Guest Post: Definition of healthcare IT acronyms

by Melissa Varnavas

After spending some time writing the recent CDI Journal article regarding electronic query systems I came to realize that information technology (IT) in the healthcare world has as many intricacies as clinical documentation does.

For example, have you ever noticed how Microsoft Word automatically changes the acronym EHR for electronic health record to HER, as in this is HER shirt. To eliminate the challenge I adopted the phrase electronic medical record (EMR) instead. These two terms, however, do not mean the same thing.

I’m not talking about Fred Astaire and Ginger Rogers arguing over the pronunciation of tomato either (or either).

A little research later, I came across the following Medical Records Briefing article written by Darice M. Grzybowski, MA, RHIA, FAHIMA, who spoke at the 2010 ACDIS Conference in Chicago. Although CDI specialists may not find themselves worrying about this aspect of jargon and its use, misuse, and abuse I found it both interesting and somewhat helpful in developing a language awareness in regard to the electronic query debate. I thought you might find it interesting also.

What’s in a name: Healthcare IT’s addiction to acronyms

by Darice M. Grzybowski, MA, RHIA, FAHIMA

The following text comes from the National Alliance for Health Information Technology (NAHIT) Web site (www.nahit.org) posting dated October 24, 2007:

“The National Alliance for Health Information Technology is leading an important effort for the Office of the National Coordinator for Health Information Technology (ONC) to develop consensus-based definitions for key health information technology terms . . . A cacophony of competing and confusing definitions, with terms often used interchangeably, is impeding progress in health information technology. A common understanding and use of terms are essential for facilitating IT adoption and innovation and achieving a useful exchange of health information to improve patient outcomes.”

The following text comes from the Modern Healthcare Online’s Web site (www.modernhealthcare.com) posting dated October 26, 2007:

“What’s the difference between an EMR, an EHR, and a PHR? Why is an HIE not a RHIO? Does anyone really care? Well, yes, the Office of the National Coordinator for Health Information Technology at HHS cares enough to pay contractors close to a half million dollars to come up with the answers. ONCHIT awarded a contract to technology and management consultant BearingPoint, McLean, VA, to develop consensus definitions for the initial-isms and one acronym, some of which (EMR and EHR, HIE and RHIO) are often used interchangeably by the healthcare hoipolloi but are occasionally argued over vehemently by the IT cognoscenti.”

How did we get to the point that such extreme dollars and taxpayer monies are needed to pay consulting firms to sort out the alphabet soup in the acronym-addicted world of healthcare informatics? Technology differences aside, there is no doubt that communication errors occur when individuals do not use the same terminology to refer to the same type of system. And terminologies for components of the electronic health record are no isolated exception in healthcare vernacular confusion.

After all, how many different ways are there to refer to certain diagnoses? Consider hypertension, also known as HTN, or elevated blood pressure, or increased diastolic/systolic pressures, or HBP, and the list goes on. We have all learned the lessons of the dangers of abbreviation misuse in clinical documentation and have been warned by The Joint Commission (remember the organization formerly known as JCAHO?) about avoiding abbreviation use as a final diagnosis.

Sometimes a rose is a rose is a rose—such as when CHINs turned into NHINs turned into RHIOs turned into HIEs. No wonder there is mass confusion and overlapping objectives.

A layman’s guide

Years ago, as a consultant trying to work with individuals of varying levels and job descriptions, it became important for me to provide a common language of terms. So, until those hired by the Office of Health Information Technology can provide us with the “real” definitions, the following list may help those of us working in the trenches.

• CCR (continuity of care record)—a subset of the patient medical record used to provide a basic set of data from one episode of care to another

• CDR or CDW (clinical data repository or warehouse)—a decision support database where defined subsets of data related to patient care activities are housed in a longitudinal fashion and utilized for business intelligence purposes
• CHIN (community health information network)—a shared resource for defined local or regional communities and businesses that have agreed to exchange health information (see HIE)
• CIS (clinical information system)—applications that are primarily used during active patient care to produce clinical documentation
• CPOE (computerized physician order entry)—a system providing automated physician-originated entry of orders during patient care, eliminating the middle step of transcription orders by the other caregiving staff members
• CPR (computer-based patient record)—the original term used to describe an electronic health record
• EDMS (electronic document management system)—the foundation repository for the complete episodic-based legal health record
• EHR (electronic health record—generic)—the global term encompassing all electronically generated components of a computer-based patient record—generally refers to hospital- or facility-based records (as opposed to EMR)
• EMR (electronic medical record)—the global term encompassing all electronically generated components of a computer-based patient record—generally refers to physician-, professional-, or clinic-based records (as opposed to EHR)
• HIE (health information exchange)—an organization whose purpose is to promote specific data exchange in the healthcare environment between a set group of stakeholders
• HIS (health information system)—typically refers to a specific vendor application that encompasses multiple applications across clinical, administrative, or financial functions
• NHIN (national health information network)—the coordination of regional health information networks into a national data bank
• LHR (legal health record)—the complete and total patient medical record, which encompasses all visit notes, transactions, and images related to direct care during a single episode of care, is able to be output for subpoena purposes (see EDMS), and becomes “closed” at a certain point of time after which it is no longer a dynamic document
• PHR (personal health record)—an electronic health record created and maintained (controlled) by the consumer/user, and with content that may come from a variety of sources
• RHIO (regional health information organization)—a defined group of community health networks that have opted to share common health information exchange (see HIE)

Terminology will continue to evolve as technology and processes change and advance. As we begin to use the same terms, we can begin to eliminate the barriers and duplication of effort, as well as reduce our use of competing resources. And maybe someday, we will be able to spend our tax dollars on care for the uninsured, as opposed to simply defining the terms of our systems.

Editor’s note: Grzybowski is president of HIMentors, LLC, in La Grange Park, IL, which focuses HIM operations, education, best practices, and EHR/EDMS implementation. She was a speaker at the 2010 ACDIS conference in Chicago. For more information, go to www.HIMentorsLLC.com, or contact her at info@HIMentors.com.