Hospital Information System Glossary

There are so many aspects to hospital information systems. To someone investigating a system solution or diving deeper into the world of hospital systems, a glossary may be helpful. That is why we pulled some research together. There are a lot of healthcare terms that are floating around and while your exact definition of these may differ, here is our interpretation of some of the most common ones.

ADT (Patient Administration) Interface – ADT stands for “admissions, discharges, and transfers” and is a digital method that exchanges patient registration information (e.g. demographics) between two systems.

Cerner - A company that specializes in Electronic Medical Record software out of Kansas City, Missouri, offering software solutions across the globe.

Discrete Results – Results that are broken down into their individual values, units and reference ranges.  These results can be more easily tracked and charted.

Data Extraction (or Abstraction) – A process by which information on documents (structured or unstructured) is saved off in another format that can be then used for other purposes.

Document Management System (DMS) – An internal computer system within the organization that is the repository for patient documents.  The documents are generally organized so that the documents can be found in a patient’s electronic medical record.

Document Classification – A process by which documents are sorted by the type of information represented on the document.  Some specific examples of document types include, but are not limited to, lab results, prescription refills, patient history or x-ray results.  Often document classification is performed by manually sorting through all of the documents that arrive into the organization either by fax or paper.

Electronic Medical Record (EMR) – The digital collection of a patient’s medical data in one provider’s office (i.e. hospital, clinic…etc) that can be shared across different health care settings.

Electronic Medical Record Software – The piece of software that collects, stores and allows for the viewing of the patient’s medical data.  Examples include Epic and Cerner.

Encounter – Anytime a patient receives help from a health care provider.  Each encounter is usually assigned a number for tracking.

Epic – A company that specializes in Electronic Medical Record software out of Verona, Wisconsin offering software solutions across the globe.

Extract Systems – A company that specializes in the classification and the capture of unstructured data from documents.

Full-time Employee or FTE – A term of measurement used to represent that amount of person time something will take.

Health Information Management (HIM) – The part of the hospital organization responsible for the management of digital and hard-copy information that is important for providing patient care.

Health Level 7 (HL7) – An non-profit organization that works on developing ANSI-standard methodologies for the exchange of health information.

HL7 Message – The type of message used to transfer health information between two systems. Message types are identified by a three-character code (i.e. ADT, ORM, ORU), used in conjunction with a trigger event.

Informatics (clinical informatics) – The study of information technology within health care conducted by and for clinicians.  Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve [patient] care, and strengthen the clinician-patient relationship.

Interface – A digital method to which health information can be discretely and most times, securely transferred and accessed between two computer systems.

Medical Record Number (MRN) – A unique number that is associated with a specific patient for that organization.  A patient could have multiple MRN’s if they have visited different healthcare facilities (i.e. non-associated hospitals).

Optical Character Recognition (OCR) – A process by which the characters from a document are turned into digital format which can then be used by other software to read the data.

Order or Orderable – A consolidation of lab test(s) that has been order by a clinician that a patient need to have done.  For example, a Basic Metabolic Panel.

OTTR – A company that specializes in transplant care software with a headquarters in Omaha, Nebraska.

Results Routing – A method by which when results are posted into the Electronic Medical Record, a notification is generated to a pre-determined group to alert them the data is available for them to review.

Structured Data – Data found on a document that is found in the same location or named in a similar manner.  For example, form-based documents tend to be structured.

Test Component – A specific laboratory test that is associated with an order.  An example of an order is a Basic Metabolic Panel, which consists of a group of test components, such as Calcium, Potassium…and more.

Unstructured Data – Data found on a document that is generally not in the same location or named in the similar manner.   For example, lab results tend to be unstructured.

Have any words to add to the glossary? Make sure to leave them in the comments—other readers may find them useful!

About the Author: Mike Beles

Mike Beles, Customer Support Specialist & Project Manager at Extract, has been involved with implementing and leading software projects for over 18 years.    He has a well-versed background in software training, support, quality assurance as well as both product and project management.