EMR: Definition of Terms
ACI – The Add Clinical Item window.
ADT – Admission, Discharge and Transfer - Admission, Discharge and Transfer systems are software systems used by healthcare facilities to track patients from arrival through departure.
Allscripts – Touchworks software application vendor
Automation –A system of operating using computers or other electronic devices to reduce time spent on manual process and paperwork.
Call Center –Personnel who will provide assistance to physicians and staff for any application issue, either hardware or software.
Carecast – TJUH patient care system
Careguide™ Template – The template is what we ship to help the provider make choices regarding meds, orders and instructions. Once the template is filled in, it results in a set of orders and instructions that now represent the patient’s health management plan for that problem.
Charge Module – A component of application that allows providers to generate charge for services provided in the ambulatory environment and send to Flowcast
Chart Alerts – Users can create chart alerts that appear on the TouchWorks Clinical Toolbar about the selected patient. These alerts can be viewed by anyone who may have a clinical encounter with the patient or otherwise have the appropriate security access.
Chart Viewer – The encounters are listed by date in reverse chronologic order. The encounter name is listed, along with the date, provider, and provider specialty.
Clinical Component – Information about a patient that is categorized for entry and viewing. Included in Clinical Components (current and historical) are medications, orders, problems, lab tests, etc.
Clinical Desktop – The Clinical Desktop contains all areas, or components, of a patient’s record. This workspace is highly configurable, and can be personalized for each TouchWorks user.
Clinical Toolbar – Icons that allow users to add clinical items, review data and track patient location and status.
Clinical Transformation – A process by which practices review current operations to determine what process needs to change to optimize how work gets done.
Co-location – A data center where a real-time mirror of applications and databases are stored. Co-location is a means to ensure a high-availability application.
Components – Configurable workspaces located on the Clinical Desktop, including Problem, Visit Summary, Meds/Orders, Allergies, ChartViewer, Patient Workslist and Health Management Plan.
Dragon™ – Voice Recognition Software
Electronic Signature – Identification of user that performed an action.
empower™ – Jefferson University Physicians' EMR System
EMR – Electronic Medical Record
Encounter Summary – Information that is entered during the intake process of the patient visit is saved to the Encounter Summary. Once it is committed, this new information is permanently saved.
Favorites – A favorites lists allows a user to save his or her most frequently used dictionary entries in separate list. These lists save time entering information, because the user can avoid searching large dictionaries for a desired entry.
Flowcast™ – JUP Practice Management System
Flow Sheets – The FlowSheets view of the Health Management Plan component displays a list of flowsheets defined for the patient based on his or her sex and age.
Future State – How the department will function at a point in time when the EMR has been implemented.
Go live – The day a practice begins using the EMR when seeing patients. Also refers to days just after the first day when on-site support staff are present in the practice.
High-availability – A software application that is scheduled to be available to users 24x7 with only minimal scheduled unavailablilty for maintenance. High availability is achieved by a combination of hardware redundancy, fail-over systems and policies.
HIPAA – Health Insurance Portability and Accountability Act – Refers to the Health Insurance Portability and Accountability Act of 1996.
HMP – Health Management Plan component of the Clinical Desktop
Horizontal Toolbar (HTB) – The horizontal toolbar (HTB) displays a collection of tabs (or functional areas) available for the active (that is, selected) vertical toolbar.
HPI – History of Present Illness
ICD9 code – The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six characters long. The codes are used for billing.
IDX – JUP Practice Management System
Interface – The exchange of data between two computer systems. Interfaces can be uni- or bi-directional.
JeffChart – TJUH patient care system
JUP – Jefferson University Physicians
MRN – Medical Record Number
Note Authoring Workspace (NAW) – Note space where clinicians document the patient encounter.
Note Forms – Note Forms are the building blocks of v11 Note. Note Forms are highly configurable and can be built using the Note Form Builder tool. AHS will be delivering several hundred Note Forms for clients to serve as a solid starting point. Note forms can have Medcin Findings, Text Items, Illustrations w/ hotspots, Pictures, Text Templates.
Optical Character Recognition (OCR) – The identification and conversion of printed or handwritten characters to digital format using an optical scanner and specialized software
Patient Banner – The Patient Banner displays information about the patient whose information is currently displayed (or is in context). It includes a brief summary of the patient’s demographic information, including his or her sex, age, date of birth and so forth.
Pharmacy Health Information Exchange™ – A network operated by SureScripts, linking electronic communications between pharmacies and physicians, allowing the electronic exchange of prescription information.
Pick lists – Lists of like items organized in a matter to be easily selected.
Point-and-click – A method to enter information into an EMR without typing. This is accomplished by pointing a mouse or computer pen to a spot on a computer screen and clicking the mouse button to activate the on-screen item.
Quicklist – The QuickList is a subset of the favorites list that includes just the items the user selects most often.
Quicksets – QuickSets are groups of orders and meds that have been previously ordered by that physician for a particular problem. They provide the user with an efficient way of entering problem-related orders.
Scanning – A process where paper is copied digitally into the EMR using a scanner and specialized software.
Slate PCs – A portable computer that is about the size of a paper tablet and weights about 3.5 pounds. The slate PCs come with a computer pen pointing device for entering data on the touch-sensitive screen.
Steady State– A practice’s workflows that will be in effect 120 days prior to go-live of the EMR.
SureScripts™ – A vendor who works with EMR vendors and electronic prescribing and pharmacy technology vendors to connect their solutions to the Pharmacy Health Information Exchange. SureScripts was founded in 2001 by the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA) to improve the quality, safety, and efficiency of the overall prescribing process.
Tasks – A TouchWorks task is defined as a request to either supply information or perform an action. Tasks are both created and completed in the system either manually or automatically (that is, triggered by the system as a result of specific activities). Utilizing tasks promotes effective communication and maximizes efficiency.
Text Templates – Text macros with predefined text and text options used to efficiently document the patient visit within a note.
TouchWorks™ – Allscripts electronic medical records software
Vertical Toolbar (VTB) – The vertical toolbar (VTB) contains all the user menus or workspaces that have been assigned to a given workplace.
VPN – Virtual Private Network - A communications network tunneled through another network. A VPN will be necessary for secure communications through the Internet when using clinical applications outside of Jefferson.
Web Client – A software application that is launched via a web browser.
Work Flow – The process by which tasks are done and how tasks interrelate to each other.
Worklist – TouchWorks can manage order and result-related activities from either a patient-centric or activity-centric (cross patient) workspace. A worklist is a series of orders and resultable orders within a patient record that meet the criteria defined in the worklist view.
Workplace – The workplace is defined by the user role within the organization. It pertains to everything that the user sees on the screen (according to security privileges).
Workspace – The largest portion of the page, where users do most of their work, is called the workspace. The information in the workspace varies based on the selected vertical and horizontal toolbar buttons.