Sayles Ch 16 – EHR

computer based patient record
One of the earliest terms used to describe the EHR was ____.
Institute of Medicine
This is a nonproft organization that provides advice to lawmakers and the public about health issues.
electronic health record
A system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support, links to bodies of medical knowledge and other aids.
Office of the National Coordinator
This group provides leadership for the development and implementation of an interoperable health information technology infrastructure nationwide to improve healthcare quality and delivery.
electronic medical record
An electronic record of health related information on an individual that can be created and managed by clinicians and staff within one healthcare organization.
electronic health record
An electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be created and managed by clinicians and staff across more than one healthcare organization.
practice management system
This supports the collection of patient demographic and insurance information, scheduling visits, and billing.
health information exchange
Services that support sharing heath information across different healthcare organizations.
meaningful use
This program provides incentives for making significant use of a certified EHR and enact sanctions on Medicare reimbursement for those who don’t use certified EHRs.
evidence based medicine
The practice of medicine utilizing guidance gleaned from research studies.
interact directly, point of contact, accessed, directly into the system
To acheive meaningful use, clinicians must ____ with the EHR as they care for patients at ____. Information must be ____ as needed and documentation is made _____.
unstructured
Data that is dictated, keyed as text, or scanned.
structured
Data that are discrete facts, figure, observations or findings entered via templates that are able to be processed by the computer.
structured data, alerts
The EHR combines _____ from many sources which can then be processed into ____.
source systems
The development of an EHR system most often begins in a healthcre organization with acquisition of ______.
source systems
These supply the EHR and other application with data.
administrative and financial systems
These are among the first systems implemented by healthcare organization.
registration, admission, discharge and transfer, patient financial systems, form creation system
Administrative and financial systems include _______, ______, and _____.
revenue cycle management
Billing systems aid in _______.
revenue cycle management
______ refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services.
charge capture
Revenue cycle management use a _____ to collect information about services performed by ancillary systems and EHR.
charge capture, claim generation, claims status inquiry and response, remittance advice, electronic funds transfers
Revenue cycle management includes _____, ____, _____, posting ______, and receiving ______.
laboratory, radiology, pharmacy
Ancillary systems for the EHR include ____, _____, and ____ information systems.
administrative and financial, applications, content, quality
HIM departments manage some of the _____ systems, support ____ that complement the EHR, and retain responsibility for _____ and ____ of EHR.
results management, clinical documentation, closed loop medication management, clinical decision support, analytics and reporting
What are the five core EHR applications required for earning meaningful use incentives?
results management
This is an application that enable diagnostic study results to be both reviewed in a report format and the data to be processed. Allows reports to be used in interactive ways.
results retrieval
These only allowed reports of results to be viewed and printed
point of care charting
Clinical documentation is also called ____ systems.
clinical documentation
These systems direct what documentation needs to be recorded for the patient and is the means to supply CDS.
clinical documentation
These systems supply templates to the user to be completed primarily via point and click, drop down, type ahead, and other data entry tools.
closed loop medication management
Refers to the use of certain systems that help assure patient safety from the point a drug is ordered to the point it is administered.
CPOE, e-prescribing, EMAR, medication reconciliation systems, automated drug dispensing machines
The closed loop medication management system includes ____, _____, _____, _____, and _____
CPOE
Many hospitals in the past implemented ____ last because it is difficult to get physicians to use such systems.
CPOE
This systems is used for entering all orders such as patient admission, laboratory tests, x-rays, nutrition, nursing, referrals, medication, etc.
clerical tasks, annoying alerts and reminders, standard order sets
Some of the problems providers have with CPOE is the performance of _____, _____, and _______.
e prescribing
This is a special type of CPOE used to make prescriptions and transmit them electronically to pharmacies.
bar code medication administration record
This system allows the nurse to scan a bar code on the patient’s wrist band to automatically date and time stamp the entry of drug administration.
electronic medication administration record
These systems help assure that a nurse administers the right drug, in the right dose, through the right route, at the right time, to the right patient.
clinical decision support
This key component of the EHR sets the EHR apart from simply automating paper documents.
clinical decision support
This system helps providers and patients make decisions about patient care.
analytics
Statistical processing of data to reveal new information.
genomic research, personalized medicine, business intelligence, disaster response
Benefits of analytics include _____, _____, ____, _____
quality, costs
Statistical analysis can help improve ____ and reduce ____.
health plans, quality or research studies, rule based lists for patient follow up
Analytics and reporting may be used for ______, ______, _____.
physician quality reporting system
Physician’s can earn incentives through quality reporting to ______.
clinical quality measures
In addition using required program elements, ______ is also a requirement for earning MU incentives.
specialty systems
These systems support documentation of patient care in areas such as intensive care units, emergency services, therapy services, rehabilitative care, hospice, etc.
picture archiving and communications
These systems capture digital images from various modalities such as xray ultrasound, etc. to provide special viewing capabilities of these images via computer.
supporting infrastructure
Hardware and software that allows various applications to work.
connectivity
These systems enable the exchange of data across separate information systems both withing a healthcare organization and across organizations.
connectivity
This allows software from different vendors to share a single patient’s data with multiple entities.
registry
Connectivity systems are required to contribute patient data to _____ to conduct quality measurement and reporting.
source system
The laboratory information system is considered a _____.
is not
The pharmacy information system is or is not considered a core EHR component.
drug knowledge database
This assists in assuring that the specific patient is not allergic to a drug.
clinical decision support system
What provides alerts and reminders to clinicians?
nurses
Point of care charting systems in hospitals are primarily used by ____.
Medication Five Rights
E MARs that utilize barcode or RFID support ____.
medication reconciliation
______ is the most difficult function of close loop medication management system to implement.
all
The meaningful use incentive program requires ____ medication management components to be present and used in a hospital.
EDMS
A transition technology used by many hospitals to increase access to health record content during the evolution to EHR.
CPOE
The EHR component that is often the most challenging for which to gain adoption in a hospital.
adopted
A system that is used by all intended users for at least basic functionality.
human users
Unintended consequences from using EHR technology are primarily due to issues with ______.
productivity
The biggest complaint physicians have with using an EHR already installed relates to ____.
customization
Cloud computing can reduce cost of EHR if _______ is not required.
25 percent
By the end of 2011, over _____ of hospitals had most, if not all, of the EHR components to be able to earn MU incentives.
e-prescribing
Many physicians eased into acquiring an EHR by starting with _____.
cost savings, administrative functions, increased charge capture, denied claims, bad debt, collection services costs
Hospitals find some _____ in ____ with EHRs. They also generally find improvements in ______ and can reduce the number of _____, ___, and _____
workflow
Notifying a coder that the physician has completed the discharge summary is an example of ________ in EDMS.
personal health record
Exchange of a standard set of health information content between providers and with patients is facilitated by _____.
consistent federated
In what form of health information exchange are data centrally located but physically separated?
identity management
The function used to provide access controls, authentication, and audit logging in an HIE is ____
certified, interoperable, used in a meaningful way
For hospitals or physicians to earn meaningful use, their EHR technology must be ____, ____, and _____.
sign a special participation agreement
To participate in the nationwide health information network, providers must _____.
clinical data warehouse
A database for online analytical processing is otherwise know as a ____.
thin client
A computer that has minimal processing capability of its own is a _____.
server redundancy
This technology would reduce the risk that information is not accessible during a server crash.
change control
Part of storage management that assures documentation is retained about changes.
relational
Online analytical processing typically requires a _____ database.
ASC X12
This type of message format standard deals with claims.
RxNorm
This type of vocabulary standard deals with clinical drug names.
NDC
This type of messaging standard deals with drug inventory.
HL7
This type of messaging standard deals with data exchange.
DICOM
This type of messaging standard deals with clinical images.
chart conversion
A plan to provide access to content of previous visit information in an EHR.
migration path
A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in healthcare organization.
easier, data quality
Copy and paste can make data entry ____ but harm _____.
correcting entries, documentation compliance, privacy
Potential problems with the reuse of data in an EHR is ______, ______, and _____.
clinical decision making
An ideal EHR system supports _____.
electronic document management system
A transition strategy to achieve an EHR is the _____.
pharmacy information system
To ensure that a computerize provider order entry system supports patient safety, you need a _____.
1960s
The concept of the EHR was first conceived in _____.
management of data
A CDR support ______ for EHR.
central data bank, patients health information
The federal government envisions a nationwide health information network to manage a _______ of all ______.
CPOE
Electronic prescribing is a special case of ____.
continuity of care record
What includes the content of information that should be exchanged among referring providers?
controlled
A vocabulary is considered ______ when it establishes meaning for terms used in the EHR.
LOINC
This terminology is used for coding lab results and other observations.
document images, email, PACS
EDMS can manage ____, ____, and ____.
screen layout
A critical element of data retrieval planning is designing _____.
macro, point and click, voice command
Structured data may be entered into an EHR via _____, _____, and _____.
natural language processing
This helps to convert narrative information to structured data.
intranet
A local area network using Internet based protocols is _____.
total cost of ownership
A tool that helps identify all costs associated with implementing an EHR is ______.
due diligence
Before contracting for an EHR product, ______ should be done to vet the vendors.
system build
The process where data tables are loaded and screen layouts are customized.
system testing
Type of testing where a team tests whether or not all of the components will work together.
chart conversion
Deciding what paper based content should be automated is called ____.
accessibility, precision, relevancy
Elements of data quality include _____, _____, and _____.
physician
The primary user of CPOE is _____.