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HIT 220 Module 5

a comprehensive system of applications that afford access to longitudinal health information about an individual across the continuum of care, assist in documentation, support clinical decision making, and provide for knowledge building electronic health record (EHR)
the need for the EHR to collect data from cradle to grave longitudinal
information that populate the EHR and include the electronic medication administration record, laboratory information system, radiology information system, hospital information system, and nursing information system Source systems
To realize the full benefits of the EHR, data should be captured at the point of care. True
The EHR should have access to knowledge-based resources such as MEDLINE, electronic drug references, and research databases. True
a snapshot of data from the EHR and includes basic information such as diagnoses, allergies, medications, and future treatment continuity of care record (CCR)
Unlike the EHR, the purpose of the CCR is not to provide a legal health record, but rather information for the continuity of care. True
a tool for collecting, tracking, and sharing important, up-to-date information on the patient's medical history. personal health record (PHR)
A PHR/s information is controlled by the patient and includes a wide range of data including allergies, diagnoses, medications, and social and family history. True
notify physicians of screenings that should be performed based on a patient's age and gender reminders
a subset of the EHR that is used for subsequent patient care is called: CCR
A reason to implement an EHR is to: improve patient care
The infrastructure required for the EHR includes which of the components not found in most information systems? Rules engine
The system that includes patient information from both the patient and the healthcare provider is called the: PHR
The phrase "womb to tomb" refers to: longitudinal record
advances the development, adoption, and implementation of healthcare information technology standards Office of the National Coordinator for Health Information Technology (ONC)
What 3 criteria must an EHR have Integrates data from multiple sources Captures data at the point of care Assists the providers in their decision-making process
a network of networks sharing patient information to provide immediate access across the nation national health information network (NHIN)
The Certification Commission on Health Information Technology (CCHIT) is the sole certifier of the EHR. True
was an advisory committee to the U.S. Department of Health and Human Services. The ultimate goal was interoperability; disbanded in 2008 American Health Information Community (AHIC)
created to address issues and effect the change needed to enable the secure and reliable exchange of electronic health information nationwide; replaced (AHIC) National eHealth Collaborative (NeHC)
the anti-kickback law; prohibits physicians or their family members from owning businesses to whom the physician refers patients for health services. Prevents physicians from receiving a fee for referring patients for any healthcare service on Medicare The Stark Law
Order communication/results retrieval Electronic document/content management Clinical messaging Patient care charting Computerized physician/provider order entry system Electronic medication administration reporting Clinical decision support system Components of an EHR
notifies clinical departments, such as the laboratory, radiology, physical therapy, and dietary departments, of orders made by the physician Order communication system
contains preprogrammed clinical decisions support designed to assist the user through making an entry appropriately clinical provider order entry
Electronic document/content management may also be called electronic document management system (EDMS) True
may utilize scanning to capture patient information from a paper record, ERM, COLD, voice, e-mail, and e-fax systems electronic document management system (EDMS)
connects the medical staff and hospital by providing access to systems such as order entry/results reporting and EDMS systems Clinical messaging
the secure transmission of clinical information from on entity to another, including providers to providers, patients to providers, payers to providers, and among members of the healthcare community, such as within a regional health information org Clinical messaging
a type of information that allows for entry of orders, which are then routed to the appropriate department for action. Once the results are available, they are routed back to the care provider for review order entry/results reporting
generally found in checkboxes, drop-down boxes, and other data entry means whereby the user chooses from options already built into the system Structured data
also called narrative data; can be entered in a free text format by the user, usually by typing Unstructured data
The use of a computerized physician/provider order entry system (CPOE) can lead to significant improvements in patient safety because of the reminders and alerts built into the system True
alerts and reminders controlled by clinical decision support built into the system that are able to help prevent medication errors and improve the quality of care through its validation mechanisms Computerized physician/provider order entry system
automates many of the medication administration processes in a healthcare facility electronic medication administration record (EMAR)
the implantation of a microchip to an item to allow tracking of that item; can also provide alerts to assist in medication timing and provide the nurse with material on the medication itself radiofrequency identification devices (RFID)
the help provided in association with data entry into an EHR system performed directly by the caregiver at the point of care clinical decision support system (CDSS)
The CDSS may be active, which means that it has alert or reminders the user must address, or passive, which means the user may choose to utilize or ignore the alerts True
used to control the reminders and alerts as well as the clinical practice and benchmarking. True
compares internal data to external data benchmarking
a secure method of communication between the healthcare provider and the patient, just the providers, or the provider and the payer patient provider portal
an application designed for the patient to manage his/her own health information for personal maintenance purposes and to provide to healthcare providers for complete and accurate histories personal health record
the capture and reporting of healthcare data that are used for public health purposes. Allows the healthcare provider to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials population health
The component of the EHR that reports infectious diseases is: population health
Clinical decision support to enhance physician orders is found in which component of the EHR? CPOE
The ability of a healthcare facility to provide EHR software to the physicians is allowed through: an exception to the Stark Law
CCHIT's role in the EHR is: certification
Which statement is true about the state of adoption of the EHR? Most EHRs are found in larger facilities and physician practices
Easy access to clinical information Speeds diagnosis Improves quality of care Patient education Improve communication between patient and provider Improved efficiency Benefits of the EHR
Cost Lack of uniform standards Training Fear Barriers to the EHR
Functionality and performance of an EHR will vary by setting True
The core function of the EHR is storing patient information. True
The EHR can link to medical devices, allowing for capture of monitoring and testing True
combined with the practice management system that performs the billing, scheduling and other administrative tasks; typically includes a summary screen that quickly accesses parts of the medical record Ambulatory care functionality of the EHR
Departmentally focused acute care EHR
The time taken to enter data is considered to be a _____ to the EHR. barrier
What function is typically found in the ambulatory EHR but not the inpatient EHR? Practice management
Which of the following is a benefit of the EHR? Improved efficiency
Which statement regarding patient education is true? Patient education can be customized for each individual patient
Which statement is true about the EHR? The EHR is different based on the setting in which it operates
The purpose of signatures, in both the paper and electronic environment, is to record the identity of the individual who performed the entry. True
One of the benefits of the electronic signature is that it automatically stamps medical record entries with the date and time of the entry. True
Digitized signature Electronic signature Digital signature 3 levels of signatures found in the EHR
a scanned image of an individual's actual signature digitized signature
requires a password or even a two-tiered authentication method to be entered before the signature is executed electronic signature
similar to the electronic signature except that it uses encryption and nonrepudiation to prove the authenticator's identity digital signature
used for secondary data; purpose is to group similar items together; a system that is clinically descriptive and arranges or organizes like or related entities ex. ICD-9-CM classification system
terms used in professional billing Current Procedural Terminology (CPT)
Standards are important to the EHR because they streamline the communication method that allows systems to speak to each other and for data to be stored using the same formats, language, and terms to describe and execute functions. True
works collaboratively with public and private sectors to achieve what they call "widespread interoperability among healthcare software applications" Health Information Technology Standards Panel (HITSP)
organizations that create standards Standards development organizations (SDOs)
responsible for accrediting SDOs in the US; provides a neutral environment for others to work together to settle on a common agreement American National Standards Institute (ANSI)
Made from consensus Due process Openness Balance ANSI requirements for approval of standards
facilitate interoperability through the standardization of the structure and content of data elements; identify the structure and content of elements to be collected by the EHR Data content standards
address the problem of multiple ways to define, classify, and represent language Vocabulary standards
systems that identify the names used nomenclature
terminology that is designed to capture detailed clinical information, which then makes it possible to share and aggregate data Systemized Nomenclature of Medicine (SNOMED)
a laboratory vocabulary that is used to order and report laboratory tests and record clinical observations for use in patient car, outcomes management, and research Logical Observation Identifiers Names and Codes (LOINC)
LOINC was not intended to share all data collected about a laboratory test, but instead to identify test results. True
a vocabulary for medications developed by the National Library of Medicine (NLM), Veterans Administration, the Food and Drug Administration, and input from HL-7 RxNorm
a database that catalogues bibliographic citations for biomedics; developed to help improve search capabilities Unified Medical Language System (UMLS)
a branch of linguistics dealing with the study of meaning, including the ways meaning is structured in language and how changes in meanings and form occur over time semantics
the study of the patterns of formation of sentences and phrase from words and of the rules for the formation of grammatical sentences in a language sentax
used to help retrieve data across many databases; UMLS Metathesaurus, SPECIALIST Lexicon, UMLS Semantic knowledge sources
developed by the Food and Drug Administration to act as a universal unique identifier for human drugs; identifies the labeler/vendor, product, and trade package size National drug codes (NDC)
a nomenclature and knowledge-based system that provides an intelligent clinical database for documentation by the clinician at the time of care MEDCIN
a crosswalk between the various terminologies that allows for interoperability mapping
an exact match is made between the systems one-to-one
a more granular term in the starting system maps to a more general term in the receiving system narrow-to-broad
a more general term in the starting system maps to a more granular term in the receiving system broad-to-narrow
there is not matching into the receiving system unmappable
an extension of workflow analysis, an early and essential step in selecting or designing new health information technology use cases
used frequently to create maps; describes how the user will interact with the system and what the system will do use cases
The most secure type of signature used in the EHR is: digital signature
ICD-9-CM is an example of a: classification system
The nomenclature used in the EHR to capture detailed clinical information is called: SNOMED CT
Which of the following organizations is an SDO? ANSI
The concept of a crosswalk between two terminologies is called mapping
supports communications between information systems; proprietary systems are able to talk to one another, allowing the exchange of data Messaging standards
Health Level 7 (HL7) Digital Imaging and Communications in Medicine (DICOM) National Council for Prescription Drug Programs Approved messaging standards
HL7 is the standard used in most applications True
specializes in standards for clinical and administrative data for the healthcare environment HL7
lists the functions that may be present in an EHR and supplies a common language for these functions Electronic Health Record System (EHR-S)
for a single interface that allows the user to interact with one system even when accessing multiple systems Clinical Context Object Workgroup (CCOW)
retrieves images and other information from imaging equipment of a variety of different vendors Digital Imaging and Communications in Medicine (DICOM)
standards that control data to be shared for new prescriptions, refills, and other communications between physicians and pharmacies National Council for Prescription Drug Programs (NCPDP)
control individual data elements such as formats and its valid characters, how data is stored, and how it can be manipulated Data structures
a group of data elements that are the minimum accepted level of information to be collected for a specific purpose along with uniform definitions Data sets
a collection of data carefully organized to be of value to the user database
a database that is developed in an open format, thus allowing the facility to use it for multiple systems data repository
a database containing data from other source systems in the healthcare facility such as laboratory information system, hospital information system, or radiology information system data warehouse
The data warehouse is not updated in real time, but is better formatted to allow for querying and data analysis True
controls screen layout, data entry, and data retrieval presentation layer
Graphical User Interface (GUI) technology is used to navigate through an information system. True
A disadvantage of unstructured data is that it is not beneficial for reporting purposes. True
One of the advantages of structured data is that it can be easily used for reporting purposes. True
the user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient template-based entry
converts unstructured text into a structured format; requires sophisticated computer software to separate the narrative into little packets Natural language processing (NLP)
the ability of one computer system to exchange data with another computer system interoperability
Basic Functional Semantic 3 levels of interoperability
a computer can send data to another computer but the receiving computer is unable to interpret the data basic interoperability
defines the structure of messages so that the receiving computer can interpret the data functional interoperability
allows the information to be used in a meaningful way semantic interoperability
a system with functional components that include both paper and electronic documents and use both manual and electronic processes hybrid record
Which of the following standards is the messaging standard used in most information systems? HL7
DICOM is a example of a: messaging standard
Which of the following is a database that is not updated in real time? Data warehouse
Check boxes is a method of data entry used in: structured data entry
The term used to describe a medical record that is partially online and partially paper-based is: hybrid record
I am a physician. I need to check test results of my patient from my office. Which components of the EHR would I use? patient provider portal
What type of standard controls the content of the data elements? data content standards
What system is used to provide an universal unique identifier for human drugs? National Drug Codes
I just clicked on an icon. I must be using what to navigate through the EHR? graphical user interface
I need to be able to group similar diagnoses together. I need a: Classification system
Created by: adale3171