Glossary

Consistently use the same set of words, spelling, and capitalization, otherwise what you write will look messy and confusing.

In general, if a feature or product isn’t unique to Commure, such as a blog, then don’t capitalize it. If it’s unique to Commure and marketable as its own product, such as Commure Listrunner, then capitalize it. Edge cases are assessed individually and documented here.

Use American English spelling for all physician-facing content. When in doubt, check the Merriam-Webster dictionary or Stedman's Medical Dictionary for the preferred spelling of specific terms not found in this list.

A

academic medical center

access

accountable care organizations (ACOs)

Groups of healthcare specialists, centers and other providers who render high-quality care to their Medicare patients on a voluntary basis.

accountable health plan

accreditation

ACLS (ACLS)

activities of daily living

activity-based costing (ABC)

An accounting software methodology enabling medical organizations to calculate costs of each case of care provided like hospital, physician, and medication expenses.

acute care

acute disease

adherence

adjudication

admin

This is the Commure user use to manage their platform or app. Example: Log in to your Commure admin.

admission

admission criteria

admission, discharge, and transfer (ADT system)

One of the four types of the hospital business system that tracks patients’ admissions, transfers, and discharges.

advanced practice nurse

against medical advice

allied health personnel

allopathic medicine

alternative medicine

ambulation

ambulatory care

ambulatory ehr systems

Software that is applied in outpatient care facilities and smaller practices allowing physicians to collect specific info about each patient and providing a full-fledged medical picture of their personal health records.

ambulatory medical record (AMR)

A computer system for collecting, managing, and retrieving EHRs in the outpatient setting.

American Academy of Professional Coders (AAPC)

The expert coding training and certification association for medical programmers, billers, compliance and practice managers in the U.S.

American Medical Association

anatomy

ancillary care

ancillary services

app

An abbreviation for application. A software program designed to perform a specific function directly for the user or another app. Apps can be integrated with Commure to enhance functions and features. The Commure App Store has both paid and free apps built by Commure and partners. Example: List your app in the Commure App Store.

appointment

appropriateness

assessment

ATLS (ATLS)

attending

attestation

authorization

autonomy

B

backup call

bathroom privileges (BRP)

bed control

behavioral health care

bench research

beneficence

beneficiary

bidirectional health information exchange (BHIE)

A medical info sharing project that allows for two-way PHI data exchanging between the U.S. Department of Defence and the Veterans Health Administration.

birddog

blood bank

BLS (BLS)

Blue Button

board certified

bolus

brand drug name

business intelligence (BI apps)

Software which supports financial and operational aspects of the healthcare system, including contract negotiations, facility management, measurement of resource utilization, and cost analysis.

C

call schedule

callback number

care plan

care team

case conference

case manager

census

central supply

Certification Commission for Healthcare Information Technology (CCHIT)

A voluntary, private sector organization for certifying health IT products, such as EHRs and the networks over which they interact.

charge nurse

chart

chief complaint (CC)

Chief Medical Information Officer (CMIO)

Chief Medical Officer (CMO)

chief resident

chronic disease

claim

claims review

clinic

clinical concept

clinical decision support system (CDSS or CDS)

A toolkit that analyzes data to enhance decision-making in the clinical workflow. The software assists physicians and health professionals in, for example, applying a particular diagnosis, specific tests or treatments for their patients

Clinical Document Architecture (CDA)

An XML-based markup standard to provide an exchange model for clinical documents

clinical documentation improvement (CDI)

The process, often supported by specialized software, that is intended for physicians to enhance their documentation of patient encounters and procedures.

clinical information system (CIS)

clinical intelligence apps (CI apps)

A voluntary, private sector organization for certifying health IT products, such as EHRs and the networks over which they interact

clinical pathway

Clinical Quality Language (CQL)

clinical reasoning

clinical research

clinical trial

clinician

closed ICU

CMS (CMS)

code status

cognitive computing

The simulation of human thought process in a computerized model. CC is a branch of artificial intelligence that uses machine learning and natural language processing to reproduce the way the human brain works. The purpose of cognitive computing is to build automated IT systems to solve problems without requiring human assistance.

community acquired

comorbidity

complication

computer on wheels (COW)

computer-assisted coding system (CACS)

Software that utilizes natural-language processing to analyze healthcare documents and generate appropriate medical codes for specific phrases and terms within the document.

computerized practitioner order entry (CPOE)

The process of listing electronic orders for medications and tests using computerized clinical decision support

constellation of symptoms

consultant

consulting team

continuing education

continuity of care

continuity of care record (CCR)

A standard for creating and providing timely access to electronic summaries of patient health for other caregivers.

contraindication

controlled medication

copayment

county hospital

coverage status

covered benefit

covered entity

curbside consult

D

delay in diagnosis

department

department chair

device representative

diagnosis

dictation

diet

Digital Imaging and Communications in Medicine (DICOM)

A standard for storing and transferring medical pictures enabling the integration of medical imaging devices and PACSs from various producers.

direct project

A system of healthcare interventions and communications for maintaining care and support for patients with chronic illness such as diabetes, HIV/AIDS, and cancer.

disability

discharge

discharge criteria

discharge planning

disease management

A system of healthcare interventions and communications for maintaining care and support for patients with chronic illness such as diabetes, HIV/AIDS, and cancer.

disorder

doctor

documentation burden

drug dosage

drug duration

drug form

drug frequency

drug representative

drug strength

drug timing

durable power of attorney

E

e-consult

e-prescription

A computer-generated appointment created by a healthcare provider and sent directly to pharmacies to avoid paperwork, phone calls or possible fraud.

electronic health record (EHR)

A patient’s official health document that is shared among multiple medical organizations. All records are stored in a digital format and include the same types of information, like contact and insurance details, a list of medications and surgeries or procedures performed, etc.

electronic intensive care unit (eICU)

A form of tele-medicine that uses state-of-the-art monitoring tools to keep an eye on patient’s state of health within the country

electronic medical record (EMR)

The patient record created by providers for specific encounters in hospitals and ambulatory environments. The data may be exportable to an EHR.

electronic protected health information (PHI)

EMT

encounter

end of life care

episode of care

F

family history

Fast Healthcare Interoperability Resources (FHIR)

A standard for electronic exchange of healthcare information. FHIR can be used in mobile apps, cloud communications, EHR-based data sharing and among institutional healthcare providers.

Federal Health Architecture (FHA)

An e-government initiative that coordinates health IT activities among federal agencies responsible for providing medical services. The FHA helps federal institutions invest in standards-compliant technology and ensure the accountability of governmental health IT programs

fee for service

fellow

fellowship

FHIR resource

first call

floor

fluid balance

follow up (f/u)

following a patient

Food and Drug Administration (FDA)

A legal act which classifies medical devices into three categories based on the associated risk to ensure safety and effectiveness of the gadgets.

formulary

G

General Data Protection Regulation (GDPR)

The set of rules that requires private and public healthcare sectors to demonstrate they are protecting their patients’ data adequately. Any healthcare provider must verify their patients’ identities and organize a system that allows the erasure or rectification of their data. Applicable for companies in EU or targeting EU citizens.

generic drug name

group practice

H

halfway home

health care system

Health Employers Data Information Set (HEDIS)

A set of standardized performance measures used by healthcare professionals to compare the quality and services provided by health plans, group practices, and hospitals.

health information exchange (HIE)

Reliable and secure sharing of the healthcare-related data among institutions, health information organizations and government facilities in compliance with national standards.

health information organization (HIO)

Is a U.S. government-led non-profit medical institution which transfers healthcare info electronically across organizations, including smaller clinics, hospitals, medical societies, major employers, and payers

health information technology (HIT)

An IT field which involves development, use, and support of information systems for the healthcare industry. Automated and interoperable healthcare information systems are expected to improve medical care, lower costs, increase efficiency and reduce error, while optimizing reimbursement for ambulatory and inpatient healthcare providers

Health Information Technology for Economic and Clinical Health (HITECH Act)

U.S. legislation passed in 2009 to encourage the adoption of electronic health records and the supporting technology.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Health Level Seven International (HL7)

A set of standards, guidelines, and methodologies for transfer, integration, and retrieval of healthcare information. In theory, the ability to exchange data should minimize the tendency for medical care to be geographically isolated and highly variable

health maintenance organization (HMO)

health risk assessment

HealthIT.gov

HIMSS (HIMSS)

HIPAA (HIPAA)

U.S. legislation that provides data privacy and security provisions for safeguarding medical data. HIPAA Privacy Rules protects sensitive patient info by establishing a set of rights and standards that apply to healthcare provides gathering and storing it electronically or otherwise.

HIPAA Privacy Rule

HIPAA Security Rule

history and physical exam (H&P)

history of present illness

HITRUST

HL7v2 message

holistic medicine

home call

home care

home grown applications

home health

home medications

home monitoring

The use of technology to remotely monitor a patient’s medical history from their home to enhance their comfort

hospice

hospital

hospital acquired infection

hospital day

hospital information system (HIS)

A computer system that addresses mainly the administrational needs of hospitals. They manage the data related to the finance department, laboratory, nursing (NIS), pharmacy (PIS), radiology (RIS) and pathology departments

hospitalist

I

iatrogenic

idiopathic

illness script

imaging

impression

in network

incidence

indwelling

informed consent

inpatient

intake and output

intensive care unit

interdisciplinary rounds

intern

International Classification of Diseases (ICD)

A system used by healthcare providers to categorize and code all diagnoses, symptoms, and procedures.

International Review Board (IRB)

interoperability

interpreter

intervention

intraoperative

isolation

J

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

junior resident

justice

L

laboratory panel

labs

language services

lethal dose

line

LOINC (LOINC)

loss to followup

low code development

M

MACRA

malpractice

Meaningful Use (MU)

The U.S. government EHR incentive program, which sets the standards for using health records and exchanging patient clinical data between healthcare providers, insurers, and patients.

medical algorithm

A step-by-step protocol to address medical challenges like diagnosis or screening. Usually, it is represented as a flowchart or stepwise instruction.

medical error

medical ethics

medical evidence

medical history

medical informatics

medical practice management software

A toolkit that is used to manage day-to-day operations of a medical practice, such as appointment scheduling, billing tasks performing and report generating.

medical record number (MRN)

medical research

medical scheduling software

A solution for managing patient appointments and allocating medical staff

medical student

Medicare

medication administration reconciliation (MAR)

MIPS

mobile health (mHealth)

The accessibility and exchange of clinical and patients’ information via mobile devices and apps.

morbidity and mortality

N

National Council for Prescription Drug Programs (NCPDP)

A non-profit ANSI-accredited organization that manages a number of standards to improve the communication within the pharmacy industry.

National Health Information Network (NHIN)

A set of technologies, standards, policies, programs, and practices that enable medical data to be shared among healthcare decision makers to improve the industry.

National Practitioner Data Bank

National Provider Identifier (NPI)

negative predictive value

neotatal intensive care unit

next of kin

night float

nonmaleficence

note

notification overload

NPO

nurse practitioner

nursing flowsheet

nursing station

O

objective

observation

occupational therapy

off service

Office for Civil Rights (OCR)

Office of the National Coordination of Health Information Technology (ONC)

A federal institution that regulates and standardizes health technology for general usage in the U.S.

on call

one liner

onset

open ICU

OpenNotes

operation

opiate

organs based curriculum

osteopathic medicine

out of network

out-of-pocket-cost

outcome

outpatient

outpatient procedure

outside hospital

overnight events

P

page forwarding

pager systems

paramedic

pathogenesis

pathology

patient

patient centered care

patient encounter costing (PEC)

A cost accounting system that is used to record, analyze, and allocate costs for the individual services provided to patients, such as medications, procedures, analysis, and boarding.

patient health record

patient identifiers

patient labels

patient list

patient portal

A website that allows patients access personal health information and communicate with their healthcare providers online.

patient presentation

patient safety

pending

periopertive

personal health information (PHI)

Medical history, laboratory results, insurance info and other data that a healthcare professional stores to identify an individual and determine appropriate care.

personal health record (PHR)

A collection of patient’s self-maintained health-related information. PHRs are stored on a personal device or the Internet and can be shared with third parties only with the consent of the owner.

physical exam

physical therapy

physician assistant

Physician Quality Reporting System (PQRS)

A quality improvement program initiated to determine whether physicians should have their Medicare payments adjusted up or down.

physiology

Picture Archiving and Communication Systems (PACS)

A healthcare imaging technology which provides economical storage and convenient access to the content, including computed tomography (CT) and magnetic resonance imaging (MRI) results.

Pixis

plain language

plan

point of care (POC)

point of service (POS)

POLST (POLST)

population health

population health management (PHM)

A discipline that studies and facilitates medical assistance across the general population or a group of individuals.

positive predictive value

post graduate year (PGY)

postop day

postoperative

practice guidelines

pre-authorization

precautions

preferred provider organization (PPO)

premium

preoperative

prerounding

prescription

presentation

prevalence

primary care practitioner (PCP, PMD)

primary diagnosis

primary team

principle investigator

private practice

PRN (PRN)

problem

problem based charting

problem based learning

procedure

prognosis

progress note

prophylaxis

protected health information (PHI)

Any part of a patient’s medical record or payment history that can be used for de-identification before researchers share the dataset publicly.

provider

provocation and palliation

public health

Pubmed

Q

quality

quality assurance

quality improvement

quality of life measures

quality-adjusted life year (QALY)

R

radiology information system (RIS)

recommendation

recurrence

referral

referral center

referral source

region and radiation

registered nurse

relative value units

remote monitoring

Differs from home monitoring with a broader coverage area. The tools are applied to a patient anywhere and send alerts to a nurse station if their condition worsens, reducing the need for close personal monitoring.

report

residency program

resident

resolution

retrospective review process

return precautions

return to work

revenue cycle management (RCM)

A financial process that healthcare facilities use to track patients care episodes from registration and appointment scheduling to the final payment.

review of systems

role

rotation

rounds

routine

running the list

rural health clinic

S

same day surgery

scheduled medication

screening

scribe

script

secondary diagnosis

Secretary of the U.S. Department of Health and Human Services (HHS)

sensitivity

sequela

service

service pager

severity

shared decision making

sign

sign off

signateur

signout

sitter

skilled nursing facility (SNF)

SNOMED (SNOMED)

social history

social worker

specialist

specificity

standing medication

stat

step down unit

studies

subjective

supportive care

surgical history

surgical intensive care unit

susceptibility

symptom

syndrome

systems based curriculum

T

team

technician

telemedicine

The adoption of telepresence or video conferencing to maintain medical consultations or treatments remotely.

telemetry

tertiary care hospital

text expansion

therapeutic dose

time out

timing

transcription

transfer

trauma center

traveling nurse

treatment decision support

A set of tools and processes that are used by patients who will receive the treatment to improve their healthcare decision-making.

triage

tube

U

UMLS Terminology Services

unsolicited data

urgent care

USPSTF (USPSTF)

utilization review (UR)

V

validation criterion

vendor neutral archive (VNA)

A medical imaging technology in which images and documents are archived in a standard format and accessible to healthcare professionals regardless of what proprietary system created the files.

virtual visit

A model of healthcare services provision that is based on remote consultations through video or voice connection.

vital signs

W

wellness

work related injury

work up

worker's compensation

workroom

workstation on wheels (WOW)