AMCA EHRC key terms

A digital, longitudinal collection of a patient's health information that is shared across care settings and designed to support coordinated, safer care by multiple authorized users.

A digital record of patient care maintained within a single practice or organization, used mainly for internal clinical and billing workflows rather than cross-organization exchange.

A health record controlled by the patient that may be populated by the individual and, when connected to a provider system, can display data supplied by clinicians.

The electronic movement of health information among organizations according to recognized standards, or the entity that governs and operates that exchange.

The ability of different information systems to exchange data and to use the exchanged data correctly, so that information remains meaningful across settings and vendors.

A standards framework that defines reusable resources and application programming interfaces for exchanging healthcare data between systems using common web technologies.

A standardized summary of a patient's clinical status, medications, allergies, and care plan that can be sent from one system to another to support transitions in care.

A federal incentive program framework that tied payment to the demonstrated use of certified EHR technology for specific objectives such as e-prescribing and health information exchange.

The successor quality payment program category that requires eligible clinicians to use certified EHR technology and exchange health information to avoid payment adjustments.

Software that handles scheduling, registration, eligibility checks, charge capture, and claims processing, often integrated with the clinical EHR but focused on business operations.

Individually identifiable health information held or transmitted by a covered entity or business associate in any form, including demographic data that could identify the person.

The federal regulation that sets national standards for when and how covered entities may use or disclose protected health information and defines patient rights over that information.

The federal regulation requiring covered entities and business associates to protect electronic protected health information through administrative, physical, and technical safeguards.

The principle that a use or disclosure of protected health information should include only the amount of information reasonably needed to accomplish the intended purpose.

A written permission from a patient that meets regulatory content requirements and allows a covered entity to use or disclose protected health information for a stated purpose.

The three core activities for which a covered entity may use or disclose protected health information without patient authorization, subject to applicable conditions and limits.

A contract that requires a vendor handling protected health information on behalf of a covered entity to safeguard the data and comply with applicable privacy and security obligations.

A person or organization that performs functions or services involving protected health information for a covered entity, such as a billing company or EHR hosting vendor.

A health plan, health care clearinghouse, or health care provider that transmits health information electronically in connection with certain standard transactions, making it subject to HIPAA rules.

A security approach that grants system permissions according to a user's job duties, so staff see only the patient information needed for their assigned work.

A chronological record of system activity that captures who accessed or changed which records and when, used to detect inappropriate access and support investigations.

The regulation requiring covered entities to notify affected individuals, regulators, and sometimes the media after an impermissible acquisition, access, use, or disclosure of unsecured protected health information.

An impermissible acquisition, access, use, or disclosure of protected health information that compromises its security or privacy, unless a regulatory exception applies.

The process of converting data into a coded form that cannot be read without the correct key, used to protect stored and transmitted health information from unauthorized viewing.

A login method that requires two independent forms of proof of identity, such as a password plus a one-time code, before granting access to a system.

The technology-based controls, such as access management, audit logging, and encryption, that protect electronic protected health information and control who can reach it.

The policies, procedures, training, and workforce management practices an organization uses to protect health information and to guide staff behavior.

A documented assessment of potential threats and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information, used to guide safeguards.

The process of removing identifying details from health information, either by stripping specified identifiers or by expert determination, so the data no longer identifies an individual.

A maintained summary of a patient's active and relevant past diagnoses and conditions that clinicians review and update to support accurate clinical decision-making.

Recording information using predefined fields, codes, or pick lists rather than free text, which supports reporting, decision support, and reliable data retrieval.

A narrative documentation entry typed in the author's own words without predefined fields, valued for clinical nuance but harder to search and report on.

A comprehensive clinical terminology used to code diagnoses, findings, and procedures so that documented concepts can be shared and interpreted across systems.

Documentation added after the time of the event, which should be clearly identified as late and include the actual date and time of entry along with the event date.

A supplemental note added to an existing record entry to correct, clarify, or provide additional information, preserving the original content and showing who added it and when.

Reusing text from one part of a record in another location, a practice that can propagate outdated or inaccurate information and requires careful review before use.

Excessive length in clinical notes caused by duplicated, auto-populated, or irrelevant content, which can obscure important findings and increase reading burden.

Tools embedded in the EHR that present patient-specific information and recommendations, such as alerts or reminders, to help clinicians make safer decisions.

A system function that lets authorized clinicians enter orders electronically, reducing transcription errors and enabling checks against allergies and drug interactions.

The electronic transmission of a prescription from a prescriber's system to a pharmacy, often with checks for interactions, formulary coverage, and controlled-substance rules.

A secure online gateway that lets patients view parts of their record, message care teams, request refills, and manage appointments.

An intermediary that receives electronic claims from providers, checks them for errors and formatting, and forwards them to payers, returning status reports to the provider.