Data Dictionary

Attachment 2

Data Dictionary: Definitions of Key Terms and Concepts

Terms	Source(s)
EHRs, certified and not certified	Authoritative source: “ONC recently revised the Certified EHR Technology definition to permit the use of 2011 Edition EHR technology to meet the definition for fiscal and calendar years 2014.”
	http://www.healthit.gov/policy-researchers-implementers/standards-and-certification-regulations
	Medicare and Medicaid Programs; Modifications to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and Other Changes to the EHR Incentive Program; and Health Information Technology: Revisions to the Certified EHR Technology Definition and EHR Certification Changes Related to Standards.
EHRs, certified	A certified EHR meets the standards and criteria for certification set by the ONCHIT, in the categories of 2011-2013 Temporary Certification, 2014 Edition and/or 2014 Revised Edition. Certified Health IT Product List for validation if necessary.
EHRs, not certified	A non-certified record includes record systems for clinical (managing patient health information in an electronic environment) and/or practice management (i.e., scheduling, business operations, billing and managing payer information).
Practice Management (software) or PMS	Authoritative source(s): “Concerns the day-to-day operations of a medical practice. Allows users to capture patient demographics, schedule appointments, maintain lists of insurance payors, perform billing tasks, and generate reports. May include business operations, financial management, human resource management, information management, organizational governance, patient care systems, quality management, risk management”
	Establishes and monitors business processes the impact clinical operations
	Provides relevant and accurate resources for patient understanding and participation in their medical care
	Implements a referral management process
	Supports efficient patient flow patterns that maximize physician schedules
	Manage front office operations to maximize patient satisfaction, collection of payments and customer service efforts
	http://bit.ly/117cgDv (Body of Knowledge for Medical Practice Management)
Clinical Management (software) or CMS	“Day-to-day operations of a behavioral health practice. Linked to quality of care standards and treatment outcomes. Anticipates emerging models for treatment of behavioral and substance use disorders. Integrates with practice management in that it establishes and uses patient communication (appointment confirmations, follow-up notifications and financial to enhance patients knowledge, understanding and participation in care.”
	http://bit.ly/117cgDv (Body of Knowledge for Medical Practice Management)
Interoperability	Authoritative source(s): “Describes the extent to which systems and devices can exchange data, and interpret that shared data. For two systems to be interoperable, they must be able to exchange data and subsequently present that data such that it can be understood by a user.” Foundational: allows data exchange from one information technology system to be received by another and does not require the ability for the receiving information technology system to interpret the data. Structural: intermediate level that defines the structure or format of data exchange (i.e., the message format standards) where there is uniform movement of healthcare data from one system to another such that the clinical or operational purpose and meaning of the data is preserved and unaltered. Semantic: “highest level, which is the ability of two or more systems or elements to exchange information and to use the information that has been exchanged. This level…supports the electronic exchange of health-related financial data, patient-created wellness data, and patient summary information among caregivers and other authorized parties. This level…is possible via potentially disparate electronic health record (EHR) systems, business-related information systems, medical devices, mobile technologies, and other systems to improve wellness, as well as the quality, safety, cost-effectiveness, and access to healthcare delivery.”
	http://www.himss.org/library/interoperability-standards/what-is-interoperability
	“The ability to exchange data effectively, while preserving its meaning, in a secure and consistent manner among different information technology systems, software applications, and networks in various settings.”
	http://www.ahip.org/Innovations-in-Health-IT/
	“Interoperability is the ability of two or more systems to communicate -- or exchange -- information and to use the information that has been exchanged. Interoperability is NOT the same thing as health information exchange. Exchanging information is only part of the picture; once the information has been exchanged, it must be useable by the recipient. Providers using different systems may not be able to share and use information, so ONC is working to set national standards to make sure that all electronic health record systems are able to work together seamlessly. ONC is coordinating with the health IT community in an open and transparent process to develop and unify standards, guidelines and policies for interoperable health information exchange.”
	http://www.healthit.gov/patients-families/health-it-terms
HIE functionality	Authoritative source(s): “Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care.” Directed Exchange – ability to send and receive secure information electronically between care providers to support coordinated care Query-based Exchange – ability for providers to find and/or request information on a patient from other providers, often used for unplanned care Consumer Mediated Exchange – ability for patients to aggregate and control the use of their health information among providers”
	http://www.healthit.gov/providers-professionals/health-information-exchange/what-hie
	“the movement of health information electronically across multiple organizations. Exchanging health information is important in order to make sure that your health care providers have access to the most up to date information about you so they can make more informed decisions about your care. HIE can improve the coordination of care for a person who is seeing multiple providers by enabling providers to share important health information.”
	http://www.healthit.gov/patients-families/health-it-terms
	“Health Information Exchange (the verb) is the electronic movement of health related information among organizations according to nationally recognized standards. Health Information Exchanges (HIEs – the noun) or Health Information Organizations (HIO) are those organizations that minimally oversee and govern the exchange of health related information among independent and disparate stakeholders according to these nationally recognized standards.”
	http://statedashboard.himss.org/hitDefinitions.aspx
Telehealth	Authoritative source(s): “Telehealth is the use of technology to deliver health care, health information or health education at a distance...Telehealth can be divided into two general types of applications: real-time communication, and store-and-forward. Real-time communication may be a patient and a nurse practitioner consulting with a specialist via a live audio/video link, or a physician and a patient in an exam room communicating through an interpreter who is connected by phone or webcam. Another example might be a cardiologist holding a teleconference with internists about new best practices in treating angina. Store-and-forward refers to the transmission of digital images, as in radiology or dermatology, for a diagnosis.”
	http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Telehealth/whatistelehealth.html
	“The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”
	http://www.who.int/goe/publications/goe_telemedicine_2010.pdf
	“The Health Resources Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”
	“Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.”
	http://www.healthit.gov/providers-professionals/faqs/what-telehealth-how-telehealth-different-telemedicine
	“For purposes of Medicaid, telemedicine seeks to improve a patient's health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”
	http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
Mobile tools	Authoritative source(s): “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices.”
	http://www.who.int/goe/publications/goe_mhealth_web.pdf
Web portals	“A patient portal is a secure online website that gives patients convenient 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can view health information such as: • Recent doctor visits • Discharge summaries • Medications • Immunizations • Allergies • Lab results Some patient portals also allow patients to: • Exchange secure e-mail with their health care teams • Request prescription refills • Schedule non-urgent appointments • Check benefits and coverage • Update contact information • Make payments • Download and complete forms • View educational materials”
	http://www.healthit.gov/providers-professionals/faqs/what-patient-portal
Consumer engagement	Consumer Engagement: “enabling people to work with healthcare professionals in full participation of maintaining their own healthcare and making informed healthcare decisions.”
	http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050578.hcsp?dDocName=bok1_050578
	“Engaged patients: • Seek information about their health and health care • Make informed and shared decisions with their health care team • Take steps to manage their health and health care • Act as partners with their health care team”
	http://www.healthit.gov/sites/default/files/nlc_using_e-healthtools.pdf
	“Technologies to support patient engagement: Patient portals, secure electronic messaging, and other e-health tools offer important opportunities to engage patients and caregivers: Patient portals allow patients to check their lab and other test results and review their health information at their convenience. Patient portals also let patients communicate with their health care team, access educational resources, request medication refills, make appointments, and handle other tasks. Secure electronic messaging between patients and their health care team facilitates communication between office visits. For example, patients can ask questions they may have forgotten or didn’t have time to ask during the visit. They can also share important updates with their health care team. Clinical summaries reviewed with patients at the end of their office visit can help them to understand and remember what happened during the visit, any changes in their health care plan, and steps to take to manage their health. Patient education resources enable patients to learn more about their health and health care. Many high-quality decision aids, self-management tools, mobile applications, and Internet-based resources can be provided to patients at the time of their office visit or via a patient portal.”
	http://www.healthit.gov/sites/default/files/nlc_using_e-healthtools.pdf
	Health Management which covers patient portals, secure messaging, Blue Button, Consumer Mediated Exchange and patient generated health data Social and Behavioral which covers social media, texting and gaming, wearables and mobile, and the social determinants of health Home Health which covers remote monitoring and telehealth, patient education, and smart homes Financial Health which includes managing health insurance and expenses, transparency and consumerism, patient onboarding and financial options”
	http://www.himss.org/library/patient-engagement-toolkit
Personal Health Records	"A personal health record (PHR) contains the same types of information as an electronic health record—diagnoses, medications, immunizations, family medical history, and contact information for providers—but it is designed to be set up and accessed by patients themselves.”
	http://www.healthit.gov/patients-families/faqs/what-difference-between-personal-health-record-and-electronic-health-record-a
	“an electronic record of an individual’s health information by which the individual controls access to the information and may have the ability to manage, track, and participate in his or her own health care.”
	http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/healthit/phrs.pdf
	“A Personal Health Record (PHR) is an electronic record of health information maintained by the patient. A PHR might contain information about medical conditions, allergies, medications, and doctor or hospital visits. The PHR makes it possible for the patient to store in one place and share information with others as needed. The patient controls how the information is used and who can access it. PHRs are usually accessed through the Internet so information is available anytime or anywhere. See http://www.medicare.gov/navigation/manage-your-health/personalhealth-records/personal-health-records-overview.aspx”
	http://www.integration.samhsa.gov/operations-administration/Resource_Guide_for_HIT.pdf
Dashboards	“A business intelligence dashboard is a graphical interface that displays the current status of metrics and key performance indicators (KPIs) for an enterprise.”
	http://searchbusinessanalytics.techtarget.com/definition/business-intelligence-dashboard
	“visualize data...interactive, providing the user several ways to parse and examine the data”
	http://dashboard.healthit.gov/help/faq.php
	A “dashboard is an electronic display comprised of key performance indicators (KPIs).” “In healthcare, most dashboards display three kinds of indicators. These indicators are financial, clinical, and operational indicators. The financial indicators address the financial health of the organization while the clinical indicators speak to both quality care and the operational aspects of a clinical department.”
	http://www.himss.org/files/himssorg/content/files/executivedashboarddevguide.pdf
Tools for integrated care	“The integration of health information technology (IT) into primary care includes a variety of electronic methods that are used to manage information about people's health and health care, for both individual patients and groups of patients…. In primary care, examples of health IT include the following: • Clinical decision support. • Computerized disease registries. • Computerized provider order entry. • Consumer health IT applications. • Electronic medical record systems (EMRs, EHRs, and PHRs). • Electronic prescribing. • Telehealth.”
	http://www.ahrq.gov/professionals/prevention-chronic-care/improve/health-it/
Social Media	“Social media refers broadly to Web-based tools that allow individuals to communicate quickly, easily, and broadly. Current popular social media sites include Twitter, Facebook, LinkedIn, and YouTube; in addition, millions of individuals publish their thoughts and interests through blogs… Social media represents a brave new world for healthcare. It offers a venue for communicating with consumers quickly and inexpensively, such as promoting new wellness programs, marketing new services, and announcing the latest achievements in patient care. It also presents challenges, including risks to information accuracy, organizational reputation, and individual privacy.”
	http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048693.hcsp?dDocName=bok1_048693

Attachment 1: Data Dictionary