Dictionary

Accountable Care Organization (ACO)
An ACO is an organized group of hospitals and physicians that together assume shared risk around the care it provides to patients. For a review of the pros, cons and new twists in ACOs, read the article here.
Accounts Receivable & Aged Accounts Receivable & Re-aging
Accounts Receivable, abbreviated and called "A.R." and written as "A/R" is the money due to a healthcare organization for services provided.  For most cash-based non-hospital practices, the A/R works as follows:
  • When a service is provided to a patient, the charges are added to the A/R.
  • For most charges that are added to the A/R, it is assumed that a portion will be paid by an insurance company, a portion will be paid by the patient, and a portion will be written off.
  • Very few, if any healthcare organizations will actually collect the entire A/R as most provide whopping amounts of charity care, negotiated payment care, government-subsidized care and care that is never compensated and is written off to bad debt as uncollectable.
  • When payments are made, the amount due is reduced and therefore, the A/R is reduced.
  • An aged A/R will divide the money owed into aging buckets of Current (less than 30 days old), 30, 60, 90, 120, and 150+ days old.
  • The older or more "aged" the charges in the A/R become, the harder it is to collect and the less value it has.
  • I think the appropriate way to age charges is from the date of service, but some groups age their A/R from the date the insurance pays and the remaining balance is due from the patient. This is called "re-aging" the account.
Adjudication (of claims)
When a claim is adjudicated, the payer (or possibly the Third Party Administrator) applies a series of payment rules such as:
  • the subscriber or beneficiary's eligibility to receive benefits
  • whether the services provided are covered under the subscriber's plan
  • the allowable charge per the contract between the care provider and the payer
  • the percentage of the allowable charge paid according to the contract
  • the application of the terms of the subscriber's plan insofar as deductibles, co-insurance, co-pays
Once these rules have been applied and a benefit or denial, or combination of the two, has been determined, the claim has been adjudicated. Some payers currently provide electronic time-of-service adjudication which allows a care provider to collect the patient's portion of the payment during the check-out process.
Advance Directive
An advance directive tells your doctor what kind of care you would like to have if you become unable to make medical decisions for yourself.  Your requests may come into play if your illness is one you won't recover from or if you are premanently unconcious.
ARRA
American Recovery and Reinvestment Act of 2009, also called “The Stimulus Package” or “The Stimulus Bill.” Of the $850B in the bill, $51B is pegged for the health care industry and $19B of that will be used to incent medical practices to adopt EMRs/EHRs.
ARRA (Stimulus Plan) Acronyms
  • A/I/U –Adopt, implement or upgrade
  • CAH –Critical Access Hospital
  • CCN –CMS Certification Number
  • CDS –Clinical Decision Support
  • CMS –Centers for Medicare & Medicaid Services
  • CY –Calendar Year
  • EHR –Electronic Health Record
  • EP –Eligible Professional
  • eRx –E-Prescribing
  • FFS –Fee-for-service
  • FY –Federal Fiscal Year
  • HHS –U.S. Department of Health and Human Services
  • HIT –Health Information Technology
  • HITECH Act –Health Information Technology for Electronic and Clinical Health Act
  • HITPC –Health Information Technology Policy Committee
  • HIPAA –Health Insurance Portability and Accountability Act of 1996
  • HPSA –Health Professional Shortage Area
  • IFR –Interim Final Rule
  • MA –Medicare Advantage
  • MCMP –Medicare Care Management Performance Demonstration
  • MITA-Medicaid Information Technology Architecture
  • MU –Meaningful Use
  • NPI –National Provider Identifier
  • NPRM –Notice of Proposed Rulemaking
  • OMB –Office of Management and Budget
  • ONC –Office of the National Coordinator of Health Information Technology
  • PQRI –Medicare Physician Quality Reporting Initiative
  • Recovery Act –American Reinvestment & Recovery Act of 2009
  • TIN –Taxpayer Identification Number
Bank Deposit (How to Make One)
Steps for making a bank deposit of any kind:
  1. Gather the checks and/or cash that you wish to deposit and total them.
  2. Prepare the deposit slip.  You may have a book of deposit slips (business account) or a deposit slip found in the back of your check book (personal account) or you may get a blank deposit slip from the bank.
  3. Stamp the name of the bank on the back with a "For Deposit Only" statement, or if the checks are made out to you personally, you may endorse the check by signing your name on the back as it is written on the check, and handwrite "For Deposit Only".  If the checks to be deposited were lost or stolen, others would not be able (theoretically) to cash your checks.
  4. If you are using a blank deposit slip from the bank, you must know your account number, or you must be able to get your account number from the teller, who must recognize you or will ask to see your photo identification.
  5. Put the day you will be depositing the money at the top of the form.
  6. List each check separately if you are using a business deposit slip.  A personal or bank deposit slip will have room for more checks to be listed on the back of the form.
  7. List cash separately in the space provided.
  8. Business deposit slips will have a place to tally the number of checks you are depositing.
  9. Total the cash and checks together.  Business deposit slips will have a second place to total the deposit.
  10. Paperclip or rubber-band the deposit slip and the checks together.  If you are depositing change, you may want to place everything in an envelope.
  11. Take the deposit to the bank.  You can mail a deposit, however, most authorities do not recommend it.
  12. You can make a deposit at an ATM machine.
  13. You can also place a deposit in the bank night deposit at any time.
  14. The teller will machine stamp or manually stamp the date the deposit was received and give a receipt to you for your records.  if you are using a two-part deposit slip, the bank will keep one part and return the second part to you as a receipt.
  15. If you have not used a face-to-face method of depositing the money, you will receive a receipt in the mail.
Black Ink & Blue Ink (and Red Ink)
It used to be that blue ink would not copy on a copier, so the rule was that all handwritten medical records must be written in and signed in black ink. Now some attorneys are counseling people to sign documents in blue ink, as it stands out from the black text and can be verified as "original." My mentor taught me to always carry a red pen with me, so when you sign an attendance list or guest log, your name will jump off the page!
Blue Ocean Strategy
Blue Ocean Strategy is a business strategy book authored by W. Chan Kim and Renee Mauborgne.  The central theme of the book is rejecting competition in current business lines and creating new demand, services or goods, a so-called "Blue Ocean." Wikipedia describes the metaphor of the market universe as red and blue oceans like this: " Red Oceans are all the industries in existence today—the known market space. In the red oceans, industry boundaries are defined and accepted, and the competitive rules of the game are known. Here companies try to outperform their rivals to grab a greater share of product or service demand. As the market space gets crowded, prospects for profits and growth are reduced. Products become commodities or niche, and cutthroat competition turns the ocean bloody. Hence, the term red oceans. Blue oceans, in contrast, denote all the industries not in existence today—the unknown market space, untainted by competition. In blue oceans, demand is created rather than fought over. There is ample opportunity for growth that is both profitable and rapid. In blue oceans, competition is irrelevant because the rules of the game are waiting to be set. Blue ocean is an analogy to describe the wider, deeper potential of market space that is not yet explored."
Botnet
A botnet is an army of infected computers that hackers can control from a central machine.
Cardiologists Explained
Interventional cardiologists - do stents and PTCAs

Non-interventional Cardiologists - do caths, but no stents or PTCAs

Invasive Cardiologists - do caths, and may do stents or PTCAs

Non-invasive Cardiologists - does not do caths, stents or PTCAs

PCTA - Percutanueous transluminal coronary angioplasty is one of the most common procedures for opening damaged or obstructed coronary arteries (sometime referred to as the "balloon" procedure.)

A stent is a wire metal mesh tube used to prop open an artery during angioplasty. The stent is collapsed to a small diameter and put over a balloon catheter. It's then moved into the area of the blockage. When the balloon is inflated, the stent expands, locks in place and forms a scaffold. This holds the artery open. The stent stays in the artery permanently, holds it open, improves blood flow to the heart muscle and relieves symptoms (usually chest pain).

Cardiac catheterization (cath) is a medical procedure used to diagnose and treat certain heart conditions. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. Through the catheter, doctors can do diagnostic tests and treatments on your heart.  Blockages in the coronary arteries also can be seen using ultrasound during cardiac catheterization. Ultrasound uses sound waves to create detailed pictures of the heart's blood vessels.

CCHIT
The Certification Commission for Health Information Technology is a private organization that certifies EMRs and EHRs based on 475 criteria spanning functionality, interoperability and security. CCHIT does not evaluate ease of use of products, financial viability of the company offering the software; or the quality of customer support offered by the software vendor. Whether or not CCHIT will be THE certifying organization to approve “qualified EMRs” will be announced at the end of the year. (Can be pronounced “SEA-CHIT” or each letter can be pronounced as in “C.C.H.I.T.”)
CfC (Conditions for Coverage)
UPDATE: 2/11/2010

Clarification on H&P Requirement Prior To ASC Procedure (Angela Mason-Elbert of CMS:

"Each patient that is seen in an ASC must have a comprehensive medical history and physical assessment (H&P) not more than 30 days before the date of the scheduled surgery. The H&P is to determine if the patient has any underlying conditions that would put the patient at risk for having such a procedure or to identify any new or existing co-morbid conditions that would require additional interventions. Additionally, the H&P could provide evidence that the ASC is not the appropriate setting for this particular procedure. The H&P, as long as it is comprehensive, can be completed the day prior to the procedure and even on the day of the procedure. It does not have to be completed prior to scheduling the procedure."

UPDATE 5/18/2009

Medicare announced that it will allow an exception for the patient notices required in advance of the day of the procedure in certain cases. Specifically, the Centers for Medicare and Medicaid Services (CMS) said:

It is not acceptable for the ASC to provide the required notice for the first time to a patient on the day that the surgical procedure is scheduled to occur, unless:

  • the referral to the ASC for surgery is made on that same date; and
  • the referring physician indicates, in writing, that it is medically necessary for the patient to have the surgery on the same day, and that surgery in an ASC setting is suitable for that patient.

In such situations the ASC must provide the required notice prior to obtaining the patient's informed consent. Cases of surgery occurring on the same day it is scheduled are expected to be rare, since ASCs typically perform elective procedures. Frequent occurrence of such cases may represent noncompliance with the advance notice requirement.

This information and new interpretive guidelines are available at www.ascassociation.org/coverage. As the ASC Association analyzes these guidelines more information will be available on the web site.

(Finalized October 30, 2008)

The OPPS/ASC (Outpatient Prospective Payment System for Ambulatory Surgery Centers) final rule modernizes Medicare’s ASC Conditions for Coverage (CfC).  The rule reflects current ASC practice by focusing on the care provided to patients and th impact of that care on patient outcomes.  Specifically, the new CfCs:

  • Define an ASC as a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following admission.
  • Strengthen Patients’ rights regarding disclosure of physician financial interests in the ASC; advance directives; the grievance process; and confidentiality of clinical records.
  • Impose stronger obligations on the governing body of an ASC to oversee its quality assessment and performance improvement (QAPI) program, while allowing ASCs flexibility to use their own information to assess and improve patient services, outcomes, and satisfaction.
  • Emphasize the importance of infection control practices.
  • Strengthen the requirements for assessing the patient’s condition at admission to verify that the surgery is appropriate and safe for the patient in an ASC setting, and at discharge to ensure appropriate post-surgical care for the patient.
  • Require the ASC to adopt a disaster preparedness plan.
Comparative Effectiveness
Comparative Effectiveness Research (CER) compares treatments and strategies to improve health. For CER, HITECH provides $300M for the Agency for Healthcare Research and Quality, $400M for the National Institutes of Health, and $400M for the Office of the Secretary of Health and Human Services.
Consumerist Patient
The consumerist patient is one who takes an active interest in the cost of his/her healthcare services.  This may be a change for practices as patients of the past would not ask any questions about the cost of services, particularly if their insurance plan covered all services at 100% of allowable.  As more responsibility for payment is falling to the patient, the patient is acting as a consumerist by:
  1. Shopping for good values in services
  2. Negotiating for service rates
  3. Looking for providers that offer cash discounts
  4. Looking for providers that offer acommodating payment plans
  5. Considering going out of state or out of the country for services (medical tourism)
Dartmouth Atlas of Health Care (The)
For more than 20 years the Dartmouth Atlas of Health Care has collated information on how medical resources are distributed and used in the United States.  The data comes straight from Medicare claims, and can be used to review and analyze local, regional and national markets.  As the Dartmouth Atlas of Health Care online site states:
These reports, used by policymakers, the media, health care analysts and others, have radically changed our understanding of the efficiency and effectiveness of our health care system. This valuable data forms the foundation for many of the ongoing efforts to improve health and health systems across America.
The funding to create the Dartmouth Atlas of Health Care online was made possible by a grant from The Robert Wood Johnson Foundation, which is the nation's largest philanthropy making grants exclusively in the health care field.
David Blumenthal, M.D., M.P.P
Selected by President Obama as his choice for National Coordinator for Health Information Technology Dr. Blumenthal will lead the implementation of a nationwide interoperable, privacy-protected health information technology infrastructure as called for in the American Recovery and Reinvestment Act.
Definition of a Group Practice (Stark)
The Group Practice Definition (courtesy of HealthNoob.com) Under Stark, a group practice is a physician practice that meets the following conditions: Single Legal Entity. The group practice must consist of a single legal entity operating primarily for the purpose of being a physician group practice in any organizational form recognized by the State in which the group practice achieves its legal status. Physicians. The group practice must have at least two physicians who are members of the group (whether employees, or direct or indirect owners). Stark defines a member of the group as a direct or indirect owner of a group practice (including a physician whose interest is held by his or her individual professional corporation or by another entity), a physician employee of the group practice, a locum tenens physician, or an on-call physician while the physician is providing on call services for members of the practice. An independent contractor is not a member of the group. Range of Care. Each physician who is a member of the group, must furnish substantially the full range of patient care services that the physician routinely furnishes, including medical care, consultation, diagnosis, and treatment, through the joint use of shared office space, facilities, equipment, and personnel. Services Furnished by Group Practice Members. Substantially all of the patient care services of the physicians who are members of the group (that is, at least 75% of the total patient care services of the group practice members) must be furnished through the group and billed under a billing number assigned to the group, and the amounts received must be treated as receipts of the group. Patient care services must be measured by one of the following:
  • The total time each member spends on patient care services documented by any reasonable means (for example, time cards and appointment schedules.)
  • Any alternative measure that is reasonable, fixed in advance of the performance of the services being measured, uniformly applied over time, verifiable, and documented.
Distribution of Expenses and Income. The overhead expenses of, and income from, the practice must be distributed according to methods that are determined before the receipt of payment for the services giving rise to the overhead expense or producing the income. Unified Business. The group practice must be a unified business having at least the following features: Centralized decision making by a body representative of the group practice that maintains effective control over the group’s assets and liabilities; and Consolidated billing, accounting, and financial reporting. Volume or Value of Referrals. No physician who is member of the group practice directly or indirectly receives compensation based on the volume or value of referrals except as provided under the specialty rules for productivity and profit shares. Physician-Patient Encounters. Members of the group must personally conduct no less than 75 percent of the physician-patient encounters of the group practice.

Special Rules for Productivity Bonuses and Profit Shares

The special rules for productivity bonuses and profit shares allow a physician who is in the group practice to be paid a share of overall profits of the group or a productivity bonus based on services that he/she has personally performed (including services “incident to” those personally performed services), provided that the share or bonus is not determined in any manner that is directly related to the volume or value of referrals of DHS by the physician. CMS now takes the position that diagnostic-testing services cannot be billed as “incident to” but practices that provide physical therapy can, however, bill physical therapy services as “incident to” services (provided that all of the “incident to” requirements are met). The Stark regulations specifically set forth examples of formulas that will be deemed not to relate directly to the volume or value of referrals. For example, a group’s profits will be deemed not to relate directly to the volume or value of referrals if revenues derived from DHS are distributed based on the distribution of the group practice’s revenue attributed to services that are not DHS payable by any Federal health care program or private payer.
Do Not Resuscitate (DNR) Order
A Do Not Resuscitate order ia a kind of Advance Directive.  A DNR is a request not to have cardiopulminary resuscitation (CPR) if your heart stops or if you stop breathing.  You can use an Advance Directive to tell your doctor that you do not want to be resuscitated.
Double Effect (as applied to terminal sedation)
The philosophical principle or rule of double effect, attributed to the 13th century Roman Catholic philosopher Thomas Aquinas, states that even if there is a foreseeable bad outcome, like death, it is acceptable if it is unintended and outweighed by an intentional good outcome — the relief of unyielding suffering before death. The principle has been applied to ethical dilemmas in realms from medicine to war, and it is one of the few universal standards on how end-of-life sedation should be carried out. See the New York Times article of December 26, 2009 here.
Dunbar's Number
British anthropologist Robin Dunbar proposed in 1992 that there is a limit to the number of people with whom each of us can maintain a stable social relationship.  Although there is no actual number proven, the number generally agreed upon as Dunbar's Number is 150.
Durable Power of Attorney (DPA)
A Durable Power of Attorney for healthcare is a kind of Advance Directive.  A DPA states whom you have chosen to make health care decisions for you.   It becomes active any time you are unconcious or unable to make medical decisions for yourself.  A DPA is generally more useful than a Living Will, but only if you have another person who you trust to make medical decisions for you.
EAP (Employee Assistance Program)
EAP is a benefit provided by some employers to assist employees with personal problems, problems at home and problems at work.  Employees may contact the EAP Providers (usually a behavioral health provider) themselves or may be referred to EAP by a supervisor or manager.  The employer pays for a certain number of provider visits for each distinct episode.  Some reasons why employees might use their EAP benefit are:
  • mental illness
  • substance abuse
  • marital problems
  • family issues
  • stress
  • domestic violence
  • performance coaching
  • communication issues
  • grief management
  • worksite violence
  • cultural understanding
  • anger management
  • diversity sensitivity
  • executive coaching
  • bullying behavior
Economic Credentialing
Economic credentialing is the practice of denying clinical privileges because of financial rather than competency concerns. Hospitals can dismiss a practitioner for economic credentialing reasons at any time; they do not need to wait until the end of a reappointment cycle to act.  Not all states allow economic credentialing; check your state laws for clarification.
EHR
The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care (as defined by NAHIT, the National Alliance for Health Information Technology.)
Electronic Faxing
Electronic faxing (also called efaxing, online faxing or internet faxing) is the process of sending a document between two people/accounts via the Internet, much in the way email sends messages over the Internet between two people.  eFaxing is a preferred method of sending information as opposed to traditional faxing as it is more compliant with HIPAA security regulations as it can be encrypted and password protected. eFaxing is also preferable because:
  1. No dedicated telephone line is required for the efax
  2. No fax machines are needed (purchase, maintenance, toner)
  3. No paper is used - it's green!
  4. Multiple faxes can be sent and received simultaneously
  5. Long-distance and monthly phone costs are eliminated
  6. Any location that has Internet access can send or receive faxes
I would also add that efaxing can also automatically index a document to a repository or to an electronic medical record.
EMR
The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care (as defined by NAHIT, the National Alliance for Health Information Technology.)
eWaste
eWaste is broken, obsolete or otherwise discarded electronics equipment. With healthcare moving forward to new products and technology, a lot of ancient systems are going to require proper disposal.  Who ya gonna call?
Formulary
A formulary is a listing of preferred prescription drugs (generic or brand name) chosen by a health plan/payer/insuror or Pharmacy Benefit Manager (PBM) for their cost to benefit ratio. Open Formulary = covers formulary and non-formulary drugs but charges the employer more for non-formulary drugs Tiered Formulary = covers formulary and non-formulary drugs but charges the patient more for the non-formulary drugs Closed Forumlary = only covers formulary drugs
GOMER
"Gomer" stands for Get Out of My Emergency Room, reflecting the annoyance of the doctors. It first appeared in widespread print in the medical novel The House of God by Samuel Shem, and was used mostly in the 1980s and 1990s. It is still used today, although many medical professionals find it disrespectful and unprofessional.
Gorilla on the Basketball Court
A short film demonstrating the "surprising limits of perception, attention, and awareness."  Viewers are instructed to count bounces or baskets made by one team, and in doing so, completely miss that a person in a gorilla suit walks among the players!  Viewers are astounded when viewing the video a second time and seeing the gorilla.   The video is part of a 2003 DVD Surprising Studies of Visual Awareness, Volume 1 produced by Viscog Productions, Inc.

H & P (History & Physical) vs. HNP (Herniated Nucleus Pulposus or Spinal Disc Herniation)
Two acronyms that confused me early on in my career were "H & P" and "HNP" because they sound exactly the same and few people enunciate clearly enough to distinguish the difference.  The context will tell you the difference, but for anyone new to healthcare the context might be just as confusing. H & P - History and Physical An H & P may be performed upon a patient's admission to the hospital, prior to a surgery/procedure, or as part of a new patient visit.  An H & P includes:
  • History of Present Illness
  • Past Medical History
  • Family History
  • Review of Systems
  • Physical Examination
  • Problem List
  • Assessment
  • Plan
Herniated Nucleus Pulposus or Herniated Disk A herniated (slipped) disk occurs when all or part of a spinal disk is forced through a weakened part of the disk. This places pressure on nearby nerves.  Also referred to as Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk. (1-2010)
Health Story Project
Health Story is a non profit, informal industry alliance of members who share a vision and mission and who contribute through active participation and annual membership dues. The project was initiated by the Association for Healthcare Documentation Integrity (AHDI), Medical Transcription Industry Association (MTIA), American Health Information Management Association (AHIMA) and M*Modal and is being managed by Alschuler Associates, LLC and Optimal Accords, LLC. Approximately 1.2 billion clinical documents are produced in the United States each year. These documents comprise around 60% of clinical information, the majority of physician-attested information and are used as the primary source of information for reimbursement and proof of service. This tremendous source of clinical information is underutilized in current computer-based record systems. Health Story is an alliance of healthcare vendors, providers and associations that pooled resources over the previous three years in a rapid-development initiative to produce data standards for the flow of information between common types of healthcare documents and electronic health records. Our Mission:  To develop and promote information standards through HL7 that support the flow of information between narrative documents and electronic medical records. The Health Story Project established the following five-year goals:
  • Establish awareness
  • Maintain strong coalition
  • Publish catalog of data standards through HL7
  • Increase market demand for standards
  • Earn national endorsement
  • Foster widespread adoption of standards
  • Declare success
From the Health Story Project website here.
HITECH
The HIT components of the stimulus package — collectively labeled HITECH are:
  1. Funding to the Office of the National Coordinator of HIT (ONCHIT)
  2. HIT adoption incentives through Medicare and Medicaid reimbursement
  3. Comparative effectiveness research for the Agency for Healthcare Research and Quality (AHRQ)
  4. Funding for the Indian Health Service
  5. Construction funds for the Health Resources and Services Administration (HRSA) for community health centers
  6. Funds for the Social Security Administration to upgrade HIT systems
  7. Funding for the Veterans Administration
  8. The Department of Agriculture will receive telemedicine funding
  9. Funds to the National Telecommunications Administration for broadband to enable telemedicine.
HSA (Health Savings Account)
Individuals or families covered under a high-deductible health insurance plan during the year are eligible to contribute to an HSA.   Here is some information on HSAs from Reed Tinsley, a Houston CPA and consultant:
  • Money contributed into an HSA is tax-deductible.  Either you contribute into an HSA on your own, or your employer contributes on your behalf.
  • Money invested within the HSA is your money and grows tax-deferred.  Unlike Flexible Spending Accounts (FSA) offered to you as part of your employee benefit package where you set aside a set amount of money to pay for your family's healthcare costs with pre-tax dollars, there is no "use it or lose it" pitfall with HSAs.
  • Money can be withdrawn tax-free from your HSA at any time to pay for your family's healthcare expenses.
  • Any money remaining in your HSA upon your reaching the age of 65 is available to subsidize your retirement.
For more information about HSAs, check out IRS Publication 969 (pdf). Reed's website is here.
INR (International Normalized Ratio) and PT (Prothrombin Time) or "Pro Time"
Prothrombin time (PT) evaluates the ability of blood to clot properly, it can be used to help diagnose bleeding.  The PT may be ordered when a patient who is not taking anti-coagulant drugs has signs or symptoms of a bleeding disorder, which can range from nosebleeds, bleeding gums, bruising, heavy menstrual periods, blood in the stool and/or urine to arthritic-type symptoms (damage from bleeding into joints), loss of vision, and chronic anemia. Sometimes the PT may be ordered when a patient is to undergo an invasive medical procedure, such as surgery, to ensure normal clotting ability. The International Normalized Ratio (INR) is used to monitor the effectiveness of blood thinning drugs such as warfarin (Coumadin). These anti-coagulant drugs help inhibit the formation of blood clots. They are prescribed on a long-term basis to patients who have experienced recurrent inappropriate blood clotting. This includes those who have had heart attacks, strokes, and deep vein thrombosis (DVT). Anti-coagulant therapy may also be given as a preventative measure in patients who have artificial heart valves and on a short-term basis to patients who have had surgeries, such as knee replacements. The anti-coagulant drugs must be carefully monitored to maintain a balance between preventing clots and causing excessive bleeding. Information provided by the American Association of Clinical Chemistry site here (1-2010).
Interoperability (hospitals)
(as defined by HIMSS- Health Information and Management Systems Society) -not yet defined for ambulatory care
It's A Dog's World Training Video
This 14-minute video is a staple for training medical office staff to see things from the patient's perspective. The video tells the parallel stories of Bob, a patient with a hurt shoulder, and his dog Max, visiting the veterinarian for a hurt paw. The two patients are treated quite differently by their healthcare personnel.  The video is in its second edition, and comes with a Leader's Guide, Power Point Program, Participant Worksheets and branded materials (reminder cards, notepads, stuffed dogs, lanyards, pens, etc.) The video can be purchased ($700) or rented ($225).  Be sure to check with your local hospital to see if they own the video and make it available for borrowing.  Purchase is not cheap, but it does get the point across extremely well and has good support materials for training staff on customer service.  If managers use it for training existing employees, then incorporate it into new employee orientation, and use the concepts as performance requirements for annual evaluations, the cost/benefit ratio is excellent. I've seen it a number of times and it still makes me laugh!
KLAS (technology evaluation company)
Pronounced like "class", KLAS is an independently owned and operated healthcare technology company headquartered in Orem, Utah whose mission is "To improve healthcare technology delivery by honestly, accurately, and impartially measuring vendor performance for our provider partners." The name KLAS comes from the first initials of the founders' names: Kent Gale, Leonard Black, Adam Gale, and Scott Holbrook. KLAS evaluates technology products in the categories of:
  • healthcare software vendors (since 1997)
  • professional services to healthcare providers including implementation, planning and assessment, vendor selection, technical consulting, IT outsourcing, and business process outsourcing (since 2004)
  • research on medical equipment, including CR/DR and MRI scanners (since 2005)
According to the KLAS website:
KLAS data and reports represent the combined opinions of actual people from provider organizations comparing how vendors, products, and/or services performed when measured against the participant’s objectives and expectations. KLAS findings are a unique compilation of candid opinions and are real measurements representing those individuals interviewed. Findings are not meant to be conclusive data for an entire client base. KLAS provides the findings as valuable data points to be used with other data points in the reader’s overall analysis. We encourage our clients, friends, and partners using KLAS research to take into account the following statements as they include KLAS data in their other due diligence.
Reports can be purchased by healthcare providers  for +/- $1000. Considering the amount of time and money invested in technology, $1000 sounds like a reasonable price to me.
Living Will
A Living Will is a type of Advance Directive which comes into play when you are terminally ill (expected to live less than 6 months.)  A living will allows you to describe the kind of care you want based on certain life-states.
Lockbox
A term referring to a service that:
  1. collects mail delivered to a special practice Post Office Box (typically only payments)
  2. opens the mail and discards the envelopes
  3. separates the checks from the accompanying paperwork
  4. scans or copies the checks and the accompanying paperwork
  5. itemizes the checks on an electronic or manual deposit slip
  6. deposits the checks in the practice's bank account or makes scanned copies available to the bank
  7. returns the original checks/paperwork to the practice, or holds it in-house for a period before shredding
  8. makes the electronic or paper copies accessible to the practice for posting to the practice management system
Pricing for this service varies based on number of pieces processed and number of functions applied to the mail.  Advantages of using a lockbox include faster deposit of daily monies and elimination of staff involvement in check-handling and making deposits.
Managing By Walking Around (MBWA)
Considered by many to be the most useful and realistic management theory ever, MBWA is the concept that you need to be present in the area you are managing to be an effective manager.  MBWA includes:
  • making rounds in every area several times daily
  • touching base with each employee to see how they are, if they are having any issues and if there is anything they need help with
  • modeling appropriate behavior and customer service by greeting patients, picking up the phone if there is no one else to do it, picking up paper off the floor, etc.
  • checking to make sure machines are operating properly, staff are following protocols, there are no bottlenecks anywhere, and there are no signs of trouble brewing.
A manager who manages from their personal office is ineffective and out of touch with the people and area s/he is managing.
Meaningful Use
To qualify as a “meaningful user,” eligible providers must demonstrate use of a “qualified EHR” in a “meaningful manner.” ARRA defers to the secretary of Health and Human Services (HSS) to set specific guidelines for determining what constitutes a “qualified EHR”; however, it does specify that e-prescribing, electronic exchange of medical records, and interoperability of systems will be determining criteria.  Starting in 2011, providers deemed to be “meaningful users” of EHR systems will be eligible to receive $40,000 - $60,000 in incentive payments paid out over five years in the form of increased Medicare and Medicaid payments.
Medicaid
Medicaid is a medical assistance program that pays medical bills for people who meet certain eligibility requirements (such as income, age, or disability) which are based on Federal regulations and State law. Medical benefits may be authorized for services such as hospitalizations, physician services, medications and different levels of care in nursing and residential facilities. Medicaid may help pay for certain medical expenses such as:
  • Doctor Bills
  • Hospital Bills
  • Prescriptions (Excluding prescriptions for Medicare beneficiaries)
  • Vision Care
  • Dental Care
  • Medicare Premiums
  • Nursing Home Care
  • Personal Care Services (PCS), Medical Equipment, and Other Home Health Services
  • In-home care under the Community Alternatives Program (CAP)
  • Mental Health Care
  • Most medically necessary services for children under age 21
MML (Medical Markup Language)
The MML is the specification for optimum exchange of clinical data between different clinical institutions. The database can be considered to be a kind of table. Each institution uses a uniquely defined table. Therefore, the exchange of a simple data set such as that includes address, name, diagnosis, etc. may lead to different sequence of data between institutions. If such data is transmitted as is, the data sequence changes. To allow for proper exchange, the database for all clinical systems should be integrated into the same structure. However this is impractical as all systems currently operating throughout the country world have to be rewritten. The MML (Medical Markup Language) is a standard format for data exchange which we have studied for the purpose above. The latest version MML has been developed via XML technology. To ensure that the specification is available for multiple electronic medical chart systems, the data is converted into MML documents (MML instances) for data exchange with other institutions. (Fig. 1) The institution receiving the data converts the MML data into its own format for mapping to the database. This allows for the data exchange for clinical institutions throughout the country while maintaining the uniqueness of each institution. Each system is designed by each vendor on a competitive basis. The principle of competition will lead to the development of a better system of operation. (definition by Hiroyuki Yoshihara, MML-WG, Electronic Health Record Research Group)
MRSA
MRSA (pronounced "mer - sa") is Methicillin Resistant Staphylococcus Aureus is a strain of Staph bacteria that is resistant to many commonly-used antibiotics.  Multiple reasons exist for the development of MRSA, but overusage of antibiotics in humans as well as animals are major factors. (1-2010)
NPI Number (National Provider Identifier)
The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).  This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care (45 CFR Part 162, Subpart D (162.402-162.414). To comply with this requirement, the Centers for Medicare & Medicaid Services (CMS) began to accept applications for, and to issue NPIs, on May 23, 2005. Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers. Legacy provider identifiers include:
  • Online Survey Certification and Reporting (OSCAR) system numbers;
  • National Supplier Clearinghouse (NSC) numbers;
  • Provider Identification Numbers (PINs); and
  • Unique Physician Identification Numbers (UPINs) used by Medicare.
They do not include taxpayer identifier numbers (TINs) such as:
  • Employer Identification Numbers (EINs); or
  • Social Security Numbers (SSNs).
ONCHIT
Office of the National Coordinator for Health Information Technology.  In 2004 the position was created by by Presidential Executive Order.  In March 2009, President Obama appointed David Blumenthal, M.D., M.P.P. to the position. The primary purpose of this position is to aid the Secretary of HHS in achieving the President’s goal for most Americans to have access to an interoperable electronic medical record by 2014 (from the HHS.gov website.)
Open Source Software
"Open-source software has no universally recognized definition. But in general, the term means that the code is not secret, can be utilized or modified by anyone, and is usually developed collaboratively by the software’s users, not unlike the way Wikipedia entries are written and continuously edited by readers. Once the province of geeky software aficionados, open-source software is quickly becoming mainstream. Windows has an increasingly popular open-source competitor in the Linux operating system. A free program called Apache now dominates the market for Internet servers. The trend is so powerful that IBM has abandoned its propriety software business model entirely, and now gives its programs away for free while offering support, maintenance, and customization of open-source programs, increasingly including many with health care applications. Apple now shares enough of its code that we see an explosion of homemade “applets” for the iPhone—each of which makes the iPhone more useful to more people, increasing Apple’s base of potential customers." - Scott Shreeve, MD on his blog "Crossover Health"
Pandemic
The WHO (World Health Organization) Level 6 requirement for a pandemic requires serious outbreaks in communities in two or more different WHO regions. According to the WHO, a pandemic can start when three conditions have been met:
  • Emergence of a disease new to a population.
  • Agents infecting humans, causing serious illness.
  • Agents spreading easily and sustainably among humans.
A disease or condition is not a pandemic merely because it is widespread or kills many people; it must also be infectious. For instance, cancer is responsible for many deaths but is not considered a pandemic, because the disease is not infectious or contagious.
Participatory Medicine
Participatory Medicine is a model of medical care in which patients are active in the management of their health.  For a comprehensive article on Participatory Medicine in the AmedNews (January 2010) click here.
Pay Wall
You see a tidbit about an article that sounds interesting, but when you click on the link you get just a few lines of the article and are encouraged to subscribe to an organization so you can gain access to the rest of the article.  You have just hit a Pay Wall.
PHR or ePHR
An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the ePHR and control of access to that data is the responsibility of the individual.
PPI (Physician Preference Item)
Physician Preference Item (PPI) is a term used to describe a range of medical supplies including orthopedic implants and cardiovascular devices which physicians choose on behalf of their patient.  PPIs are estimated to be a significant  portion of a facility's supply costs, and as such, are now the target of potential policy changes away from the current philosophy which allows physicians a free choice when it comes to devices and implants.  Devices and implants are often bundled into the facility cost of a procedure/surgery, and many payers will not pay separately for a device/implant, leaving the hospital or ASC (ambulatory surgery center) to "eat" the cost.
Recruiters / Search Firms / Head Hunters
There are two models for search firms, retained and contingency.

A retained firm works for the organization and is paid a flat fee upfront (a retainer) to launch the search and an additional fee when the position is filled.  Retained firms usually visit your community to understand your needs and culture, carefully sourcing candidates who will be a good fit for your organization.  Retained firms are often the answer for hard-to-recruit for locations or specialties.

A contingency firm works for the candidate and is paid if/when you hire a candidate they found for you.  There is an agreement that you sign before they present any candidates stating that you will agree to pay them if you hire anyone they have introduced to you, typically within 12 months of the introduction.  You may sign an agreement with as many contingency firms as you like.  There is a great variance in candidates sent by different firms - some are pre-screened and some are not.  Because their goal is to place candidates, they may well be presenting a candidate to you and to your competition simultaneously.  Make sure that a contingency firm presents a name to you before sending a CV in case another firm has also presented the same candidate.  Some firms charge a flat fee and some charge a percentage of the hired employee's first year gross salary. Contingency firm fees hover around $10K for mid-level providers (nurse practitioners and physician assistants) and around $20K for physicians.

Some recruiters have the reputation of being out for themselves and not serving their clients (candidates and organizations), but instead only serving themselves.  The professional organization for physician recruiting organizations is the National Association of Physician Recruiters (NAPR) which has a Code of Ethics that members must adhere to.  You can research member firms here.

On the NAPR website, it notes a collaboration with MGMA:

MGMA, in collaboration with NAPR, surveys its membership to obtain the most recent physician starting salary placement compensation data. This is the fourth year of data collection and the third year of stand-alone publication for the Physician Placement Starting Salary Survey report. The report provides accurate data on the range of physician placements to assist recruiters and health care organizations in benchmarking salaries and other employment terms. The report also allows users to compare and learn more about the factors affecting first-year placement compensation. All survey participants receive a complimentary copy of the Physician Placement Starting Salary Survey
Revenue Cycle
The revenue cycle for a medical practice is the process of collecting reimbursement for a provided service. Some of the common steps are:
  1. Development of a "retail" fee schedule and a financial policy (payment practices.)
  2. Negotiating and signing payer contracts to accept specific fee schedules for services.
  3. Providing services to patients and collecting patient-responsibility portions at the time of service.
  4. Posting charges for services rendered and billing payers (filing claims.)
  5. Receiving payments from payers; appealing payments when not compliant with contracts.
  6. Sending statements to patients for any remaining portions due.
  7. Writing balances off the accounts receivable or sending patients to collection agencies/reporting agencies (credit bureaus) or pursuing legal action if patient payments are not made.
SBAR (communication format)
SBAR stands for Situation, Background, Assessment and Recomendation and is pronounced "S - BAR." SBAR is a standard format initially utilized by nurses to bring a physician up to speed on a problem.   At some point in time, it was realized that nurses and physicians communicate differently.  Generalizing, nurses want to "tell the story" of a problem and physicians want "the headlines." The IHI (Institute for Healthcare Improvement) says:
The safety attitudes questionnaire administered at Kaiser Permanente identified that physician and nurse perceptions of teamwork were significantly different. Physicians tended to view the care environment as fairly collaborative, whereas nurses saw it as much less so. To address the issue, Kaiser Permanente developed a communication tool that was adapted from the US Navy, called SBAR. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety. S=Situation (a concise statement of the problem) B=Background (pertinent and brief information related to the situation) A=Assessment (analysis and considerations of options — what you found/think) R=Recommendation (action requested/recommended — what you want)
Second Life (SL)
Second Life is a virtual world accessible via the Internet. A free program called the Second Life Viewer enables its users called Residents, to interact with each other through avatars (two-dimensional representations of people.)  Residents can explore, meet other residents, socialize, participate in individual and group activities, and create and trade virtual property and services with one another, or travel throughout the world, which residents refer to as the grid. Second Life is for people aged 18 and over, while Teen Second Life is for people aged 13 to 17. (definition adapted from Wikipedia) Among many other applications, SL is used to simulate situations in healthcare and teach clinical students in an almost real-world setting.  In 2009, Medical Group Management Association (MGMA) used Second Life as part of its virtual conference.
SOAP Note
SOAP stands for Subjective, Objective, Assessment and Plan.  It is a standard format for documenting a patient encounter and can be used both for face-to-face encounters as well as triage phone calls.

Subjective = what the patient reports as the problem, symptoms, location, duration, severity, etc.

Objective = the visual and physical examination of the patient (does not apply to phone triage)

Assessment = the diagnosis, or possible diagnosis of the problem

Plan = what the next step in treating the problem will be (medication, tests, referral, follow-up) or in the case of phone triage (work-in appointment vs. home instructions vs. ER)

Social Media
Social media is media designed to be distributed through social interaction using Internet and web-based technologies.  Social media use is said to be the defining factor in the idea that the current period in time will be defined as the "Attention Age." Wikipedia lists the following information and examples of social media:
Social media can take many different forms, including Internet forums, weblogs, social blogs, wikis, podcasts, pictures, video, rating and bookmarking. Technologies include: blogs, picture-sharing, vlogs, wall-postings, email, instant messaging, music-sharing, crowdsourcing, and voice over IP, to name a few. Many of these social media services can be integrated via social network aggregation platforms like Mybloglog and Plaxo. Examples:
Communication
Collaboration
Multimedia
Reviews and opinions
Entertainment

Social Networking
Social media researchers Danah Boyd of Microsoft Research New England in Cambridge, Mass., and Nicole B. Ellison of Michigan State University define social networking as having three distinct features
  • they must provide a forum where users can construct a public or semipublic profile;
  • create a list of other users with whom they share a connection;
  • and view and move around their list of connections and those made by others.
Examples of social networking sites are FaceBook, LinkedIn, and Twitter.
Starting and Ending the Day Protocols
Starting the Day:
  1. Disarm the burgler alarm.
  2. Turn on the lights.
  3. Check the condition of the office - did the cleaners miss anything?  Check the patient bathrooms for cleanliness and supplies.
  4. Check that yesterday's specimens were picked up by the lab.
  5. Make coffee.
  6. Turn on the copiers to give them a chance to warm up.  Make sure all copiers and faxes are full of paper.
  7. If you're using paper charts, make sure there aren't any "unfound" charts for the day's patients.
  8. Check the fax machines to see if any faxes arrived overnight.
  9. Have a morning huddle with the staff.  Discuss which providers are working, any problems from yesterday, any unusual things expected today, any schedule changes, any staff assignment changes, and any protocol reminders.
  10. Make sure the lab/clinic person has performed the lab controls and checked the refrigerator/freezer temperatures and documented them.
  11. Unforward the phones from the answering service, disconnect the answering machine, and have a staff member take any messages from overnight.
  12. Open the safe and remove the check-out change drawers, placing them at check-out.  Make sure change is available.
  13. Unlock the doors.
Ending the Day:
  1. Make sure all patients have left the practice.
  2. Lock the doors.
  3. Check to make sure the coffee pot is off and the lunch room has been tidied by the staff.
  4. Confirm who is on first and second call.
  5. Turn the phones over to the answering service (make sure they have the call provider name(s)) or the answering machine (make sure it states how to contact the provider(s) on call).
  6. As appropriate, send emails or distribute lists with the next day's schedule if the providers are rounding, performing surgery, or working at alternate sites.
  7. If using paper charts, make sure charts are pulled for next day's patients.
  8. Turn off radios, fans, heaters, copiers, etc.
  9. Make sure fax machine is loaded with paper.
  10. Have staff sign off all computers.  Perform computer backup, if not automatically run.
  11. Lock the change drawer and the day's deposit in the safe.
  12. Lock the sample closets, Rx pads, and all on-site medications.
  13. Turn off the lights, lock the doors and set the burgler alarm.
Steampunk
The term Steampunk denotes a time when steam power was still widely used—usually the 19th century, and often Victorian era England—but with prominent elements of ...either science fiction or fantasy, such as fictional technological inventions like those found in the works of H. G. Wells and Jules Verne! Steampunk fashion relys heavily on "brass bits, buckles and buttons"! Not healthcare, but interesting nonetheless!
TED
TED stands for Technology, Entertainment and Design.  TED started in 1984 as an annual conference held in Long Beach, California with the goal of bringing together people from the three fields to give 18-minute talks about innovation and possibilities.  The TED Talks site has more than 400 talks by people from an expanded array of fields and the videos of their talks are available to be shared and reposted without cost. From the TED Talks site:
Our mission: spreading ideas.  We believe passionately in the power of ideas to change attitudes, lives and ultimately, the world. So we're building here a clearinghouse that offers free knowledge and inspiration from the world's most inspired thinkers, and also a community of curious souls to engage with ideas and each other. This site, launched April 2007, is an ever-evolving work in progress, and you're an important part of it
TED has also spawned the TED Prize which is "designed to leverage the TED Community's exceptional array of talent and resources. It is awarded annually to three exceptional individuals who each receive $100,000 and, much more important, the granting of "One Wish to Change the World." After several months of preparation, they unveil their wish at an award ceremony held during the TED Conference. These wishes have led to collaborative initiatives with far-reaching impact."
VistA (Veterans Health Information Systems and Technology Architecture)
VistA, (Veterans Health Information Systems and Technology Architecture) which was originally developed in the 1970's by the Veterans Administration, is an open-source (meaning that the code is available for others to collaborate upon and improve) clinical documentation system that is used by all the 160-plus VA hospitals in the United States, plus all of their outpatient ambulatory clinics. Providing care to over 4 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics and 135 nursing homes , about a quarter of the nation's population is potentially eligible for VA benefits and services because they are veterans, family members or survivors of veterans. The VistA system has been in use by the Veterans Administration for more than 20 years, and as such is one of the most mature electronic medical records in existence. As the Veterans Administration does not bill third-party payers, VistA is not a billing system. VistA was released to the public through the Freedom of Information Act by the Veterans Administration and today is publicly available on CDs for a nominal fee. Althought the software is free, there is a cost to install, implement and maintain it. WorldVistA was formed to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. The system was originally developed by the U.S. Department of Veterans Affairs (VA) for use in its veterans hospitals, outpatient clinics, and nursing homes. WorldVistA has a number of development efforts aimed at adding new software modules such as pediatrics, obstetrics, and other functions not used in the veterans' healthcare setting. WorldVistA seeks to help those who choose to adopt the VistA system to successfully master, install, and maintain the software for their own use. WorldVistA will strive to guide VistA adopters and programmers towards developing a community based on principles of open, collaborative, peer review software development and dissemination.
Voice Recognition
Voice recognition (VR), sometimes called speech recognition (SR), is a technology that translates the spoken word into the written/electronic word.  In healthcare it is most commonly used for physician notes in the medical record.  The physician dictates the information and either edits the information himself/herself, or a staff member edits the information.  The physiican note can be printed for inclusion in the paper chart, or can be imported into the electronic chart.  Some electronic medical record (EMR) software products have speech recognition built-in, and some have the ability to integrate with speech recognition software.