CCH Healthcare Terminology

Healthcare Terminology

First we’ll cover the organizations in the healthcare ecosystem. Then we’ll introduce terms related to the business itself or processes within a healthcare business. Finally, we’ll talk about well-known acronyms that can cause confusion for IT professionals changing from one vertical to another.

Government, Private, and Nonprofit Entities

While working within the medical community, you will run into acronyms for government, private, and nonprofit entities.

American Medical Association (AMA) The American Medical Association is the national association for physicians, medical residents, and first-year medical students. Though only approximately 20 percent of doctors are members of the association, it does represent 135,000 practicing physicians. Unfortunately, unless you become a medical student at a minimum, you cannot join.

American Nurses Association (ANA) The American Nurses Association represents the interests of 3.2 million nurses based in the United States. Their work involves providing resources to nurses to improve clinical outcomes and supporting the migration to electronic charting. They are leading the front when pushing for nurse informatics.

Critical Access Hospital (CAH) To be a critical access hospital, the facility must meet the following CMS requirements.

• The hospital is located in a state that has established with CMS a Medicare rural hospital flexibility program, has been designated by the state as a CAH, and is currently participating in Medicare as a rural public, nonprofit or for-profit hospital.
• The hospital was a participating hospital that ceased operation during the 10-year period from November 29, 1989 to November 29, 1999.
• The hospital is a health clinic or health center that was downsized from a hospital, is located in a rural area or is treated as rural, is located more than a 35-mile drive from any other hospital or CAH (in mountainous area the mileage is 15 miles), maintains no more than 25 inpatient beds, maintains an annual average length of stay of 96 hours per patient for acute inpatient care, and complies with all CAH Conditions of Participation, including the requirement to make available 24-hour emergency care services 7 days a week.

Additionally, a CAH can have up to 10 beds for rehab or psychiatric care.

CMS Certification Number (CCN) A CMS certification number is the hospital identification number that is tied to their Medicare provider agreement.

Center for Disease Control and Prevention (CDC) The Center for Disease Control and Prevention is a government entity that is part of the Department of Health and Human Services. The group’s mission is to create the expertise, information, and tools that people and communities need to protect their health.

Center for Medicare and Medicaid Services (CMS) The Center for Medicare and Medicaid Services is another government agency, though its charter is to support the Medicare and Medicaid needs of the United States. Additionally, the Office of the National Coordinator (ONC) works within the CMS organization. The ONC is responsible for the meaningful use definition, the National Health Information Network (NHIN), and the national health information technology plan.

U.S. Food and Drug Administration (FDA) The U.S. Food and Drug Administration has been tasked with assuring the safety and security of human and veterinary medications, implants, medical devices, food supply, and radiation-emitting devices.

Federal Fiscal Year (FFY) When our federal government creates a budget, it is done across a time period called the Federal Fiscal Year. The FFY runs from the first day in October to the last day of September. The fiscal year identifier is for the year the budget ends. So if the budget ended on September 30, 2011, the budget is identified as FFY11.

Health Information Technology Policy Committee (HITPC) The federal government has asked for recommendations when developing policies that affect the nation’s health information network. This includes data interchange, certification criteria, and other standards. The committee that heads those policy discussions and recommendations is called the Health Information Technology Policy Committee.

Health Professional Shortage Areas (HPSAs) Health Professional Shortage Areas are geographic or demographic populations that are underserved. This could be an area where the percentage of citizens per physician is too high. Though there might be enough physicians in a community, there may be a medically underserved population (MUP) that reflects that there are not enough providers to meet the needs of a particular socioeconomic, cultural, or linguistic group.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) JCAHO (“jay-Ko”), the former Joint Commission on Accreditation of Healthcare Organizations, is now known as the Joint Commission. The Joint Commission has accredited more than 19,000 healthcare organizations in the United States. Its goal is to improve healthcare by providing quality improvement recommendations based on their audits. At a minimum, losing Joint Commission accreditation could mean the hospital won’t receive federal reimbursement for Medicare or Medicaid services rendered, but most likely an unaccredited hospital would be shut down.

Medicare Care Management Performance Demonstration (MCMP) As part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the Secretary of Health and Human Services was required to create a pay-for-performance program with physicians to meet the needs of Medicare patients by adopting health information technology. The Medicare Care Management Performance Demonstration provides a reimbursement for participating physicians who meet or exceed the guidelines of promoting continuity of care, stabilizing medical conditions, reducing adverse outcomes, and minimizing or preventing episodic chronic conditions that previously resulted in an emergency room visit or hospitalization.

National Health Information Network (NHIN) The National Health Information Network is the ultimate goal of the EHR funding. This information interchange location will be similar to an ATM. The patient’s provider can go to a computer terminal, authenticate, and then pull down the necessary information regarding the patient being seen.

Notice of Proposed Rulemaking (NPR) A Notice of Proposed Rulemaking is used to inform the public that the federal government is looking to add, change, or remove a rule or regulation. These notices typically include a comment period when the public can voice their concerns.

Medicare Physician Quality Reporting Initiative (PQRI) The Medicare Physician Quality Reporting Initiative is an incentive payment program for physicians who see Medicare patients. This program requires that physicians report on the quality metrics that are published yearly by CMS.

World Health Organization (WHO) The World Health Organization provides leadership on health issues at an international level. This includes setting standards, setting evidence-based policy, and supporting countries that need assistance uncovering health trends.

Healthcare Business Processes

The following acronyms are related to the business process.

Adopt, Implement, or Upgrade (A/I/U) This is used to indicate the adoption, implementation, or upgrade of an EHR/EMR to meet the requirements of ARRA incentive payments.

Clinical Documentation Architecture (CDA) Clinical Documentation Architecture is a standard from the HL7 group meant to specify the encoding, semantics, and structure for exchanging clinical documents. The CDA became available in HL7 v3. This reference architecture will become more important to be familiar with as disparate EHR applications are required to exchange data.

Clinical Decision Support System (CDSS) A clinical decision support system is an application written to help clinicians make better treatment or care plans. Clearly, physicians do not have the time to review all the clinical data available in a treatment and outcomes database. In early CDSSs, information was fed into the application, and the application outputs the next best steps for patient care. This could include care or treatment. Since clinicians have attended typically decades of college, they were not comfortable with technology dictating the next steps. Refinements to CDSSs now do more analysis on the data regarding the patient and compare their demographics, lab results, and other clinical criteria. From there the clinician can see many options for treatment or care and select the most appropriate for clinical care. The options that are not applicable to the case are removed from the system. This allows the system to constantly learn.

Continuity of Care Records (CCR) These are documents shared across clinical boundaries to support the ongoing care of a patient. The record is typically transmitted electronically. Even if it is not sent electronically, the record contains sections on insurance, allergies, problem lists, diagnosis, patient demographics, and care plan.

Computerized Physician Order Entry (CPOE) This is a requirement to meet the ARRA funding reimbursement. The types of orders entered by the physician include labs, radiology, pharmacy, and therapy. The idea is that physicians typically have illegible handwriting, which is a problem when the pharmacist is trying to interpret the doctor’s dosing directives.

Early Editions of CPOE

A local children’s hospital was going through their first installation of a CPOE system. When we spoke to an NICU physician, she stated that the hospital was expecting a 60 percent reduction of bad medication orders in just the first month of utilization. During a recent encounter with the new CIO, we found out that they are experiencing a nearly 98 percent error rate in order entry.

While there we noticed that there was a un-secured wireless network. This network was implemented to support the physicians, and the rollout of CPOE. When we noticed that the wireless was unsecured, we spent a few minutes with the physician showing her the clear-text orders going from the workstation to their clinical system. Although the hospital got the CPOE system right, they hadn’t provided the appropriate security to protect the network.

About two weeks after the IT team made contact with us. The team was interested in learning how to secure the environment without being intrusive to the physicians. In the end, time was spent with their IT folks and helped them improve the security of the wireless network.

Days in Account Receivable (DAR) Days in account receivable is a financial measurement used by a hospital to gauge cash flow. If this number goes too high, then the business is effectively providing loans to their patients.

Discharged Not Final Billed (DNFB) This is a key indicator in how efficient the billing department is. Hospitals track and review the number of days from the patient being discharged and the final billing being coded, and this time period is called a discharged not final billed. Reducing the number of days a patient’s billing sits in a DNFB improves the bottom line and cash flow of the organization.

Diagnosis-Related Group (DRG) A diagnosis-related group is a classification system/framework that hospitals use to classify cases into one of a possible 500 or so groups. The group is based on an ICD code. The reason for the grouping is to allow hospitals and payers to understand what hospital resources, including human, medication, and supplies, are used within those groups.

ePrescribing (eRx) ePrescribing is a national patient safety initiative meant to reduce medication errors by making eprescriptions more accessible to the population as a whole.

Fee for Service (FFS) When a doctor or other medical staff sees a patient, it is typically based on a fee-for-service model. This means that each service provided in the visit is paid for individually. The fees, therefore, are separate and unbundled. Other payment models exist, such as pay-for-performance (P4P).

Health Information Exchange (HIE) and Health Information Network (HIN) The ultimate goal of the surge in healthcare informatics is the end state of having a health information exchange. An HIE is a system of interconnects where information is shared across a number of entities. The goal is to have local HIE exchanges first to work out the kinks. From there, a regional HIE would share information about the patients who are most likely to be seen. Then, there will be the national HIE called the Health Information Network.

Health Level Seven (HL7) This is a method for exchanging data about a patient in near real time. HL7 has multiple versions currently available. Most U.S. medical practices and hospital systems use HL7 v2.5 and v3.0. Earlier releases will be phased out, especially with the advent of the ARRA funding. The funding forces EHR vendors to support customers who are migrating off their dated infrastructure. Please note that migration is typically a complex endeavor. Many old HL7 interfaces must be rewritten to support the newer formats.

Intensive Care Unit (ICU) This is an area where patients with acute trauma are being treated. This includes patients who require ventilators or breathing or feeding tubes or are in a medically induced coma. ICUs typically have more advanced types of technology than in any other patient area. Being able to monitor medication, vital signs, and other critical body functions from a central location is typically another differentiator in an ICU wing.

Integrated Delivery Network (IDN) This is a group of ambulatory care facilities and private providers working together to provide continuity or continuum of care for a specific geographic area or market. One of the goals of an IDN is to reduce the cost of care for a particular patient population. Financial capitation, optimum use of resources, and improved patient access are all perceived benefits of a IDN.

Long-Term Care (LTC) LTC facilities are exactly what you would perceive them to be. These are care facilities that provide medical services and, in many instances, nonmedical services for patients who have chronic illness or a disability and, therefore, cannot care for themselves. Many long-term facilities have on-site medical staff. They also typically have staff to help keep the patients bathed and assist with normal daily activities, such as taking medicine.

Medical Assistant (MA) This is an employee who handles routine clinical and clerical tasks.

Master Person Index (MPI) This is a database that contains a unique ID for all patients who have ever used the healthcare facility. The MPI typically includes enough demographic and personal information to validate that only one record exists for the patient. Additionally, if the MPI is extended to meet other reporting needs, it might have other core data elements such as the type of service rendered, patient disposition, and aliases they have used.

Metropolitan Statistical Area (MSA) When you read or hear this term, think of it as a geographical region with a high population and critically close economic ties. These areas are defined by the U.S. Office of Management and Budget. The Bureau of Labor and Census Bureau utilizes the statistical areas as a way to identify statistical trends. MSAs are used by Medicare for competitive bidding.

Neonatal Intensive Care Unit (NICU) This is an ICU for babies. Monitoring and trending are important uses of technology in the NICU. In some cases, a baby’s weight gain is measured in grams, so the equipment must be able to measure and capture that data. Connecting weigh tables, vital sign monitoring devices, and other care systems to a central monitoring station allows for clinical staff to be alerted promptly of any measurement abnormalities.

Pay for Performance (P4P) This is a payment model used where services are bundled and the medical provider is paid based on outcome, quality, and efficiency.

Physician Assistant (PA) This is a clinician who practices medicine under the supervision of a physician or surgeon. PAs typically provide diagnosis and preventative care for patients that the doctor has asked them to handle. In some cases, such as rural clinics, a PA may be the only medical clinician in the area. In this case, they are required to confer with a physician as required by their state laws. Since doctors are becoming scarce, PAs are becoming a more prevalent fixture in the care setting.

Picture Archiving and Communication System (PACS) Imaging systems need to have a system to share the pictures with the appropriate staff no matter their proximity to the actual imaging equipment. To meet the need, an imaging center deploys a PACS. Radiologists are one of the most costly employees in a clinical setting. To reduce the amount of time spent tracking down jackets of images, to improve diagnosis, and to reduce the amount of film storage, imaging centers rely on the features available when working with a PACS system. Also, remember that a PACS system uses the DICOM file format for transmitting imaging data.

Personal Health Record (PHR) The PHR is a new phenomenon. A PHR is utilized by patients who want to track their own medical information outside the provider’s EMR or paper-based system. For many chronic patients, they want to track their own medical information because of the number of medications, procedures, or therapies they are on or have received. Patients with hypertension, heart problems, or dialysis are good candidates for a PHR. Additionally, the patient now has the power to manage their own health information no matter their location.

Regional Health Information Organizations (RHIO) RHIOs became a hot topic around 2005. After much effort was put into trying to define, develop, and operationalize them, only a few survived. In California, the first RHIO, CalRHIO, died in January 2010. An RHIO exists to exchange data between provider boundaries to support regionally acceptable goals while providing privacy and security of the information. For IT professionals, the three of the pillars of the RHIO (which are the most challenging to accomplish) are the security of the RHIO, the privacy of the data, and interoperability. There is a boatload of money to be made to the group that solves those problems.

Registered Nurse (RN) This is the largest occupation within healthcare, based on statistics from the Bureau of Labor. There are roughly 2.6 million nurses servicing patients. Nearly 60 percent of RNs are hospital-based. RNs are critical in the care continuum, because they are the faces of the care setting. They are also a group that must be managed when deploying an EMR. The nursing staff typically has competing needs when charting patients’ vital signs, chief complaints, problem lists, allergies, and the like. An ER nurse needs to be able to triage the information quickly with the least amount of interference from a computing platform. Typically, nurses in other areas of the hospital will be less sensitive to the amount of time it takes to enter and access data.

Knowledge of the Tools

Bear with me (Patrick Wilson) as I explain why knowing the technical tools are critical in the clinical settings.

More than a decade ago, one of my kids was born. As a parent of a newborn and enjoying (at the time) two jobs, I was not necessarily the most awake person as I attempted to change diapers for the first time. I tried to find a moist cloth to clean him, but there were only dry cloths. I rang the nurse desk and asked what I should do since I didn’t have the right cloths.

Giggling on the other end, the nurse said, “Reach in front of you. See the faucet? Rotate the right handle 90 degrees and place the dry cloth under the water. That will cause the cloth to be wet.”

She hung up and probably was laughing her head off with the other ladies.

You will have similar issues when you work with clinical nursing staff. You know the tools, but they might not. Be patient with them as they type, ping, or work to resolve an application problem with you. Your knowledge of the environment and tools must be translated into plain English whenever you assist the medical staff, or they will become frustrated with the technology and the staff supporting it. Keep communication clear and concise. Use terminology they understand, describe each task in detail, and explain the steps required to complete it. And lastly, make sure the phone is on mute if you are about to chuckle about the situation.

Situation, Background, Assessment, Recommendation (SBAR) Communication is critical among professionals, no matter the vertical. To improve communication in a clinical setting, a framework called SBAR was designed. When communicating with clinical staff as an IT professional, you can use this framework to make sure all the appropriate information is reviewed. In complex situations, this can be a time-saver. The staff understands the SBAR framework, and as an IT professional, you can glean the appropriate information without having to go out on limb to discover a way to pry the information from the staff.

Systemwide Information Flow Stops

Recently, a medical system where we provide services had a systemwide PACS outage. This affected the entire emergency room workflow, interrupted the work of the radiologists, and meant that the clinical staff members who needed to review images throughout the clinics and hospital were unable to function. We got a call midmorning, and the conversation started off something like this: “What is the current situation of the down PACS machine? We need an assessment of the recovery time ASAP, and what are your recommendations for continuing workflow? Lastly, we will need to know why the [insert explicative here] system went down so it won’t happen again. RIGHT!?”

The clinical staff was thinking about workflow decisions that had to be made immediately. Patients were in critical condition, and without the ability to collect and read particular radiology images, they could not be treated. The right person to read the images was at another location and was not receiving the data. Was the best option for the emergency room staff to send patients via ambulance to another hospital? This was an expensive option but one that must be made if necessary. Operationally, the clinical staff was thinking in the SBAR format. The PACS administrator and the vendor engineer were thinking in terms of “How do we fix this outage now?”and weren’t providing the answers staff wanted.

We, the vendor, and our on-site systems staff worked out a communication plan where information flowed from them to us. We could then format the information in a consumable way for the clinical staff, give them an initial briefing, and provide updates every 15 minutes.

So, as we received information about the status of the system, we would translate it. Initially, the vendor and the on-site PACS administrator reported that “The system is experiencing an indexing problem. There are images in the cache queue that are not being transmitted to archive. This is causing the database to get backlogged and not transmit images for current radiology studies. Once we start the reindexing and push the log jam through, the system will be more responsive. However, the system’s performance will be impacted until that occurs. Current reindexing rates are five studies per minute. There are 4,500 that are stuck. We still don’t know if that will fix it, though it is our best shot.”

Using the SBAR format, we reported by email to clinical staff. The message looked like this:

Situation Images unavailable available through the PACS system.

Background Unknown root cause, but initial troubleshooting with vendor points to a broken database used to reference images.

Assessment Treat system as being down. We estimate the system completely operational in 15 hours based on the recovery steps. The system will be partially available during recovery. Not all studies available. Images are still correctly assigned to the right patient.

Recommendation Work with current downtime procedures if image or study is not available. Use your best clinical judgment on patient movement.

Update frequency 15 minutes.

The email went out every 15 minutes with current information. The organization also has an operational alerts system. Updates were added there, as well.

What happened when there was no change in the update? Well, our professional communication tactic was talk with the charge nurse and head clinician. From there, when necessary, we worked out a modified update schedule. Without information flowing up to the clinical staff, the IT department’s relevance diminishes tremendously in their eyes.

When we spoke with the radiologists a week after the incident, we talked about the challenges they face when a critical system goes down. First, they wanted to make it clear that IT professionals are not in the business of making life and death calls for patients on a moment’s notice. Second, the clinical staff must make workflow decisions with the latest information they have. Lastly, the physicians lose respect with the IT staff when information doesn’t flow. As physicians, they understand that the IT staff has to troubleshoot the system, just like the human body, but IT professionals must not become so focused on their job that they are not able to communicate their status to others. When communication gaps happen, the medical staff questions the competency of the IT team and raises those issues with the CEO of the hospital. Communication must be constant, consistent, and in a format that the medical staff can understand.

Skilled Nursing Facility (SNF) An SNF can also be referred to as a convalescent home. This is where a patient who needs constant care, typically for the remainder of their life, will live.

Strengths, Weaknesses, Opportunities, Threats (SWOT) SWOT is an analysis tool used by many when looking to either expand or exit a business. Healthcare facilities use a SWOT analysis to see what type of services they might be best suited to deliver. Another use is for outlining the reasons to deploy an EMR solution. A well-documented SWOT analysis will help the organization select the right application vendor and lead to a better outcome for the dollars spent.

Terms You Thought You Knew

The following terms are utilized differently in healthcare than they are in normal circles of technology.

Computer-Aided Detection/Diagnosis (CAD) This is used extensively in the radiology imaging environment. For many of us in the computer field, the acronym CAD refers to computer-aided design. There is no designing in the healthcare vertical acronym. Even online knowledge services such as Wikipedia refer to CAD only as computer-aided design. CAD systems in the healthcare vertical are used to search images for abnormalities and bring it to the attention of the physician, surgeon, or radiologist.

Integrated Delivery System (IDS) This is used interchangeably with an integrated delivery network (IDN). For those of us in information security, we know an IDS as an intrusion detection system.

Primary Care Physician (PCP) This is the doctor assigned to a patient. Based on a patient’s medical insurance, the PC is selected for them. In some cases, the PCP is selected by the individual. In either case, the PCP is meant to be the general practitioner who knows the patients care across all continuums. A PCP for us techies, though, refers to the priority code point, which is the priority field within an 802.1q tagged frame.

Request for Information (RFI) This is another acronym that has mixed use in the medical and IT verticals. Both verticals use RFI to gather information about a particular technology or vendor solution. However, those in security also know it as remote file inclusion. This is a vulnerability where a file can be added to a website and then run remotely as though the server administrator wanted it to run.