Glossary of Terms and Acronyms Related to e-Health
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A certified EHR is defined as a qualified electronic health record that is certified as meeting the standards applicable to the setting (e.g. ambulatory or hospital-based) as adopted by the Office of the National Coordinator for Health Information Technology (ONC).
Reference: Certified Health IT Product List: http://chpl.healthit.gov
Clinical Data Repository means a real time database that consolidates data from a variety of clinical sources to present a unified view of a single patient and is used by a state-certified health information exchange service provider to enable health information exchange among health care providers that are not related health care entities as defined in section 144.291, subdivision 2, paragraph (U). This does not include clinical data that are submitted to the commissioner for public health purposes required or permitted by law, including any rules adopted by the commissioner.
CDS refers broadly to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information.
A Health Level Seven (HL7) XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes). The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from HL7, Integrating the Healthcare Enterprise, and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for stage 1 of the “meaningful use” EHR Incentive Program and HITECH final rule. It is commonly referred to as Consolidate CDA or C-CDA.
Clinical Transaction means any meaningful use transaction or other health information exchange transaction that is not covered by section 62J.536.
In Michigan, we have a solution to improve patient matching across organizations – Common Key Service. The “common key” is a unique, not human readable attribute assigned to every patient. Organizations utilizing the Common Key Service will be able to ensure they are talking about the same unique patient as an external identifier that can integrate within an existing electronic medical record system.
CPOE is a computer application that allows a provider's orders for diagnostic and treatment services (such as medications, laboratory, and other tests) to be entered electronically instead of being recorded on order sheets or prescription pads. The computer compares the order against standards for dosing, checks for allergies or interactions with other medications, and warns the provider about potential problems.
Reference: United States Department of Health and Human Services. Office of the National Coordinator for Health Information Technology (ONC) Glossary: https://www.hhs.gov
HIPAA’s Privacy Rule requires patient authorization (consent) for certain disclosures of protected health information (PHI) but it does not require consent when the disclosure is for the patient’s treatment, for payment for that treatment, or for health care operations purposes. In contrast, the MHRA requires patient consent when a health care provider discloses an individual’s health records for treatment, payment, or health care operations and for most other releases, with limited exceptions. Minnesota Health Records Act, Minnesota law governing health records information, Minnesota Statutes 144.291 through 144.298. A digital or hardcopy record, signed and dated by a patient or a patient's legally authorized representative, authorizing the release of a patient's health records. Review and align with MN law (how differs from HIPAA)
Reference: Minnesota Health Records Act
A representation whether verbal or electronically captured in the electronic health record from a provider that holds a signed and dated consent from the patient authorizing the release of protected health information.
Reference: Minn. Stat. §144.293 sub. 9(b)
Role based access or role based access control (RBAC)
A security administration model used in information technology. Each system user is assigned one or more roles, and each role is assigned one or more privileges that are permitted to users in that role. Security administration with RBAC consists of determining the operations that must be executed by persons in particular jobs, and assigning employees to the proper roles.
The Continuity of Care Document (CCD) is a joint effort of HL7 International and ASTM. CCD fosters interoperability of clinical data by allowing physicians to send electronic medical information to other providers without loss of meaning and enabling improvement of patient care. CCD is an implementation guide for sharing Continuity of Care Record (CCR) patient summary data using the HL7 Version 3 Clinical Document Architecture (CDA), Release 2. CCD establishes a rich set of templates representing the typical sections of a summary record, and expresses these templates as constraints on CDA. These same templates for vital signs, family history, plan of care, and so on can then be reused in other CDA document types, establishing interoperability across a wide range of clinical use cases.
HL7/ASTM Implementation Guide for CDA® R2 -Continuity of Care Document (CCD®) Release 1 may also go by the following names or acronyms:
Covered entities are defined in the HIPAA rules as (1) health plans, (2) health care clearinghouses, and (3) health care providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards.