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270 Cards in this Set
- Front
- Back
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What positions may be created by EHR technology?
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clinical analyst
health information technician records and info coordinator |
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What may be the duties of an EHR specialist?
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assemble health information
enter data statistical analysis study/research clinical audit data management National Database registrar oversee workflow/training daily office functions |
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Reason for recent changes in technology.
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increase in errors
increase in healthcare costs decrease in standard of care |
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Common causes of medical error
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lost medical records
miscommunication poor handwriting mislabeled specimens |
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HIPAA Act of 1996
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designed to protect patient's private health information
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Standards
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commonly agreed upon specifications
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Length of President Bush's 2004 goal
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10 years
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ONCHIT
Office of National coordination for Health Information Technology |
established to meet Bush's 10 year goal
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HITSP
Health information technology standards panel |
identified standards for electronic exchange
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CCHIT
Certification Commission for Health Information technology |
developed certificatlion criteria
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NHIN
National Health Information Network |
Links medical records across the country
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Institute of Medicine
8 core functions of EHR |
1. Health information and data elements
2. results management 3. order management 4. decision slupport 5. electronic communications and connectivity 6. Patient support 7. Administrative processes 8. Reporting and population management |
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Advantages of EHR
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Safety
quality of care efficiency cost reduction |
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EHR
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includes data from all sources over time
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EMR
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data from 1 physician's encounters
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PHR
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record maintained and owned by patient
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Total conversion
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costly
allows all data to be converted at once |
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Incremental conversion
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gradual change
lower cost, smoother, less impact on office but still have paper |
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Hybrid conversion
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use a combination of paper and electronic forms.
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Purpose of clinical standards
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interoperability
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Clinical vocabularies
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set of common definitions for medical terms
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SNOMED-CT
Systemized Nomenclature of Medicine Clinical Terms |
clinical vocabulary designed to encompass all terms used in medicine, including medical, procedural and diagnostic
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LOINC
Logical Observation Identifiers Names and codes |
a clinical vocabulary including terms and codes used for electronic exchange of lab results and clinical observations
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UMLS
Unified Medical Language system |
thesaurus database of medical terms
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Classification systems
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organize related terms into categories for easy retrieval
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ICD-9
Internatinal Classification of diseases |
standardized classification of diseases
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CPT
Current Procedural Terminology |
- developed and maintained by AMA
- system of classification for medical services and procedures in an outpatient setting |
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HCPCS
Healthcare Common Procedure coding system |
Codes for products, supplies and services not included in CPT.
Maintained by CMS Centers for Medicare and Medicaid Services |
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Messaging standards
HL7, DICOM, NCPDP, IEEE1073 |
make it possible to transfer data from laboratory or pharmacy
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LOINC - Logical Observation Identifiers Names and Codes
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clinical vocabulary used in the exchange Laboratory Results and clinical observations
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HL7 Version 2.3 +
Health Level Seven Version 2.3+ is the messaging standard for: |
scheduling, medical record and imaging management, patient administration, observation reporting, financial management, public health notification, patient care
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NCPDP
National Council for Prescription Drug Programs messaging standard for : |
retail pharmacy transactions
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Institute of Electrical and Electronics Engineers, Inc
messaging standard for: |
Device-Device connectivity
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DICOM
Digital Imaging and Communications in Medicine messaging standard for: |
Image information to workstation
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HL7 Version 2.4+
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Demographics standards
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SNOMED CT
Systematized Nomenclature of Medicine Clinical Terms messaging standard for: |
Lab result contents
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HL7 2.x+
messaging standard for: |
units of measure
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HL7 2.3.1
messaging standard for: |
immunizations
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Federal Drug Terminologies
messaging standard for: |
medications
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LOINC
messaging standard for: |
lab test order names
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HIPAA Transactions and code sets are the messaging standard for:
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financial/payment
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SNOMED CT and the National Cancer institute Thesaurus are messaging standards for:
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anatomy
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SNOMED CT is messaging standard for:
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1. Diagnosis/problem lists
2. nursing 3. lab result contents 4. nonlaboratory procedures 5. anatomy |
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Human Genome Nomenclature is the messaging standard for:
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Genes
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HL7 2.4 + messaging standard for
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1. Demographics
2. clinical encounters |
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HL7
Health Level Seven Version 2.3 |
messaging standards for scheduling, medical record and image management, patient administration, public health, patient care, financial
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NCPDP
National Council for Prescription Drug Programs messaging standard for: |
retail pharmacy transactions
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Institute of Electrical and Electronics Engineers, Inc
messaging standard for: |
Device-Device connectivity
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DICOM
Digital Imaging and Communications in Medicine messaging standard for: |
Image information to workstation
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HL7 Version 2.4+
messaging standard for: |
Demographics
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HL7 and Clinical Document Architecture (CDA) are the messaging standard for:
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text-based reports
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Environmental Protection Agency Substance Registry System is the messaging standard for:
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Chemicals
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Proper phone etiquette
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1. answer promptly and kindly
2. speak properly and into phone 3. give caller your undivided attention 4. speak clearly 5. be courteous 6. ask permission before placing caller on hold 7. remain calm and composed |
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Patient flow
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1. appointment scheduling, information collection
2. patient check-in, payment collection 3. rooming, vitals, examination and documentation 4. checkout 5. coding and billing. review test results |
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Elements of a chart
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1. vital signs
2. chief complaint 3. progress nots 4. past medical history 5. family history 6. social history 7. allergies 8. medication list 9. HPI 10. ROS - review of symptoms 11. Diagnosis and assessment 12. Plan and treatment |
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Decision support tools will do:
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1. screen for illness and disease
2. identify at risk patients 3. aid with disease management |
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primary benefits of hospital EHR
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1. unlimited access to patients' information
2. decreased waiting time for medication delivery and test results 3. increased efficiency and accuracy in overall patient care |
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CPOE
Computerized Physician Order Entry |
application used by healthcare providers to enter patient care information. Key...the right patient, medication, dose, time, route of administration
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order sets
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pre-defined groupings of standard orders for a condition, disease or procedure.
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ADE
Adverse Drug Events |
side effects or complications from medications
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medication reconciliation
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process of obtaining and updating an accurate list of all a patient's medications
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computer based PHR
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access through software on personal computer. Information transferred to a portable memory device
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internet based PHR
- tethered |
individuals are granted access by an outside organization. Editing capabilities may be limited, and the organization maintains ownership of the record
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internet based PHR
- untethered |
individuals are granted access through a web based application with a username and password.
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internet based PHR
- networked and interoperable |
continually updated, but does not ensure privacy or security.
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HIPAA Title I
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health insurance reform
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HIPAA Title II
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rights for the transfer of electronic health care data
- Administration and Simplification standards put privacy and security mechanisms in place |
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covered entities
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healthcare providers who transmit electronic information in the normal course of business and are covered by HIPAA regulations
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Clearinghouse
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company that processes health information and executes electronic transactions
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DRS
Designated Record Set |
any item, collection or grouping of information that includes protected health information and is maintained by a CE
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ePHI
Electronic protected health information |
protected health information that is created, received, maintained or transmitted electronically
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NPP
Notice of Privacy Practices |
document that describes practices regarding the use and disclosure of protected health information
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PHI
protected health information |
individually identifiable health information that is transmitted or maintained by ANY form of media
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TPO
treatment, payment and operations |
conditions under which protected health information can be released without consent from the patient
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Protected Health Information
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name,address
names of relatives and employers SSN phone, fax, email health plan id account number fingerprints website address medical record number serial numbers of vehicles photographic images |
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types of authorization
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General - release for uses other than TPO
Specific - required for info about HIV, STD, drug and alcohol abuse |
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Clinical Templates
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progress notes made within the EHR
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Clinical Vocabularies
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A standardized system of medical terminology
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CPT
Current procedural terminology |
a system of classification for services and procedures used in the outpatient setting
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DICOM
Digital Imaging and Communications in Medicine |
A standardized system used to transfer information between imaging systems
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HIT
Health information technology |
The use of technology as a resource to manage patient health care information
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HL7
Health Level Seven |
A messaging standard used to transfer data between applications
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Healthcare common procedure coding system
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A system of classification for certain services and procedures not listed in the CPT manual
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Arthr/o
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joint
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Bi/o
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life
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glioblastoma
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glue/germ/tumor;
cerebral tumor |
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carcin/o
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cancerous, cancer
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cephal/o
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head
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cerebr/o
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cerebrum (largest part of brain)
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cyt/o
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cell
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dent/i
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teeth
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derm/o
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skin
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electr/o
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electrical activity
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enter/o
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intestines
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fet/o
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fetus
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gastr/o
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stomach
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rhin/o
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nose
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sarc/o
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flesh
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thromb/o
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clotting
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ur/o
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urinary tract
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-al
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pertaining to
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-algia
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pain
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dynia
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pain
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ectomy
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excision, removal
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emia
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blood condition
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genic
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produced by, pertaining to producing
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-globin
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protein
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-itis
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inflammation
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-oma
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tumor, mass swelling
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-osis
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condition, usually abnormal
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-pathy
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disease condition
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-sis
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state of, condition
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Ante-
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before, in front of
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anti-
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against
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brady-
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slow
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dia-
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through
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end-, endo-
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within
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epi-
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above, upon
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Hyper-
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excessive, above normal
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Hypo-
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deficient, below normal
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peri-
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surrounding, around
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pre-
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before
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sub-
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under, below
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-ectomy
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excision
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-graphy
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process of recording
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-metry
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process of measurement
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-scopy
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a visual examination (with a scope)
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-stomy
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a new opening
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-tomy
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incision
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-tripsy
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process of crushing
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musculoskeletal
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function: support, movement
Organs: muscles, bones, joints function: protection organ: bone marrow |
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pre-
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before
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sub-
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under, below
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-ectomy
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excision
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-graphy
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process of recording
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-metry
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process of measurement
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-scopy
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a visual examination
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- stomy
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a new opening
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-tomy
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incision
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-tripsy
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process of crushing
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Musculoskeletal
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Function: support, movement, protection
Organs: muscles, bones, joints, bone marrow |
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Integumentary
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Function: protection
Organs: skin, hair, nails |
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Gastrointestinal
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Function: nutrition
Organs: stomach, intestines |
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Urinary
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Function: elimination of nitrogenous waste
Organs: kidneys, bladder, ureters, urethra |
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Reproductive
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Function: reproduction
Organs: ovaries, testes |
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Blood/Lymphatic
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Function: transportation
Organs: blood cells |
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Immune
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Function: protection
Organs: lymph glands |
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Cardiovascular
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Function: transportation
Organs: heart, vessels |
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Respiratory
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Function: delivers oxygen to cells
Organs: lungs, bronchi, trachea |
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Nervous/Behavioral
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Function: receive/process information
Organs: brain, nerves, mind |
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Immune
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Function: protection
Organs: lymph glands |
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Endocrine
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Function: effects changes through chemical messengers
Organs: pancreas, thyroid |
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Cardiovascular
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Function: transportation
Organs: heart, vessels |
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Respiratory
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Function: delivers oxygen to cells
Organs: lungs, bronchi, trachea |
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Nervous/Behavioral
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Function: receive/process information
Organs: brain, nerves, mind |
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Endocrine
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Function: effects changes through chemical messengers
Organs: pancreas, thyroid |
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anterior (ventral)
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front surface of the body
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posterior (dorsal)
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back side of the body
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deep
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away from the surface
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Proximal
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near the point of attachment to the trunk or near the beginning of a structure
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distal
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far from the point of attachment to the trunk or far from the beginning of a structure
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Inferior
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below another structure
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Superior
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above another structure
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medial
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pertaining to the middle or nearer the medial plane of the body
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lateral
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pertaining to the side
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supine
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lying on the back
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prone
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lying on the belly
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Synarthrosis
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immovable joints held together by fibrous tissue
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amphiathroses
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joints joined together by cartilage that is slightly oveable, such as the vertebra or the pubic bones
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diathroses
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joints with free movement - ball-and-socket, hinge joints
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synovial joints
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free moving joints surrounded by joint capsules. Many have bursae-sacs of fluid between the joint and the tendon
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Extension
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increase the angle of a joint
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flexion
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decrease the angle of a joint
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abduction
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movement away from the midline
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adduction
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movement towards the midline
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Supination
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turning the palm or foot upward
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pronation
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turning the palm or foot downward
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dorsiflexion
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raising the foot, pulling the toes towards the shin
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plantar flexion
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lowering the foot, pointing the toes away from the shin
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Eversion
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turning outward
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inversion
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turning inward
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protraction
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moving a part of the body forward
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retraction
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moving a part of the body backward
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rotation
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revolving a bone around its axis
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simple fracture
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no skin rupture
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compound fracture
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skin rupture, leaving chance of infection
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comminuted fracture
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the bone is crushed or shattered
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compression fracture
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the fractured area of the bone collapses on itself
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Colles fracture
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the break of the distal end of the radius at the epiphysis often occurs when the patient has attempted to break his or her fall
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Complicated fracture
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the bone is broken and pierces an internal organ
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impacted fracture
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the bone is broken and the ends are driven into each other
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hairline fracture
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a minor fracture appears as a thin line on x-ray and may not extend completely through the bone
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Greenstick fracture
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the bone is partially bent and partially broken; common in children
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Pathologic fracture
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any fracture occurring spontaneously as a result of disease
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Salter-Harris fracture
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a fracture of the epiphyseal plate in children
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Sprain
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traumatic injury to a joint involving the soft tissue such as muscle, ligament or tendon
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strain
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a lesser injury than a sprain, usually as a result of overuse or overstretching
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dislocation
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bone is completely out of place and sublaxation is partially out of joint
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Albino
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deficient in pigment
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Collagen
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structural protein found in the skin and connective tissue
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Melanin
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major skin pigment
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Lipocyte
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a fat cell
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Macule
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discolored, flat lesion (freckle, tattoo)
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polyp
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benign growth extending from the surface of the mucous membrane
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fissure
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groove or crack like sore
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nodule
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solid, round or oval elevated lesion more than 1 cm
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ulcer
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open sore on the skin or mucous membranes
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vesicle
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small collection of clear fluid, blister
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wheal
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smooth, slightly elevated, edematous area that is redder or paler than the surrounding skin
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alopecia
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absence of hair from areas where it normally grows
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gangrene
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death of tissue associated with loss of blood supply
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impetigo
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bacterial inflammatory skin disease characterized by lesion, pustules and vesicles
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Who gives bonus for use of certified EHR
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CMS
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Why do HIPAA regulations effect EHR?
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Because of the portability of the health record
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What codes do providers use to show they are using e-prescribing?
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G codes
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How many regulations were set in place to standardize how information would be coded or termed for transfer?
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20
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Clinical information standards are needed for all but
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Provider identification
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an application used by physicians and others to enter patiend care orders
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computerized physician order entry
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A log of information about prescription orders
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Medication administration record
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Who was mandated to use HIT systems with standards recognized by HHS?
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federal departments and agencies that purchase and deliver health care.
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Stark Law
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initially prohibited referrals of Medicare patients to facilities with which the physician has a relationship
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HHS relaxed Stark Law
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allows hospitals to donate HIT systems to physicians.
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adverse event
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patient harm that results from treatment by the health care system, rather than by their conditionpre
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preventable adverse event
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a medical error that could have been prevented
ex. medication error |
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MMA
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act created a voluntary prescription drug benefit known as Medicare Part d.
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ONC funding was given too
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a. the development of industry-wide HIT standards
b. development of a certification process for HIT products c. creation of a model of a widespread HIT network |
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4 areas AHIC recommended to HHS to speed implementation of IT
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1. Consumer empowerment
2. EHR 3. biosurveillance 4. chronic care |
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ASP
Application service provider |
service provider housing the application
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5 steps of ov workflow
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1. pre-visit
2. pre-exam 3. exam MA, Physician 4. post-exam 5. post-visit - review codes, prepare and submit claim |
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HIPAA code sets
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IDC-9-CM- international classification of diseases
HCPCS -Healthcare common procedure reporting system CPT - Current procedural terminology |
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Advantages of computer-assisted coding
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1. ensures documentation exists
2. aids in code selection 3. reduces number of unbilled procedures 4. automatically enters codes 5. reduces time until claim submission |
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disease management
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systematic approach to improving the health of people with chronic diseases
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formulary
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list of pharmaceutical products and appropriate doses (best and most economical)
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e-prescribing conflicts, problems detected
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drug-allergy
drug-disease incorrect dosage incorrect duration drug-age drug-gender drug-drug interaction |
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chronic disease
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conditions that rarely improve and often cannot be cured
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clinical guidelines
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descriptions of recommended patient care for a given condition based on scientific evidence
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computer-assisted coding
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preliminary codes assigned by the software
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decision support tools
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a feature of many EHR's which make the latest clinical info available at the point of care
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functions of HIS
Hospital Information System |
financial information
laboratory information pharmacy information picture archiving and communiation Systems PACS Radiology informatin clinical information |
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Components of an Inpatient EHR system
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clinical documentation
computerized order entry clinical decision support e-prescribing e-administration records e-results reporting |
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Uses of clinical documentation
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care planning and continuity
evidence of the course of care facilitate communication supply data for research supply data for quality review provide info for coders |
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CPOE
Computerized physician order entry |
application for physician to enter patient care orders
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order sets
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predefined groupings of standard orders for a condition, disease or procedure
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MAR
medication administration record |
log with information about a medication order
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transition points
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times when patient moves from one setting to another
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medication reconciliation
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a process of obtaining and updating an accurate list of a patient's medications
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EMAR
Electronic medication administration records |
work with CPOE (computerized physician order entry) systems to increase patient safety by enabling e-tracking of medication administration bedside
uses barcode |
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5 rights
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right patient
right medication right dose right time right route |
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PACS
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computerized system for capturing, transmitting, archiving and displaying medical images
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CDHP
Consumer driven health plan |
high deductible
low premium tax free savings account |
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NPHR
Networked personal health record |
allows the transfer of information to and from multiple sources
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HL7
Health Level 7 |
An organization that develops health care standards
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PHR-S FM
Personal Health Record System Functional Model |
A model of the features of PHR developed by the HL7
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Administrative Simplication Standards
|
HIPAA Title II on the uniform tramsfer of electronic health care data and privacy protection
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HIPAA privacy rule
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Provides protection for individually identifiable health information and grants rights to individuals
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business associate
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entity that works under a contract for a covered entity and is subject to HIPAA policies
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DHS
Designated Record Set |
Any item, collection, or grouping of info that includes PHI and is maintained by a CE
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Minimum necessary standard
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using reasonable safeguards to protect PHI
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de-identified health information
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information that neither identifies nor provides a basis to identify an individual
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OCR
Office for Civil Rights |
investigates complaints of HIPAA violations
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HIPAA goals (3)
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confidentiality
Integrity availability |
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IDS
Intrusion detection system |
surveillance of a computer network
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Safeguards to PHI
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physical
administrative technical -firewall, IDS, passwords |
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health information exchange
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state, regional or community network that enables electronic exchange of health care information
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role-based authorization
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limits access to patient information based on the user's role in the organization
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audit trail
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records of who has accessed a computer or network and the operations performed
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technical safeguards
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automated processes to protect data and control data access
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practice partner
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an EHR and practice management program for ambulatory practices
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park feature
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allows a user to leave a workstation without exiting the program
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evaluation and management codes
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procedure codes used to represent the processes a physician performed
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