Glossary

Release of Information List of Terms and Links to More Info

The medical record fulfillment, release of information, and care coordination field makes use of many specialized health-related terms and abbreviations. This glossary provides definitions that can help you better understand the information on this website.

A

Advancing Care Information (ACI)

The Advancing Care Information performance category is a category in the Medicare & Medicaid Services Merit-based Incentive Payment System program. It promotes the secure exchange of health information by healthcare providers and encourages them to use certified electronic health records technology.

Audit log

An audit log is a chronological record of events pertaining to a release of information request. It provides documentary evidence of the specific sequence of events and is kept for security purposes. Also referred to as an “audit trail.”

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C

Covered entity

A covered entity is a healthcare provider, health plan, or healthcare clearinghouse that electronically transmits any protected health information associated with transactions that are governed by standards set out by the Department of Health and Human Services.

Custodian

A custodian is an organization that’s responsible for the storage and safeguarding of patients’ health records. The custodian must ensure that the medical records are stored and, when properly requested, released in compliance with HIPAA regulations.

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Electronic health information (ePHI)

Electronic health information is protected health information that’s created, stored, transmitted or received by hospitals, other HIPAA-covered entities and their business associates. This protected health information pertains to providing healthcare and receiving payment for services.

Electronic health record (EHR)

An electronic health record provides a broad perspective of a patient’s health. It contains data from all the healthcare providers involved in a patient’s care. Furthermore, all the physicians who are authorized by the patient can access the record with the purpose of providing care to him or her.

Electronic health record - meaningful use (EHR-MU)

Electronic health record - meaningful use refers to the meaningful leveraging of EHR technology such as electronic prescribing. It also refers to ensuring the technology facilitates the electronic sharing of health information in order to enhance the quality of care.

Electronic medical record (EMR)

An electronic medical record is a digital version of a patient’s medical history that a healthcare provider maintains in order to provide that patient with quality care.

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Health information exchange (HIE)

Electronic health information exchange enables healthcare providers to access and, when appropriate, share a patient’s health information digitally. This can greatly improve the speed, efficiency and security with which a patient can receive care.

Health information management (HIM)

Health information management involves acquiring, reviewing, analyzing and safeguarding both hard copy and digital medical information.

Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act is legislation that defines standards that protect patients’ PHI. HIPAA regulations offer patients more control regarding how their medical information is disclosed and used — plus, it allows them access to their own medical records.

More Information

Health Information Technology for Economic and Clinical Health (HITECH) Act

The HITECH Act is legislation that promotes the adoption of health information technology, as well as its meaningful use. In Subtitle D, it includes a number of provisions that strengthen the criminal and civil enforcement of HIPAA regulations in order to mitigate security and privacy concerns regarding the electronic transmission of PHI.

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Meaningful use

The meaningful use category was officially known as the Medicare EHR Incentive Program for eligible clinicians. Under the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System -- or MIPS -- it’s now referred to as the Advancing Care Information performance category.

Medical record

A medical record is a chronological written history of a patient’s health issues, diagnoses and test results. It also lists all procedures performed and treatments prescribed.

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Protected health information (PHI)

Protected health information refers to health information that’s generated, stored, transmitted or received by HIPAA-covered organizations and their business associates regarding providing healthcare and receiving payment for their services.

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Quality assurance (QA)

The practice of maintaining a desired level of quality, privacy and security in the release of information process. This involves verifying that an authorization for ROI is complete and valid, as well as that all released information is correct.

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Release of information (ROI)

A release of information is an official statement in which a patient authorizes a healthcare provider to release a portion of his or her PHI to a third party for a specific purpose.

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Requestor

A patient or party that requests the release of information. If the requestor is not the patient, the patient must authorize the other party to request the release of information prior to filing a request.

Release of information department (ROI department)

A release of information department can be found in a mid-sized or large healthcare institution, usually within the HIM department. It handles tasks such as providing patients with medical records release forms, obtaining patients’ consent, determining what data can be released and certifying medical records before releasing them to third parties.

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State statute pricing

State statute pricing is the medical records copying charge allowed in a state according to state law. Some states allow healthcare providers to charge a flat fee for an entire medical record or a per-page copy fee up to a specific dollar amount. In the event that the amount is very high and can’t be validated by the true costs of copying the records, it may be in conflict with HIPAA regulations that allow patients right of access. In that case, HIPAA regulations prevail, meaning that the dollar amount must be cost-based and reasonable.

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