Access - When a patient possesses all of the necessary information needed to view, download, or transmit their information. This could include providing patients with instructions on how to access their health information, the website address they must visit for online access, a unique and registered username or password, instructions on how to create a login, or any other instructions, tools, or materials that patients need in order to view, download, or transmit their information.
Active Patients - Patients with at least two office visits in the last 24 months.
Care Plan - The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).
C-CDA (Consolidated Clinical Document Architecture) - C-CDA is based on components of two standard formats that were previously required for certified EHRs, and those were the Continuity of Care Record (CCR) and the Continuity of Care Document (CCD). Now, what it means by 'Consolidated' is that both of those formats are now 1; C-CDA. This format is an all encompassing template that includes patient data for Allergies, Adverse Reactions and Alerts Encounters, Functional Status, Immunizations, Instructions, Medications Administered, Medications, Plan of Care, Problems, Procedures, Results, Social History, and Vital Signs. The layout of information in the template is considered structured data.
Clinical Decision Support - Health IT (HIT) functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care.
Computerized Provider Order Entry (CPOE) - A provider's use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device.
Direct Messaging - is part of the Meaningful Use Stage 2 requirements. Works similar to a regular email address, but your direct messaging address is an encrypted, HIPAA-compliant address that removes all potential security risks that you would potentially have with a regular email address. Direct messaging allows you to electronically send secure, encrypted health information directly to known, trusted recipients over the Internet. Direct messaging allows a provider to send a C-CDA file to other providers, which can be directly imported into any Meaningful Use Stage 2 certified EHR eliminating the need for faxes, and having to enter in patients information manually to a patients file.
To use direct messaging you will have to go through a verification process in which you will be given an address that looks similar to email@example.com, or if you are in a practice group it will look like firstname.lastname@example.org.
Direct messaging is apart of Meaningful Use Stage 2 requirements and pertains to Core Objective 7, Measure Two and Core Objective 15, Measure One.
Direct Messaging Core Objective 7 - Patient's don't necessarily have to use Direct Messaging, as this includes them downloading their own C-CDA file.
Direct Messaging Core Objective 15 - This means that at least half of a provider's referrals must be electronic (instead of faxing or printing). This also includes downloading the C-CDA file to give to providers who don't have a Direct Address.
Electronic Product Radiation - Any ionizing or non-ionizing electromagnetic or particulate radiation, or any sonic, infrasonic, or ultrasonic wave that is emitted from an electronic product as the result of the operation of an electronic circuit in such product.
EP - Eligible Professional
First Degree Relative - A family member who shares about 50 percent of their genes with a particular individual in a family. First degree relatives include parents, offspring, and siblings.
Imaging - The description of radiology services from the Stage 2 CPOE objective is the minimum description of imaging. We describe radiologic services as any imaging service that uses electronic product radiation. Electronic product radiation is defined at 21 CFR 1000.3 as: "any ionizing or non-ionizing electromagnetic or particulate radiation, or [a]ny sonic, infrasonic, or ultrasonic wave that is emitted from an electronic product as the result of the operation of an electronic circuit in such product." If the provider desires to include other types of imaging services that do not rely on electronic product radiation they may do so as long as the policy is consistent across all patients and for the entire EHR reporting period.
Laboratory - A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving, as a mailing service and not performing testing are not considered laboratories.
Laboratory Order - Order for any service provided by a laboratory that could not be provided by a non- laboratory.
Medication Reconciliation - The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider.
NwHIN (Nationwide Health Information Network) Exchange - This is a collection of standards, protocols, legal agreements, specifications and services that enables the secure exchange of health information over the internet.
Patient-Specific Education Resources identified by Certified EHR Technology - Resources or a topic area of resources identified through logic built into certified EHR technology, which evaluates information about the patient and suggests education resources that would be of value to the patient. An example of this would be using the Mayo Data drchrono provides you.
Permissible Prescriptions - The concept of only permissible prescriptions refers to the current restrictions established by the Department of Justice on electronic prescribing for controlled substances in Schedule II-V. To see the list of substances in Schedule II-V click here. Any prescription not subject to these restrictions would be permissible.
Prescription - The authorization by an EP to a pharmacist to dispense a drug that the pharmacist would not dispense to the patient without such authorization.
Problem List - At a minimum a list of current, active and historical diagnoses. We do not limit the EP to just including diagnoses on the problem list.
Radiology Order - Order for any imaging services that uses electronic product radiation. The EP can include orders for other types of imaging services that do not rely on electronic product radiation in this definition as long the policy is consistent across all patient and for the entire EHR reporting period.
Relevant Encounter - An encounter during which the EP performs a medication reconciliation due to new medication or long gaps in time between patient encounters or for other reasons determined appropriate by the EP. Essentially an encounter is relevant if the EP judges it to be so. (Note: Relevant encounters are not included in the numerator and denominator of the measure for this objective.)
RxNorm - This is a normalized naming system for generic and branded drugs; and a tool for supporting semantic interoperation between drug terminologies and pharmacy data base systems. The National Library of Medicine (NLM) produces RxNorm.
Secure Messaging - Any electronic communication between a provider and patient that ensures only those parties can access the communication. This electronic message could be email or the electronic messaging function of a PHR, an online patient portal, or any other electronic means.
SNOMED-CT (Systematized Nomenclature of Medicine - Clinical Terms) - Enables providers and electronic medical records to communicate in a common language, thus increasing the quality of patient care across many different provider specialties. In laymen's terms, it's a file format that all Stage 2 certified EHR's use that allows every EP to send patient information without fear of compatibility issues to other EP's.
Specialized Registry - Sponsored by national specialty societies and specialized registries maintained by public health agencies.
Structured Data - Refers to data or information that is organized in a structured manner, making it computer “processable” and identifiable for data-mining and analytic purposes.
Summary of Care - A summary of care record must include the following elements:
- Patient name.
- Referring or transitioning provider's name and office contact information (EP only).
- Encounter diagnosis
- Laboratory test results.
- Vital signs (height, weight, blood pressure, BMI).
- Smoking status.
- Functional status, including activities of daily living, cognitive and disability status
- Demographic information (preferred language, sex, race, ethnicity, date of birth).
- Care plan field, including goals and instructions.
- Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider.
- Reason for referral
- Current problem list (EPs may also include historical problems at their discretion).
- Current medication list, and
- Current medication allergy list.
Transition of Care - The movement of a patient from one clinical setting (inpatient, outpatient, physician office, home health, rehab, long-term care facility, etc.) to another or from one EP to another. At a minimum, transitions of care include first encounters with a new patient and encounters with existing patients where a summary of care record (of any type) is provided to the receiving provider. The summary of care record can be provided either by the patient, or by the referring/transiting provider or institution.
Transmit - Any means of electronic transmission according to any transport standard(s) (SMTP, FTP, REST, SOAP, etc.). However, the relocation of physical electronic media (for example, USB, CD) does not qualify as transmission although the movement of the information from online to the physical electronic media will be a download.
Unique Patient - if an EP sees a patient more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure. All the measures relying on the term ‘‘unique patient’’ relate to what is contained in the patient’s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period.