Chapters 1-6 Health Information Management Technology An Applied Approach

1918
The hospital standardization program was started by the American College of Surgeons in:
1928
HIM has been recognized as an allied health profession since:
6 months
The Consortia’s education program is designed to be completed in what amount of time?
Accreditation Commission for Health Care (ACHC)
a private non-profit accreditation organization offering services for home health care, hospice, and alternative site healthcare (ie: infusion nursing, home/ durable med. equip. supplies.)
American College of Surgeons
ACS
Administrative and clinical
The two major types of data that are contained in the health record
Advance directive
The administrative documents that provide information on the patient’s desires for healthcare for use if he/she is incapacitated?
American Health Information Management Association
AHIMA
AHIMA Communities of Practice
a virtual network of AHIMA members
AHIMA Foundation
an arm of AHIMA that promotes education and research in health information management?
AHIMA House of Delegates
Which of the following functions as the legislative body of AHIMA?
AHIMA Values:
*The public’s right to accurate and confidential personal health information
*Innovation and leadership in advancing health information management practices and standards worldwide
*Adherence to the AHIMA Code of Ethics
*Advocacy and interdisciplinary collaboration with other professional organizations
AHIMA Vision
Quality healthcare through quality information
American Medical Association
AMA
American Academy of Professional Coders
provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers, and in payer organizations
American Associate of Medical record Librarians (AAMRL)
The name adopted by the Association of Record Librarians of North America in 1944; precursor of AHIMA
American College of Surgeons
The hospital standardization movement was inaugurated by the:
American College of Surgeons (ACS)
The scientific and educational association of surgeons formed to improve the quality of surgical care by setting high standards for surgical education and practice
American Health Information Management Association
An association whose purpose is to ensure quality, confidentiality and availability of HI across diverse organizations, settings, and disciplines
American Health Information Management Association (AHIMA)
The professional membership organization for managers of health record services and healthcare information systems as well as coding services; provides accreditation, certification, and educational services
American Medical Record Association
AMRA name adopted by AAMRL/1970
American Recovery and Reinvestment Act of 2009 (ARRA)
Previously known as the stimulus bill or HR1. The actions related to health information technology are spread throughout the law; however the bulk of the items are in Title XIII – Health Information Technology; also called Health Information Technology for Economic and Clinical Health Act or HITECH
Blue Cross/Blue Shield
BCBS
CAHIIM
The organization that accredits HIM education programs is:
Care Plan
a summary of the patient’s problems from the nurse or other professional’s perspective w/ a detailed plan for interventions.
Committee on Accreditation of Rehabilitation Facilities (CARF)
Which group focuses on accreditation of rehabilitation programs and services?
Center for Disease Control and Prevention
CDC
Certification
The formal process for conferring a health information management credential is called:
Certification
the process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements 2. an evaluation performed to established the extent to which a particular computer syste, network design, or application implementation meets a prespecified set of requirements
Certified Documentation Improvement Practitioner (*CDIP)
An individual who has achieved specialized skills in the cancer registry
Chief information officer CIO)
responsible for evaluation and acquisition of clinical and nonclinical technological systems that best meet the business needs of the organization
Clinical Information Systems (CIS)
an automated system that the function is medical record processing (e.g chart assembly), medical record data collection and analysis, information confidentialtiy and security
Center for Medicare and Medicaid Services
CMS
Code of Ethics
A statement of ethical principles regarding business practices and professional behavior.
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
The accrediting organization for educational programs in health informatics and information management.
Commission on Certification for Health Informatics and Information Management (CCHIIM)
oversees AHIMA’s certification process and for setting policies and procedures pg18
Communities of Practice
The virtual network used by AHIMA members is:
To be the professional community that improves healthcare by advancing best practices and standards for HIM and the trusted source for education, research, and professional credentialing.
Mission of AHIMA
Component state associations
(CSAs) promote the mission and purpose of AHIMA in its state
Consultation
An attending physician requests the advice of a second physician who then review the health record and examines the patient. The second physician records impressions in what type of report?
Communities of Practice
CoP
Credentialing
The process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners, for granting medical staff membership to provide patient care services.
Curriculum
A prescribed course of study in an educational program.
data
the dates, numbers, images, symbols, letters, and words that represent the basic facts and observations about people, processes, measurements, conditions, and conditions.
Department based
The traditional model of HIM practice was:
Det Norske Veritas
an international accrediting organization
Department of Health and Human Services
DHHS
Enterprise content and information manager
Manages an organization’s non clinical paper and electronic documents including developing systems to index and track the location of content and information within the enterprise
Expressed consent
Written or spoken permission to proceed with care is classified as:
Food and Drug Administration
FDA
Fellowship Program
Program of earned recognition for AHIMA members who have made significant and sustained contributions to the HIM profession through meritorious service, exellence in professional practice, education, and advancement of the profession through innovation and knowledge sharing.
Foster professional development
The primary focus of AHIMA is to:
Health data analyst
Retrieves, analyzes and reports health data using appropriate software and statistical techniques
Health Information Management (HIM)
An allied health profession that is responsible for ensuring the availability, accuracy, and protection of the clinical information that is needed to deliver healthcare services and to make appropriate healthcare-related decisions.
Health record
the principal repository for information and data about the health care services provided to an individual patient.
Health record receiver
responsible for monitoring quality of health information and reconciling information within health record banks and monitoring records for quality
HIM director
works with the design development and implementation of the EHR monitoring and reconciling interfaces running electronic data integrity audits and supervising a staff of individuals in a “virtual” HIM department
Health Insurance Portability and Accountability Act
HIPAA
Health Maintenance Organization
HMO
Hospital Standardization Program
an early twentieth-century survey mechanism instituted by the American College of Surgeons and aimed at identifying quality of care problems and improving patient care
House of Delegates
An important component of the volunteer structure of AHIMA that conducts the official business of the organization and functions as its legislative body.
information
factual data that have been collected, combined, analyzed, interpreted, &/or converted into a form that can be used for a specific purpose.
Information focused
The new model of HIM practice is:
licensure
refers to state or county regulations that healthcare facilities must meet to be permitted to provide care
Master Patient Index (MPI)
a list or database created and maintained by a healthcare facility to record the name and identification number of every patient who has ever been admitted or treated in the facility.
National Cancer Registrars Association (NCRA)
An organization of cancer registry professionals that promotes research and education in cancer registry administration and practice.
National Committee for Quality Assurance
Which group focuses on accreditation of managed care?
NCRA
Which professional organization sponsors the Certified Tumor Registrar (CTR) certification
New Graduate Membership
status for new graduate/ full 1 year membership at a reduced rate
Newborn
Sleeping patterns, head and chest measurements, feeding and elimination status, weight and Apgar scores are recorded in what records?
Occupational Safety and Health Administration
OSHA
Pathology report
A report that provides information on tissue removed during a procedure
personal health record (PHR) liasion or consultant
assists individuals in completion of their personal health records
Physician’s group consultant
Aids in EHR system implementation, auditing documentation practices, or assisting with revenue cycle management
Privacy officers
creates the rules for exchange of health information and ensures that the health information remains confidential
Preferred Provider Organization
PPO
Registered Health Information Administrator
RHIA certification after 4 year program in HIM and credentialing examination
Registered Health Information Technician
RHIT certification after 2 year program in HIM and credentialing examination
Registration
The act of enrolling.
Revenue Cycle Management (RCM)
an automated system’s functions are: >admitting, patient access management >case management >charge capture >health info. management >patient financial services, business office >finance >compliance >Info. Technology
Revenue cycle manager
oversees all of the processes that make up the revenue cycle from documentation, coding through billing to improve efficiency in the cycle
Social Security Administration
SAS
Student Membership
AHIMA membership category for students enrolled in an AHIMA accredited or approved program.
Terminology modeler
creates digital links among various terminologies and classification systems
The electronic health record system (EHR)
An automated system that the function is medical records processing (e.g., chart assembly), Medical record analysis and completion, release of information, medical record file services, medical record data collection and analysis, department organization and management, forms management (format and content), information confidentiality and security
The House of Delegates
Which functions as the legislative body of AHIMA
The Mission of AHIMA
To be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing.
undergo Medicare certification surveys
An accrediting organization is awarded deemed status by Medicare for one of its programs. This means that facilities receiving accreditation under its guidelines do not need to:
Voice/text/speech system (VTS)
an automated system that the function is medical record report dictation and transcription
Accreditation organization
A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations.
aggregate data
Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed.
Allied health professional
A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietician, social worker, or occupational therapist)
Centers for Medicare and Medicaid Services
The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care Financing Administration (HCFA) prior to 2001
Coding specialist
The healthcare worker responsible for assigning numeric or alphanumeric codes to diagnostic or procedural statements.
Confidentiality
A legal and ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure
Data
The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions.
Data accessibility
The extent to which healthcare data are obtainable.
Data accuracy
The extent to which data are free of identifiable errors.
Data comprehensiveness
The extent to which data are complete.
Data consistency
The extent to which healthcare data are reliable.
Data currency
The extent to which data are up-to-date.
Data definition
The specific meaning of a healthcare-related data element.
Data granularity
The level of detail at which the attributes and values of healthcare data are described.
Data precision
The extent to which data have the values they are expected to have.
Data quality management
A managerial process that ensures the integrity (accuracy and completeness) of an organization’s data during data collection
Data relevancy
The extent to which healthcare-related data are useful for the purpose for which they were collected
Data timeliness
Refers to data being recorded at or near the time of the event or observation.
Diagnostic codes
Numeric or alphanumeric characters used to classify and report diseases, conditions, and injuries.
Electronic health record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.
Health Record
A paper- or computer-based tool for collecting and storing information about the healthcare services provided to a patient in a single healthcare facility; also called a patient record, medical record, resident record, or client record, depending on the healthcare setting.
Health Record Format
refers to the organization format of electronic information or paper forms within the individual health record.
Information
Factual data that have been collected, combined, analyzed, interpreted, and/or converted into a form tha can be used for a specific purpose.
Integrated health record format
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments. Commonly used in paper-based record systems.
Interoperability
The ability, generally by adoption of standards, of systems to work together.
Personal health record (PHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed and controlled by the individual
Privacy
The quality or state of being hidden from, or undisturbed by, the observation or activities of other persons or freedom from unauthorized intrusion; in healthcare-related contexts, the right of a patient to control disclosure of personal information.
Problem-oriented health record format
Patient record in which clinical problems are defined and documented individually. Organized into 4 components: the database, the problem list, initial plans, and progress notes. Commonly used in paper-based record systems.
Procedural codes
The numeric or alphanumeric characters used to classify and report the medical procedures and services performed for patients.
Quality improvement organizations (QIO)
An organization that performs medical peer review of Medicare and Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy, and quality of care; and appropriateness of prospective payments for outlier cases and non-emergent use of the emergency room; until 2002, called peer review organization.
Reimbursement
Compensation or repayment for healthcare services
Security
1) The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration, destruction, or loss. 2) The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and control access to the content of these systems.
Source-oriented health record format
A system of health record organization in which information is arranged according to the patient care department that provided the care; mostly used by acute care hospitals. Commonly used in paper-based record systems.
Third-party payers
An insurance company (for example, Blue Cross/BlueShield) or healthcare program (for example, Medicare) that reimburses healthcare providers (second party) and/or patients (first party) for the delivery of medical services.
Transcriptionist
A specially trained typist who understands medical terminology and translates physicians’ verbal dictation into written reports.
DELETE Utilization Management organization
An organization that reviews the appropriateness of the care setting and resources used to treat a patient.
Primary Purposes of the Health Record
Patient care delivery; Patient care management; Patient care support processes; Financial & other administrative processes; Patient self management
Secondary Purposes of the Health Record
These purposes of the health record: Education; Regulation; Research; Public Health and Homeland Security; Policy Making and Support; Industry; are considered: -secondary -primary.
Data
Chapter Question: We had 324 Medicare patients last month. This statement represents which of the following: Information / Data / Content of the PHR / Patient-Specific information
PHR
Chapter Question: I am a patient. My medical history, including information from myself and my physicians is stored on the Internet. This is an example of which of the following: Health Record / EHR / PHR / Data
Patient Care Management
Chapter Question:Which of the following is an example of a primary purpose of the medical record? Education / Policy making / Research / Patient Care Management
Getting patients involved in their own care
Chapter Question: Examples of patient care delivery usage of the medical record include which of the following uses? -Developing of practice guidelines -Communication between caregivers -Reimbursement for patient care – Getting patients involved in their own care
This is a false statement as the PHR is controlled by the patient and the EHR is controlled by the caregiver.
Chapter Question: Critique this statment: The PHR and EHR are synonyms
True
True or False: the health record is the principal repository for data and information about the healthcare services provided to individual patients
False – it is “data”
True or False: The lab test “hemoglobin: 14.6 gm/110 ml” is considered information.
True
T/F The primary purposes of the health record are associated directly with the provision of patient care services, as well as the documentation of the patient’s health status.
False – it is a primary purpose
T/F Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.
False – it is a secondary purpose
Use of the health record to study the effectiveness of a given drug is considered a primary use of the health record.
Third-party payer
Chapter Question:Which of the following users of the health record is an example of an institutional user? -Third-party payer- Patient- Physician- Employer
Patient care managers and support staff
Chapter Question:Which of the following users would utilize aggregate data?- Patient care providers- Coding and billing staff- Law enforcement officers- Patient care managers and support staff
Research
Chapter Question:I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization?
This is a false statement as the information is used for other purposes such as analysis.
Chapter Question:Critique the following statement: A user of health records includes only care providers who document in the health record or refer to it for patient care. t/f
Make decision on healthcare reimbursement.
Chapter Question:I work for CMS; how would I use the health record?-Make decision on healthcare reimbursement.-Medical research- Issuing hospital and medical staff licenses-Accrediting healthcare organizations
Results management
Results retrieval technology that permits the view of data by type and manipulation of several different types of data.
Order-entry / Order Management (CPOE)
provides physicians and other providers the ability to place orders via the computer from any number of locations and add decisions support capability to enhance patient safety.
Clinical Decision Support
The process in which individual data elements are represented in the computer by a special code to be used in making comparisons, trending results, and supplying clinical reminders and alerts (such as abnormal lab results).
False – Individual
Chapter Question: True or False A physical therapist documenting in the health record is an institutional health record user.
False – Institutional
Chapter Question: True or False An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.
False – CMS is not an accrediting body
Chapter Question: True or False CMS uses data to accredit hospitals
True
Chapter Question: True or False A researcher uses data to determine the recommended treatment.
False
Chapter Question: True or False Patients do not have the right to add missing information to the health record
Clinical Decision Support
Chapter Question: A physician just received notification from an EHR system that a patient’s lab test had a dangerously high value. This is an example of what kind of clinical tool?-Electronic records management -Clinical decision support-Results management-Order-entry/Order management
Confidentiality
Chapter Question:I just told my physician something embarrassing about myself. I told him because I expect him to use the information for my care only. This concept is called:-Data relevancy-Security-Confidentiality-Privacy
Relevancy
Chapter Question:Someone suggested that we collect a patient’s eye color. This was not implemented. What quality characteristic would be the justification for not collecting this information?-Relevancy-Granularity-Consistency-Accuracy
Consistency
Chapter Question:It was suggested that we enter the patient’s age manually in all of our information systems rather than entering it once in one system and interfaced to the other systems. What quality characteristic would be the justification for not doing this?-Accuracy-Consistency-Granularity-Relevancy
Data Analysis
Chapter Question:According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information?-Data warehousing-Data analysis-Data collection-Data applications