Labs.
calibration: The set of operations that establish, under
specified conditions, the relationship between values indicated by a measuring
instrument or measuring system, or values represented by a material measure or
a reference material, and the corresponding values of a quantity realized by a
reference standard.
call center: A bank of telephones in a managed care
healthcare organization with appointment clerks and advice nurses who together
(1) make appointments for the member, (2) give the member advice on medical
care based upon protocols, including when self care is appropriate and when the
patient should come in, and (3) connect the member with medical resources,
including physicians and patient education.
capitation: The
payment of premiums or dues directly to the provider organization in the form
of fixed periodic payment for comprehensive care, set in advance.
capture (data): The recording of data on a form or its entry
into a computer.
care activity: Specific tasks to be performed (that one
“does”) in the care of a patient to arrive at a specific outcome in a clinical
pathway.
caregiver: A healthcare organization employee in any
way, directly or indirectly, providing care for a patient.
caregiver messaging
system: A system to enable
communication between caregivers for care of the patient using e-mail messages
that includes the ability to identify a patient associated with the message and
to include the message in the patient’s medical record.
care management: Aggregates encounters and other events into episodes for a particular occurrence of a medical condition, possibly across care settings, rather than just focusing on a single encounter or event of an illness or injury.
care plan: A written framework that provides the
direction of care for a patient.
care, primary: See “primary care”.
care, secondary
medical: Medical care of a patient
by a physician acting as a consultant. The physician providing primary care
usually refers the patient for this care.
care team: A group of caregivers who jointly care for
patients. Care teams may be defined for one or all of the following reasons: (1) to identify nurse practitioners or physicians assistants who
are supervised by a particular physician, (2) to identify other caregivers
working with or supervised by the physician, (3) to identify to whom to send
diagnostic test results if the ordering caregiver is unavailable, (4) to
identify to whom to send clinical messages or e-mail if the recipient is not
available, or (5) to identify physicians who will back up a physician if the
latter physician is unavailable.
Cascading Style
Sheets: Tags within HTML that create templates to control different aspects the HTML
page's layout, including text font-faces, text line-heights, text styles (like
bolding and italics), colors, and margins.
case: One instance of case management for a
particular patient. A case is often assigned to a case manager.
case management: An organized system for delivering health
care to an individual that includes
assessment and development of a plan of care, coordination of services,
referrals and follow-ups.
case manager: A person specifically assigned to oversee
the case management of an individual for a particular case.
case notes: A set of notes developed by a case manager
for a particular case.
CD-ROM: A term referring to storage of information
on a CD (compact disc) using ROM (read-only-memory) format.
certified nurse-midwife: A healthcare practitioner who is educated, and who has acquired a national certification and a license within a state, in the two disciplines of nursing and midwifery.
certified
registered nurse anesthetist: A
registered nurse with training and certification in anesthesiology, who may
substitute for an anesthesiologist in many surgical procedures.
change: In
this book, in the context of a project, a modification in the way an
agreement, workflow or automated system is implemented when the implementation
matches the documentation of the implementation. See “error”.
change control
board: A group responsible for
reviewing changes to controlled documents during a project.
change control
process: A defined process to
insure that important documents on which a project depends are not changed
without careful consideration. Often a change control board is set up to agree
upon or reject changes to these “controlled documents”. See “controlled
document”.
character: Any
symbol, letter, digit, or punctuation mark that can be typed on a keyboard.
character-based
terminal: A type of data terminal
that displays only alphanumeric or text characters
chart: See “medical record”.
charting by
exception: A charting methodology
in which data is entered only when there is an exception from what is normal,
from what is expected or from what was previously recorded. Reduces time spent
documenting.
chart room: A location storing patient medical records.
check box: A box where a pointing device can be put and
with a button press a check mark can be entered or removed. A check sets an
option. Where there are other check boxes, these check boxes remain as is. Compare
this to a “radio button”, where selecting one radio button turns another off.
checkpoint/restart: A technique associated with transactions
where the state of the database is recorded at the start of a transaction, and
if the transaction should abnormally terminate, then the database would be
restored to that state.
chief complaint: The primary reason a patient is coming in
for medical care.
chiropractor: A medical professional who treats disease
based on the theory that disease is caused by interference with nerve function,
and uses manipulation of the joints and the spine to restore normal function.
chronic condition: A condition that lasts a long time, or
recurs frequently, and can be treated but not eradicated; opposite of
“acute illness”.
chronic disease: Illness that persists over a long period of
time and affects the physical, emotional, intellectual, social and spiritual
functioning of the patient.
chronic disease
management case: A case to track a
patient who is being treated for a chronic condition over many encounters where
there is likely to be long term continuing care.
CICS (IBM
Corporation’s Customer Information Control System): A widely used teleprocessing monitor
(transaction processing system) for online application systems found on IBM
mainframes.
client: A client process in a client-server
architecture. A client is any computer that issues processing request to a
server.
client-server
architecture: A network
configuration in which decentralized client processes request services from
centralized server processes.
clinical: Pertaining to a clinic or to the bedside;
pertaining to or founded on actual observation and treatment of patients, as
distinguished from theoretical or basic sciences.
clinical checking: Checking for patient drug allergies and for
drug/drug, drug/food, drug/laboratory and other interactions.
clinical data
repository (CDR): A database that
combines clinical data related to a patient from various healthcare
organization clinical systems. Example information is patient demographics,
radiology data, laboratory data, medications, physician orders and H&P’s.
(In an automated patient medical record system, this is a portion of the
information in the automated patient medical record.)
clinical epidemiology: The
use of epidemiology in direct patient care.
clinical
information: Data contained in the
patient record. Information may also include summary information such as found
in CPR repositories: significant health
problems, lab results, current medications, etc.
clinical
laboratory: Health care
professionals who perform a variety of laboratory tests that contribute to the
diagnosis and treatment of disease.
Areas covered by the clinical laboratory include hematology, clinical
chemistry, immunology, immunohematology, and microbiology
clinical laboratory
information system: A clinical system that manages clinical
laboratory data to support laboratory management, laboratory data collection
and processing.
clinical
pathway: A structured way to identify
care activities and caregiver work flow needed to care for a patient with a
particular condition or disease. Paths through a clinical pathway can be
adjusted for the particular needs of an individual patient. Also, clinical
pathways for separate diseases can be combined into one clinical pathway.
clinical practice
guidelines: Parameters related to a
specific disease or medical condition that help clinicians make clinical
decisions.
clinical record: See “medical record”.
clinical social
worker (CSW): A person who possesses a master’s or doctor’s degree in
social work, has performed at least two years of supervised clinical social
work, and either: is licensed or certified as a clinical social worker by the
State in which the services are performed, or in the case of an individual in a
State that does not provide for licensure or certification, has completed at
least 2 years or 3,000 hours of post master’s degree supervised clinical social
work practice under the supervision of a master’s level social worker in an
appropriate setting such as a hospital, SNF, or clinic.
clinical summary: A summary of clinical information about a
patient, which may include demographics information, significant health
problems, past encounters, primary care physicians and other significant
caregivers, and medications.
clinical system:
Information system that manages clinical data to support patient care and
clinical decision making.
clinical trial: A scientifically rigorous investigation of
new methods, materials such as medications, or procedures in the treatment of a
particular disease or condition.
clinician: Someone who sees, evaluates, and treats
patients, especially a physician, nurse practitioner, or physician assistant.
cluster: A group
of computers working together to share resources or workload.
clustering: The
use of clusters.
code: The programming content of any application.
coding scheme: A method of replacing each member of a
vocabulary of names (such as a patient problem or diagnosis) by a number or “mnemonic”.
column: All the values from multiple rows in a
database table corresponding to a particular data element in the table.
Common Gateway
Interface (CGI) processing: A
protocol that enables a web server to pass a web user’s request to an application
program and to receive data to forward back to the user. For example, a program
using CGI can read and write data files and produce different results each time
(whereas a Web server by itself can only read data files).
communicable
disease: Any disease that can be
transmitted from one person or animal to another by direct or indirect contact.
communications
protocol: Communications standards
that identify how two computers coordinate the exchange of data.
community-based
charts: When multiple facilities of
a healthcare organization share the same set of paper patient medical records.
co-morbidity: An accompanying illness or disease that
coexists with an already established medical diagnosis.
compiler: A program that translates programs written
in a higher level language such as COBOL, C or C++, into code that a computer
can execute. Compiled programs run faster than interpreted programs, such as
those written in Java. See
“interpreter”.
complaint: A reason a patient is coming in for medical
care.
complementary
medicine: See “alternative
medicine”.
component
adaptability: The use of various strategies to procure, develop or
structure a system or component of a system so that the system or component can
more easily be replaced in the future by another equivalent system or
component.
compression: An algorithm to transform and compact text
or image data to minimize storage requirements or transmission time.
computed
radiography: X-ray images captured
in a computer, instead of on film.
computer: A device capable of accepting data, manipulating it in a prescribed way, and displaying or storing the results where it is instructed.
computer language: The vocabulary and syntax of a set of
symbols that may be used to tell a computer what it is to do.
computer-based
patient record (CPR): An electronic
patient record.
Computer-based
Patient Record Institute (CPRI): An
organization whose primary purpose is to promote automation of the patient
chart
computer telephony
integration (CTI): Systems to enable
a computer to act as a call center, accepting incoming calls and routing them
to the appropriate device or person.
conceptual view: Models of systems, workflows, etc. which are
vehicles for communication and for critique.
concurrency: (1) medicine: Multiple caregiver access to a
patient’s medical record, which may be for the same encounter, with possibly
more than one update occurring at the same time. (2) computer science: In
database processing, the situation wherein multiple processes access the same
database record at the same time for various database functions, which may
include reading, updating, deleting, etc. In either case, concurrency rules
must insure no loss or corruption of the data.
concurrent review: The investigation of patient care while it
is in progress, with the intention of modifying that care if appropriate and
determining if continued treatment is medically necessary.
conditional order: A type of medication where the medication is
given based upon a condition occurring (e.g., the patient experiences pain).
conditional
treatment case: In this book, a
case developed by a primary care physician, urgent care physician, nurse
practitioner, or advice nurse that may be later used to generate a treatment
case, or may later be dispensed with.
confidentiality: The act of limiting disclosure of private
matters; maintaining the trust that an individual has placed in one who has
been entrusted with private matters;
not disclosing information about a patient that is considered to be privileged
and cannot be disclosed to a third party without the patient’s consent.
consent: The agreement of an individual for a given
action relative to the individual. This may be consent for treatment, special
procedures, release of information, and advance directives. “Expressed consent”
is written; “implied consent” is an action other than an expressed consent on
the part of a patient that demonstrates consent; while “informed consent” is
freely given consent that follows a careful explanation by a caregiver.
consultation: Process in which the help of a specialist
is sought to provide advice or care for a patient. A request for a consultation
is often accompanied by a referral; see “referral” and “referral letter”.
content
facilitator:
contingency plan: Plan of action to minimize or negate the
adverse effects of a risk should it occur.
continuity of
care: The coordination of care
received by a patient over time by possibly given by multiple caregivers.
contraindication: Any condition, especially any condition of
disease, which renders some particular line of treatment improper or
undesirable.
control: An item that may appear within a window
to allow the user to control the window. These include list boxes, input
fields, buttons, check boxes, radio buttons, and others.
control chart: A control chart is a graph of data used in
statistical process control that incorporates statistical content- a mean
(average) and upper and lower statistical thresholds (control limits), to guide
interpretation and decision-making of the data. A “trend document” is a form of
control chart. See “trend document”.
controlled
document: An important document
created during a project that can not be changed without approval of a change
control board within a change control process. Examples of such documents are
documents to record project objectives and goals, business requirements,
workflow requirements, system requirements, program specifications, user
documentation. See “change control process”.
controlled
substance: A drug whose
distribution and use is controlled by federal and/or state government
regulation. Controlled substances,
which may include narcotics, stimulants and sedatives, are divided into five
classes called schedule I through schedule V. See “schedule I through V drugs”.
cooperative
business objects (CBOs): Real world
“business objects” used in a GUI interface of a computer system that are
relatively independent from each other.
cooperative editing
systems: Multi-user systems where the actions of one user are
instantaneously propagated to all the other participating users.
coordination of
care: Methods to assist caregivers
in coordinating their care of a patient.
copayment: Fixed dollar payments a patient makes per
visit or prescription filled.
copy: (1) To copy information and keep it so you
can paste it somewhere else on the screen. (2) To make an exact copy of a file
so you can place the duplicate in another location.
corporate database: A database sharing data across many systems
in an organization to avoid redundant entrance of information and to insure
that data in the organization is in a consistent format. See “application
database”.
co-sign: (1) Verbal medical orders from a physician may
be entered and signed by a caregiver other than the physician (e.g., a registered nurse, physician assistant,
pharmacist, respiratory therapist) but must be later co-signed by the physician (e.g., within 24 hours). (2) Medical or nursing students documentation
(e.g., a progress note) may be co-signed by an instructor, indicating the
instructors agreement with the information and acceptance of responsibility for
the documentation.
cost-benefit
analysis: Identification and
evaluation of all costs and benefits associated with a particular project.
CPR repository: In this book, a national database containing
a summary of a patient’s clinical information in a format using national or
international data standards. Possible information might include patient
identification information, a patient problem list, patient practitioners,
patient encounters, services (including medications, diagnostic tests, immunizations, procedures and therapies),
assessments/exams, and care plans.
CPT (Physicians’
Current Procedural Terminology): A
system describing medical and surgical procedures in a hierarchical format with
six major sections, developed by the American Medical Association. The current
version is CPT-4.
CPU (central
processing unit): The part of a computer that controls all the other
parts. The CPU fetches instructions from memory and decodes them. This may
cause it to transfer data to or from memory or to activate peripherals to
perform input or output. Sometimes just called the “processor”.
credentialing: A system that uses national databases to
record or verify a healthcare practitioner’s professional credentials. For
example, a credentialing system may (1) verify that a healthcare practitioner
has a license to practice, (2) record or verify hospital privileges, (3) verify
DEA certification, (4) record board certification, (5) identify sanctions
against licensure, and (6) identify Medicare/Medicaid sanctions.
crisis: See “panic”.
critical pathway: See clinical pathway.
cryptographic
techniques: Methods of concealing
data by representing each character or group of characters by others.
CT (computed
tomography) scan: A diagnostic test
that combines the use of x-rays through the body from multiple angles, the
resultant absorption values are analyzed by a computer to produce
cross-sectional slices.
cursor: A flashing line, square, rectangle or
other symbol on the screen that moves when you move the mouse or other pointing
device and can also be moved around via characters or character combinations
entered through the keyboard.
cut: To remove information but keep it around so
you can paste it back somewhere else.
Defense Advanced
Research Projects Agency (DARPA):
The U.S. federal government agency that was the originator of the
Internet.
data: Symbols that represent observations; often
called raw data to emphasize that they are unprocessed. Data are processed and
interpreted to yield “information”.
database: The collection of permanently stored
data used by one or more applications.
database
administration: The tasks necessary
to insure data integrity, non-redundancy of data, immediate up-to-dateness of
data, integrity of the meaning of data as recorded in data dictionaries,
security, and database software installation and upgrades.
database management
system (DBMS): A scheme using
“software” and sometimes “hardware” to store and retrieve large quantities of
interrelated data by one or many different application programs.
data communication: The sending, transmission and reception of
information between different electronic systems.
data dictionary: A
database about data objects in a database, defining the use of each table in
the database and the meaning of each row and data element in each table in a
database. See “meta-data”.
data element: The smallest, meaningful piece of
information in a business transaction or database. A data element may condense
lengthy descriptive information into a short code. Equivalent to a data field
in a paper document; a series of data elements are used to build a row in a
relational database.
Data Flow Diagrams
(DFDs): A structured analysis tool
used to track the flow of data through an entire (business, software or other)
system, identify transformations on data, and identify data repositories.
data mining:
Discovering useful relationships in data warehouses. See “data warehouse”.
data model: A model of the logical data content of a
system, expressed in terms of entities, relationships and attributes, such as
may appear in an entity-relationship diagram.
data warehouse: A system for storing, retrieving and
managing large amounts of data that planners and researchers can use without
slowing down the day-to-day operations of the production database.
DEA license: License allowing a physician to prescribe
controlled substances. See “Drug Enforcement Administration (DEA)”.
deadlock: A situation wherein two or more processes
are unable to proceed because each is waiting for one of the others to do
something.
decoupling: Changing systems so they use industry
standard connections so that any one system can be replaced by a different one
using the same standards without having any effect on any of the other ones.
dedicated
line: A permanent connection with a
network.
demand management: An approach in HMOs to instruct a patient in
self care or to “triage” the patient to the appropriate and most cost effective
caregiver for the patient’s medical complaint.
descriptive disease
prediction: In this book, a method to predict disease by
reviewing the medical records of a large number of persons over a long period
of time and identifying those factors either singly or in combination
predispose a person to a particular disease. No determination is made as to
whether these factors could be used as risk factors for the disease or not.
Descriptive disease prediction could be done through a computer program doing
pattern matching or using a data warehouse to do on-line analytic
processing (OLAP). See “disease
prediction”, “on-line analytic processing” and “descriptive epidemiology”.
descriptive
epidemiology: A branch of epidemiology identifying
patterns or trends in diseases and injuries.
desktop computer: A microcomputer using the traditional
full-size case, monitor and keyboard that are designed to be used in a
stationary “desk-centered” environment. See “portable computer”.
development system: An
automated system used by the programmers, analysts and testers to develop,
modify or test the system rather than one used by the organizational users of
the system.
(medical) diagnosis
(Dx): Identification of the cause
of a patient’s illness or discomfort; identification of a specific disease or
pathological process.
DSM-IV (Diagnostic
and Statistical Manual of Mental Disorders): Diagnostic classification systems that allow consistent diagnoses
of emotional illnesses published by the American Psychiatric Association.
diagnostic
findings: The results of a
diagnostic test. For clinical laboratory tests, diagnostic findings (results)
are identified as “normal”, “out-of-range”, “abnormal”, “negative”, “positive”,
and “panic” or “crisis”. In general, for results of diagnostic procedures
outside of the clinical laboratory, results are “normal”, “abnormal”,
“negative” or “positive”. Some results, such as x-rays, require interpretation
by an expert to get the results and this description.
diagnostic image: A number of technologies producing images of
the internal body including (1) x-rays, (2) fluoroscopy, (3) nuclear medicine,
(4) angiography, (5) ultrasound (ultrasonography), (6) interventional
radiology, (7) computed tomography, (8) magnetic resonance imaging (MRI) and
(9) computed radiography.
diagnostic related
group (DRG): A way of classifying patients for government reimbursement and
sometimes to establish an initial care plan. Classification is based upon the
following: primary and secondary
diagnoses, primary and secondary procedures, and length of stay.
diagnostic tests: Clinical laboratory tests and other
diagnostic procedures.
dialog box: A window that a GUI program displays to
prompt a reply from a user. The dialogue box could consist of multiple
controls, which may include list boxes, input fields, buttons, check boxes,
radio buttons, etc. See “modal dialog box” and “modeless dialog box”.
differential
diagnosis: Identification of a
disease by comparison of the symptoms of two or more similar diseases.
DICOM (Digital
Imaging and Communications in Medicine):
A standard that has been developed by ACR/NEMA to meet the needs of
manufacturers and users of medical imaging equipment for interconnection of
devices on standard networks. The current version is DICOM-3.
digital: Information represented as discrete
numeric values, such as 0 or 1, as opposed to analog. See “analog”.
digital
signature: Cryptographic data that
undeniably identifies a message with its sender.
dimmed: A menu option that a user can see but not choose. Dimmed items are usually shown in gray letters instead of black.
direct cause
disease prediction: In this book, a theoretical approach to
disease prediction where the total of a person’s genetics and significant
environmental factors are recorded enabling prediction of future diseases based
upon analytic epidemiology studies. See “disease prediction” and “analytic
epidemiology”.
directory: A listing of all the file names and
subdirectories that are available on a computer system or on computers in a
network.
discharge: Termination of a period of inpatient
hospitalization through the formal release of the inpatient by the hospital; to
release from care at a medical care facility by a physician or other medical
care worker, such as from the hospital or emergency department.
discharge planning: Set of decisions and activities involved in
providing continuity and coordination of care once the patient is discharged
from a healthcare facility.
discrete event simulation: The modeling of a system (e.g., a work flow) as it evolves over time by a representation in which the state variables change instantaneously at separate points in time. These points in time are the ones at which an “event” occurs. The time between events is modeled statistically and the expected total time of the running of the system (the execution of a work flow) can be determined by running the model, randomly selecting time values within constraints, over and over again.
disease: A pathological condition of the body that
presents a group of clinical signs, symptoms and laboratory findings peculiar
to it.
disease management: Identifying populations (patients) with
particular acute and chronic diseases, such as diabetes, cancer, coronary
artery disease or asthma, and introducing interventions throughout the life
cycle of the disease that will both improve the quality of life and lower the
costs associated with the disease process.
disease prediction: In
this book, any approach to predicting that a patient will get a disease, or to
predicting when a patient will get a disease, when a disease will worsen, or
when a treatment decision for a disease will need to be made, most often
expressed in terms of the probability of that event happening compared to the
probability of that event happening for the general population or for an
applicable population group. This book identifies these forms of disease
prediction: analytic disease prediction, direct cause disease prediction,
descriptive disease prediction, and disease progression analysis.
disease progression
analysis: In this book, determining the probable progression of a
disease or progression to developing a disease for a particular patient by
measuring a medical value or state for that patient over time that is
predictive of the disease and comparing this progression of values or states
with other patients who have developed the disease. Measurements could be recorded
on a trend document. See “disease prediction” and “trend document”.
disk: The most common high volume auxiliary storage
medium for a computer system. Usually refers to a magnetic disk, but also
refers to an optical disk.
disk mirroring: A method of fault tolerance for information
stored on disks that involves writing the same information on two different
disks with two different controllers. If one drive is lost or unavailable, the
other is still available.
distributed
database: A database that is stored
at multiple locations within a network either by partitioning the data or
replicating the database.
distributed
facility group: In this book, the
set of medical facilities of a healthcare organization handled by a particular
computer system that is part of the automated patient medical record system,
where the automated patient medical record system consists of a number of
distributed computer systems, each in a different geographic location.
distributed
systems: Implementation of a single
application system on multiple computer systems at different locations with the
systems usually connected by a network.
docking station: An addition to a portable computer, such as
a pen computer, to add capabilities such as an AC power supply, full size
monitor, CD-ROM drive, sound card, hard drive, a recharging unit, etc., to make
the computer act more like a desk-top computer when it is being used in a
designated fixed location.
document: Written,
and sometimes pictorial, form of communication that permanently records
information relevant to the health care of a patient.
document type definition (DTD): A DTD defines the elements, attributes, entities and rules for creating one or more documents in a markup language (SGML, HTML, or XML).
documentation: Manuals, online help, README files and other
instructions that come with a software package.
document list: A list of documents in a medical record for
an identified patient.
documentation
management system: A system that
supports enterprise-wide on-line documentation on an Intranet. A documentation management system enables
enterprise wide creation, controlled access, review and update, routing and
management of documents.
domain: The set of values allowed for a data
element in a given column or for the set of data elements in a group of columns
of a relational database.
domain name: An addressing construct on the Internet
network used for identifying and locating computers on the Internet (e.g.,
“www.whitehouse.gov”), which can be translated by a name server into a numeric
IP address. Domain names must be registered through an agency associated with
the National Science Foundation (NSF).
dosage: The determination and regulation of the
size, frequency, and number of doses of medication or radiation for a patient.
dose: A quantity to be administered at one
time, such as a specified amount of medication (e.g., 5 g. for 5 grams).
download: Transferring data or software from a
central location to a remote location (e.g., your server or workstation) via a
communications link.
drag: The action of using a mouse or other
pointing device to select and move an object on the screen.
drag and drop: The action of using a mouse or other
pointing device to select and move an object, placing it somewhere else on the
screen.
drill down: For tree structured connected document such
as hypertext, to go from a higher level down document to a lower level one by
selection at the higher level.
drive: Any device that reads and writes information,
such as a hard drive, floppy drive, CD-ROM drive, or tape drive.
drug allergy: Hypersensitivity to a pharmacological agent,
with reactions that could range from those that are very mild (e.g., a rash) to
those that very severe.
drug compendium: A listing of drugs and information about them used by healthcare practitioners who prescribe them. It is used to validate drug orders. It includes both HMO formulary and non-formulary drugs, enables clinical checking (drug interaction checking) and enables drug costing.
Drug Enforcement
Administration (DEA): U.S.
Government agency that is part of the U.S. Department of Justice that enforces
drug laws and regulations including regulations concerning the legal
manufacture and distribution of controlled substances. See “DEA license”.
drug
formulary: In this book, a listing
of all the drugs an HMO recommends, the most effective and least cost
ones. Some managed care organizations
charge more for non-formulary drugs, whereas in some managed care organizations
non-formulary drugs are not covered at all.
drug interaction: Interactions of a drug with other drugs,
with foods, with laboratory tests, or other interactions.
drug jumping: Going from physician to physician and/or
facility to facility to get a prescribed medication, especially a narcotic or
other controlled substance, and especially for a patient who is addicted to
that drug.
DTD (Document Type
Definition): See “XML DTD”.
durable medical
equipment (DME): Equipment leased
or sold to patients for use in their homes (e.g., wheelchairs, walkers, canes).
durable medical
equipment (DME) formulary: A
database that lists and describes all durable medical equipment (DME) offered
to patients within a healthcare organization. See “durable medical equipment”.
durable power of
attorney for healthcare: See
“healthcare proxy”.
DxPlain:
An experimental system of clinical decision support provided by time shared
telephone links, which was developed at Harvard University Massachusetts
General Hospital in the late 1960s.
EBCDIC: Extended binary-coded decimal interchange
code: A character-coding scheme found mostly in large-scale IBM computers.
E code: An injury code, sometimes used for an injury
registry, with the injury registry being a database for recording injuries from
which epidemiological studies can be done.
EDIFACT: EDI for Administration, Commerce, and
Transportation (EDIFACT). An international UN-sponsored EDI standard primarily used
in Europe and Asia. An alignment is envisioned between ANSI ASC X12N and
EDIFACT EDI standards in the future to create a single EDI standard. The
standard is used for the electronic interchange of structured data related to
trade in goods and services.
effective: Producing the intended result.
efficacy: The ability to produce the desired effect.
efficient: Serving as an immediate agent in the
production of an event.
elective: Subject to the choice or decision of
the patient or physician; applied to procedures that are advantageous to the
patient but not urgent.
electrocardiography
(ECG or EKG): ECG is the graphic tracing of the variations in
electrical potential of the heart.
electroencephalography
(EEG) : A graphic tracing of the variations in electrical
potential of the brain.
electronic
clipboard: A clipboard and a radio controlled pen. A
writing tablet is put on the clipboard and any writing on the paper is also
recorded through the clipboard. The commercial version of this is the CrossPad
made by the Cross Pen Company.
electronic commerce (E-commerce): The paperless exchange of business information using Electronic Data Interchange (EDI), electronic mail, electronic bulletin boards, electronic funds transfer and other similar technologies. Also known as ANSI ASC X12N standards in the U.S.
Electronic Data Interchange (EDI): The computer to computer exchange of business data in a standardized format between Trading Partners.
electronic health record (EHR): Another term for the automated patient medical record. Health care record stored in electronic format.
electronic medical
record (EMR): Another term for the
automated patient medical record. Health care record stored in electronic
format.
electronic
signature: A code or symbol that is
the electronic equivalent of a written signature can legally substitute for the
written signature.
elective admission: An admission to the hospital that could be
medically delayed without endangering the patient, such as for an elective
surgery.
eligibility/coverage: Refers to the period of time a healthcare
organization subscriber or dependent is entitled to benefits.
e-mail (electronic mail): The use of a computer network by individual users to send, store, and receive messages or documents to and from other individuals.
emergency: The sudden onset of a condition or an
accidental injury requiring immediate medical or surgical care. See “prudent
layperson standard”.
emergency
department (ED): A hospital area
staffed and equipped for the reception and treatment of persons requiring immediate medical care.
encapsulation: Hiding data and methods within the object
class from outside programmers.
encounter: A face to face interaction between a patient
and a healthcare provider. In some cases this may also include an interaction
via a phone call or television if this takes the place of the face to face
interaction. Encounters could include
all of the following: an inpatient stay,
outpatient visit, emergency department visit, advice nurse call, a phone call
between a patient and a physician, a home health visit, a skilled nursing
facility (SNF) visit.
encounter status: An event that may logically precede, occur
during or be a result of an encounter or potential encounter, or a result of a
situation causing the encounter not to occur. For example, encounter statuses
for an outpatient visit could be patient wait-listed, appointed, appointment
canceled, appointment no show, patient registered, in the examination room,
visit completed, diagnoses and procedures identified.
encounter synopsis: A summary of a patient encounter.
encryption: The transformation of confidential plain text into a cipher text in order to protect it from being read by a third party.
endemic: Present or usually prevalent in a population
or geographical area at all times; said of a disease. This is opposed to
“epidemic” and “sporadic”.
end-stage renal
disease (ESRD): A disease of the
kidneys that ends up requiring either dialysis or renal replacement.
enterprise
management system: A package of
software systems that together manage a distributed computer network, composed
of possibly disparate computers, as if the distributed network was a mainframe
system.
enterprise
scheduling system: A
multi-dimensional healthcare organization scheduling system that schedules
patients with caregivers and resources (e.g., patients with caregivers,
patients and caregivers with rooms--such as operating rooms, patients and
caregivers with classes, patients and caregivers with equipment) and provides
information for charging for associated services, for automatic ordering of
associated supplies, and for recording caregiver time for the caregiver payroll
system.
entity: Something about which information is stored. An entity might be a tangible item, such as a patient, physician or room. An entity can also be intangible, such as an agent.
entity-relationship
(ER) diagrams: A database analysis
diagram that documents business entities about which database information will
be stored that shows the relationships that exist between the entities.
entrance “by
exception” : See charting by
exception.
epidemic: Occurring suddenly in numbers clearly in
excess of normal expectancy; said especially of infectious diseases but applied
also to any disease, injury, or other health-related event occurring in such
outbreaks. This is opposed to “endemic”
and “sporadic”.
epidemiology: Study of the occurrence, distribution, and
causes of disease and the application of this study to the control of health
problems.
episode: One or more healthcare services received by
an individual during a period of relatively continuous care by healthcare
practitioners in relation to a particular clinical problem or situation.
episodic: Care handled by a single outpatient
encounter, possibly including calling back the patient. Also see “acute care”.
error: In
this book, in the context of a project, an inconsistency between how a
project agreement, a workflow or an automated system is implemented and how it is
documented—the error may either be an error in the implementation or in the
documentation. See “change”.
error of
commission: Mistake resulting from
overdiagnosis or diagnosing a nonexistent health problem.
error of omission: Mistake resulting from failure of the
caregiver to diagnose a health problem or disease.
essential business
practice: Some aspect of the
current environment and systems that must be preserved in a changed environment
because it is essential for the proper functioning of the organization.
Ethernet: A local area network architecture (also
known as the IEEE 803.2 standard) developed by the Xerox, Digital and Intel
that operates at 10 Mbps and uses the CSMA/CD protocol for media access
control. Ethernet is being extended to 100 Mbps. Also, gigabit Ethernets are
being considered.
etiology: A
study of the causes of disease. Also see “analytic epidemiology”.