Cases that cannot adequately be assigned to an appropriate DRG owing to unique combinations of diagnoses and surgeries, very rare conditions, or other unique clinical reasons. Such cases are grouped together into clinical outlier DRGs and are therefore considered outliers. Also see outlier.

Study of disease by the use of laboratory tests and methods of body tissue and fluids.

Description of an activity or practice that may result in favorable outcomes for patients with a specific disease. A clinical pathway uses defined resources to keep costs down. It may be based on research, literature, or common practice. Also called critical pathway, practice guideline, or treatment protocol.

This is a method or instrument to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality.

Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.

Right or permit to provide medical, dental, and other medical services to patients by a hospital facility within certain limits based on the physician’s education, professional license, experience, competence, ability, health, and judgment. Also called practice privileges.

Written plans or guidelines that specify procedures to be followed in performing a specific examination, treating certain injuries, conducting research, providing medical care for a particular condition, and evaluating appropriateness of certain procedures. Also known as medical protocols or protocols.

Health care professional that specializes in the diagnosis, treatment, and prevention of a wide range of personality, mental, and behavioral disorders. Generally, clinical psychologists are state licensed and may practice independently. Many insurance companies pay for their services. However, they do not treat physical causes of mental disease with drugs or other medical or surgical treatments because they are not licensed to practice medicine. Also see psychologist.

Health care organization created by academic medical centers to integrate medical school, faculty practice plan, and hospital.