CAIH key terms

Electronic movement of health-related data between organizations according to national standards, allowing clinicians to view or receive patient information across separate care settings and systems.

The ability of different information systems to exchange data and to use the exchanged data correctly, spanning technical, syntactic, semantic, and organizational layers of agreement between systems.

A standards framework from HL7 that models healthcare data as modular resources exchanged over modern web APIs, supporting mobile apps, analytics, and payer-provider data sharing.

A specification that combines FHIR data resources with an OAuth 2.0 authorization profile, letting third-party applications launch inside a clinical workflow and access only permitted patient data.

A standardized clinical summary built on the CDA format that carries problems, medications, allergies, results, and care plan information when a patient transitions between providers.

An HL7 XML specification for structured clinical documents that preserves human-readable narrative while adding coded, machine-processable sections for exchange and reuse.

A comprehensive clinical terminology of concepts with hierarchical relationships and synonyms, used to encode findings, procedures, and diagnoses precisely inside electronic health records.

A standard code system for identifying laboratory tests and clinical observations, enabling results from different laboratories to be compared and aggregated consistently.

The U.S. clinical modification of the international classification of diseases, used to assign diagnostic codes for billing, quality reporting, and population health statistics.

A longitudinal, clinician-facing digital record of a patient's health information that supports order entry, results review, documentation, and decision support across care encounters.

A system function that lets clinicians enter orders electronically for medications, laboratory tests, and imaging, replacing handwritten orders and enabling real-time safety checks.

Tools embedded in clinical workflow that present patient-specific knowledge, such as alerts, order sets, or reference information, to improve decisions and outcomes.

Desensitization that occurs when clinicians receive excessive or low-value warnings, causing them to override or ignore alerts, including ones that signal genuine patient danger.

The profession and practice of governing patient health data, covering record integrity, privacy, release of information, coding, and regulatory compliance throughout the data lifecycle.

The end-to-end process of capturing charges, submitting claims, posting payments, and managing denials so that a healthcare organization is paid accurately for services delivered.

An intermediary that receives claims from providers, validates and reformats them against payer requirements, transmits them onward, and returns electronic remittance and rejection messages.

Computer-to-computer exchange of business documents in standardized formats, such as the X12 transactions used for healthcare claims, eligibility checks, and remittance advice.

A system that stores, retrieves, and displays medical images such as radiographs and scans, integrating with imaging modalities and the EHR through the DICOM standard.

The standard for storing and transmitting medical images and associated metadata, defining file formats and network services that let modalities, archives, and viewers interoperate.

An enterprise image repository that stores studies in standard formats independent of any viewing application, allowing organizations to consolidate images and change viewers without migrating data.

A widely deployed messaging standard using delimited segments and fields to exchange events such as admissions, orders, and results between clinical systems.

Middleware that receives, transforms, routes, and monitors messages between disparate systems, handling format mapping, error queues, and retransmission when a target system is unavailable.

A registry that assigns a unique identifier to each patient and links records from multiple systems, supporting accurate identification and reducing duplicate or fragmented records.

The process of determining whether records from different sources describe the same person, using demographic comparison, probabilistic scoring, and manual review to prevent mismatches.

The decision rights and accountability framework that defines who may access, define, and change data assets, along with the policies and standards that keep data trustworthy.

The degree to which data are complete, accurate, timely, consistent, and fit for their intended use in clinical care, reporting, and analytics.

The interdisciplinary study of how health data, information systems, and technology are designed and used to support clinical care, research, and health system management.

A structured examination of how tasks, roles, and information move through a care process, used to identify bottlenecks and design technology that fits real clinical work.

The extent to which a system lets intended users achieve goals effectively, efficiently, and with satisfaction in their actual environment, evaluated through testing and observation.

U.S. federal law establishing national standards for protecting individually identifiable health information, including privacy, security, breach notification, and transaction rules.

Individually identifiable health information held or transmitted by a covered entity or business associate, in any form, that relates to a person's health, care, or payment.

The regulation governing when and how protected health information may be used or disclosed, defining permitted and required disclosures, patient rights, and authorization requirements.

The regulation requiring administrative, physical, and technical safeguards to protect electronic protected health information, including access control, audit logging, and encryption decisions.

The principle that uses and disclosures of protected health information should be limited to the least amount reasonably needed to accomplish the intended purpose.

A contract required between a covered entity and a vendor that handles protected health information, specifying permitted uses, safeguards, and breach reporting obligations.

The controlled process of disclosing patient records to authorized requesters after verifying consent or legal authority, tracking what was sent and to whom.

Security mechanisms that determine who may view or modify resources, enforced through unique user accounts, role-based permissions, authentication, and periodic entitlement review.

An access model that grants permissions to job roles rather than individuals, so users inherit the rights their responsibilities require and changes are managed at the role level.

A chronological record of system activity that captures who accessed or changed what data and when, supporting security investigations, compliance reviews, and forensic analysis.

An authorization framework in which a user grants an application scoped, time-limited access to resources without sharing credentials, commonly used for patient-facing health app connections.