EHR Glossary: Complete Guide to Electronic Health Record Terminology (2026)

Clear, concise definitions for the terms, acronyms, and concepts you will encounter when evaluating, implementing, or optimizing an electronic health record system. Bookmark this page as your go-to reference.

A

Ambient AI Documentation

Ambient AI documentation uses artificial intelligence to passively listen to provider-patient conversations during clinical encounters and automatically generate structured clinical notes. This technology dramatically reduces the documentation burden that contributes to physician burnout, allowing clinicians to focus on patient care rather than typing. Modern ambient AI tools integrate directly with EHR systems to populate note templates, suggest diagnoses, and auto-code encounters.

API (Application Programming Interface)

An API is a set of protocols and tools that allows different software applications to communicate and exchange data. In the EHR context, APIs enable third-party applications — such as patient portals, billing platforms, and telehealth tools — to integrate with the core EHR system. The FHIR standard defines the dominant API framework for healthcare data exchange, and the 21st Century Cures Act requires certified EHR vendors to provide open APIs.

Related: EHR Interoperability Guide

ASAM Criteria

The ASAM Criteria is a comprehensive, multidimensional assessment framework developed by the American Society of Addiction Medicine for evaluating patients across six dimensions and matching them to the appropriate level of care for addiction treatment. It is widely regarded as the national standard for placement, continued stay, and discharge decisions in substance use disorder treatment. Behavioral health EHR systems designed for addiction treatment often include built-in ASAM assessment tools and automated level-of-care recommendations.

B

Bed Management

Bed management is an EHR module that tracks real-time bed availability, patient assignments, and occupancy rates across residential and inpatient treatment facilities. Effective bed management tools help admissions coordinators optimize census, reduce empty-bed days, and streamline intake workflows. For behavioral health organizations operating multiple facilities, this feature directly impacts revenue by maximizing occupancy and improving patient flow between levels of care.

Behavioral Health EHR

A behavioral health EHR is an electronic health record system specifically designed for mental health, substance use disorder, and behavioral health treatment settings. Unlike general medical EHRs, these systems include specialized features such as treatment planning, ASAM assessments, group therapy documentation, 42 CFR Part 2 compliance, and progress note formats like BIRP, DAP, and SOAP. Leading BH EHR vendors include Netsmart, AZZLY Rize, Valant, and TherapyNotes.

BIRP Notes

BIRP notes are a clinical documentation format that structures progress notes into four sections: Behavior (observable client actions and statements), Intervention (therapeutic techniques applied), Response (how the client responded to interventions), and Plan (next steps and homework). BIRP is widely used in behavioral health settings and is often preferred by payers reviewing clinical documentation for medical necessity. Most behavioral health EHR systems include BIRP as a built-in note template alongside DAP and SOAP formats.

C

CDR (Clinical Data Repository)

A clinical data repository is a centralized database that aggregates patient data from multiple clinical systems — including the EHR, laboratory information systems, imaging systems, and pharmacy platforms — into a unified, queryable store. CDRs enable organizations to run population health analytics, quality reporting, and clinical research queries across their entire patient base. Large health systems often deploy a CDR alongside their EHR to support data warehousing and business intelligence needs.

Clinical Decision Support (CDS)

Clinical decision support refers to EHR functionality that provides clinicians with knowledge-based alerts, reminders, and evidence-based recommendations at the point of care. Examples include drug-drug interaction warnings, allergy alerts, preventive care reminders, and diagnostic suggestions based on documented symptoms. Well-designed CDS improves patient safety and care quality, while poorly configured CDS can lead to alert fatigue, which is a leading complaint among EHR users.

Cloud EHR

A cloud EHR is an electronic health record system hosted on remote servers managed by the vendor or a cloud infrastructure provider (such as AWS, Azure, or Google Cloud) and accessed via a web browser or application. Cloud EHRs eliminate the need for on-site servers, reduce upfront capital expenditures, and transfer infrastructure security responsibilities to the vendor. As of 2026, the majority of new EHR deployments are cloud-based, with on-premise installations declining steadily.

CPOE (Computerized Provider Order Entry)

CPOE is an EHR feature that allows providers to enter medical orders — including prescriptions, laboratory tests, imaging studies, and referrals — electronically rather than on paper. CPOE systems include built-in clinical decision support to check for errors, duplicate orders, and contraindications at the time of entry. CPOE adoption is a core requirement of ONC-certified EHR systems and has been shown to reduce medication errors by 50% or more.

D

DAP Notes

DAP notes are a clinical documentation format organized into three sections: Data (the factual information gathered during the session, including client statements and observations), Assessment (the clinician's professional analysis of the data), and Plan (the next steps, goals, and follow-up actions). DAP is commonly used in behavioral health and counseling settings because it provides a streamlined structure that is faster to complete than SOAP notes while still meeting most payer documentation requirements.

Data Migration

Data migration is the process of transferring patient records, clinical data, billing history, and administrative information from one EHR system to another. It is one of the most complex and risk-prone phases of an EHR implementation, requiring careful mapping of data fields, validation of transferred records, and cleanup of legacy data. Costs typically range from $2,000 to $15,000 depending on data volume and complexity, and the process can take 4 to 12 weeks.

E

EHR vs. EMR

While often used interchangeably, EHR (Electronic Health Record) and EMR (Electronic Medical Record) have distinct meanings. An EMR is a digital version of a patient's chart within a single practice or organization — it replaces paper records but is not designed for external sharing. An EHR is a broader, interoperable record designed to follow the patient across multiple providers, health systems, and care settings. In practice, nearly all modern systems marketed as "EMRs" actually function as EHRs with data sharing capabilities.

EPCS (Electronic Prescribing for Controlled Substances)

EPCS is a DEA-regulated capability that enables providers to electronically prescribe Schedule II through Schedule V controlled substances. It requires identity-proofing, two-factor authentication, and a third-party audit trail to ensure prescription integrity. EPCS is now mandated in most states and is especially critical for behavioral health and MAT providers who regularly prescribe controlled medications like buprenorphine. Not all EHR systems include EPCS natively — some require a separate add-on or integration.

e-Prescribing

e-Prescribing (electronic prescribing) is the electronic generation and transmission of prescriptions directly from the provider's EHR to the patient's pharmacy, replacing handwritten, printed, or faxed prescriptions. It improves accuracy, reduces medication errors, and provides automatic drug interaction and formulary checking. The Surescripts network processes the vast majority of e-prescriptions in the United States. For controlled substances, see EPCS.

ERA/EOB (Electronic Remittance Advice / Explanation of Benefits)

An ERA is an electronic document sent from an insurance payer to a healthcare provider that details how claims were adjudicated, including payment amounts, adjustments, denials, and patient responsibility. The EOB is the patient-facing counterpart explaining what the insurance plan covered. EHR and practice management systems that support automatic ERA posting can dramatically accelerate the revenue cycle by eliminating manual payment entry.

F

FHIR (Fast Healthcare Interoperability Resources)

FHIR is a modern healthcare data exchange standard developed by HL7 International that uses RESTful APIs — the same technology powering web and mobile applications — to enable EHR systems to share patient data securely and efficiently. FHIR R4 is now federally mandated under the 21st Century Cures Act, and as of 2025, over 90% of certified EHR vendors support it. FHIR is foundational to TEFCA, patient access APIs, and the growing ecosystem of SMART on FHIR applications.

42 CFR Part 2

42 CFR Part 2 is a federal regulation that provides stringent privacy protections specifically for patient records related to substance use disorder treatment, going beyond standard HIPAA requirements. Under Part 2, SUD treatment records cannot be shared without explicit written patient consent, even for treatment, payment, or healthcare operations purposes. Behavioral health EHR systems must include Part 2-compliant consent management, segmented data sharing, and audit trails. Recent regulatory updates (effective 2024-2026) have begun aligning Part 2 more closely with HIPAA, but significant restrictions remain.

H

Health Information Exchange (HIE)

Health Information Exchange refers to both the process and the organizations that facilitate the electronic sharing of health data among providers, payers, and public health agencies. HIEs can operate as directed exchange (point-to-point), query-based exchange (pull model), or consumer-mediated exchange (patient-directed). Regional and state HIEs are now connecting to the national TEFCA framework through Qualified Health Information Networks (QHINs), creating a nationwide interoperability backbone.

Related: EHR Interoperability Guide

HIPAA (Health Insurance Portability and Accountability Act)

HIPAA is landmark federal legislation enacted in 1996 that establishes national standards for the protection of individually identifiable health information (PHI). For EHR systems, HIPAA compliance requires administrative safeguards (access controls, workforce training), physical safeguards (facility access controls), and technical safeguards (encryption, audit logs, automatic logoff). Any EHR vendor handling PHI must sign a Business Associate Agreement (BAA) and maintain compliance with the HIPAA Security Rule, Privacy Rule, and Breach Notification Rule.

HL7 (Health Level Seven)

HL7 is an international standards-developing organization that creates frameworks for the exchange, integration, sharing, and retrieval of electronic health information. HL7 v2 messaging has been the workhorse of healthcare data exchange for decades, handling ADT (admit/discharge/transfer) messages, lab results, and orders between systems. HL7's newer standard, FHIR, is rapidly becoming the dominant interoperability framework due to its modern API-based architecture and federal mandates.

I

ICD-10 (International Classification of Diseases, 10th Revision)

ICD-10 is the standardized coding system maintained by the World Health Organization and used globally to classify diseases, disorders, injuries, and health conditions. In the United States, ICD-10-CM (Clinical Modification) is required for clinical documentation and diagnosis reporting, while ICD-10-PCS (Procedure Coding System) is used for inpatient procedure coding. EHR systems must support ICD-10 code lookups, favorites lists, and integration with clinical decision support to ensure accurate coding and clean claims submission.

Interoperability

Interoperability is the ability of different EHR systems, medical devices, and health IT applications to communicate, exchange data, and use shared information effectively across organizational boundaries. True interoperability spans four levels: foundational (basic data transport), structural (standardized formats), semantic (shared clinical terminology), and organizational (governance alignment). The 21st Century Cures Act and TEFCA are driving rapid improvements in interoperability through mandated FHIR APIs and information blocking prohibitions.

Related: EHR Interoperability Guide

IOP (Intensive Outpatient Program)

An intensive outpatient program is a structured behavioral health treatment program that provides several hours of therapy per day (typically 3-4 hours), multiple days per week, without requiring the patient to reside at a treatment facility. IOPs are commonly used for substance use disorder treatment, eating disorders, and mental health conditions. In the ASAM framework, IOP corresponds to Level 2.1 of care. EHR systems serving IOP programs need robust group therapy scheduling, attendance tracking, and level-of-care transition workflows.

K

KLAS Rating

KLAS ratings are performance scores published by KLAS Research, an independent healthcare IT research firm, based on extensive interviews with healthcare providers who use the systems being evaluated. KLAS evaluates EHR vendors on dimensions including usability, implementation quality, vendor support responsiveness, training effectiveness, and overall satisfaction. KLAS scores are widely referenced in the EHR selection process and are considered one of the most objective vendor performance benchmarks available.

L

Level of Care (LOC)

Level of care refers to the intensity and type of clinical services a patient receives, categorized along a spectrum from basic outpatient services through intensive outpatient, partial hospitalization, residential treatment, and inpatient hospitalization. In behavioral health, the ASAM Criteria defines specific levels (0.5 through 4) for addiction treatment. EHR systems must track level-of-care assignments, transitions, and authorizations to ensure appropriate care, accurate billing, and regulatory compliance.

LOS (Length of Stay)

Length of stay measures the duration of time a patient spends in a treatment program or facility, calculated from admission to discharge. LOS is a critical operational and clinical metric in behavioral health, influencing staffing, bed utilization, payer authorization, and outcomes reporting. EHR systems with robust census reporting and bed management capabilities track LOS automatically and can trigger alerts when patients approach authorization limits or target discharge dates.

M

MAT (Medication-Assisted Treatment)

Medication-assisted treatment combines FDA-approved medications (such as buprenorphine, methadone, and naltrexone) with counseling and behavioral therapies to treat substance use disorders, particularly opioid use disorder. MAT is recognized as the gold standard for opioid addiction treatment. EHR systems supporting MAT programs need EPCS capabilities, prescription drug monitoring program (PDMP) integration, 42 CFR Part 2 compliance, and workflows for tracking medication adherence and take-home dose protocols.

Meaningful Use

Meaningful Use was a CMS incentive program (active 2011-2018) that set specific objectives for how healthcare providers should use certified EHR technology to improve care quality, safety, and efficiency. The program evolved through three stages of increasing requirements. It has been replaced by the Promoting Interoperability program, which shifts the focus toward health information exchange, patient access, and FHIR-based interoperability. The term "Meaningful Use" remains widely used colloquially to refer to federal EHR compliance requirements.

MIPS (Merit-Based Incentive Payment System)

MIPS is a CMS quality payment program that adjusts Medicare Part B payments to eligible clinicians based on performance across four categories: quality measures, Promoting Interoperability, improvement activities, and cost. Strong MIPS performance can result in positive payment adjustments of up to 9%, while poor performance can trigger penalties. EHR systems play a central role in MIPS compliance by automating quality measure reporting, tracking improvement activities, and generating the data required for Promoting Interoperability attestation.

O

ONC Certification

ONC (Office of the National Coordinator for Health IT) certification confirms that an EHR system has been tested and verified by an ONC-Authorized Certification Body (ONC-ACB) to meet federal standards for functionality, security, and interoperability. Certified EHR Technology (CEHRT) designation is required for practices participating in MIPS, Promoting Interoperability, and other CMS quality programs. You can verify a vendor's certification status on the ONC Certified Health IT Product List (CHPL).

On-Premise EHR

An on-premise EHR is a system installed and hosted on servers physically located at the healthcare organization's facility, requiring in-house IT staff or a managed services provider to maintain hardware, apply security patches, manage backups, and ensure uptime. On-premise deployments offer direct control over data and infrastructure but carry higher upfront costs, ongoing maintenance burden, and disaster recovery challenges compared to cloud EHR alternatives.

P

Patient Portal

A patient portal is a secure, web-based application — typically integrated with the EHR — that gives patients 24/7 access to their health information, appointment scheduling, secure messaging with providers, prescription refill requests, lab results, and billing statements. Patient portals are a core requirement of the Promoting Interoperability program, and high portal adoption rates are linked to improved patient satisfaction, better medication adherence, and reduced no-show rates.

PHP (Partial Hospitalization Program)

A partial hospitalization program is a structured day treatment program that provides intensive psychiatric or behavioral health services for approximately 5-6 hours per day, five or more days per week, while the patient returns home or to a supportive living environment at night. PHP serves as a step-down from inpatient care or a step-up from IOP when a patient needs more intensive services. In the ASAM framework, PHP corresponds to Level 2.5 of care.

Practice Management

Practice management (PM) software handles the administrative and financial operations of a healthcare practice, including patient scheduling, registration, insurance verification, charge capture, claims submission, payment posting, and financial reporting. Many modern EHR vendors offer integrated EHR + PM platforms, eliminating the need for separate systems and reducing duplicate data entry. The combination of EHR and practice management is often referred to as a "complete" or "all-in-one" solution.

Related: EHR Cost Guide

Promoting Interoperability

Promoting Interoperability (PI) is the current CMS program — formerly known as Meaningful Use — that incentivizes eligible clinicians and hospitals to use certified EHR technology to improve patient engagement, health information exchange, and care coordination. The program includes specific measures around e-prescribing, health information exchange, patient portal access, and public health reporting. Performance in PI directly impacts MIPS scores and Medicare payment adjustments.

R

RCM (Revenue Cycle Management)

Revenue cycle management encompasses the entire financial lifecycle of a patient encounter, from initial appointment scheduling and insurance verification through charge capture, claims submission, payment posting, denial management, and patient collections. Effective RCM is critical to a practice's financial health, and EHR systems with integrated RCM capabilities — or tight integrations with dedicated RCM platforms — can automate eligibility checks, scrub claims for errors before submission, and track denial patterns.

Residential Treatment

Residential treatment refers to a 24-hour structured care setting where patients live at the facility while receiving intensive therapeutic services including individual counseling, group therapy, psychoeducation, and medication management. In the ASAM framework, residential treatment spans Levels 3.1 through 3.7 of care. EHR systems for residential programs require bed management, census tracking, length-of-stay monitoring, and support for concurrent utilization review workflows.

S

SaaS (Software as a Service)

SaaS is a cloud-based software delivery model where the vendor hosts the application on its infrastructure and users access it through a web browser or thin client on a subscription basis. In the EHR market, SaaS pricing is typically structured as a per-provider-per-month fee that includes hosting, updates, backups, and support. SaaS EHR systems are functionally equivalent to cloud EHRs and offer lower upfront costs, automatic updates, and scalable infrastructure compared to on-premise licenses.

SOAP Notes

SOAP notes are the most widely used clinical documentation format, structuring progress notes into four sections: Subjective (the patient's reported symptoms, concerns, and history), Objective (clinician observations, vital signs, and test results), Assessment (clinical diagnosis and analysis), and Plan (treatment decisions, prescriptions, and follow-up actions). SOAP notes are used across virtually all healthcare specialties. Most EHR systems include customizable SOAP note templates, and many ambient AI tools can auto-generate SOAP-formatted notes.

SUD (Substance Use Disorder)

Substance use disorder is a medical condition defined in the DSM-5 as a pattern of recurrent alcohol or drug use that causes clinically significant impairment, including health problems, disability, and failure to meet responsibilities. SUD treatment spans a continuum from outpatient counseling through IOP, PHP, residential, and medically managed inpatient care. EHR systems for SUD treatment must support ASAM assessments, 42 CFR Part 2 consent management, MAT workflows, and state reporting requirements.

T

TCO (Total Cost of Ownership)

Total cost of ownership is a financial estimate that captures the complete cost of an EHR system over its expected lifetime, including not just the subscription or license fee but also implementation, data migration, training, customization, hardware (for on-premise systems), ongoing support, interface fees, and the productivity loss during transition. TCO analysis is essential when comparing cloud vs. on-premise models, as a lower monthly subscription can be misleading if implementation and add-on costs are high.

TEFCA (Trusted Exchange Framework and Common Agreement)

TEFCA is a federal initiative, mandated by the 21st Century Cures Act, that establishes a universal governance framework for nationwide health information exchange through a network of Qualified Health Information Networks (QHINs). TEFCA aims to create a "network of networks" where any provider can electronically query and retrieve patient records from any other participating provider, regardless of which EHR system either uses. As of 2026, TEFCA is actively onboarding QHINs and expanding use cases including treatment, payment, public health, and individual access.

Telehealth

Telehealth is the delivery of healthcare services remotely using video conferencing, secure messaging, or telephone — integrated within an EHR to maintain clinical documentation continuity. EHR-integrated telehealth ensures that virtual visits generate the same structured notes, billing codes, and treatment records as in-person encounters. Following the permanent expansion of telehealth flexibilities post-pandemic, most EHR vendors now offer built-in or tightly integrated telehealth capabilities, and payer reimbursement parity has been established in many states.

Treatment Planning

Treatment planning is the clinical process of creating a structured, goal-oriented care plan that documents a patient's diagnoses, treatment objectives, measurable goals, specific interventions, responsible providers, target dates, and progress metrics. In behavioral health, treatment plans are typically required for regulatory compliance, accreditation (CARF, Joint Commission), and payer authorization. EHR systems with strong treatment planning modules allow clinicians to build plans from templates, link goals to evidence-based interventions, and track progress over time with outcome measures.

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How to Choose an EHR — A step-by-step guide to evaluating and selecting the right EHR for your practice.
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