Health IT Definitions and Acronyms

After all these years, there is still no consensus about electronic record terms and concepts in healthcare. For the purpose of better understanding Medical Records Institute and the healthcare IT industry in general, we offer the following definitions:

CCD – Continuity of Care Document – a modification of the CCR developed by standards organization HL7 in cooperation with ASTM E31 Committee on Healthcare Informatics

CCR – Continuity of Care Record developed by ASTM E31 Committee on Healthcare Informatics. Data about a patient’s healthcare that enables physicians to collect and easily transfer a patient’s health relevant information. A CCR includes payer information, family history, problems, medications, procedures, healthcare providers etc.

CDA – Clinical Documentation Architecture developed by HL7

CPOE – Computerized Physician Order Entry – The electronic entry of doctor’s instructions for patient care.

CPR – computer-based patient record – A now antiquated term (popular in the 1990s) for a multi-disciplinary and multi-provider record of a patient’s health data. This term, which focuses on the person as a patient and thereby excludes wellness information, was abandoned for the more encompassing term EHR.

EMR – electronic medical record – This is the term MRI uses to describe systems in current use, i.e., the EMR consisting of electronic health information about a single patient at a single provider setting. It is contained within an enterprise-wide system in which limited interoperability can be achieved by selecting interoperable software and hardware.

EHR – electronic health record – Includes all health information about a single person derived from multiple sources, e.g., one or more hospitals, several physician offices, other healthcare providers, wellness providers, such as sports clubs, payers, employers, and others. MRI recognizes that it will be a long time before interoperability among these sources, and thus the HER, will be achieved.

EPR – electronic patient record - Although used in the title of the TEPR conference (Towards the Electronic Patient Record - originally titled in the mid 1980s), this term has been replaced by EMR and EHR.

HIT – health information technology and health IT - The application of information technology in healthcare, centering around the use of IT for the documentation, storage, retrieval, transfer and sharing of health information. See also: health informatics and medical informatics.

health IT – See HIT.

health informatics – The application of information technology in healthcare, centering around the use of IT for the documentation, storage, retrieval, transfer and sharing of health information. See also: HIT and medical informatics.

information capture – A term that refers to the method by which information is recorded, and/or inputted into a health IT system. Examples include the use of voice recognition software, dictation and transcription, tablets, and keyboard entry.

IT – information technology

medical informatics - The application of information technology in healthcare, centering on the use of IT for the documentation, storage, retrieval, transfer and sharing of health information. See also: health informatics.

MRI – Medical Records Institute

NHII – National Health Information Infrastructure

PHR – personal health record

PMS – practice management software – Computer programs that deal with the office management aspects of a medical practice (billing, booking appointments, tracking insurance information, etc.).

QIO – Quality Improvement Organization

RHIA – Registered Health Information Administrator

RHIO – Regional Health Information Organization

RIO – return on investment

TEPR – Towards the Electronic Patient Record – annual conference sponsored by Medical Records Institute, drawing stakeholders from throughout the healthcare industry to address the ecosystem of health information technology and electronic health records