Glossary

Analyze

To DETERMINE actions in the flow of processing data by comparing, correlating, or weighting certain data and by applying clinical or business rules, hence leading to a decision (see DECIDE). For example, the system may ANALYZE patient information using a drug-interaction database and a set of clinical rules. Another example is that the system may ANALYZE various protocols relative to a patient’s condition. Another example is that a person may ANALYZE a proposed update to a patient’s home address and DECIDE to reject the proposed update.

Annotate

To UPDATE data by attaching comments or notes to the data without editing the data. For example, an Attending physician may ANNOTATE the information entered by the Resident physician before signing the report.

Archive

To STORE data by moving the data to long-term storage media and deleting or purging data on the original online storage, according to scope of practice, organizational policy, and/or jurisdictional law. For example, the system at the Oak Street Hospital automatically ARCHIVES patient-related data that is older than eight years by encrypting and compressing it, moving it to long-term storage, purging it, identifying the data by month and year, and creating a pointer to the archived data. Another example is that a system may automatically ARCHIVE outpatient clinic schedules that are being replaced.

Attest

To UPDATE information by ATTESTing that an EHR record (or part of an EHR record) is genuine.. For example, a resident physician may ATTEST that the information contained in an EHR record was created by her. Another example is that an attending physician may annotate a resident’s version of the record and then ATTEST to those changes. Note: Attestations may be applied, affixed or bound to an EHR record, for example, via a digital signature, certification, or other verifying mark.

Audit

To TRACK system-initiated or user-initiated activities by analyzing logs based on policies or rules. For example, the system may automatically AUDIT the daily log for multiple-failed-logon-attempts. Another example is that an administrator may AUDIT the excessive use of extraordinary (i.e., “break-the-glass”) access to certain patient information in the Emergency Department.

Authenticate

To CONTROL ACCESS to a system by validating the identity of a user, another system or a device before authorizing access. For example, the system may AUTHENTICATE Dr. Jones by validating his identity using a UserID and a biometric device. Another example is that the system rejects Sara Smith’s attempt to AUTHENTICATE to the system after three failed password entries.

Authorize

To CONTROL ACCESS to a system by applying permissions to use certain functionality or to view certain data. For example, the system may AUTHORIZE Dr. Jones, an Emergency Department physician, to view Emergency Department patient records (note: We assume that the administrator has entered a set of permissions for all Emergency Department physicians). Another example is that the system does not AUTHORIZE deletion by Sara Smith of a patient record that has already been signed.

Auto-populate

To CAPTURE data by inputting it automatically using previously-existing data, providing a default value, or deriving it from other data, or by following various data-entry business rules. For example, the system may AUTO-POPULATE the city, state/province, and country fields when a user enters a zip-code. Another example is that the system may AUTO-POPULATE a newborn’s home address with the mother’s home address.

Backup

To STORE data by placing a copy of the data onto an electronically-accessible device for preservation in case the original is lost, corrupted, or destroyed. For example, a system may BACK UP the incremental changes made to a patient’s record by storing it locally on a daily basis. Another example is that an administrator may BACK UP a complete copy of certain data by storing it at an offsite facility.

Capture

To MANAGE data by auto-populating, entering, importing, or receiving the data, either through human intervention or automated means. For example, a system may CAPTURE patient’s data entered by a physician through the keyboard or sent by the physician using a mobile device. Another example is that the system may CAPTURE laboratory results by automatically receiving laboratory data or by keyboard entry for locally performed tests.

Control Access

To AUTHENTICATE users and/or systems and AUTHORIZE access to functionality and/or data. For example, the system may CONTROL ACCESS to the patient’s data by authenticating Dr. Jones’ identity and authorizing him to update his patient’s records. Another example is the system may CONTROL ACCESS to the system by refusing a hospital visitor the ability to authenticate to the system. NOTE: the set of CONTROL ACCESS Action-Verbs requires data specifying permissions. This permission data is managed via the MANAGE data Action-Verbs set.

Decide

To DETERMINE actions in the processing of data by choosing a certain alternative based on an analysis, and acting accordingly. For example, the system may DECIDE to render a notification to off-duty nurses to report for duty based on clinic rules and the receipt of a tornado alert. Another example is that the system may DECIDE to RENDER an alert to a clinician that a prescribed drug is contraindicated with the patient’s listed allergies, based on the analysis conducted.

Decrypt

To STORE data by converting encrypted data back into its original form, so it can be understood. For example, the system may DECRYPT clinical data received from an authenticated external laboratory system.

De-identify

To MANAGE-DATA-VISIBILITY by removing identifiers from data in such a way that the risk of identifying an individual is very small under the circumstances, as specified by scope of practice, organizational policy, and/or jurisdictional law. For example, a system may DE-IDENTIFY data for a researcher who wants to perform an analysis of drug effectiveness on diabetic patients. Another example is where a hospital may DE-IDENTIFY data for a set of patients to transmit to a university professor looking for illustrative cases for educational work.

Delete

To REMOVE data by making it inaccessible to the application. For example, a user may DELETE an existing patient-appointment at the request of the patient. Note: In the case where the data becomes invalid but needs to remain in the system, the word “TAG” is preferred over the word “DELETE” or the word “Nullify”. This type of action is considered a data “Tagging” process and not a data deletion process. For example, a health information management professional may desire to TAG a certain clinical term as obsolete, but the term needs to remain in the system for backward compatibility purposes.

Determine

To MANAGE data by analyzing it and making a decision based on the analysis. For example, the system may DETERMINE the possible severity of a patient’s allergic reaction to a proposed drug by analyzing the patient’s profile against a drug database and deciding whether the clinician should be presented with an alert or not. Another example is that a system may DETERMINE the next steps in a workflow based on an analysis of a patient’s laboratory results, the patient’s profile, and the clinical rules of the clinic, this analysis leading to a decision as to the appropriate next steps in the clinical process.

Edit

To UPDATE data by correcting, amending, appending, or augmenting the data. For example, the physician may EDIT the patient’s home address by correcting the civic number from 368 to 638 Oak Street. Another example is that a physician may EDIT existing notes about an injury by appending an x-ray picture of a broken bone.

Encrypt

To STORE data by transforming the data into a form that is difficult to understand by unauthorized people or systems. For example, the system may ENCRYPT sensitive information such as the patient’s financial information.

Enter

To CAPTURE data by inputting it manually (for example, via a keyboard) or through other input devices. For example, the user may manually ENTER the patient’s street address via the keyboard. Another example is that the user may ENTER the patient’s body weight via an electronic weight scale.

Exchange

To MANAGE data by importing, receiving, exporting, or transmitting the data between systems. For example, the PHR Account Holder may exchange family history information with the PHR systems of other family members.

Extract

To RENDER data by locating, retrieving and possibly assembling data based on certain criteria and for certain purposes. For example, a system may EXTRACT for a clinician all the x-ray reports regarding the patient’s chest. Another example is that the system may automatically EXTRACT allergy history when the physician enters a prescription. Another example is that a system may EXTRACT for a researcher the number of pneumonia-like cases treated at the Emergency Department within a specific time period. Another example is that a system may EXTRACT and aggregate information using a cohort of patients who have pneumococcal disease and categorize that cohort by specific age-ranges.

Harmonize

To UPDATE data by aligning and reconciling it with other information in the system, or with the data of another system (or systems). For example, the system may HARMONIZE a patient’s new home address with the data of systems of other members of the care-team.

Hide

To MANAGE-DATA-VISIBILITY by making specific information invisible so that the existence of the information is not expressed except to authorized users; viewers of the patient record receive no indication that the hidden information exists or does not exist. For example, the system may HIDE the existence of a patient’s psychiatric record from all viewers except for the patient’s psychiatrist. Note: the verb “unhide” is an acceptable verb to reverse the action of hiding.

Import

To CAPTURE data into a local system by proactively accessing data from an external source and then downloading and integrating the data into the local system. For example, the system may IMPORT the latest drug trial data every Friday evening. Another example is that the user may IMPORT various sets of best practices related to juvenile diabetes.

Inactivate

To maintain control of data by removing access to the data in such a way as the data is no longer active for a certain reason. For example, the PHR Account Holder may no longer employ a list of local oncologists, while the PHR Account Holder is stationed in another country for a while.

Integrate

To UPDATE data by merging other data with the existing data in a controlled manner. For example, a user may INTEGRATE summaries of health care services that were provided in another jurisdiction into the patient’s local record. Another example is that an EHR system may INTEGRATE a single-sign-on application with the EHR system’s existing user-authentication services. Another example is that an EHR system may INTEGRATE multiple third-party modules to enhance its capabilities.

Link

To UPDATE data by associating one piece of data with another piece of data. For example, the system may LINK a patient’s encounter note with the patient’s laboratory results. Another example is that a system may LINK attestable changes to a patient’s record to the author’s identifying information.

Log

To TRACK system-initiated or user-initiated activities (including access to data and/or functionality, attempts to access data and/or functionality, actions performed on data and/or functionality, and changes to system characteristics or versions) by storing a chronological trace of these activities. For example, the system may LOG the fact that modifications were made to a patient’s record by storing the date, time, and identity of the user who modified the record as well as what changes were made to that record. Another example is that the system may LOG the fact that updates were applied to a drug-interaction database table, by storing the date and time at which it was updated.

Maintain

To MANAGE data by storing, updating, and/or removing the data within a system. For example, a system may provide the ability for a clinician to MAINTAIN data by keeping or discarding it. Another example is that a system may provide the ability for a clinician to MAINTAIN data by correcting or annotating it.

Manage (Data)

To handle data by capturing, maintaining, and rendering data, determining actions about data, and managing data visibility. For example, the system may provide the ability for a user to MANAGE patient and family preferences as they pertain to current treatment plans. Another example is that a clinician’s system may provide the ability for the clinician to MANAGE patient data by creating a patient’s record, updating a clinical note, utilizing clinical decision support tools, and transmitting the patient’s billing information.

Manage-Data-Visibility

To MANAGE data by de-identifying/re-identifying, masking/unmasking or hiding/unhiding that data. For example, the system may provide the ability for an administrator to MANAGE-DATA-VISIBILITY in terms of who is allowed to view what specific patient data.

Mask (verb)

To MANAGE-DATA-VISIBILITY by obscuring (masking) specific data elements in order that this information is not available except to authorized users; viewers of the patient record can see that the data exists but cannot see actual contents. For example, the administrator may MASK the pregnancy status of all patients who are below the age of eighteen except for the obstetric unit staff. Note: the verb “unmask” is an acceptable verb to reverse the action of masking.

Present

To RENDER data by delivering the data to local users in a meaningful and appropriate way. For example, the system may PRESENT to a physician (upon manual request) a list of patients who are scheduled for care today, ordered by time-of-day, with the patient’s known diagnosis using the physician’s preferred terminology and language of choice. Another example is that the system may PRESENT an alert automatically when a newly-arriving laboratory value is received that is out of normal range. Another example is that a system may PRESENT to a physician a patient’s lung respiration sounds. Another example is that a system may PRESENT patient-instructions using an audio and video system. Note: It is reasonable to assume that any data that is presented ought to be formatted, filtered, translated, transformed, mapped, and/or normalized, etc., as appropriate.

Pseudonymize

To MAINTAIN data by creating a pseudonym for its subject. For example, the name "Robert Q. Jamison" may be replaced with a pseudonym such as "John Smith" in a health care document before sharing it with others.

Purge

To REMOVE data by making it unrecoverable at the storage and/or media-level. For example, the system may PURGE the patient record for John Smith according to a rule that targets all records that are older than seven years. (Note: Destroy and Purge are synonyms; PURGE is the preferred term.)

Receive

To CAPTURE data from an external source by taking in that data without manual / real-time user intervention. For example, the system may RECEIVE various emails for a clinician who will later review them. Another example is that the system may RECEIVE from authenticated and authorized external systems laboratory results for a given patient. Another example is that the system may RECEIVE a facsimile transmission from an external device.

Recover

To STORE data by rebuilding original data using backups of data. For example, the system may RECOVER last week’s data following a hard disk failure, using an offsite backup copy. (See BACKUP.)

Re-identify

To MANAGE-DATA-VISIBILITY by combining data in such a way that the patient’s identity is re-established according to scope of practice, organizational policy, and/or jurisdictional law. For example, the system may RE-IDENTIFY de-identified data by providing a key that allows authorized users to re-establish the link between a given patient and that patient’s de-identified data.

Remove

To MAINTAIN data by making the data inaccessible or unrecoverable according to scope of practice, organizational policy, and/or jurisdictional law. For example, a system may, at a physician’s request, REMOVE by purging patient information that was received by mistake. Another example is that a system may, upon request by an administrator, REMOVE by deletion the schedule of outpatient clinic opening hours. NOTE 1: The data may be deleted either by removing the data’s pointer from the directory or by overwriting the data in such a way that the original data is unrecoverable. NOTE 2: In the case where the data becomes invalid but needs to remain in the system, the word TAG is preferred over the word REMOVE or “Nullify”. This type of action is considered a data “Tagging” process and not a data deletion process. For example, a health information management professional may desire to TAG a certain clinical term as obsolete, but the term needs to remain in the system for backward compatibility purposes.

Remove Access

To MAINTAIN data by disallowing access to the data in such a way as the data can no longer be retrieved.

Render

To MANAGE data by extracting, presenting and transmitting data to users or systems. For example, the system may RENDER a list of patients with a given disease that has been extracted from the clinic’s active patient records. For example, the system may RENDER laboratory results by presenting them on a computer screen. Another example is that the system may RENDER data by transmitting a drug prescription to a pharmacy.

Restore

To STORE data to the production system by using previously archived data. For example, the system may RESTORE patient-encounter data for a returning patient whose data had been archived due to inactivity. Another example is that the system may RESTORE, for evidentiary support, patient data that had been archived after the patient expired. (See ARCHIVE.)

Save

To STORE data by placing it onto an electronically-accessible device for preservation. For example, a clinician may SAVE a given patient’s demographic data or a newly-prescribed medication. Another example is that an administrator may SAVE an updated list of physicians that have practice privileges at the local hospital.

Secure (System)

To ensure system reliability and integrity by controlling access to system functionality and/or data, tracking activities, and sustaining system operations. For example, the system may provide the ability for an administrator to SECURE a system by setting configuration parameters for controlling access, tracking, and sustaining system operations. Another example is that the system may SECURE access to a patient’s record by controlling access to its content, tracking users who have modified the patient’s record, and sustaining the record’s availability on a continual basis.

Send

To OUTPUT data from the PHR Account Holder’s system by exporting it in such a way as to (passively, automatically) route it to another system. For example, a PHR Account Holder’s system may (passively, automatically) send weekly reports to a diabetes specialist’s system regarding the PHR Account Holder’s current weight.

Store

To MAINTAIN data by backing up, decrypting, encrypting, restoring and saving that data onto electronically accessible devices. For example, a clinician may STORE a given patient’s demographic data or a newly-prescribed medication. Another example is that an administrator may configure a system to STORE progressive copies of certain data on a regularly-scheduled basis for backup purposes. Note: data may be stored as plain text or in encrypted or compressed form.

Sustain (operations)

To SECURE a system by promoting actions that enable the system to perform predictably and as intended. For example, a system may SUSTAIN (OPERATIONS) by applying business rules that enforce role-based access to the authorization management portion of the system, thus protecting the PHR Account Holder’s data according to pre-determined security and privacy rules.

Synchronize

To OUTPUT data from the PHR Account Holder’s system by exporting it in such a way as to coordinate certain data with another system (or systems). For example, the PHR Account Holder may coordinate the medications prescribed by two physicians with a list of home remedies so that each relevant, authorized stakeholder has a current list of the PHR Account Holder’s medications/remedies.

Tag

To UPDATE data by marking it for special use. For example, a nurse may TAG the previous week’s records for patients that presented with a severe cough and fever. Another example is that a general practitioner may TAG certain data for review by an oncologist. Another example is that an administrator may TAG an interchange standard version as being deprecated. Note: see “flag” if the meaning is to signal a situation. Note: the verb “untag” is an acceptable verb to reverse the action of tagging.

Track

To SECURE a system by logging and auditing system-initiated and/or user-initiated activities. For example, the system may TRACK the amount of time that the system was unavailable last month. Another example is that the system may provide the ability for an administrator to TRACK the number of active users of a newly-installed set of system functionality.

Transmit

To RENDER data by delivering the data to devices or other systems in a meaningful and appropriate way. For example, the system may (without human intervention) TRANSMIT an alert to a physician’s beeper. Another example is that the system may (upon human intervention) TRANSMIT a given patient’s encounter summary to an external facility. Another example is that the system may TRANSMIT data to another facility after mapping local codes to national codes. Note: It is reasonable to assume that any data that is transmitted ought to be formatted, filtered, translated, transformed, mapped, and/or normalized, etc., as appropriate.

Unhide

To MANAGE-DATA-VISIBILITY by making visible the existence of previously hidden information (see HIDE). For example, the system may provide the ability for a patient to UNHIDE his psychiatric record, and hence the existence of that part of his record becomes visible to all authorized clinicians.

Unmask

To MANAGE-DATA-VISIBILITY by making masked information visible. For example, the administrator my desire to UNMASK certain patient financial information for the admission Department. For example, a system may provide the ability for an emergency department physician to UNMASK a patient’s pregnancy status that was presented by the system as “******”, to reveal a status of “Pregnant”.

Untag

To UPDATE data by removing marking for special use. For example, a nurse may UNTAG the previous week’s records for patients that presented with a severe cough and fever that had been previously tagged. Another example is that a general practitioner may UNTAG certain data after completion of review another provider.

Update

To MAINTAIN data by annotating, editing, harmonizing, integrating, linking and tagging the data. For example, a clinician may UPDATE a patient’s medication dosage. Another example is that the system may UPDATE a patient’s record.

Access

Instead, use CONTROL-ACCESS if the context is one of controlling access to the system.. Use RENDER or PRESENT or another relevant Action-Verb when the context is one of accessing data.

Affirm

Instead, use TAG (with an appropriate qualifier). Affirm, Assert, Declare, Indicate, and State are synonyms.

Alert

Instead, use “RENDER or PRESENT or TRANSMIT an alert to a person or another system (including a device)”. An Alert typically occurs after analyzing some data and arriving at a decision that someone must be alerted. See DETERMINE for some examples.

Amend

Instead, use EDIT.

Append

Instead, use the term EDIT. This means editing data by adding new data to existing data.

Assert

Instead, use TAG (with an appropriate qualifier). Affirm, Assert, Declare, Indicate, and State are synonyms.

Augment

Instead, use EDIT, ANNOTATE, or LINK with the appropriate qualifiers. Augmentation is the addition of information to existing healthcare data.

Calculate

Instead, use “DETERMINE and STORE” or “DETERMINE and PRESENT”, as appropriate in the context.

Compute

Instead, use “DETERMINE and STORE” or “DETERMINE and PRESENT” as appropriate in the context.

Configure

Instead, use “MANAGE configuration parameters for…”. For example, the user may desire to STORE configuration parameters regarding the preferred type of human language. Another example is that an administrator may UPDATE configuration parameters that control external access to the system by restricting access during the weekends.

Conform

To comply... Note: The verb ‘Conform’ is used with a special meaning in the FM and is not part of the Action-Verb model. It is a special instruction for including the functional requirements of one function in another function. For example: “The system SHALL conform to function IN.1.1 (Entity Authentication)”.

Correct

Instead, use EDIT.

Create

Instead, use “DETERMINE and STORE” or “DETERMINE and RENDER” or “DETERMINE and PRESENT” as appropriate to the context.

Declare

Instead, use TAG (with an appropriate qualifier). Affirm, Assert, Declare, Indicate, and State are synonyms.

Deprecate

Instead, use TAG with an appropriate qualifier. Deprecation of certain information may be required when that data becomes invalid, but needs to remain in the system. For example, a health information management professional may desire to TAG a certain clinical term as deprecated, but the term is retained in the system for backward compatibility purposes.

Destroy

Disable-Access

Instead, use “CONTROL ACCESS by removing permissions to use specific functionality and/or manage specific data”.

Disclose

Instead, use “RENDER and TAG” with a label that identifies the data’s purpose as “for disclosure use only”.

Display

Instead, use PRESENT.

Document

Instead, use ENTER, or “TAG with” appropriate references, or “LINK to” sources.

Eliminate

Instead, use DELETE or PURGE as applicable.

Export

Use RENDER instead.

Flag

Instead, use “RENDER an alert”, or “PRESENT an alert”, or “TRANSMIT a notice”, if the intent is to signal a situation (i.e. flag a situation).

Generate

Instead, use “DETERMINE and STORE” or “DETERMINE and PRESENT” or “DETERMINE and RENDER“ as appropriate to the context.

Grant-Access

Instead, use CONTROL ACCESS.

Identify

Instead, use other Action-Verbs adapted to the context. . For example, instead of ‘…to uniquely identify a patient…’, one should say ‘…to MAINTAIN a unique identifier for a patient…’ Another example is: instead of ‘…to help identify the patient...’, use ‘…help DETERMINE the identity of the patient.’.

Input

Instead, use CAPTURE, ENTER, RECEIVE, IMPORT or AUTO-POPULATE, depending on the context and scope of actions described.

Label (verb)

Use “TAG with a label”.

Merge

Instead, use INTEGRATE.

Modify Access

Instead, use: “MANAGE data regarding permissions”

Notify

Instead, use “RENDER or PRESENT or TRANSMIT a notification to a person or another system (including a device)”.

Nullify

Instead, use “TAG as nullified”.

Obsolete

Instead, use “TAG as obsolete”.

Order

Instead, use “ENTER the parameters for an order”.

Permit Access

Instead, use “AUTHENTICATE a user and AUTHORIZE access based on permissions assigned to that user”.

Persist

Instead, use “STORE“.

Print

Instead, use RENDER, PRESENT, OR TRANSMIT, depending on the context.

Prioritize

Instead, use “TAG with a priority level”, or “DETERMINE priorities”.

Provide access to

Instead, use CONTROL ACCESS, or PRESENT, as appropriate to the specific context.

Query

Instead, use ANALYZE or RENDER (or its children Action-Verbs), because queries or searches are implied when rendering or analyzing data.

Reactivate

Instead, use TAG with an appropriate qualifier. Reactivation of certain information may be required when that data, previously deprecated or made inactive, becomes valid again. For example, a health information management professional may desire to TAG a certain clinical term as reactivated.

Reconcile

Instead, use ANALYZE and DECIDE, or DETERMINE, or HARMONIZE depending on the context and the meaning intended.

Record

Instead, use STORE (or its children Action-Verbs).

Reject

Instead, use ‘’PRESENT or RENDER a message of rejection” or “TAG as rejected”.

Replace

Instead, use EDIT, or “DELETE the old and SAVE the new”, or “TAG as obsolete and SAVE the new”, based on the context.

Report

Instead, use “RENDER a report”, or “PRESENT a report”.

Repudiate

Instead, use “TAG as repudiated or rejected”.

Retain

Instead, use STORE (with the possible addition of language that includes the notion that retention management may be needed to accommodate scope of practice, organizational policy, or jurisdictional law). For example, the system may provide the ability to STORE personal health information, and DELETE that data only as allowed by the organization’s data-retention policies.

Revoke-Access

Instead, use “CONTROL ACCESS by eliminating permissions to use system functionality or to manage data”.

Search

Instead, use ANALYZE or RENDER (or its children action-verbs), because queries or searches are implied when rendering or analyzing data. For example, instead of saying “The system SHALL provide the ability to search patient records based on previous names”, one can say ‘‘The system SHALL provide the ability to PRESENT a list of records with possible patient name matches using previous patient names”.

Select

Instead, use “ENTER a selection”.

Sign

Instead, use “TAG-with-authenticated-signature”. For example, a system may TAG a patient note with an authenticated signature when the physician completes the patient’s note.

State

Instead, use TAG with an appropriate qualifier. Affirm, Assert, Declare, Indicate, and State are synonyms.

Support

Instead, use “PRESENT templates to do XYZ”, or DETERMINE, or other Action-Verbs depending on the context and functionality to specify.

Suspend-Access

Instead, use “CONTROL ACCESS by temporarily withholding permissions to use system functionality or to manage data”.

Synthesize

Instead, use “ANALYZE and STORE” or “ANALYZE and PRESENT”.

Trigger

Instead, depending on the context, use “DECIDE on a course of action based on an analysis of certain data and rules”, or “DECIDE and RENDER some information (for example, an alert or a notification) based on the analysis of certain data and rules”.

View

Instead, use PRESENT.

Term

Instead use...