The following is a list of basic terms you will need to know as you navigate the EHR market:
Basic Terminology
- Certification - This relates to a national effort to "certify" various requirements for EHR software. The Certification Commitee for Health Information Technology (CCHIT) is tasked with determining what basic "must have" features EHR systems contain in order to be "certified."
- Electronic Health Record (EHR) - This term refers to computer software that physicians use to track all aspects of patient care. Typically this broader term also encompasses the practice management functions of billing, scheduling, etc.
- Electronic Medical Record (EMR) - This is an older term that is still widely used. It has typically come to mean the actual clinical functions of the software such as drug interaction checking, allergy checking, encounter documentation and more.
- Integrated EHR - This refers to an EHR that is integrated with practice management software. Typical choices include purchasing a fully integrated product which performs all the functions of practice management software, or a stand-alone EHR which is compatible with an existing practice management system.
- Structured and unstructured data entry - There are several ways of entering data into your EHR as you practice. These include dictating straight into the software (voice recognition), templates, and writing (handwriting recognition).
- Templates - Pre-structured portions of the software for common and/or basic visits. These templates fill in a standard set of data which you may then customize for each individual visit. Templates can be used with dictation, writing, or choosing among a menu of options formulated for each specific template.
EHR 101
Tutorial Content
Basic Terminology
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