Glossary
Glossary of digital health terms.
Clear, sourced definitions of the terms used across health information systems, from the electronic health record to national surveillance. For depth on any topic, see the guides.
Records and systems
- Electronic health record (EHR)An electronic health record (EHR) is a longitudinal digital record of a person's health and care, held in a form that authorised clinicians across different providers and settings can securely access, add to and share.
- Electronic medical record (EMR)An electronic medical record (EMR) is the digital version of the paper chart held by a single clinic or practice, containing the medical and treatment history of the patients cared for within that one organisation.
- Health information exchange (HIE)Health information exchange (HIE) is the secure electronic sharing of clinical information between authorised organisations, and also the shared infrastructure, governance and services that make that sharing possible across a region or country.
- Health management information system (HMIS)A health management information system (HMIS) collects, aggregates and analyses routine data from health facilities, such as service counts, morbidity and stock, so that district, provincial and national managers can plan, monitor and report on health services.
- Hospital information system (HIS)A hospital information system (HIS) is the integrated software that runs a hospital's clinical, administrative and financial operations, including registration, admissions, beds, orders, results, pharmacy, billing and reporting, around one shared patient record.
- Master patient index (MPI)A master patient index (MPI) is the service that keeps a single, authoritative identity for each patient across one or more systems, assigning identifiers, matching new registrations to existing patients and linking records that belong to the same person.
- Patient portalA patient portal is a secure website or mobile app, linked to a provider's health record, through which patients can view results, medicines and visit summaries, book appointments and send messages to their care team.
- Personal health record (PHR)A personal health record (PHR) is a record of a person's health information that the individual manages and controls, which may stand alone or bring together information from clinicians, laboratories and the person's own entries.
- Shared health record (SHR)A shared health record (SHR) is a regional or national repository that holds a longitudinal, person centred record of clinical information contributed by many facilities, so authorised providers can see a patient's history wherever they present for care.
- Unique health identifierA unique health identifier is a number or code assigned to one person, and only that person, for use across health services, so that records held by different facilities and programmes can be reliably linked to the right individual.
Clinical care
- Break glass accessBreak glass access is an emergency override that lets an authorised clinician open a patient record outside their normal access rights, after confirming a reason, with the access logged and reviewed afterwards.
- Clinical decision support (CDS)Clinical decision support (CDS) is software that gives clinicians patient specific alerts, reminders and recommendations at the point of care, drawing on the patient's record and clinical knowledge, to support decisions that the clinician still makes.
- Clinical documentationClinical documentation is the record clinicians make of each patient encounter, including history, examination, observations, assessment, plan, orders and outcomes, which supports continuity of care, communication between staff, quality review and reporting.
- Computerised provider order entry (CPOE)Computerised provider order entry (CPOE) is the process by which a clinician enters medication, laboratory, imaging and other orders directly into an electronic system, which checks them and sends them to the department that carries them out.
- Early warning scoreAn early warning score is a bedside scoring system that converts routine observations, such as respiration rate, oxygen saturation, blood pressure, pulse, consciousness and temperature, into one number that signals deterioration and triggers a set clinical response.
- Electronic medication administration record (eMAR)An electronic medication administration record (eMAR) is the digital record, kept by nurses, of every dose given, held or missed for a patient, linked to the prescriber's order so that medicine, dose, route and time can be checked at the bedside.
- National Early Warning Score 2 (NEWS2)NEWS2 is the National Early Warning Score 2, published by the Royal College of Physicians in 2017, which scores six physiological parameters and adds points for supplemental oxygen to give a total that sets the urgency of clinical response.
- TriageTriage is the structured process of sorting patients by clinical urgency on arrival, usually in an emergency department, so that the sickest are seen first, using a validated scale that assigns each patient a priority category and a target time to assessment.
Laboratory and imaging
- Critical valueA critical value is a laboratory result so far outside the expected range that it indicates an immediate risk to the patient's life, and it must be communicated to a responsible clinician without delay, with the notification confirmed and recorded.
- Digital Imaging and Communications in Medicine (DICOM)DICOM (Digital Imaging and Communications in Medicine) is the international standard for storing, exchanging and displaying medical images and related information, defining both the image file format and the network services that imaging devices and systems use.
- Laboratory information system (LIS)A laboratory information system (LIS) is software that manages the full testing process in a medical laboratory, from the electronic request and sample identification to analyser results, quality control, verification and delivery of the validated report.
- Levey Jennings chartA Levey Jennings chart is a quality control chart on which a laboratory plots successive control results against their established mean, with lines at 1, 2 and 3 standard deviations, so that shifts, trends and outliers become visible.
- Picture archiving and communication system (PACS)A picture archiving and communication system (PACS) stores, retrieves and displays medical images such as X ray, CT, MRI and ultrasound in the DICOM standard, and delivers studies and reports to radiologists and clinicians across a hospital or network.
- Specimen trackingSpecimen tracking is the recorded chain of custody of a laboratory sample from collection through transport, receipt, processing, analysis and storage, using a unique identifier, usually a barcode, so that the location and status of the sample are always known.
- TeleradiologyTeleradiology is the electronic transmission of medical images, such as X ray and CT studies, from the place where they are acquired to a radiologist elsewhere, who interprets them and returns a report to the treating clinician.
- Westgard rulesWestgard rules are a set of statistical control rules, applied to quality control results plotted on a Levey Jennings chart, that tell a laboratory whether an analytical run is in control and whether its patient results can be released.
Pharmacy and supply
- Cold chainThe cold chain is the system of equipment, trained people and procedures that keeps vaccines and other temperature sensitive products within their required temperature range, usually 2 to 8 degrees Celsius, from manufacture to the point of use.
- Controlled drug registerA controlled drug register is the formal record of every receipt, issue, administration and disposal of a controlled medicine, such as morphine, kept with a running balance for each preparation that is checked regularly against physical stock.
- Drug interaction checkingDrug interaction checking is the automated screening of a new prescription against the patient's current medicines and recorded allergies, so that clinically significant interactions are flagged by severity to the prescriber and the pharmacist before the medicine is given.
- Logistics management information system (LMIS)A logistics management information system (LMIS) is the set of records and reports used to collect, organise and present data on health commodities across a supply chain, so managers can see stock on hand, consumption and losses at every level.
- Pharmacy management systemA pharmacy management system is software that manages the medication process in a pharmacy, from receiving and verifying prescriptions to dispensing, stock control and safety reporting, so every medicine issued can be traced to a patient, a prescriber and a batch.
- StockoutA stockout occurs when a health facility or store has none of a product available to issue. Stockout frequency and duration are the most direct measures of whether a medicine supply chain is reaching patients.
Standards and terminology
- Fast Healthcare Interoperability Resources (FHIR)FHIR (Fast Healthcare Interoperability Resources) is the HL7 International standard for exchanging health data as modular resources, such as Patient, Encounter and Observation, through a web API. Release 4 was the first release to carry normative content.
- FHIR Bulk Data AccessFHIR Bulk Data Access is an HL7 implementation guide that defines an asynchronous way for an authorised client to export large sets of FHIR data, for a whole system, all patients or a defined group, as newline delimited JSON files.
- HL7 Version 2 (HL7 v2)HL7 Version 2 is a messaging standard from HL7 International in which systems send event triggered messages, such as an admission, an order or a verified result, to one another. It is one of the most widely implemented health data standards in the world.
- International Classification of Diseases, Eleventh Revision (ICD 11)ICD 11 is the eleventh revision of the World Health Organization's International Classification of Diseases, adopted by the World Health Assembly in 2019 and in effect from 1 January 2022. It was designed for digital use and contains around 17,000 unique codes.
- International Classification of Diseases, Tenth Revision (ICD 10)ICD 10 is the tenth revision of the World Health Organization's International Classification of Diseases, the classification used to code diagnoses and causes of death for national and international morbidity and mortality statistics.
- Logical Observation Identifiers Names and Codes (LOINC)LOINC (Logical Observation Identifiers Names and Codes) is the international standard, maintained by the Regenstrief Institute, that gives each laboratory test and clinical observation a universal code and name, so results can be identified the same way in every system.
- SMART on FHIRSMART on FHIR is the HL7 SMART App Launch specification, which defines how an application is authorised to connect to a FHIR server using OAuth 2.0, and how it opens in context, such as on the patient a clinician is viewing.
- Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)SNOMED CT is a clinical terminology owned by SNOMED International that provides coded concepts for diagnoses, findings, procedures, body structures, organisms and substances, so clinical detail can be recorded consistently and processed by software.
Public health and national systems
- Civil registration and vital statistics (CRVS)Civil registration and vital statistics (CRVS) is the government system that records vital events, such as births, deaths and causes of death, as a continuous, permanent, compulsory and universal legal record, and compiles them into national vital statistics.
- Disease surveillanceDisease surveillance is the continuous, systematic collection, analysis and interpretation of health data to detect outbreaks and track disease, so that public health authorities can act. Sources include case reports, syndromic counts, laboratory results and event reports.
- District Health Information Software 2 (DHIS2)DHIS2 is an open source platform developed by the HISP Centre at the University of Oslo and used by ministries of health as a national health management information system for collecting, reporting and analysing aggregate and individual level data.
- Integrated disease surveillance and response (IDSR)Integrated disease surveillance and response (IDSR) is the strategy used across the WHO African Region that brings surveillance for priority diseases into one system of detection, reporting, analysis and response, with shared case definitions, reporting forms and thresholds.
- Open Health Information Exchange (OpenHIE)OpenHIE is an open community and reference architecture for national health information exchange. It describes shared components, such as a client registry, facility registry, shared health record and interoperability layer, and the workflows that connect them.
- Syndromic surveillanceSyndromic surveillance counts patients who meet a syndrome definition, such as influenza like illness or acute diarrhoea, before a laboratory diagnosis is made, and raises an alert when counts rise above an expected threshold.
Governance and operations
- Audit trailAn audit trail is a secure, chronological record of who accessed or changed information in a system, what they did and when, kept so that every action on a patient record can be reviewed and accounted for.
- Data sovereigntyData sovereignty in health is the principle that health data is governed by the laws and decisions of the country and organisation where it is collected, including where it is stored, who may access it and when it may be shared or transferred.
- Data synchronisation and conflict resolutionData synchronisation keeps copies of the same records consistent across devices and servers. Conflict resolution is how a system handles two changes to the same record that were made before those copies were brought back into agreement.
- Role based access control (RBAC)Role based access control (RBAC) is a security model in which permissions are assigned to roles, such as doctor, nurse or pharmacist, and users receive permissions only through the roles they hold, so each person can see and do what their work requires.