Ch 10 - Ehr - Intro Computers Hit

Front 1

continuum of care, documentation, clinical decision making, knowledge building.

Back 1

The EHR affords access to longitudinal health information about an individual across the _____, assist in _____, support ____, and provide for _____.

Front 2

multiple sources, point of care, decision making process

Back 2

The EHR integrates data from ______, compares data at the _____, assists providers in ______.

Front 3

source systems

Back 3

Information systems that populate the EHR.

Front 4

clinical, administrative, financial

Back 4

Source systems are ____, ____, and ____.

Front 5

continuity of care record

Back 5

A snapshot of data from the EHR and includes basic information such as diagnoses, allergies, medications, and future treatment.

Front 6

CCR

Back 6

A subset of the EHR that is used for subsequent patient care is a

Front 7

patient care

Back 7

Implementing an EHR can improve ____

Front 8

rules engine

Back 8

The infrastructure required for the EHR includes which component not found in most information systems?

Front 9

rules engine

Back 9

This controls alerts, reminders, order sets, and protocols.

Front 10

PHR

Back 10

System that includes patient information from both the patient and the provider.

Front 11

longitudinal record

Back 11

The phrase womb to tomb refers to ____.

Front 12

stark law

Back 12

This prevents physicians from receiving a fee for referring patients for any healthcare services whose care is paid for by a federally funded program.

Front 13

stark law

Back 13

This prohibits physicians or their family members from owning businesses to whom the physician refers patients for health services.

Front 14

CPOE

Back 14

This contains preprogrammed clinical decision support designed to assist the user through making an entry appropriately.

Front 15

order communication system

Back 15

This part of the EHR notifies clinical departments of orders made by the physician.

Front 16

electronic document management system

Back 16

This part of the EHR utilizes scanning to capture patient information from the paper record.

Front 17

clinical messaging

Back 17

This part of the EHR connects the medical staff and hospital by providing access to systems.

Front 18

clinical messaging

Back 18

This is the secure transmission of clinical information from one entity to another, including providers to providers, patients to providers, etc.

Front 19

structured, unstructured

Back 19

Patient care charting generally allow ____ and ____ data.

Front 20

structured

Back 20

This type of data is generally found in checkboxes, drop down boxes, and other means where the user chooses from options built into the system.

Front 21

unstructured

Back 21

This type of data can be entered in free text format by the user.

Front 22

patient safety, reminders, alerts

Back 22

The use of the CPOE can lead to significant improvements in _____ because _____ and ____ are built into the system.

Front 23

electronic medication administration record

Back 23

This part of the EHR automates many of the medication administration process in a facility.

Front 24

electronic medication administration record

Back 24

This part of the EHR can provide alerts to assist in medication timing and provide the nurse with reference material on the medication.

Front 25

clinical decision support system

Back 25

This part of the EHR provides help in association with data entry into an EHR system performed directly by the caregiver at the point of care.

Front 26

clinical decision support system

Back 26

This part of the EHR may notify the care provider of patient allergies or contraindications for medication or other treatment.

Front 27

patient provider portal

Back 27

This part of the EHR is a secure method of communication between the health care provider and the patient, just the providers or the provider and payer.

Front 28

patient provider portal

Back 28

This part of the EHR may include secure email or remote access to test results and provide patient monitoring - or access to patient education materials.

Front 29

population health

Back 29

This part of the EHR is the capture and reporting of healthcare data used for public health purposes.

Front 30

population health

Back 30

This part of the EHR allows healthcare providers to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials.

Front 31

exception to the Stark Law

Back 31

The ability of a healthcare facility to provide EHR software to physician is allowed through _____.

Front 32

certification

Back 32

CCHITs role in the EHR is

Front 33

larger facilities, physician practices

Back 33

Most EHRs are found in _____ and _____.

Front 34

cost savings, cost avoidance, productivity improvement

Back 34

Economic benefits of the EHR are ______, _____, and _____.

Front 35

easier access, faster diagnosis and treatment, quality of care, mistakes, documentation

Back 35

Clinical benefits of the EHR include _____, ______, improvement to ______, reduction in ______, and enhanced ______.

Front 36

providers, patients

Back 36

The EHR can improve communication between ______ and allow physicians to spend more time with ______.

Front 37

cost, uniform standards, training, fear

Back 37

Barriers to implementing the EHR include ____, lack of ______, ______, and ____.

Front 38

interoperability

Back 38

The lack of consistent standards in the EHR prevents _______.

Front 39

infrastructure

Back 39

This is made up of hardware, network, database, server, personnel.

Front 40

storing patient information

Back 40

The core function of the EHR is ______.

Front 41

medical devices

Back 41

The EHR can link with _______ allowing the capture of monitoring and testing.

Front 42

practice management system, billing, scheduling

Back 42

The ambulatory EHR frequently is combined with the ________ to perform ____ and _______.

Front 43

digitized

Back 43

Scanned image of an individual's actual signature.

Front 44

electronic

Back 44

Type of signature that requires a password or two-tiered authentication.

Front 45

digital

Back 45

Type of signature that used encryption and nonrepudiation to prove authenticator's identity.

Front 46

classification systems

Back 46

These are used for secondary data and group similar items together.

Front 47

reimbursement, quality of care, planning, statistics, public health reporting

Back 47

Classifications are used for which five tasks?

Front 48

interoperability

Back 48

Standards are important for ______.

Front 49

health information technology standards panel

Back 49

This organization works collaboratively with public and private sectors to achieve widespread interoperability among healthcare software applications.

Front 50

standards development organizations

Back 50

Organizations that create standards.

Front 51

american national standards institute

Back 51

This organization is responsible for accrediting standards development organizations.

Front 52

health information technology standards panel, standards development organizations, american national standards institute

Back 52

HITSP, SDO, ANSI

Front 53

vocabulary, messaging, data content

Back 53

For a system to be interoperable, it needs to follow the specific standards in which three categories:

Front 54

SNOMED

Back 54

The most widely recognized nomenclature in healthcare is

Front 55

systematized nomenclature of medicine, logical observation identifiers names and codes, unified medical language system, national drug codes

Back 55

SNOMED, LOINC, UMLS, NDC

Front 56

SNOMED

Back 56

This nomenclature system includes diagnoses, procedures, signs, symptoms, and cause of injury.

Front 57

LOINC

Back 57

This is a laboratory vocabulary used to order and report laboratory tests and record clinical observations.

Front 58

RxNorm

Back 58

This is a vocabulary for medications and provides standards for drug ingredients and strength as well as dose formats and relationships to other drugs.

Front 59

UMLS

Back 59

A database that catalogues bibliographic citations for biomedics and was developed to improve search capabilities.

Front 60

NDC

Back 60

These were developed by the FDA to act as a universal unique identifier for human drugs.

Front 61

MEDCIN

Back 61

This nomenclature and knowledge based system is designed to provide intelligent clinical database for documentation by the clinician at the time of care.

Front 62

mapping

Back 62

This is a crosswalk between the various terminologies; links between terminologies.

Front 63

use cases

Back 63

These are frequently used to create maps and describes how the user will interact with the system and what the system will do.

Front 64

digital

Back 64

The most secure type of signature used in the EHR is

Front 65

classification system

Back 65

ICD 9 is an example of a

Front 66

SNOMED

Back 66

The nomenclature used in the EHR to capture detailed clinical information is called

Front 67

SDO

Back 67

HITSP is considered a

Front 68

messaging standards

Back 68

Also called interoperability or data exchange standards.

Front 69

messaging

Back 69

With these standards, proprietary systems are able to talk to one another and allow the exchange of data.

Front 70

HL7

Back 70

This SDO provides standards for interoperabiltiy that improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer for all stakeholders.

Front 71

DICOM

Back 71

The use of this standard allows images to be transferred between systems from different vendors and allowing imaging to share information with clinical systems and EHR.

Front 72

Digital imaging and communications in medicine, national council for prescription drug programs

Back 72

DICOM, NCPDP

Front 73

NCPDP

Back 73

These standards are used by pharmacies and payer and control data to be shared for new prescriptions, refills, and other communications.

Front 74

data structures

Back 74

Refers to data stored in EHR and the way it is managed.

Front 75

data set

Back 75

Group of data elements that are the minimum accepted level of information to be collected for a specific purpose along with uniform definitions.

Front 76

data sets

Back 76

UHDDS, UACDS, MDS, DEEDS are all _____.

Front 77

Uniform hospital discharge data set, uniform ambulatory care data set, minimum data set, data elements for emergency department systems

Back 77

UHDDS, UACDS, MDS, DEEDS

Front 78

Joint Commission

Back 78

ORYX is a data set developed by the ______ to study outcomes and healthcare performance.

Front 79

database

Back 79

Collection of data carefully organized to be of value to the user.

Front 80

databases

Back 80

The EHR is a collection of ______.

Front 81

data repository

Back 81

Database that is developed in an open format allowing the facility to use it for multiple systems from one source - updated in real time.

Front 82

data warehouse

Back 82

Database containing data from other source systems in the healthcare facility - not updated in real time but is better suited for allowing querying and data analysis.

Front 83

presentation layer

Back 83

This controls the screen layout, data entry, and data retrieval.

Front 84

unstructured

Back 84

Also called narrative or free text data, this is usually entered using a keyboard, dictation, or voice recognition.

Front 85

unstructured

Back 85

This type of data allows data entered to be mores specific and detailed.

Front 86

reporting

Back 86

Unstructured data is not beneficial for _____ purposes.

Front 87

structured

Back 87

Drop down lists, check boxes, radio buttons, and other forms of controlled data entry are used in ______ data entry.

Front 88

template based entry

Back 88

This is a cross between free text and structured data entry where the user is able to pick and choose data that are entered frequently.

Front 89

interoperability

Back 89

The ability of one computer system to exchange data with another computer system.

Front 90

basic, functional, semantic

Back 90

Interoperability is divided into which three levels?

Front 91

basic

Back 91

Type of operability where the computer can send data to another computer but the receiving computer is unable to interpret the data.

Front 92

functional

Back 92

Type of operability that defines the structure of the messages so that the receiving computer can interpret the data.

Front 93

semantic

Back 93

Type of operability that allows the information to be used in a meaningful way.

Front 94

hybrid record.

Back 94

System with functional components that include both paper and electronic documents and use both manual and electronic processes.

Front 95

HL7

Back 95

____ is the messaging standard used in most information systems.

Front 96

messaging standard

Back 96

DICOM is an example of a ____

Front 97

real time

Back 97

A data warehouse is not updated in ____.

Front 98

structured data

Back 98

Check boxes are a form of ____.

Front 99

reminder

Back 99

I am entering orders on patient in my office. The computer tells me that I should order a mammogram. This is a ____.

Front 100

EMAR

Back 100

This component of the EHR uses bar codes to identify patients.

Front 101

provider portal

Back 101

The provider would use the _____ to check test results of a patient.

Front 102

healthcare providers

Back 102

The EHR improves communication between ____.

Front 103

practice management

Back 103

The ______ function is seen in the ambulatory EHR but not inpatient.

Front 104

data content

Back 104

Standard that controls content of data elements.

Front 105

SNOMED CT

Back 105

Terminology used to capture detailed clinical information.

Front 106

national drug codes

Back 106

This system is used to provide an universal unique identifier for human drugs.

Front 107

mapping

Back 107

A way to link ICD 9 and ICD 10 is through ____.

Front 108

more specific

Back 108

An advantage of unstructured data is that it can be ____.

Front 109

graphical user interface

Back 109

This provided tool such as icons, colors, buttons, and menus to help users navigate through an information system.

Front 110

NCPDP

Back 110

This is a messaging standard that is used by pharmacies and payers.

Front 111

HL7

Back 111

This messaging standard is used for clinical and administrative data.

Front 112

use cases

Back 112

Tools that provide very detailed information for programmers to use when developing they system.

Front 113

clinical data repository

Back 113

The infrastructure of the EHR should include a _____.

Front 114

subpoena audit trails

Back 114

A legal concern regarding the EHR is the ability to _____.

Front 115

False

Back 115

True or false. The US leads the way in EHR adoption by physicians.

Front 116

False

Back 116

True or false The EHR is not used for public health purposes.

Front 117

multiple ways

Back 117

In the EHR, data can be viewed in ____.

Front 118

printing, access

Back 118

In the hybrid environment, we must address issues such as ____ and ____.

Front 119

False

Back 119

True or false. The order entry/results reporting system is always utilized by the physician.

Front 120

A reason to implement an EHR is to

Back 120

improve patient care

Front 121

reminders

Back 121

notify physicians of screenings that should be performed on all 65 year old males with a past history of elevated PSA

Front 122

CCR

Back 122

A subset of the EHR that is used for subsequent patient care

Front 123

PHR

Back 123

The system that includes information from both the patient and the provider

Front 124

population health

Back 124

The component of the EHR that reports infectious diseases

Front 125

CCHITs role in the EHR

Back 125

certification

Front 126

Clinical decision support to enhance physician orders is found in which component of the EHR?

Back 126

CPOE

Front 127

Jason is on Zoloft 100 mg QD for his hospital stay on trial basis. Where would I find when this medication was given?

Back 127

EMAR

Front 128

The time it takes to enter data into the EHR is considered to be a

Back 128

barrier

Front 129

Which of the following is a benefit of the EHR?

Back 129

improved efficiency

Front 130

What function is typically found in the ambulatory EHR but not in the inpatient?

Back 130

practice management

Front 131

What is the CORE function of the EHR?

Back 131

storing patient infomation

Front 132

Which of the following is a primary barrier to EHR implementation?

Back 132

cost

Front 133

The most secure type of signature in the EHR is

Back 133

digital signature

Front 134

The concept of the crosswalk between two terminologies is called

Back 134

mapping

Front 135

Which of the following organizations is an SDO?

Back 135

ANSI

Front 136

ICD-9-CM is an example of a

Back 136

classification system

Front 137

The nomenclature used in the EHR to capture detailed clinical information is called

Back 137

SNOMED CT

Front 138

Which of the following databases is not updated in real time?

Back 138

data warehouse

Front 139

Checkboxes is a method of data entry used in

Back 139

structured data entry