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Glossary of Terms

Abstracting

The process of collecting and storing additional clinic information that is not otherwise recorded in the EMR

Access & Revenue Cycle Readiness (ARCR)

Operational leaders across the organization to lead the organization readiness activities (strategy and decision making from design through stabilization, recognizing and mitigating implementation risks, and supporting change management efforts) in preparation for the future state workflows

Accession Number

A unique alphanumeric identifier assigned to imaging or lab orders

Accommodation Code

A code associated with a patient's room that can be used to calculate bed charges triggered on the patient's hospital account. Each room in a hospital has an associated accommodation code based on the type or level of care provided in that room

Accordion Report

A highly configurable report that can display documentation flowsheet data, intake/output data, MAR administration data, lab results, and other patient information. The term "Accordion" refers to the ease with which users can expand and condense the time intervals within the report.

Activation / Cutover

The transition to Epic from current state / legacy systems; typically pertains to a short period of time - hours rather than days or weeks

Activity

The main place where users or administrators enter and view data in Hyperspace. For example, the Order History activity is used to view information for an order and the Medications activity is used to manage a patient's prescriptions. An activity can consist of a form, a report, or a series of forms.

Addendum

Information added to or edited in an encounter, a study, or a note after the encounter is closed or the study or note is signed. Typically displays the addition or change in context, not just as an added piece of information

Admission

An ADT (admission / discharge / transfer) action which is associated with a patient being assigned to a bed in an inpatient setting

Admission Assessment

An assessment of a patient's condition performed when a patient is checked into the hospital.

Admission Type

The classification of admission. This information appears on claims and is typically selected from a standard list: Emergency, Urgent, Routine, Newborn, Trauma, and Labor & Delivery.

Admission, Discharge, Transfer (ADT) Event

An action on a patient to specify patient movement (Admission, Transfer In, Transfer Out, Leave of Absence Out, Leave of Absence Return, Discharge, Hospital Outpatient Visit), current place (Census, Leave of Absence Census), or change in the billing drivers (Patient Update).

Advance Beneficiary Notice (ABN)

Advance Beneficiary Notice of non-coverage (also sometimes referred to as Medicare waiver of liability) is a notification provided to Medicare beneficiaries when a service is expected not to be covered by Medicare.

After Visit Summary (AVS)

Report summarizing such things as orders, diagnoses, and notes for an encounter that you can print and send home with the patient; also used for inpatient admissions and includes discharge instructions.

Age-based Override Contexts

Age-based override contexts allow customers to have different medication defaults based on the patient's age. These override contexts can be configured for both inpatient and outpatient administration of medications.

Ambulatory Advisory Group (AAG)

The AAG for the Project 20/22 will evaluate issues that involve or impact Ambulatory Care workflow, content, and EHR adoption

American National Standards Institute (ANSI)

Private non-profit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States

Anesthesia

Provides clinical documentation tools wherever anesthesia services are performed

Application Testing

Verify build and application workflows are correct before starting Integrated Testing. Confirm Application readiness for identified workflows

Appointment Desk

The patient workspace that opens when a patient is looked up via the Appts button. This workspace shows information about the patient’s appointments, orders, referrals, and waitlist entries.

ASAP

Epic's emergency department information system application

At-the-Elbow (ATE)

Floor support during go-live.

Audit Trail

The audit trail tracks changes to a record. It keeps track of the old and new information, who changed the information, and when the information was changed.

Authorization/Certification

A payor’s way of indicating that a patient’s care is medically necessary and reimbursable.

Automated Dispensing System (ADS)

Also known as Automated Dispensing Cabinets (ADC), these are secure medication cabinets that allow access to commonly administered medications by nursing staff; commonly referred to by the name of the company which manufactures and markets the hardware— examples include Pyxis, OmniCell.

Automatic Pill Filling System

A robot that receives information from Epic and fills outpatient prescription medications accordingly.

Barcode Scanning

The use of barcodes to aid in the accurate identification of patients or medications. Problems with the actual barcoding and medication administration documentation process should be directed to Clin Doc, problems with medications not barcoding properly should be directed to Willow Inpatient.

Beacon

Oncology: Automates the creation of treatment plans by physicians based on standard protocols and treatment decisions guided by decision support

Beaker Clinical Pathology

Epic's Lab Application: Provides integration eliminating the need for multiple interfaces. Barcode-enabled workflows allow lab techs to track specimens within and across sites. Work lists display outstanding and overdue tests in real time

Best Practice Advisory (BPA)

Best Practice Advisories are a central tool in the Epic decision support system that serve as reminders or warnings to clinicians during their workflows. Advisories can appear based on specific patient, provider, and facility criteria you define. You can configure many aspects of advisories, including the warning text that appears, the workflows in which the advisory is analyzed, the service areas, specialties, and departments to which the advisory applies, and the patient characteristics that determine if the advisory appears.

Biomedical Device Integration (BMDI)

Biomedical Device Integration - Integration of medical equipment into an electronic health record

Bones

Epic’s system application for Orthopedics and Sports Medicine

Break the Glass

A security check used to ensure that only the appropriate users have access to information in restricted patient records. Typically users need to enter their password and a reason that they are accessing the patient record in order to proceed. Users receive a pop-up window when they attempt to access a record that is protected by Break the Glass.

Break/Fix

Fixing build that is not working as designed; review of system issues to determine severity and priority to be resolved.

Bridges

Epic's interface tool that sends and receives data to/from Epic, generally using the HL7 standard protocol.

Bugsy

Infection Control: Application for infection surveillance, which helps detect, monitor and report certain types of infections in the inpatient setting

Business Continuity Access (BCA) / Downtime

Formerly known as Downtime Reporting, allows your site to perform batch printing of key Epic reports without having direct access to patient information during a server downtime.

Cadence - Scheduling

Epic scheduling application that allows users to schedule patient visits/appointments

Care Plan

A logical set of activities, steps, assessments and expected outcomes designed to guide clinicians in making decisions about activities to perform during each visit.

CareEverywhere

An application that provides access at the point of care to the patient's medical records from other organizations. A Health Information Exchange optimized for Epic to Epic transfer of information

Carts

A cart allowing pharmacies to efficiently dispense meds that are due during a specific period of time. Pharmacies will prepare upcoming doses and place them in the cart to be dispensed at set intervals or prepare all types of a similar type of medication at once to be delivered at a specified time (IVs, TPNs, etc.). Synonym: batch fills.

Case (OpTime)

Epic’s equivalent of the surgical listing. Contains the record of a surgical encounter. A case contains information related to a patient’s surgical encounter up until the day of surgery.

Case Manager

A health care professional, typically a social worker who works to ensure that patients receive cost effective care and are adherent to their care plan.

CCBO

Clinical Content Build Out - Content design for the Epic applications e.g., Flowsheet templates, Note templates, etc.

CDI Query

CDI = Clinical Documentation Improvement; Query- a message sent to a provider from a CDI user asking for additional information regarding a patient’s visit or documentation.

Certificate of Terminal Illness

A document used to verify that a physician believes a patient has six months or less to live. A CTI must be signed by the medical director or hospice physician for each benefit period after the 2nd benefit period. This form is used primarily for billing purposes (no claim can be sent until the CTI is signed).

Change Impact Report

Output of Operational Impact Assessment with policy, process, and role impacts categorized

Change Management Advisory Group (CMAG)

Serves as a forum for change management / Communications / Training leadership to provide standards and guidelines for Vision 20/22 Epic Project

Charge

A transaction that debits (or credits, in the case of a reversal) the balance of the HAR, relative to the price of its related service.

Charge Capture

The process of triggering or entering charges from a clinical or billing application.

Charge Description Master (CDM)

List of all billables to patient or patient's health insurance provider

Charge Router

Tool used to transition charge data from clinical to billing systems. It is a centralized place to handle all chargeable events. The module routes charges either to Resolute Hospital Billing or Resolute Professional Billing, based on criteria defined within the charge router build.

Charge Testing

Validate the type and amount of a large volume of charges based on expected inputs and triggers in Epic. Confirm charges incorporated in Epic build can be triggered from end-user workflows. Validate that all clinical charge capture, fee schedules and cost center assignment build is accurate

Chart

A patient's medical record, either the electronic medical record or the paper chart. When working with Chart Tracking, this term usually refers to the representation of the paper chart in the system.

Chart Analysis

Process by which HIM users review a patient’s chart for certain elements and follow-up with other users if those elements are not present or complete.

Chart Review

A tool where you can review reports about a patient's encounters labs, imaging orders, procedures, medications, and more.

Check In

Workflow used to document that a patient is ready to be seen for an appointment / by provider

Check Out

Workflow used to document that a patient is finished with an appointment

Claim (Billing)

Standard forms used to document patient service charges and bill the guarantor's insurance company.

Claim Edit

A system action that checks a claim for missing or inaccurate information and either leverages automation to resolve pre-defined issues or routes the claim to a work queue to be reviewed and addressed by assigned users.

Clinical Advisory Group (CAG)

Represents the needs of and serves as an advocate for clinicians / allied health providers across the entire health system, will focus on decisions related to inpatient workflows

Clinical Case Management

Case Management: Application designed to centralize the workflows for case managers

Clinical Decision Support (CDS)

Tools such as Best Practice Advisories or Drug Interaction Alerts that are intended to prompt a user to perform an action such as entering or changing an order based on predefined criteria being met

Clinical Labor and Delivery (L&D) Status

A patient's status within a labor and delivery context. Common statuses include Labor, C-Section, or Postpartum.

Coding Query

A secure message sent to physicians via Hyperspace to inquire about documentation in a specific patient’s chart in regards to coding the account

Cogito

Epic's enterprise intelligence suite, which includes everything related to Epic reporting and analytics (Clarity, Radar, Reporting Workbench, data warehouse, Analytics). Short for "Cogito ergo sum Enterprise Intelligence."

Community Library

A section on the Epic UserWeb where customers and Epic share content such as reports, SmartForms, and Flowsheets.

Compounding and Repackaging

An activity which facilitates and provides efficient documentation for the compounding and repackaging of medications within Epic. (CNR)

Contact Move

A function performed by HIM to move all documentation associated with an encounter from one patient to another.

Content Development

Activity during which clinical and revenue cycle content is reviewed and agreed upon for build

CORe

Clinical Operational Readiness Program - Brings together operational leaders across the organization to lead the organization readiness activities in preparation for the future state workflows and use of the new EHR

Core Team

Team members who are fully dedicated to the Epic Project team

Cosigning Orders

The responsible provider (usually the attending provider) double checks orders that were already placed by others on his/her behalf. The cosign is essentially the stamp of approval. An attestation by a provider that orders recorded by a nurse or pharmacist based on a protocol or given telephonically by the provider were correctly entered. Usually occurs after the order has been carried out.

Credentialed Trainer

Conduct classroom training and physician personalization activities as well as assist end users as go-live support resources

C-Section Button

A button on the Grease Board or L&D Manager used to initiate an emergent C-Section workflow.

Current Procedural Terminology (CPT)

The CPT code set is used to codify medical and surgical services and procedures performed by physicians and other clinicians.

Curriculum Review Boards (CRBs)

Inter-disciplinary groups will review and provide feedback on curriculum at the end of each development “bucket” in order to provide consistent feedback throughout the process. Groups can include CCHC Application Analysts, Epic Team members, SMEs, and Training Team staff

Cutover

The tasks that must be executed to turn on the new system and interfaces; typically pertains to a short period of time - hours rather than days or weeks

Dashboard

Personalized home pages that typically contain charts, graphs, and other graphics so users can get a quick sense of the health of metrics. Epic provides dashboards using two tools: Radar and SAP BusinessObjects. Radar dashboards are personalized home pages that can contain graphs, reports, links, and other data that is important for a user. Radar dashboards mostly contain operational reporting data and get their data from Chronicles. The SAP BusinessObjects contain analytical data and get their data from Clarity.

Data Binding

Association of a SmartData element or Chronicles item with a SmartForm component or a Classic SmartForm control. Related Terms: SMARTDATA ELEMENT, SMARTFORM.

Data Courier

Hyperspace utility used to copy static records or custom category list entries from one environment to another.

Data Migration, Environments, Change Control

Workgroup focused on data migration between Epic environments (e.g., POC / Test / Production) and change control of the migration process

Decision Tracker

Internal project document to track decisions made across teams, governance, and project activities.

Deficiency

Any incomplete part of a patient's chart; created manually or automatically and assigned by HIM staff to staff for completion.

Deficiency Detective

Activity used by deficiency analysts to review events and documentation related to a patient’s encounter.

Deliveries Complete

An action which finalizes all documentation in the Delivery Summary.

Delivery Note

The Delivery Note is housed in the Delivery Summary and used to write a note about the delivery. There is only one Delivery Note for the patient, and it appears to anyone who accesses the Delivery Note tab of the Delivery Summary.

Delivery Summary

The Delivery Summary is a document used to record the information that happens during a delivery which is relevant to the care of both the mother and the baby. Synonym: HSB.

DICOM

Digital Imaging and Communications in Medicine is an industry standard for communicating with imaging equipment, printers, and PACS systems.

Discharge Instructions

Information and instructions provided to patients to follow upon discharge. These generally come from a third party data vendor. Synonym: clinical references.

Discharge Placement

This navigator section allows case managers to fax configurable reports with clinical information to post-discharge facilities to determine if the facilities can accept the patient.

Doc Review

Activity used by coders to review documentation related to a patient’s encounter.

Dual-Mode Order Entry

Type of order entry that allows clinicians to place both during-visit and after-visit orders.

Duplicates

Multiple records existing in the system for the same patient.

EAP / Orders Workgroup

Procedure Orders (non medication) Catalog Workgroup - Reconcile orders across facilities and departments for enterprise build, validate naming/numbering conventions, and downstream system impact for third party systems

EAP file

EAP is the INI for the Procedure master file, including your organization’s non-medication orders, which also stores your organization’s charge, payment, and adjustment procedures.

eLearnings

On-line learning videos that explain Epic workflows and functionality

Electronic Health Record Support Assistant (ESA)

Part of Training. Serve as the support role on the floor that will allow for continuity prior to go-live, during go-live, and ongoing. Will continue to be a resource for reinforcing and supporting optimization in the practice in collaboration with training team (e.g. RTD).

Eligibility (RTE) Query (previously RTE (or Eligibility) Query)

Eligibility message sent from Epic to a payor to verify coverage and benefit information.

Emergency Department (ED) Manager

Geographical representation of the Emergency Department. The map displays information about the patient and allows staff to move patients in and out of rooms.

Encoder

A third party system used by coders to enter diagnosis and procedures codes and assign DRGs (Diagnosis Related Groupers) for accounts.

Encounter

A clinical contact with a patient. For example: an office visit, an admission, or a triage call. If more than one evaluation or procedure takes place at that visit, it is still usually considered one encounter. In billing applications, charges or other transactions can be associated with encounters.

End User Devices (EUD)

Technical components such as printers, workstations, handhelds, etc.

End User Training

Process to train end users in system functionality.

Enterprise Master Patient Index (EMPI)

Enterprise Master Patient Index - database used to maintain consistent and accurate information about each patient registered by the organization

Epic Foundation

Epic’s recommended and prebuilt system incorporating multiple organizations' best practice workflows

EpicCare Ambulatory

Application that combines chart review, order management, and documentation. It organizes patient information, suggests actions, and guides coordinated care across physical care settings. It allows provider preferences and creation of preference lists

EpicCare Inpatient - Inpatient Clinical Doc

Application for inpatient documentation performed by clinicians and may include notes, flowsheets, assessments, plan of care and medication administration. Used by nurses, nurse practitioners, managers, therapists, physicians, physician assistants, case managers and social workers

EpicCare Inpatient - Inpatient Orders

Application for the ordering of workflows of inpatient orders. Can be used to share order details, sign orders, place orders and find orders

EpicCare Link - Physician Portal

Giving referring providers access to information about the care you provide to their patients. They may access progress / consult notes, lab results, discharge instructions, and other portions of the chart

Epic's Master Files

Epic’s name for database table within their infrastructure

Episode

A patient condition that spans several encounters, such as pregnancy, back pain, or worker's compensation. Encounters can be linked to an episode for easier review and reporting. Used primarily in EpicCare Ambulatory and in hospital outpatient departments using EpicCare Inpatient.

E-Prescribe

To electronically send medications to a pharmacy, instead of printing them for the patient. This often occurs upon discharge, as part of the discharge medication reconciliation.

ERX

The Epic master file for medications. The ERX number is commonly referenced if the user is familiar with Epic.

Estimated Date of Delivery

Estimated day that a new born will be delivered.

Executive Steering Committee (ESC)

Executive Steering Committee - Serves as the final approval forum for decisions, issues, and risks escalated by the project team and advisory groups

External Pharmacy

A pharmacy outside of your healthcare system.

Extract, Transform, Load (ETL)

ETL is a type of data integration that refers to the three steps (extract, transform, load) used to blend data from multiple sources

Facility List

A list of orderable medications specific to the facility or hospital location that a provider is ordering from.

Facility Structure

The facility structure establishes the organizational hierarchy for system build, including physical locations, departments, rooms, beds, and associated roll-ups for revenue and other reporting requirements.

Filter

A restriction applied to a set of returned results. Used frequently in the Chart Review activity to find relevant information.

Floor Stock

A stock of commonly used, generally low risk medication, readily accessible by nursing with little to no security. Labels do not print for these products and they are not dispensed from the pharmacy.

Flowsheet

A subset of patient data appearing in chart form. The flowsheet format can be useful when analyzing trends. You can specify a data set and view that data in a flowsheet by clicking the Lab Flowsheet button in the Chart Review activity.

Form Factor

A form factor is a computer or piece of electronic hardware's overall design and functionality

Formulary

A list of approved medications for ordering / usage for the organization / facility

Full Screen Status Board

A status board that is displayed on a large monitor in a hallway where multiple users can see it at once.

Functional Testing

System Testing within a single Application

FYI Flag

Indicator manually added to a patient’s chart to call attention to important information either about the patient or an encounter.

Go Live Readiness Assessment (GLRA)

A global evaluation of all factors contributing to go-live in preparation for the implementation of Epic software. This includes examination of planning, hardware, system build, and end-user training. Go-Live Readiness Assessments are held at 90, 60, 30, and 15 days prior to go-live.

Governance

Decision-making leadership groups for escalation of project-related decisions.

Grand Central - Bed Management

Through this clinicians can access an efficient census workspace that allows them to view and update current information on patients in their care and flexible work queues help to plan for upcoming admission, discharge and transfer events

Graph Package

A consolidated set of reports or metrics related to a specific operational area. For example, Resolute Hospital Billing has a graph package to trend high-level financial metrics.

Grease Board

The L&D (Labor and Delivery) Grease Board is a highly configurable activity that offers a variety of different views for the patients in a Labor and Delivery unit.

Guarantor

The individual ultimately responsible for medical bills from a patient encounter. Generally, patient charges not covered by insurance will be billed to the guarantor.

Hands On Experiences

Opportunity for end users to get more hands on experience with new devices (i.e., Rover, Tablets) as well as gain information on workflow related education, guidance and support.

Health Information Management (HIM)

Module that supports the acquisition, analysis and protection of digital medical information via applications such as deficiency tracking, release of information and hospital coding

Health Maintenance

An activity that helps you systematically track preventive care procedures for your patients.

Healthy Planet

Population Management: Epic's population health module, helps healthcare organizations, clinically integrated networks, health plans, and accountable care organizations improve quality and decrease the cost of care for their patient populations. With payment models increasingly focused on reducing cost and improving outcomes, efficient management of high-cost and high-risk patients is a necessity

Held Time

Time reserved on a provider’s schedule for tentative times when the provider may not be available to see patients (ex: possible meeting, possible vacation, etc.).

Historical Medications

A medication that a patient has taken in the past. Entering patient-reported historical medications in Epic helps you to maintain a complete list of the patient's medication history. When medication orders expire or are discontinued, they also become historical medications. Problems should be directed to the project team based on inpatient vs. outpatient (ambulatory). Medication related problems should be directed to Willow Inpatient.

History & Physical Examination (H&P)

The starting point of the patient's "story" as to why they sought medical attention or are now receiving medical attention

History Activity

An activity where you can view and document a patient's medical, surgical, family, and socioeconomic history. You might also be able to access this information from the History navigator section.

Hospital Account Record (HAR)

Hospital accounts are used to track charges, payments, and adjustments related to hospital or technical fee billing. Hospital accounts are usually specific to a single patient encounter, and must be linked to a single patient and a single guarantor account. Ultimately, hospital accounts enable billing for hospital services.

Hospital Billing (HB) - Resolute

Resolute Hospital Billing is the application that populates appropriate fields and submits hospital claims to third party payers in HIPAA-compliant transaction formats. Rules based claim scrubbing helps to accelerate reimbursement and minimize rejected claims.

Hospital Chart

The main patient workspace for EpicCare Inpatient.

Hospital Chart Completion Folder

In-Basket folder for deficiency notification messages, coding queries, CDI queries, unsigned transcriptions, and verbal order and cosign order notifications. Providers use this folder to follow-up on all outstanding documentation.

Hospital Outpatient Department (HOD)

Hospital Outpatient Departments - A specialty department that provides outpatient-type care to patients who may or may not be admitted to another department in the hospital. There is also a project HOD workgroup to help design and review workflows and build pertaining to any departments that are classified as HOD areas

HTT/HTR Files

A unique ID assigned to all transactions; a temporary transaction receives an HTT ID until it posts to an account, at which point the system assigns a permanent HTR ID.

Identity - MPI

Master Patient Index: The tool designed to keep Epic's database clean by eliminating duplicate records and by actively preventing users from creating them in the first place. It unites demographic, registration, and encounter data from Epic and non-Epic systems. Streamlined utilities make it easy to merge records when duplicates are found and to unmerge patient records when necessary

Identity ID

An identity ID (IID) is an identifier used to map a record in Epic to its corresponding record in a downstream system. Identity IDs are the tool we use to translate between systems when communicating via interfaces. Epic will send the identity ID mapped to a record when sending outbound communication, and will translate the identity ID it receives back to an ERX ID when receiving inbound communications from downstream systems.

Implant

Anything put inside the patient during surgery. Implant information is tracked extensively in case of recalls from manufacturers.

InBasket

Electronic messaging system used within Epic applications.

InBasket & Results Routing

InBasket & Results Routing Workgroup - Facilitate discussions with physicians on inbox messaging content, layout, and rules

InBasket Medication Message

An InBasket message sent by nurses from the MAR to communication to the pharmacy, generally regarding a patient's medications. Synonym: Rx message.

InBasket Message

A message that is sent to inform a user of something in the system. In Basket messages can be manually sent by other users or automatically generated by the system, such as when a notification is sent to a user when a Reporting Workbench report finishes running.

Inpatient Interpreted Admission

Reporting or billing event which indicates when the patient first became an inpatient patient (with a base patient class of inpatient). This is recorded using the patient class that is mapped to a base patient class.

Intake/Output (I&O)

An activity where a patient's intake and output can be recorded and tracked in a flowsheet format.

Integrated Pharmacy

A pharmacy inside your healthcare system using Willow Ambulatory.

Integrated Testing

Testing of high-impact/risk business process scenarios linked together to achieve the larger goal of validating business lifecycle – validates business rules, configurations and technology

Integrated Workgroup (IWG)

Multiple disciplines and business areas collaborating on topics which require input from multiple teams. The workgroup will discuss workflows / system configuration related to the topic / department focus of the workgroup (Examples of Integrated Workgroup - InBasket, Patient Movement, Activation and Cutover)

Interactive Face Sheet

An HTML Summary form used in Registration workflows, and is usually the first form in the workflow.

Interactive Voice Response

A third party system patients use to request refills.

Interface Testing

Validate all application interfaces involved in a clinical “real-world” scenario are working as expected. Validate data communicates to ancillary and downstream systems as expected

Interim Billing

A method of billing that allows claims to be sent while the patient is still in the hospital. A bucket is created for each date range that the hospital bills for.

Intraprocedure Activity

Area where an anesthesia provider will document during a procedure.

Invoice Number

The number assigned to an individual claim during claims processing.

Invoice/Claim

A standardized form used to communicate account information and charges to be billed to a third party payer

Key Performance Indicators (KPIs)

Epic assists customers with measuring KPIs by providing a package of reports related to the business metrics that it considers crucial to monitoring the health of a customer system. Measuring KPIs is part of the Good Install program. Some Management Metrics are KPIs, some are not.

Labor and Delivery (L&D) Greaseboard

Within Epic, the greaseboard is an 'Activity' / Screen where L&D patients can be found

Labor and Delivery (L&D) Manager

An activity used to admit and transfer patients, assign staff to patients, view bed assignments of patients in the department, and view L&D statuses of patients.

Labor and Delivery (L&D) Map

The L&D Map provides a graphical representation of the L&D unit and allows for easier patient tracking.

Lactation Consultant

A healthcare professional who provides advice for breastfeeding.

Learning Hub

An online, engaging platform where end users will receive all their online education for Epic based on their role.

Learning Management System (LMS)

Cape Cod Healthcare will use HealthStream to track training compliance, provide e-learnings, and administer assessments

Legacy Data Collection Workbooks (LDCW)

Outline the information about your organization or legacy systems that you need to collect before officially kicking off your implementation

Liability Bucket

Also referred to as a “bucket”, this indicates who is currently liable for a specified portion of an account balance; liability may fall into the prebilled bucket (account not yet billed), insurance bucket (payor is responsible for balance), or self-pay bucket (guarantor responsible for balance).

Lines, Drains, Airways (LDAs)

LDAs (Lines/Drains/Airways) are Flowsheet groups that are used to document on lines, drains or airways that are inserted into a patient. They can also be used to document wounds and burns.

Link/Associate

Generally used when trying to link or associate the study to the patient, encounter, or an order.

Log

Information related to a patient’s surgical encounter on the day of surgery (nurses must create the log when they open the patient up on the day of surgery).

Management Metrics

Metrics that area leads need to measure in order to assess how their organization is doing in their area.

Mapped Record Testing

Verify that master records in Epic are mapped correctly to third party systems.

Medical Record Number (MRN)

Medical Record Number, unique patient identifier.

Medication Administration

The process of giving a medication to a patient. Problems with the actual documentation process should be directed to Clin Doc, problems with the medication being administered should be directed to Willow Inpatient.

Medication Administration Record (MAR)

A chart where all administrated meds are recorded

Medication Labels

Labels used by the pharmacy to prepare and identify medications being dispensed to patients.

Medication Monograph and Medication Guide

A documents assigned by the FDA to be given to patients when they pick up their prescriptions. They are specific to the drug the patient is picking up.

Medication Order

An order placed for a medication. Not to be confused with orders for procedures. Problems with the ordering process should be directed to Orders. Problems prescription medication orders should be directed to EpicCare Ambulatory, where other medication problems can be directed to Willow Inpatient.

Medication Reconciliation

The process of indicating which orders should be active for a patient upon admission, transfer, or discharge. This workflow is typically found in a navigator section.

Medication Record

A record in the Medication (ERX) master file. Epic works with third-party vendors who supply medication and interaction information, and this master file is generally populated by importing that data. In Epic, any order that is not a procedure is considered a medication.

Merge

Function performed by HIM to combine duplicate records into one record.

Modality

A modality is a type of medical imaging e.g., ultrasound, nuclear medicine (NM), radiography, computed tomagraphy (CT), magnetic resonance imaging (MRI)

MyChart

Epic patient portal application that allows patients to view their medical records and interact with their physicians over the Internet.

MyChart Bedside - Inpatient Portal

Allows patients (and proxies) to keep friends and family informed while they are admitted, includes interactive tools for patient education and tracking of milestones toward recovery/discharge, and includes the ability for family and friends to order gifts and flowers for the patient

MyChart Patient Portal - Outpatient Portal

Allows patients to easily access their own Epic medical record. Allowing patients to improve their own health, reduce the cost of customer service and provide a vital communication link to support accountable care e.g. view results, view / schedule appointments, communicate provider, refill request, etc

MyList

A list of patients available in the Patient List activity and maintained by a user.

MyReports

An activity linked to the library that contains reports a user has added to her favorites, recent results, and saved results.

Narrator

Nursing documentation tool that displays nursing tasks, a summary of the patient’s events during the visit, and all nursing assessments and notes.

National Drug Code (NDC)

A unique code assigned by the FDA to every medication sold in the United States. It relates to the package of the medication. In Epic, NDCs can be grouped into NDC groupers (NDGs) in certain Willow Inpatient workflows.

Navigator

A series of sections meant to follow a particular workflow, such as an office visit or medication reconciliation. Common examples include the Visit Navigator, the Discharge Navigator, and the Call Navigator

Notes

An activity where clinicians can write notes to add to a patient's chart or view previous notes.

NoteWriter

An activity that generates note text based on point-and-click documentation. Information that a clinician document from the NoteWriter includes a patient's history of present illness, review of systems, medical decision making, and physical exam.

Nurse Acuity

The Epic Nursing Workload Acuity Scoring System is a tool designed to help with staffing decisions. The total score reflects the patient's acuity and workload. The acuity and workload can be classified as low, medium and high and is based on real time documentation.

OB (Obstetric) History

The purpose of OB History is to provide a quick way to view the essential details of woman's obstetric history.

One-Step Medication

A workflow in which a user orders and administers a medication in a single process, which speeds up medication administration in surgery or emergency situations. Typically, a physician orders a medication, a pharmacist verifies the order, and a nurse administers the medication. Because a one-step medication does not go through that process, there are strict build requirements for these records.

Openings

The number of appointments that can be scheduled during a time slot without overbooking, also called regular openings.

Operational Impact Analysis

Part of Change Management. Operational impact assessment sessions offer the opportunity to show workflows to those who will be using them during and after go-live. The sessions grant the users an opportunity to provide feedback to best determine how to prepare for upcoming changes.

Operational Lead

Lead of an operational area or department (manager/ director)

Operational Metrics

Metrics that are supportive of the management metrics – given a good result or improvement in an operational metric you may see associated improvement in your KPIs.

OpTime

Epic's OR management system which includes tools for all key perioperative processes e.g. Surgery scheduling, perioperative documentation, preference care management

OR Location

Refers to a group of operating rooms that all have the same settings. One hospital can have multiple OR locations (for example, a Main or and a Labor & Delivery OR). This is also different than a user’s login department, of which OR Locations can have multiple.

Order Composer

A form that appears when placing orders in which you enter information necessary for an order by clicking buttons or choosing options from selection lists. You can access the Order Composer by clicking an order's Summary Sentence.

Order Entry

An activity where clinicians can place medication and procedure orders for a patient.

Order Review

An activity full of information for all orders that have been placed during the admission even discontinued ones.

Order Set

A preconfigured group of orders that is commonly ordered together for a specific problem or diagnosis. Order Sets can be suggested based on entries on your patient's problem list, and you can also mark Order Sets you use frequently as your favorites.

Order Transmittal

The process of sending orders to the correct place. A subset of the orders project team owns the build for order transmittal. Synonym: OTx.

Orders Activity

Primary activity in the inpatient chart for managing orders, placing new orders, or taking other actions on orders.

Out of Contact Occasion

An In Basket feature that allows a user to delegate access to her messages while end user is away.

Outcome and Assessment Information Set

A data set developed by Medicare for CMS reimbursement for home health agencies (HHAs). Must be filled out at every cert period, SOC, transfer, ROC, discharge, or significant change in condition.

Overbook

To schedule an appointment into a slot that has already reached its limit of regular appointments but allows for extra bookings (i.e., has overbook slots built).

Palliative Care

Services designed to provide relief of symptoms that interfere with quality of life when treatments will not alter the course of the illness.

Panel

A group of predefined visit types that are commonly scheduled together and will often have restrictions on the timing of the visit types.

Parallel Revenue Cycle Testing (PRCT)

A comparative testing process that uses future workflow and system functionality to address prioritized billing scenarios and perform a detailed comparison of future to legacy claims

Patient Class

A patient class must be entered before a hospital account can be created. Patient classes determine the account class for a hospital account. When a patient class is changed, the hospital account class changes accordingly.

Patient Education

An activity where you can document educational topics and points that you discuss with the patient or his family members. Also called the Education activity.

Patient Flag

Short, free-text note associated with a patient record. Types of FYIs include patient flags, patient messages, patient notices, permanent comments, registration notes, and reported registration comments.

Patient Header

The section that appears at the top of the patient's chart or encounter workspace that shows important patient information, such as vitals and allergies.

Patient Lists

An activity where you can assemble and view lists of patients and view reports for each patient. You can also open a patient's hospital chart from here by double-clicking that patient.

Patient Movement

The Patient Movement workgroup coordinates with physicians, bed management, case management, and registration stakeholders to define process flows for communication of orders, patient placement, and transfers.

Patient Station

A tool used by staff to look up patient encounters.

Patient Summary Report

An activity in the hospital chart that displays configurable reports about the patient.

Patient Workqueue

A tool used to identify patient contacts with informational errors or to find records with certain characteristics. The workqueue might present users with follow-up instructions or it might simply act as a list of contacts to be worked.

Pattern

A tool used to create provider schedules.

Payment

Money sent by the patient to cover the costs of care received.

Payor Directory

A list of payors included in the system.

Payor Faxing

This navigator section is designed for case managers to fax configurable reports to payors containing pertinent clinical information and details of the utilization reviews. Case managers can maintain the directory of payor contact information directly from within Hyperspace.

Perfusion

Perfusion is the process of diverting blood away from the heart and lungs (using a special heart/lung bypass machine), adding oxygen to the blood, then returning the blood to the body—all without the blood having to go through the heart.

Personalization

Improves efficiency by allowing users to set their preferences in the system and tailor Epic screens to meet their needs and the needs of their respective disciplines

Phase of Care

An attribute assigned to orders that tell nurses when a medication or task is supposed to be completed during a patient’s surgical care. These are often: pre-op, intra-op, PACU, and post-op.

Physician Advisory Group (PAG)

Advisory group representing the needs of and serves as the advocate for physicians and associated clinicians across the entire health system. Will focus on decisions related to provider workflows

Physician Pulse

An activity in Hyperspace that serves as a personal proficiency dashboard for you. Physician Pulse analyzes clinical data for various metrics and determines areas in which you can make improvements in your use of Epic. Physician Pulse also provides access to e-learning lessons and tip sheets related to the identified areas.

Pool

A predefined group of providers/resources that appears automatically when scheduling certain visits.

Postpartum

A period beginning after the birth of a child and extending for about six weeks.

Practice Labs

Provide an opportunity to further explore learning concepts with both independent and staffed drop-in sessions

Preadmission

The process of gathering important admission-related information prior to a patient’s arrival at the hospital. Preadmission helps prevent users from creating duplicate encounters.

Pref Cards / Implants

Preference Cards / Implants Workgroup focused on reconciling and standardizing surgical / procedural preference cards and implants

Preference Card

A record that includes all the information required to set up a room for a surgeon for a specific procedure/location combination. This can include: surgical supplies, positioning, equipment, instruments, staff, etc.

Preference List

A set of common orders that can be personalized to a role, department, or location to expedite the ordering process.

Pregnancy Wheel

The Pregnancy Wheel is used to determine a mother's estimated date of delivery (EDD), last menstrual period (LMP), or the gestational age (GA) of the fetus. If you know one of these pieces of information, the Pregnancy Wheel calculates the other dates.

Prelude - Registration

Epic application used for registration and verification of insurance information

Preprocedure Evaluation

Note that is written before the patient is cleared for anesthesia. This note is written using NoteWriter and is very complicated, so be specific when entering details for pre-eval issues.

Prescription Label

A label is needed to fill a prescription. An end user might call because labels are not printing and it is urgent (printing issue).

Principal Trainers (PTs)

Training Professionals who apply expertise in instructional design and adult learning principals to build meaningful and valuable curriculum for delivery. Own the success of training for their application, including the creation of all training materials

Print Group

Component of a report; each report is composed of one or more print groups.

Prior to Admission Medications

A medication that the patient was taking before being admitted to the hospital.

Procedure

An order for lab tests, consults, and imaging. Not to be confused with Medication Orders.

Procedure Log

Activity that enables users to document various parts of an invasive cardiology exam as they happen in real time.

Procedure Orders

All non-medications in Epic. End-users would probably just call it an order, but the project team might call it a procedure order.

Procedure Workspace

Similar to the Intraprocedure Activity, can be used for documentation during a procedure.

Professional Billing (PB) - Resolute

Resolute Professional Billing is the application that populates appropriate fields and submits professional claims to third party payers in HIPAA-compliant transaction formats. Rules based claim scrubbing helps to accelerate reimbursement and minimize rejected claims.

Profile

One-stop-shop for operational readiness leads to ensure effective monitoring of key metrics. Includes key metrics, recommended reports, workqueues, and edits owned by each readiness area.

Profiled Prescriptions/Profile Only

Places a prescription on the patient’s med profile and “holds” it to be filled at a later date. If a physician selects “Fill Later” it causes the prescription to be profiled in Willow Ambulatory.

Protocol

A defined set of chemotherapy orders. Protocols are built in Epic behind-the-scenes, and are converted to Treatment Plans when applied to a patient. These are not to be confused with Research Study Protocols.

Provider Master (SER)

The master file of provider records for the enterprise

Purchase Request

A pharmacy technician creates a purchase request in Epic to request stock from a supplier. A separate technician uses the same request to receive stock from the supplier the next day.

Questionnaires

Cadence uses scheduling questionnaires that prompt the scheduler to ask the patient predefined questions that may change the appointment or prevent scheduling of the appointment.

Quick Lists

List of the most commonly used orders.

Quick Reference Guides/ Learning Aids

Provide an overview of specific Epic functionality via step by step instructions

Radar Dashboard

Main hyperspace distribution tool for data/reports and other resources.

Radiant

Radiology: Combines tools for rules-based scheduling, documentation, results communication, chart/film tracking and detailed statistical reporting. It allows for the linking of images and reports in one system

Readiness Agent Network (RAN)

Group comprised of selected allied health staff who will learn about the Vision 20/22 Epic implementation to help increase awareness and readiness for the change to Epic

Reading Palette

Study-specific activity where a reading physician reads images and records a narrative and impression.

Reading Work List

The main hub and workflow center for reading physicians. Typically, it is used by cardiologists to manage the studies assigned to them.

Ready to Plan

Case managers are able to get involved in the bed planning process and do criteria reviews prior to a patient’s bed placement to determine if the patient meets appropriate criteria for admission.

Recommended Item

An item that it is recommended a user fills out before completing a form or signing an order. An incomplete recommended item does not prevent the user from closing the form or signing the order.

Record Viewer

An administrative activity that allows you to view information about any record in Chronicles.

Recurring Account

A series of linked hospital accounts used for multiple, related, outpatient visits.

Referral

The action (and documentation) of directing a patient from one care provider to another for specific services. In certain cases, referrals may require authorization from an insurance company in order to be reimbursed.

Refill Authorization Request

When a patient runs out of refills, a member of the pharmacy staff needs to submit a refill authorization request to the provider to get a new prescription for the patient.

Refund

Process of returning a payment to the submitter of the payment

Registry

A collection of records (for example, patients). These records are defined by a set of inclusion rules and metrics that determine the patients who should be included in the registry and the information about each patient that should be collected.

Regulatory Quality Reporting

Regulatory Quality Reporting Workgroup to coordinate the decision making, build and testing of Clinical Quality Reporting for external metric reporting

Rehab

Rehab: Used alongside EpicCare Inpatient or Epic Care Ambulatory, the Rehab module is tailored to the unique regulatory and patient care needs of rehabilitation facilities

Release of Information (ROI)

An activity which generates patient information from the Electronic Health Record (EHR) to be released to a specified party.

Releasing Orders

The act of activating an order from a treatment plan or therapy plan. Orders must be released from treatment plans in order to be administered to a patient. For outpatient medications, upon release, medications will either be e-prescribed to the patient’s pharmacy or a prescription will print.

Report

A set of information that can be printed, viewed on screen, faxed, or sent via In Basket. Made up of one or more print groups.

Report Library

A repository of all reports available to an end user.

Reporting (Registries)

Clinical registries provide a useful and efficient mechanism to collect and manage patient aggregated information (e.g., Cancer Registry). Registries have demonstrated value and utility for studying a population for research, education, and practice management.

Reporting Workbench

An Epic tool that provides a flexible, template-based reporting integrated with Hyperspace.

Required Item

A piece of information that must be filled out before the workflow can continue.

Research Study (RSH) record

RSH record - Research study record.

Results Console

In the Results Console section, you can quickly and easily enter results from an external source without manually placing a historical order or entering back office results. You can also review existing results.

Return

A return is a medication that was not given to the patient, but was instead returned to the pharmacy.

Revenue Cycle Advisory Group (RCAG)

Forum for business and revenue cycle leaders to provide decisions/direction and oversight for the Vision 20/22 project

Risk Registry

Application-specific risk mitigation documentation outlining all major risks for your application as defined and agreed upon by Epic and operational leadership.

Routing Rule

A routing rule is comprised of one or more criteria. Routing rules can be used within account workqueues as a filtering tool. They further specify which accounts should qualify for the workqueue.

Rover

EpicCare Inpatient Clinical Documentation: Module that uses mobile devices to allow Inpatient nursing staff to do review and documentation tasks. Some of the functions that Rover helps with are chart review, medication administration, flowsheet documentation, and recording patient photos

RVU Multiple Procedure Indicator

To satisfy CMS and other payors' claim requirements, you can check whether you're correctly billing multiple units for a single provider on a single day according to the RVU multiple procedure indicator, as defined by CMS.

Site Readiness Owner

May serve as Readiness Agents but typically are in higher-level leadership roles and are responsible for the holistic readiness for their assigned site

Smart Data Element

A data entity for which you want to capture a value. Used in locations such as SmartForms and the NoteWriter to capture data instead of using Chronicles items. SmartData elements are records in the Clinical Concepts Lexicon (HLX) master file. When you specify a value for a SmartData element, that value is stored separately in the Concept Values (HLV) master file. SmartData elements were previously referred to as concepts. The term concept is still used to define third-party reference terminologies, which are not used directly for data storage.

SmartBlock

A type of SmartLink used in a note template for the NoteWriter. The SmartBlock includes the Classic SmartForm or SmartForm to display as well as the text generation template to use.

SmartBlock macro

A tool that clinicians can use in the NoteWriter to quickly make a pre-defined set of selections on a form. Similar to SmartForm macros, but SmartBlock macros are associated with SmartBlocks instead of individual SmartForms within a SmartBlock. For example, this lets you use one macro to make selections on multiple tabs of the Physical Exam.

SmartCode Analyzer

A tool that works with the Level of Service Calculator to analyze encounter information and automatically suggest a level of service code if enough information is available.

SmartData identifier

The unique character string that identifies a SmartData element or concept. Stored in the Concept Identifier (I HLX 40) item.

SmartData Manager

Activity used to find, edit, and create SmartData elements. This activity was previously referred to as the Concept Center.

SmartForm

A customizable form in Hyperspace used for gathering clinical and other patient data.

SmartForm Designer

Activity used to build SmartForms in Hyperspace.

SmartForm macro

A tool that clinicians can use to quickly make a pre-defined set of selections on a SmartForm. Similar to SmartBlock macros, but SmartForm macros are associated with individual SmartForms instead of with SmartBlocks, which allows for the use of different macros for different SmartForms within a SmartBlock.

SmartGroup

A reusable group of orders and documentation elements, such as a chief complaint or level of service, which can be used in Protocol-based SmartSets and Order Sets.

SmartLink

A SmartTool that pulls (or "links") information from the patient record directly into your documentation. For example, if you enter .name, the patient's name is pulled in.

SmartList

A SmartTool that allows you to choose from a list of pre-configured choices in a SmartText or SmartPhrase. These can be single- or multiple-response lists.

SmartPhrase

A SmartTool that allows you to type a few characters that automatically expand into a longer phrase or block of text. For example, pt. becomes patient.

SmartSet

A documentation template. A group of orders and other elements, such as notes, chief complaints, SmartGroups, and levels of service, that are commonly used together to document a specific type of visit.

SmartSet Base

Type of BestPractice Advisory (LGL) record used to restrict Protocol-based SmartSet usage based upon patient, encounter, or provider criteria. SmartSet Base records can link to one or more Criteria BestPractice records. Restrictions can be attached at the SmartSet, section, or SmartGroup levels.

SmartSet Editor

The activity used to create and modify SmartSets and Order Sets.

SmartSet Suggestion

Type of BestPractice Advisory (LGL) record used to suggest the use of a Protocol-based SmartSet based upon patient, encounter, or provider criteria. SmartSet Suggestion records and Criteria BestPractice records can be attached at the SmartSet level. When the criteria are matched, these SmartSets appear in the Suggestions section of the SmartSet or Order Set selectors.

SmartText

A text template that can include text, SmartPhrases, SmartLists, and SmartLinks. Frequently used in progress notes, but can be used in many different types of records

SmartTool

Pre-configured text that can be used to standardize documentation, such as notes, within the system. SmartTools include SmartLinks, SmartLists, SmartPhrases, and SmartTexts.

SmartTool Butler

A window accessible from SmartTool-enabled text boxes from which you can search for and select SmartPhrases and SmartLinks.

SmartTool-enabled text box

Any text box in Hyperspace where you can use SmartTools.

SnapShot

Activity or report that shows a quick overview of patient data, such as the problem list, medications, allergies, and comments. Users might have access to SnapShot as a stand-alone activity, a SnapShot tab in the Chart Review activity, or SnapShot reports in the Patient Summary activity.

Specialist Trainers

Physicians who are trained in Epic methodology and provide Epic training support to physician colleagues aligned to their area of medical practice/expertise

Specialty Build & Configuration

Phase during which Application Teams build system based on workflows

Stork

Peri-natal (L&D): Organizes the complete course of obstetric care and supports the documentation workflow of Labor and Delivery with integration of the pre-natal visits / episode of care

Subject Matter Expert (SME)

Subject Matter Expert - Operational representative that has deep functional or workflow expertise

Super User/ATE Development

Process to train and develop support resources

Supply Management

Workgroup focused on supply workflow for departments that uses supplies for patient care

Surgical and Procedural Orders Management (SPOM)

Surgical and Procedural Orders Management Workgroup to coordinate the build, training, and testing of orders in the surgical areas. Define the phases of care to facilitate orders and medications during patient's transitions in care

Technical Advisory Group (TAG)

Technical advisory group to provide standards and guidelines, as well as input and feedback regarding Project Vision 20/22 system design, implementation and stabilization

Unified Communication

Workgroup focused on inter-disciplinary / care team communications for patient workflows

User Acceptance Testing

Get end users' feedback on workflow and build in final stages of integrated testing. Most of the changes will be related to content and ease-of-use rather than workflow build. These sessions also foster end users' confidence in the system by exposing them to a near-finished product before go-live

Users & Security

Workgroup to define the strategy for how we will use security classes, profiles, user roles, etc. Group will also define each role and template and assign template to each user

Welcome - Patient Kiosks

Welcome offers patients self-service options at the start of the care process, such as checking in for an appointment, using an intuitive touch screen interface

Willow

Pharmacy / Medication Management: Automates the key component of Epic's "closed-loop" medication ordering and administration process. Allows for medication verification and dispensing and order appears automatically on the MAR

Workflow

Technical design document outlining system interactions by process and role

Workflow Dress Rehearsal

Activity to practice an end-to-end patient-based workflow in the production environment

Workflow Inventory

Comprehensive list of all workflows (technical design document outlining system interactions by process and role) applicable to the project. Stored in Workflow Inventory Tracker for status tracking and progress reporting across applications.

Workflow Walkthrough (WFWT)

Six days of sessions focused on walking through Epic Foundation workflows and demos

Workgroup

Working team focused on a specific functional area or department