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.
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
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.
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.
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.
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.
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.”
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.”
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.
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.
