Health TechHealth Tech GlossaryPart 2 of 7
Records and Interoperability Glossary
75 terms from the Health Tech book's Records and Interoperability part, each defined in a line and linked to the chapter that explains it.
- A40 (merge patient): the HL7 v2 ADT event telling a receiver that two patient identifiers now refer to one patient (HL7 v2 & Interfaces).
- ACK (acknowledgment): the HL7 v2 reply that takes custody of a message: AA, AE or AR in original mode, CA, CE or CR for an enhanced-mode commit (HL7 v2 & Interfaces).
- Addendum: information added to a signed note under a new date and signature, leaving the original unchanged (EHRs, PMSs & the Clinical Record).
- ADT (admission, discharge and transfer): the HL7 v2 patient administration feed carrying registrations, visits, demographics updates and merges (HL7 v2 & Interfaces).
- Amendment (HIPAA): a patient's request to change information in the designated record set, decided within 60 days with one 30-day extension (EHRs, PMSs & the Clinical Record).
- Backend Services (SMART): server-to-server authorization with a signed JWT and system scopes, no user involved (SMART on FHIR & App Platforms).
- Bridge (dental imaging): a link that launches imaging software on the same patient from the practice management system, by command line or file (C-CDA, Documents & Images).
- Bulk Data ($export): FHIR's asynchronous export of many patients' data as NDJSON files, by patient, group or system (FHIR).
- C-CDA (Consolidated Clinical Document Architecture): the US library of CDA XML templates for clinical documents such as the CCD, referral note and discharge summary (C-CDA, Documents & Images).
- CapabilityStatement: the FHIR resource a server returns at
/metadatalisting the resources, interactions, searches and guides it supports (FHIR). - CCD (Continuity of Care Document): the C-CDA summary of a patient's current state, the document networks return when asked for the record (C-CDA, Documents & Images).
- CDS Hooks: an HL7 standard for an EHR to call outside decision support at workflow points such as opening a chart or signing an order, returning cards (FHIR).
- CDT (Code on Dental Procedures and Nomenclature): the ADA's copyrighted, yearly-updated HIPAA code set for dental services (Terminologies & Code Sets).
- Chart status (dental): the state of a charted procedure: treatment planned, complete, existing current or other provider, referred out, or a condition (EHRs, PMSs & the Clinical Record).
- CommonWell: an EHR vendor alliance running a master person index and record locator service, and a designated QHIN (Networks & Exchange).
- CPT (Current Procedural Terminology): the AMA's copyrighted code set for physician and professional services, HCPCS Level I (Terminologies & Code Sets).
- Credential service provider (CSP): a service that proofs a person's identity and issues a credential, such as an IAL2 claims token for TEFCA individual access (Patient Matching & Identity).
- CVX: CDC's code set for vaccines administered, paired with MVX manufacturer codes (Terminologies & Code Sets).
- Designated record set: the medical and billing records, and any records used to make decisions about individuals, that HIPAA's access and amendment rights reach (EHRs, PMSs & the Clinical Record).
- DFT (detail financial transaction): the HL7 v2 message that posts charges, payments and adjustments to a billing system (HL7 v2 & Interfaces).
- DICOM (Digital Imaging and Communications in Medicine): the international standard for medical images and their metadata, ISO 12052 (C-CDA, Documents & Images).
- DICOMweb: DICOM's RESTful services: QIDO-RS to query, WADO-RS to retrieve, STOW-RS to store and UPS-RS for worklists (C-CDA, Documents & Images).
- Direct (secure messaging): S/MIME-encrypted email between providers' Direct addresses through HISPs, the certified push for referrals (C-CDA, Documents & Images).
- Duplicate (patient): one person with two records in the same system, fixed by a merge (Patient Matching & Identity).
- eHealth Exchange: a network of networks whose participants, federal agencies among them, sign the DURSA; a designated QHIN (Networks & Exchange).
- EHR (electronic health record): the clinical half of a practice's software: problems, medications, allergies, notes, orders and results (EHRs, PMSs & the Clinical Record).
- EHR launch: a SMART launch from inside the EHR, which passes
issandlaunchso the app opens in the clinician's current context (SMART on FHIR & App Platforms). - EMPI (enterprise master patient index): the registry linking every local identifier for a patient across an organization's systems to one identity (Patient Matching & Identity).
- Exchange purpose: the reason asserted for a network query (treatment, payment, operations, public health, government benefits, individual access), which decides who must answer (Networks & Exchange).
- FDI/ISO notation: two-digit tooth numbering whose first digit is the quadrant, 11 to 48 for permanent teeth and 51 to 85 for primary (EHRs, PMSs & the Clinical Record).
- FHIR (Fast Healthcare Interoperability Resources): HL7's REST standard for health data as typed JSON resources; R4 is the US production version (FHIR).
- HCPCS Level II: CMS's alphanumeric codes for supplies, equipment, drugs and services outside CPT, updated quarterly (Terminologies & Code Sets).
- HIE (health information exchange): a regional or state organization, or the practice generally, of sharing records between organizations (Networks & Exchange).
- HISP (health information service provider): the service that sends and receives Direct messages and manages certificates for its users (C-CDA, Documents & Images).
- HL7 v2: the pipe-delimited event messaging standard that runs most hospital interfaces, used by 95% of US health care organizations in 2024 (HL7 v2 & Interfaces).
- IAL2 (identity assurance level 2): NIST's remote or on-site identity proofing with stronger evidence and verification, the bar for TEFCA individual access (Patient Matching & Identity).
- ICD-10-CM: the US diagnosis code set maintained by CDC's NCHS, released by fiscal year from October 1 with April updates (Terminologies & Code Sets).
- ICD-10-PCS: CMS's procedure code set for hospital inpatients (Terminologies & Code Sets).
- Implementation guide (IG): a package of FHIR profiles, searches and examples that narrows the base standard for a use case, such as US Core (FHIR).
- Individual access services (IAS): TEFCA's exchange purpose letting a person's approved app retrieve their own records after IAL2 proofing (Networks & Exchange).
- Interface engine: middleware that receives, transforms, routes and stores interface messages between systems, such as Rhapsody, Mirth Connect, Iguana or Cloverleaf (HL7 v2 & Interfaces).
- LOINC: the code system for lab tests, observations and document types (Terminologies & Code Sets).
- MBI (Medicare Beneficiary Identifier): Medicare's 11-character random identifier that replaced SSN-based claim numbers (Patient Matching & Identity).
- MLLP (Minimal Lower Layer Protocol): the TCP framing for HL7 v2: a 0x0B start byte, then 0x1C and 0x0D at the end, with no security of its own (HL7 v2 & Interfaces).
- MPI (master patient index): the registry of every patient an organization knows, which matches, links and merges them (Patient Matching & Identity).
- NDC (National Drug Code): FDA's three-segment drug package identifier, moving to a uniform 12-digit format effective March 7, 2033 (Terminologies & Code Sets).
- Odontogram: the tooth chart on which dental findings and procedures are recorded by tooth and surface (EHRs, PMSs & the Clinical Record).
- ORU (observation result): the HL7 v2 message carrying lab and other results as OBR and OBX segments (HL7 v2 & Interfaces).
- Overlay: two people's information on one record, the dangerous matching error, fixed by an unmerge and a clinical review (Patient Matching & Identity).
- PACS (picture archiving and communication system): the server that stores medical images and serves them to viewers (C-CDA, Documents & Images).
- Patient discovery: the first step of a network query, sending demographics so each responder can match and return its local identifier (Networks & Exchange).
- Plan of care (therapy): a therapy plan with diagnosis, goals and treatment frequency and duration, which Medicare requires certified and recertified at least every 90 days (EHRs, PMSs & the Clinical Record).
- PMS (practice management system): the business half of a practice's software: schedule, demographics, insurance, charges, claims and the ledger (EHRs, PMSs & the Clinical Record).
- Problem list: a patient's coded current and past conditions, distinct from the diagnoses billed for one encounter (EHRs, PMSs & the Clinical Record).
- Profile (FHIR): a set of constraints on a resource (required and must-support elements, bound value sets, extensions) (FHIR).
- QHIN (Qualified Health Information Network): a network designated by the RCE to exchange under TEFCA's Common Agreement; 11 as of October 2026 (Networks & Exchange).
- RCE (Recognized Coordinating Entity): The Sequoia Project, which designates QHINs and maintains TEFCA's SOPs under contract with ASTP/ONC (Networks & Exchange).
- Record locator service: a network service that says which members hold records for a person (Networks & Exchange).
- Referential matching: patient matching that consults third-party identity data from outside health care to link records (Patient Matching & Identity).
- RxNorm: NLM's normalized names for clinical drugs, each with an RXCUI, linking prescriptions to NDCs and commercial drug databases (Terminologies & Code Sets).
- SIU (scheduling information unsolicited): the HL7 v2 appointment notifications, S12 booked through S26 no-show (HL7 v2 & Interfaces).
- SMART App Launch: the OAuth 2.0 profile for FHIR apps, covering launch context, v2 scopes, PKCE and discovery; 2.0.0 is the certification baseline (SMART on FHIR & App Platforms).
- SNOMED CT: the clinical terminology for findings, disorders and procedures, distributed in the US by NLM in March and September editions (Terminologies & Code Sets).
- SOAP note: the note structure of subjective, objective, assessment and plan, used across medicine, dentistry, therapy and veterinary care (EHRs, PMSs & the Clinical Record).
- Standalone launch: a SMART launch outside the EHR, in which the app requests context through scopes such as
launch/patient(SMART on FHIR & App Platforms). - Subscription (FHIR): a client's request to be notified of events on a topic, by rest-hook or websocket, ideally with id-only payloads (FHIR).
- Taxonomy code: the NUCC's ten-character code for a provider's type and specialty, used in HIPAA transactions and on the NPI application (Terminologies & Code Sets).
- TEFCA (Trusted Exchange Framework and Common Agreement): the federal framework connecting networks through QHINs under one agreement, live since December 2023 (Networks & Exchange).
- Universal tooth numbering: the US system numbering permanent teeth 1 to 32 and primary teeth A to T (EHRs, PMSs & the Clinical Record).
- US Core: the US national FHIR implementation guide expressing USCDI; 6.1.0 was the certification baseline by December 31, 2025 (FHIR).
- USCDI (United States Core Data for Interoperability): ASTP/ONC's versioned list of data classes certified health IT must exchange; v3 is the certification baseline (EHRs, PMSs & the Clinical Record).
- Value set: a purpose-built list of codes from one or more code systems, with a definition and dated expansions (Terminologies & Code Sets).
- VSAC (Value Set Authority Center): NLM's repository of public value sets, including CMS's eCQM value sets (Terminologies & Code Sets).
- X12: the standards body and format for HIPAA's administrative transactions: 837 claims, 835 remittances, 270/271 eligibility, 276/277 claim status, 278 authorizations (The Health Tech Business).
- Z segment: a locally defined HL7 v2 segment, where each interface keeps the fields the standard doesn't have (HL7 v2 & Interfaces).