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139 Cards in this Set

  • Front
  • Back
continuum of care, documentation, clinical decision making, knowledge building.
The EHR affords access to longitudinal health information about an individual across the _____, assist in _____, support ____, and provide for _____.
multiple sources, point of care, decision making process
The EHR integrates data from ______, compares data at the _____, assists providers in ______.
source systems
Information systems that populate the EHR.
clinical, administrative, financial
Source systems are ____, ____, and ____.
continuity of care record
A snapshot of data from the EHR and includes basic information such as diagnoses, allergies, medications, and future treatment.
A subset of the EHR that is used for subsequent patient care is a
patient care
Implementing an EHR can improve ____
rules engine
The infrastructure required for the EHR includes which component not found in most information systems?
rules engine
This controls alerts, reminders, order sets, and protocols.
System that includes patient information from both the patient and the provider.
longitudinal record
The phrase womb to tomb refers to ____.
stark law
This prevents physicians from receiving a fee for referring patients for any healthcare services whose care is paid for by a federally funded program.
stark law
This prohibits physicians or their family members from owning businesses to whom the physician refers patients for health services.
This contains preprogrammed clinical decision support designed to assist the user through making an entry appropriately.
order communication system
This part of the EHR notifies clinical departments of orders made by the physician.
electronic document management system
This part of the EHR utilizes scanning to capture patient information from the paper record.
clinical messaging
This part of the EHR connects the medical staff and hospital by providing access to systems.
clinical messaging
This is the secure transmission of clinical information from one entity to another, including providers to providers, patients to providers, etc.
structured, unstructured
Patient care charting generally allow ____ and ____ data.
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.
This type of data can be entered in free text format by the user.
patient safety, reminders, alerts
The use of the CPOE can lead to significant improvements in _____ because _____ and ____ are built into the system.
electronic medication administration record
This part of the EHR automates many of the medication administration process in a facility.
electronic medication administration record
This part of the EHR can provide alerts to assist in medication timing and provide the nurse with reference material on the medication.
clinical decision support system
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.
clinical decision support system
This part of the EHR may notify the care provider of patient allergies or contraindications for medication or other treatment.
patient provider portal
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.
patient provider portal
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.
population health
This part of the EHR is the capture and reporting of healthcare data used for public health purposes.
population health
This part of the EHR allows healthcare providers to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials.
exception to the Stark Law
The ability of a healthcare facility to provide EHR software to physician is allowed through _____.
CCHITs role in the EHR is
larger facilities, physician practices
Most EHRs are found in _____ and _____.
cost savings, cost avoidance, productivity improvement
Economic benefits of the EHR are ______, _____, and _____.
easier access, faster diagnosis and treatment, quality of care, mistakes, documentation
Clinical benefits of the EHR include _____, ______, improvement to ______, reduction in ______, and enhanced ______.
providers, patients
The EHR can improve communication between ______ and allow physicians to spend more time with ______.
cost, uniform standards, training, fear
Barriers to implementing the EHR include ____, lack of ______, ______, and ____.
The lack of consistent standards in the EHR prevents _______.
This is made up of hardware, network, database, server, personnel.
storing patient information
The core function of the EHR is ______.
medical devices
The EHR can link with _______ allowing the capture of monitoring and testing.
practice management system, billing, scheduling
The ambulatory EHR frequently is combined with the ________ to perform ____ and _______.
Scanned image of an individual's actual signature.
Type of signature that requires a password or two-tiered authentication.
Type of signature that used encryption and nonrepudiation to prove authenticator's identity.
classification systems
These are used for secondary data and group similar items together.
reimbursement, quality of care, planning, statistics, public health reporting
Classifications are used for which five tasks?
Standards are important for ______.
health information technology standards panel
This organization works collaboratively with public and private sectors to achieve widespread interoperability among healthcare software applications.
standards development organizations
Organizations that create standards.
american national standards institute
This organization is responsible for accrediting standards development organizations.
health information technology standards panel, standards development organizations, american national standards institute
vocabulary, messaging, data content
For a system to be interoperable, it needs to follow the specific standards in which three categories:
The most widely recognized nomenclature in healthcare is
systematized nomenclature of medicine, logical observation identifiers names and codes, unified medical language system, national drug codes
This nomenclature system includes diagnoses, procedures, signs, symptoms, and cause of injury.
This is a laboratory vocabulary used to order and report laboratory tests and record clinical observations.
This is a vocabulary for medications and provides standards for drug ingredients and strength as well as dose formats and relationships to other drugs.
A database that catalogues bibliographic citations for biomedics and was developed to improve search capabilities.
These were developed by the FDA to act as a universal unique identifier for human drugs.
This nomenclature and knowledge based system is designed to provide intelligent clinical database for documentation by the clinician at the time of care.
This is a crosswalk between the various terminologies; links between terminologies.
use cases
These are frequently used to create maps and describes how the user will interact with the system and what the system will do.
The most secure type of signature used in the EHR is
classification system
ICD 9 is an example of a
The nomenclature used in the EHR to capture detailed clinical information is called
HITSP is considered a
messaging standards
Also called interoperability or data exchange standards.
With these standards, proprietary systems are able to talk to one another and allow the exchange of data.
This SDO provides standards for interoperabiltiy that improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer for all stakeholders.
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.
Digital imaging and communications in medicine, national council for prescription drug programs
These standards are used by pharmacies and payer and control data to be shared for new prescriptions, refills, and other communications.
data structures
Refers to data stored in EHR and the way it is managed.
data set
Group of data elements that are the minimum accepted level of information to be collected for a specific purpose along with uniform definitions.
data sets
UHDDS, UACDS, MDS, DEEDS are all _____.
Uniform hospital discharge data set, uniform ambulatory care data set, minimum data set, data elements for emergency department systems
Joint Commission
ORYX is a data set developed by the ______ to study outcomes and healthcare performance.
Collection of data carefully organized to be of value to the user.
The EHR is a collection of ______.
data repository
Database that is developed in an open format allowing the facility to use it for multiple systems from one source - updated in real time.
data warehouse
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.
presentation layer
This controls the screen layout, data entry, and data retrieval.
Also called narrative or free text data, this is usually entered using a keyboard, dictation, or voice recognition.
This type of data allows data entered to be mores specific and detailed.
Unstructured data is not beneficial for _____ purposes.
Drop down lists, check boxes, radio buttons, and other forms of controlled data entry are used in ______ data entry.
template based entry
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.
The ability of one computer system to exchange data with another computer system.
basic, functional, semantic
Interoperability is divided into which three levels?
Type of operability where the computer can send data to another computer but the receiving computer is unable to interpret the data.
Type of operability that defines the structure of the messages so that the receiving computer can interpret the data.
Type of operability that allows the information to be used in a meaningful way.
hybrid record.
System with functional components that include both paper and electronic documents and use both manual and electronic processes.
____ is the messaging standard used in most information systems.
messaging standard
DICOM is an example of a ____
real time
A data warehouse is not updated in ____.
structured data
Check boxes are a form of ____.
I am entering orders on patient in my office. The computer tells me that I should order a mammogram. This is a ____.
This component of the EHR uses bar codes to identify patients.
provider portal
The provider would use the _____ to check test results of a patient.
healthcare providers
The EHR improves communication between ____.
practice management
The ______ function is seen in the ambulatory EHR but not inpatient.
data content
Standard that controls content of data elements.
Terminology used to capture detailed clinical information.
national drug codes
This system is used to provide an universal unique identifier for human drugs.
A way to link ICD 9 and ICD 10 is through ____.
more specific
An advantage of unstructured data is that it can be ____.
graphical user interface
This provided tool such as icons, colors, buttons, and menus to help users navigate through an information system.
This is a messaging standard that is used by pharmacies and payers.
This messaging standard is used for clinical and administrative data.
use cases
Tools that provide very detailed information for programmers to use when developing they system.
clinical data repository
The infrastructure of the EHR should include a _____.
subpoena audit trails
A legal concern regarding the EHR is the ability to _____.
True or false. The US leads the way in EHR adoption by physicians.
True or false The EHR is not used for public health purposes.
multiple ways
In the EHR, data can be viewed in ____.
printing, access
In the hybrid environment, we must address issues such as ____ and ____.
True or false. The order entry/results reporting system is always utilized by the physician.
A reason to implement an EHR is to
improve patient care
notify physicians of screenings that should be performed on all 65 year old males with a past history of elevated PSA
A subset of the EHR that is used for subsequent patient care
The system that includes information from both the patient and the provider
population health
The component of the EHR that reports infectious diseases
CCHITs role in the EHR
Clinical decision support to enhance physician orders is found in which component of the EHR?
Jason is on Zoloft 100 mg QD for his hospital stay on trial basis. Where would I find when this medication was given?
The time it takes to enter data into the EHR is considered to be a
Which of the following is a benefit of the EHR?
improved efficiency
What function is typically found in the ambulatory EHR but not in the inpatient?
practice management
What is the CORE function of the EHR?
storing patient infomation
Which of the following is a primary barrier to EHR implementation?
The most secure type of signature in the EHR is
digital signature
The concept of the crosswalk between two terminologies is called
Which of the following organizations is an SDO?
ICD-9-CM is an example of a
classification system
The nomenclature used in the EHR to capture detailed clinical information is called
Which of the following databases is not updated in real time?
data warehouse
Checkboxes is a method of data entry used in
structured data entry