HIT, Chapter 11

Interoperability

sharing of information across EHRs and other IT systems and the capability of different information systems and software applications to communicate and exchange data

Value

refers to the combination of quality and cost

Computerized provider order entry (CPOE)

used by providers to enter orders for medicatios, lab tests, and other procedures, and the destination systems

BC-MAR

used by nurses to manage drug administration and other procedures

Telehealth

services that assist in providing remote diagnosis and treatment

Templates

a guide for documentation

Meaningful Use (MU)

term used for the program designed to incentivize the use of EHRs

Adoption

the term associated with the intent of MU. Reflects that the organization has implemented all major component of technology

Optimization

the healthcare organization implements all of the technology available

Source systems

supply the EHR and other applications with data

-administrative, financial, ancillary or departmental systems

R-ADT

register patients for inpatient or outpatient services. Captures demographic and insurance data

Patient financial system (PFS)

serve to check patient insurance eligibility, capture charges, and compile and send claims

Revenue cycle management (RCM)

refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services

What are 5 core clinical EHR systems?

1. results management

2. POC documentation

3. CPOE and BC-MAR

4. CDSS

5. reporting

POC charting

informs user what documentation is needed, supports structured data collection, and provides documentary evidence of patient care actions

Closed-loop medication management

refers to the use of certain systems that help ensure patient safety

Medication reconciliation

compare drugs ordered against drugs dispensed and administered

Drug knowledge database

a subscription service that provides current information about drugs; send alerts for drug-allergy and drug-drug contraindication

Alert fatigue

when an excessive number of alerts are used in an information systems, users may ignore them

Medication five rights

1. right drug

2. right dose

3. right route

4. right time

5. right patient

Clinical decision support (CDS)

helps healthcare staff make decisions about patient care

Clinical decision support system (CDSS)

requires the combination of data from more than one sources and ability to deliver the alert back to appropriate system(s

Clinical data repository

A central database that focuses on clinical information

Cloud computing

uses a vendor to archive data and in some cases also provides application software

Patient portal

enable patients to log on to a website from home or a kiosk to have access to their health information

Personal health record

an electronic or paper health record maintained and updated by an individual

Health Information Exchange (HIE)

another way to exchange information across multiple organization and individuals

eHealth exchange

federal agencies and nonfederal organizations coming together to offer a interoperable health information exchange service

Systems Development Life Cycle (SDLC)

steps taken from an initial point of recognizing the need for a desired result, through the steps taken to ensure that all components needed are addressed

Sunsetting

no longer selling or supporting

A radiology information system is which of the following?

a. Core clinical component

b. Hospital information system

c. Source system

d. Supporting infrastructure

c. Source system

When an EHR is integrated into the daily routine of clinicians it is said to be in what stage of existence?

a.Adoption

b.Implementation

c.Meaningful use

d.Optimization

a.Adoption

Which of the following is a fundamental change in how medicine is practiced using health IT?

a.Clinical decision support

b.Clinical transformation

c.EHR optimization

d.Medical informatics

d.Medical informatics

Which of the following is a program that assures there is documented approval for altering an application?

a.Change control

b.Configuration management

c.System build

d.System maintenance

a.Change control

What health information exchange is a sophisticated structure that enables both receipt of data and the ability to query an exchange for data?

a.CONNECT

b.Direct

c.Microsoft Vault

d.File Transfer Protocol

a.CONNECT

Infusion pumps and robotics are examples of which of the following?

a.EHR systems

b.Medical devices

c.Smart peripherals

d.Specialty clinical applications

c.Smart peripherals

What is interoperability?

a.The ability to share health information with other health IT systems

b.A form of health information exchange

c.A process that integrates all health information into one database

d.A system of technologies that work together to achieve a common purpose

a.The ability to share health information with other health IT systems

Revenue cycle management is accomplished through use of which of the following systems?

a.Eligibility verification system

b.Form creation system

c.Patient financial service system

d.Registration-admission, discharge, transfer system

c.Patient financial service system

Structured data are which of the following?

a.Able to be processed by a computer

b.Images of data on a printout

c.Organized according to a classification system

d.Required for all parts of the EHR

d.Required for all parts of the EHR

Ideally, clinical documentation in an EHR should be performed _____________.

a.At the point of care

b.Before the patient is discharged from the hospital

c.Via speech dictation when the clinician has completed examination of the patient

d.Within one business day of collection

a.At the point of care

The source of drug-drug contraindication information in a computerized provider order entry system is ___________.

a.Clinical decision support system

b.Drug knowledge database

c.Evidence-based medicine

d.RxNorm

b.Drug knowledge database

Which of the following is an example of clinical decision support?

a.Authenticate a document

b.Digital dictation system

c.View lab results

d.Workgroup tool

d.Workgroup tool

A standard vocabulary is used to achieve what type of interoperability?

a.Process

b.Semantic

c.System

d.Technical

b.Semantic

A way to send secure messages over the Internet is which of the following?

a.Cloud computing

b.Digital imaging and communications network

c.Virtual private network

d.Web services architecture

c.Virtual private network

In order to locate a patient via a health information exchange organization, there must be which of the following?

a.Identity matching

b.Identity management

c.Record locator service

d.Unique patient identifier

a.Identity matching

The systems development life cycle _________________________.

a.Ensures all components for a system to achieve its value are in place

b.Identifies when products or services need to be sunset or discontinued

c.Helps organizations select appropriate software

d.Relates applications to the technology needed to run them

a.Ensures all components for a system to achieve its value are in place

A form of clinical decision support that guides a user in appropriate documentation is which of the following?

a.Digital dictation

b.Point of care documentation

c.Reminder system

d.Template

d.Template

What is the combination of quality and cost of healthcare?

a.Care process

b.Risk

c.System

d.Value

d.Value

True or false: Computerized provider order entry systems can be used to order narcotics.

a.True

b.False

a.True

True or false: A clinical data repository supports sophisticated data analytics.

a.True

b.False

b.False

True or false: A master patient index is used to locate where patients may have records within a health information exchange organization.

a.True

b.False

b.False

True or false: An organization's goals that are supported by health IT can be achieved more quickly and completely if monitoring results is performed.

a.True

b.False

a.True

True or false: The Logical Observations Identifiers Names and Codes (LOINC) vocabulary is used to encode laboratory orders and results

a.True

b.False

a.True

True or false: Medication reconciliation is very difficult to implement and often one of the last applications within the medication management set of systems.

a.True

b.False

a.True

True or false: A portal is the same as a personal health record.

a.True

b.False

b.False