Chapter 16 Questions with correct Answers

Chapter 16 Questions with correct Answers Theory in Practice PCP manages overall care, link to PHR, prior physician send information using standard continuity of care document content and format specifications for exchanging information between providers. New PCP's EHR is prepopulated with the current problem list,labs, and other data. Patient medications can be populated from a pharmacy benefit manager. If patient has an accident and goes to ER, is admitted requires physical therapy after discharge, their info can be immediately retrieved because all providers because they are part of a HIEO and patient has given a consent directive. Health Information Exchange Organization (HIEO) Allow providers to have immediate access to the specific information needed to treat a patient throughout his care. Patient must provide a consent directive to opt-in to the sharing of such info with all participants in the HI Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:01 / 0:15 Full screen Brainpower Read More Accountable care organization A health reform mechanism that ties reimbursement to quality metrics and reduced costs in an assigned population of patients. PCMH Patient-Centered Medical Home. A program to provide comprehensive primary care that partners physicians with the patient and their family to allow better access to healthcare and improved outcomes. System A set of components that work togethrr to accomplish a goal. Define EHR Broad: A system that includes major clinical applications plus connection points to many other applications in a healthcare organization and with other healthcare and related organizations. IOM Institute of Medicine. This is a nonprofit organization that is part of the National Academies that provides advice to lawmakers and the public. ONC Office of the National Coordinator. 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, gathered, managed, and consulted by authorized 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, managed, and consulted by authorized clinicians and staff ACROSS MORE THAN ONE HEALTHCARE ORGANIZATION. HIT Health Information Technology. The technical aspects of processing health data and records, including classification and coding, abstracting, registry development, storage, and so on. PMS Practice Management System. Software designed to help medical practices run more smoothly and efficiently by supporting collection of patient demographic and insurance information, scheduling visits, and billing. Telehealth A telecommunication system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for medical consultation and treatment HIE Health information Exchange. Services that support sharing health information across different healthcare organizations. Medical devices Instruments that collect or supply health information as they monitor patients' vital signs, aid in analyzing lab specimens, and perform other diagnostic and therapeutic support; and others. MU Meaningful use. Term used in ARRA/HITECH legislation for providers to qualify for incentives for using EHR. There are 3 types of requirements for meaningful use: 1) Use of certified EHR technology in a meaningful manner 2) that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care 3) use of certified EHR technology,the provider submits information on clinical quality measures Structured Data Data stored in databases based on a standard data dictionary or controlled vocabulary that makes use of the data in very precise ways. Discrete, i.e., drop-down lists, check boxes, radio buttons and any other form of controlled data, Unstructed data Refers to narrative data - dictated, keyed as text, or scanned. template A pattern used in computer-based patient records to capture data in a structured manner. Source systems This system supplies the EHR and other applications with data. May include administrative, financial, ancillary or departmental systems. Name two broad types of source systems. Administrative and financial R-ADT Registration, admission, discharge and transfer systems in hospitals which register patients for admission or outpatient services, captures demographic and insurance data, and supplies this data to all other applications. This system also closes the account when a patient is discharged. PFS Patient financial systems. Sometimes called billing systems in a physician's practice, aid revenue cycle management. RCM Revenue cycle Management. Is the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services. What is a form creation system? A system that automates some of the authorization, consent, advance directive, and other administrative forms used to manage healthcare administrative processes. Ancillary systems (a type of source system) are also called...? Clinical departmental systems. What do clinical department systems do? Primarily serve to manage the department in which they exist, while at the same time providing key clinical data for the EHR. What are the three main departmental systems necessary for an EHR to function in a hospital? 1. Laboratory information system (LIS) 2. Radiology information systems (RISs) 3. Pharmacy information system What are some examples of an administrative and Financial applications (source systems)? 1. R-ADT PMS 2. MPI 3. PFS 4. HIM 5. EDMS 6. QA 7. OC/RR LIS Laboratory information system. An information system that collects, stores, and manages laboratory tests and their respective results. RIS Radiology information system. A system that collects, stores, and provides information on radiological tests such as ultrasound, magnetic resonance imaging, and positron emission tomography. Pharmacy information system A system that assists care providers in ordering, allocating, and administering medication; focuses on patient safety issues, especially medication errors and providing optimal patient care. Name examples of Departmental Clinical Applications. 1. Lab 2. Blood bank 3. Radiology 4. PACS 5. Inpatient pharmacy 6. Dietary 7. Others. What are the 5 main components needed for EHR/Core Clinical EHR (key capabilities)? 1. Results management 2. Clinical documentation 3. Closed-loop medication management 4. Clinical Decision support (CDS) 5. Analytics and reporting Results Management An application that enables diagnostic study results (primarily lab results) to be reviewed in a report format and the data within the reports to be processed. The importance of results management is extremely importance as 70% of the ability to reach a diagnosis depends on lab results. What is another name for clinical documentation systems? Point-of-care charting systems Define Clinical documentation systems 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. Templates are often used to completed using point and click, drop-down, and other data entry tools. Closed-loop medication management Information systems used to provide patient safety when ordering and administering medications. Systems include CPOE, e-prescribing, BC-MAR (barcode), medication reconciliation systems, and automated drug dispensing. Alert fatigue When an excessive number of alerts are used in an information system, users may get tired of looking at alerts and ignore them. Medication Five Rights (critical to avoid medication errors) The frequency and care which must be taken to assure that a nurse administer 1)the right drug,2 )in the right dose, 3) through the right route,4) at the right time, and 5) to the right patient. DDRTP = David Draws Red Tulip Picture CDS Clinical Decision Support. A functionality within the EHR that allows clinicians and patients to make decisions about patient care. The process in which individual data elements are represented in the computer by a special code to be used in making comparison, trending results, and supply clinical reminders and alerts. Name types of clinical decision support 1. Data Display - flow sheets, summaries, data always available 2. Workflow - in-basket, schedule/patient list, email/patient visits 3. Data Retrieval - single sign-on, customized screens, ease of navigation 4. Data Entry - structured data/registry support, context-sensitive templates Analytics and Reporting Refers to statistical processing of data to reveal new information by the ability to collect information and the ability to send it out. examples: data mining, forecasting, neural networks Core Measures Standardized performance measure developed to improve the safety and quality of healthcare. Specialty Systems and Automated medical device Systems that support documentation of patient care in specialty areas, such as intensive care units, emergency services, respiratory and other therapy services, rehabilitiave care, behavioral healthcare, hospice, and many others. Should not replicate information collected or services provided by other systems in the organization. PACs Picture archiving and communication systems. They capture digital images from various modalities, such as x-ray, ultrasound, and others and provide special viewing capabilities of these images via a computer. Some of these also have the ability to connect directly with a radiology information system. Examples of Automated medical devices 1) blood pressure 2) fetal monitoring strip 3) vital signs monitors 4) cardiac output monitors 5) defibrillators 6) electrocardiographs 7) infusion pumps 8) ventilators 9) physiologic monitors, and more Supporting infrastructure Technology that allows usage of an application this includes both hardware and additional software. Connectivity Systems Enables the exchange of data across separate information systems both within a healthcare organization and across organizations. Message format standards Protocols that help ensure that data transmitted from one system to another remain comparable. Interface The zone between different computer systems across which users want to pass information Is clinical data both textual and contextual? Yes. Largely textual because clinicians prefer to describe patient conditions in narrative form. Narrative data also depends on context or situation to make the data meaningful. Define Textual A term referring to the narrative nature of much of clinical documentation to date Define Contextual The condition of depending on the parts of a written or spoken statement that precede or follow a specified word or phrase and can influence its meaning or effect. EDMSs Electronic Document Management Systems. A storage solution based on digital scanning technology in which source documents are scanned to create digital images of the documents that can be stored electronically on optical disks. Manages many types of digital documents like emails and e-faxes. It facilitates various functions that must be performed often simultaneously or in a specific sequence (workflow support). ESA Electronic signature authentication. This system requires the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval. Digital dictation A process in which vocal sounds are converted to bits and stored on computer for random access