Clinical Terminology For Healthcare IT

Clinical Terminology For Healthcare IT

Like most workplaces, Healthcare IT organizations have people from lots of different backgrounds. Understandably, quite a number of analysts and project managers come from the clinical side as nurses, pharmacists, medical assistants, physicians, and technicians.

Then there are folks like me, who come from an operational/technical side. While some of my qualifications came from college, most of my skills came from good old OJT, with a decent amount of technical aptitude. As I’ve grown in my Health IT career, I’ve had to pick up a lot of clinical concepts and terms that I wouldn’t be exposed to in other industries. So if you’re a network or firewall administrator, client systems manager, or in another technical position, I’m going to highlight some clinical terminology for Healthcare IT. As a technical person, do you need to know clinical terms? Not really, but why not take a few minutes to make you a better team member, and help you better understand the needs of your more clinically-inclined colleagues.
I can’t possibly make this anything near a comprehensive list of clinical terms, as there are many thousands. I’ll just try to call out the ones that I have found to be relevant in my work as an analyst.


In Healthcare, acuity refers to the level of disease severity in a patient, group of patients, or clinical care area. It defines how much medical care is needed for the condition or patient. It is sometimes used in the context of an acuity score, which compiles different data to arrive at a number to better understand how to care for a patient. Acuity matters when you work with your clinical users on IT projects and support. The equipment used by the ICU is going to get higher priority support than say, the supply inventory software.

AVS – After Visit Summary

If you’ve been to the doctor or hospital even once in the past 15 years, you’ve received a document at the end of the visit that summaries things like:

  • What you were seen for
  • What the diagnosis was
  • Medications or other orders that were placed during the visit
  • Medications that you are currently on
  • Instructions to patient on how to care for themselves after the visit

CMS – Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services is a large Federal agency that works under the Department of Health and Human Services (HHS). The department employs about 6,000 staff, and is responsible for these and other areas:

  • Managing Medicare and Medicaid
  • Oversight of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  • Managing State Children’s Insurance programs
  • Quality programs in long-tern care facilities
  • Laboratory quality standards
  • Maintenance of
  • Regulations for Home Health agencies

It’s not hard to see that a large Federal agency has a lot of authority over Healthcare practices and technology at many levels. CMS can change regulations and requirements for Healthcare technology systems at any time.

CMS can put out mandates that require technology vendors develop or change major features of their products on short notice.

Since CMS is a political body, they are also subject to the actions of Congress. This is certainly applies in our current political climate, where the Administration is vowing to scale back or eliminate many regulations. As a technical worker in Healthcare, your clinical colleagues will appreciate that you understand that their requests are not just their own ideas. They are constantly driven by regulatory pressures.

Clinical Documentation Improvement

Clinical documentation improvement is a skill and a job position that has to do with best practices for documenting everything clinical that gets entered into an electronic system. A clinical documentation improvement specialist guides other clinicians to ensure that the data entered on a patient’s clinical status is translated into coded data, which is industry standard sets of codes for diagnoses and procedures.

CDI provides a clinical context to the old saying, “garbage in/garbage out”. If a clinician isn’t documenting properly in the electronic record, then it will be impossible to extract meaningful data for disease analysis, public health data, and other measurements.


Comorbidities are chronic medical conditions that accompany or are otherwise associated with a primary diagnosis. For example, a patient with Diabetes may have comorbidities of sleep apnea and cardiovascular disease. This applies to technology when clinicians want to get this data on a population of patients so that they can reach out to patients who are at the highest risk.

Date of Service

I regularly get requests from my clinicians to create reports with things like top diagnoses for a period, number of therapy visits for various patient groups, and so on. In a lot of those cases, they are looking for data based on when the patient was seen. That is a date of service, as opposed to when billing went out, or when an encounter was closed, like when a clinician did not finish documenting on that same day.

H & P (History and Physical)

History and Physical (H & P) is a medical term to describe the documentation of pertinent medical history, along with performing a physical on a patient. The physical is usually done head to toe, and physician observations are noted in the electronic system. The H & P is used to help a physician arrive at a diagnosis.

MAR – Medication Administration Record

MAR stands for medication administration record, which is documentation when the patient actually gets a medication into their system. First, every medication gets an order. Then the medication is dispensed, like from a pharmacy or an automated dispensing unit. Finally, the med is administered. In a primary care setting, all of these actions may happen right around the same time, for example when you get a flu shot.
However, if a patient is on chemotherapy for example, that med may be ordered long before it is administered, and there will be multiple administrations, once for every time the patient comes in for their chemo.

PHI – Protected Health Information

PHI stands for protected health information, and is a really important security concept for all of us in Healthcare. Any information that can be used to individually identify a patient is considered PHI, and if in the wrong hands, it could be used for hacking or extortion. Examples of PHI are:

  • Any part of a patient’s name
  • Addresses (anything more specific than state)
  • Telephone numbers
  • Email addresses
  • Dates, including, birth, death, and hospital admit
  • Social Security numbers
  • Photos
  • Names of relatives
  • Vehicle identification numbers
  • Account numbers

All of these data points highlight that anyone who has access to healthcare data must protect that data from any risk of inappropriate and illegal access. That includes looking at any medical records that don’t directly pertain to the performance of your job.

PHQ-2 or PHQ-9

PHQ stands for patient health questionnaire, and the 2 or 9 has to do with the number of specific questions that are asked of patients concerning their mental well-being. The questionnaire is used as a screening tool for depression. The PHQ-2 asks:

  1. During the past month, have you often been bothered by feeling
    down, depressed, or hopeless?
  2. During the past month, have you often been bothered by little
    interest or pleasure in doing things?

The PHQ-9 of course has nine questions to gather more detail on a patient’s mental health.

Point of Care Test

A point of care test (POCT) is a test or reading that is initiated and resulted at the same place and time where the patient is being seen. Glucose readings, strep tests, pregnancy test, and some urine collections are examples of POCTs. Also, because POCTs are completed in the care setting, results are not interfaced from an external lab system.

Protocol Orders

Protocol orders are orders that can be placed by clinicians according to a pre-defined set of guidelines that line up with their clinical practice qualifications. An example would be “when fever is above 101F, RN to give 650 mg of Tylenol”. That order would not need to be authorized by a physician because the clinical judgment required to approve that order is well within the scope of what a Nurse is trained for.

Release of Information

When an outside entity requests medical information on a patient, Healthcare organizations need to follow specific guidelines and laws to be sure that the request is legally authorized, and that the correct information is provided to the entity. A common form of release of information (ROI) is a lawyer’s request for records in a potential malpractice case. Another example would be when a patient is involved in a medical research study or clinical trial.
Every major electronic health records (EHR) system has functionality that makes ROI a structured and repeatable process.

Risk for Readmission

Risk for readmission is just what it sounds like – a measure for how likely a patient is to be readmitted to the hospital for a condition that should have been fully resolved in a previous encounter. This is a really big deal for several reasons:

  • Patients are not served well when a condition is not properly resolved by a hospital visit
  • Readmissions within 30 days of discharge costs the Healthcare industry tens of Billions per year, according to the Agency for Healthcare Research and Quality
  • Healthcare staff are not being utilized efficiently when there is an unnecessary readmission

Scope of Care

Scope of care is the definition of what a Healthcare practitioner is permitted to do in keeping with their professional license. This ties in with the above definition on protocol orders. A Nurse may be permitted to dispense certain medications without getting a new order from a physician. A certified nursing assistant (CNA) however cannot administer medications in most care settings.
There are a few exceptions to some scopes of care that depend on the care setting. For example, in a residential care setting (also called adult family home), a CNA may be allowed to administer some medications under the direction of an RN.
Scope of care matters on the technical side because it is controlled by security. If a clinical user is restricted from doing something that their job calls for, (or has too much access) then there is probably some level of security set incorrectly in the clinical application.

Many clinical software systems can set user security at a department or group level, at an organization level, or down to the particular user.

Value Based Purchasing

Value Based Purchasing (VBP) is a really big deal in Healthcare right now. VBP is an initiative from CMS that pays hospitals and other organization payments in part for the quality of care they provide to Medicare beneficiaries, as opposed to just paying for the services delivered. It is a provision of the Affordable Care Act (Obamacare), and it relies on technology to support the ability to measure how well a clinical care area is meeting quality measures.

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Clinical Terminology For Healthcare IT
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Clinical Terminology For Healthcare IT
Clinical Terminology For Healthcare IT. Learn key clinical terms that can help if you are a technical person who wants to know more about Healthcare IT.