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ADL (Activities of Daily Living)
In long-term care clinicians analyze each resident’s ability or inability to perform these specific activities and
functions. The assessments and related care plans are used to help each resident improve or maintain the highest
possible level of independence in performing these activities or alternatively to plan for any required assistance.
ADT (Admissions and Discharge Tracking)
The transactions and tracking of admissions, discharges and transfers both internal and external to the site.
ARRA (American Recovery and Reinvestment Act)
The American Recovery and Reinvestment Act passed in February 2009. The act directs the Health and Human Services Department and several
related federal agencies to develop and implement the processes to support adoption and funding of HIT (Health Information Technology) in
several specific medical settings including Skilled Nursing Facilities (SNF).
ASP (Application Service Provider)
An Application Service Provider is Software provider that offers application software to users via a web browser (
web-based system). The application is usually "hosted" through the vendor's data center thereby eliminating the
need for the customer to have and maintain sophisticated installations of computer servers and communication devices.
Other terms that mean something similar but have differences are "On Demand Software" and "Software as a Service"
which is also known as "SAAS".
Care Plan
A care plan describes the care to be provided by all clinical and other personnel to a patient or nursing home
resident. It contains specific actions for the caregivers to implement which are intended to either address or
resolve problems identified by the physician or other clinical staff.
CCHIT (Certification Commission for Health Information Technology)
The Certification Commission is an independent, 501(c)3 nonprofit organization recognized as a certification body for
electronic health records. Their mission is to accelerate the adoption of robust, interoperable health information
technology by creating a credible, efficient certification process.
CCD (Continuity of Care Document)
This is a defined form and method of exchanging relevant discharge and admission information that has been developed
by HL7. It represents a defined method to create interoperability and to be able to share patient information between
disparate EHR systems.
Clinical Assessments or Observations
An Electronic Medical Record (EMR) is divided into a number of small input screens. Each screen collects data for a specific set of
tests or observed behaviors, known as a Clinical Assessemnt or Clinical Observation.
CNA (Certified Nursing Assistant)
Much of the direct care in SNFs is delivered by Certified Nursing Assistants. The activities and records of the CNAs
are vital to monitoring and documenting the observations and activities of each resident on a daily basis. A person
who assists patients or residents with ADL’s and is a provider of basic direct care. CNAs must provide this care
under the supervision of a RN (Registered Nurse), LVN (Licensed Vocational Nurse), or a LPN (Licensed Practical Nurse).
CPOE (Computerized Physician Order Entry)
A function or module in the clinical application software that allows the providers to order medications, lab tests,
clinical procedures, and other types of activities electronically. It creates an environment where order communication
is much faster and more accurate.
DUR (Drug Utilization Review) )
This is a review, usually performed by a pharmacist, of past or current medications to determine effectiveness,
potential dangers, possible drug interactions etc., using all resident factors such as diagnosis, age, weight, gender
and medical history.
EDI (Electronic Data Interchange)
The is an electronic exchange of structured data, by agreed message standards, from one computer
system application to another with minimum human involvement.
EHR (Electronic Health Record)
The electronic health record is a more advanced version of an EMR which provides communication with disparate clinical
systems and allows for the sharing of medical information electronically. To achieve interoperability disparate EMRs
and clinical systems must have common methods of communicating electronically that are safe, secure and with
communication and data standards that allow for the sharing to be seamless and accurate.
EMR (Electronic Medical Record)
The electronic medical record is generally considered to be the composite of all medical and personal information
collected regarding individual patients and maintained in a single medical setting such as a SNF or physician office.
A complete EMR will allow for medical information collection, access on demand and retention for all medical and
patient information that is appropriate and required to accomplish the desired patient care and regulatory compliance.
The quality of an EMR should be measured and evaluated based on several factors including: ease of use, adaptability
and support of good practices and workflow in the care setting, functional efficiency and the quality of information
captured and available for use within the care setting.
e-Prescribing (Electronic Prescription or eRX)
Electronic Prescription is a prescriber’s ability to electronically send through a mobile device or computer an accurate, error free, and
understandable prescription directly to a pharmacy or CPOE module of an EMR. This is most often used for medication
orders.
FDA (Food and Drug Administration)
The FDA is a governing body, representing a part of the Department of Health & Human Services, that is responsible for
regulating items such as food, drugs, dietary supplements, vitamins, medical devices, and blood products.
HIPAA (Health Insurance Portability and Accountability Act of 1996)
In the context of HIT the purpose of the act and its amendments is to provide regulations that protect the privacy and
confidentiality of health information.
HIT (Health Information Technology)
This is the general category of computerized information systems and information devices that are used to assist in the recording,
storage and access to health information in electronic form.
HITECH (Health Information Technology for Economic and Clinical Health Act)
HITECH, is the Health Information Technology for Economic and Clinical Health Act, or the "HITECH Act", which
established programs under Medicare and Medicaid to provide incentive payments for the "meaningful use" of certified
electronic health records (EHR) technology. HITECH was enacted through the ARRA.
HL7 Interface (Health Language 7)
Officially Health Level Seven International is the global authority on standards for interoperability of health
information technology.
Interoperability
Interoperability describes the electronic sharing of information or actual care related communications between disparate EMRs
and EHRs. The communication of information may be directly through EDI or through regional or national data repositories that
are designed and managed for this purpose. The regional and nation organization are usually referred to as HIE (health information
exchange) or RHIO (regional health information organization). For LTC the most common examples of interoperability are direct
communication with vendor pharmacies, labs and hospitals.
Lab Interface
The purpose of a lab interface is for the physician’s order to be entered through CPOE and communicated through EDI
to the reference laboratory. Once the lab test is completed and the results quantified, the test results are
communicated through EDI to the EHR system and made available for physician review and included in the respective
patient’s electronic chart.
(LTC) Long-Term Care
LTC generally refers to and includes all settings of post acute care but in some instances only refers to licensed SNFs
(skilled nursing facilities or nursing facilities), ALF (assisted living facilities) and ILF (independent living facilities).
The more global definition for post acute care (PAC) includes other licensed organizations such as: LTC acute hospitals, sub
acute facilities, long term rehab facilities and home health agencies.
MDS (The Minimum Data Set)
The Minimum Data Set has been used as the reimbursement and quality reporting mechanism for approximately 20 years
in LTC. The current version is 2.0 and version 3.0 is scheduled to become effective October 1, 2010.
(MAR) Medication Administration Record
he medication administration record whether on paper or electronic as an eMAR refers to the functions of medication administration
including clinical documentation. This function done correctly assists and supports the administration of the ordered medications
to the correct patient, at the proper time and with all desired safeguards for patient safety properly followed.
The eMAR has become the desired standard of practice with much its improved quality of information made available in real time. The paper MAR has many weaknesses and possible points of failure when compared with a properly designed and implemented eMAR. The eMAR allows for improved patient safety and enhanced patient care.
OBRA (The Omnibus Reconciliation Act of 1987)
The Omnibus Reconciliation Act of 1987 created many changes for LTC. Specifically, it launched the MDS and PPS as
the new standards for reporting and payment for Medicare.
PDA
This is the acronym that refers to personal digital assistant or pocket PC. The PDA is commonly used as a small
computer device in health care to support POC activities.
Pharmacy Interface
The purpose of a properly designed and implemented pharmacy interface is for the physician’s order for medication to
be entered through the CPOE and communicated through EDI to the appropriate pharmacy. Once the medication order is
received at the pharmacy it is ready for evaluation along with the other pertinent patient information to determine
the expected efficacy or any contraindications. The approved or modified medication order is then confirmed through
EDI to the EHR system.
POC (Point of Care)
Point of Care documentation refers to the ability to document and record patient care activities and patient observations in a
timely fashion and at the point of care. Properly designed POC devices, tools and systems are fundamental to supporting the workflow
of clinicians to enhance patient care and create operational efficiencies through the use of POC charting. The POC tools and
devices may be implemented in many forms including: computer carts, wall mounted computers, mobile PDAs, and mobile tablet computers.
Near to the point of care devices would include hallway mounted computers or kiosks.
PPS (The Prospective Payment System)
The Prospective Payment System created with the OBRA and generally covers reimbursement methods for Medicare services in Skilled Nursing
Facilities and other health care settings.
Quality Improvement Organization
These most often are state sponsored and administered organizations for the enhancement of patient care.
RAI (The Resident Assessment Instrument)
The Resident Assessment Instrument is the extensive set of rules and interpretations to be employed in connection
with completing and using the MDS for reimbursement and quality indicators.
RUG (Resource Utilization Group)
Resident Assessment Protocol is the defined set of conditions or triggers that cause an event to require a decision
to create a care plan under Medicare guidelines.
SaaS (Software as as Service)
Software as a Service is generally defined as making the functions of a software system available to a customer through the
internet and with remote hosting of the system. Additionally, not having the application software and mass database storage devices
being maintained or owned by the customer is considered part of the services to be offered. The benefits to the customer of SaaS
are many but most importantly the benefits include a lower cost of acquiring the software’s features and functions, a lower cost to
manage and maintain the system and database environment and reduced complexity and staffing in the customer’s IT and IS organization.
Structured Progress Notes
Progress notes using preformatted clinical phrases, along with clinical pathways and drill down to the
desired level of clinical detail allows for complete clinical documentation and efficiency of entry. This method of clinical
documentation also allows for standardized nomenclature and which supports interoperability directly when the sharing of information
is based on standard data formats and nomenclature. Free form text input of clinical information represents the opposite method to
structured notes.
TAR (Treatment Administration Record)
Similar to the MAR except used for treatments and other patient care activities. The treatment administration record whether
on paper or electronic as an eTAR refers to the functions of treatment administration including clinical documentation. This
function done correctly assists and supports the administration of the ordered treatments to the correct patient, at the proper
time and with all desired safeguards for patient safety properly followed. Wound care and other special treatments can be fully
and correctly documented.
The eTAR has become the desired standard of practice with much its improved quality of information made available in real time. The paper TAR has many weaknesses and possible points of failure when compared with a properly designed and implemented eTAR. The eTAR allows for improved patient safety and enhanced patient care.
WiFi
is the common acronym that refers to wireless communication in a LAN configuration or WLAN
and uses the IEEE protocol of 802.11.