Chapter 16- EHR – Flashcards
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What is a value
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combination of quality and cost
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what is a set of components that work together to accomplish a goal?
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system
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what is a record of health related information on an individual that can be created, gathered, managed, and consulted by authorized clinicains and staff within one healthcare organization?
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electronic medical record
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what is an electronic record of health-related information on an individual that conforms to nationally recognzied interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
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electronic health record
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What is the ultimate goal of meaningful use
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provide seamless exchange of information among providers at all levels of the healthcare continuum and provide support for fully integrated evidnce based medicine
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what is the practice of medicine utilizing guidance gleaned from research studies?
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evidence based
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in the absence of research studies this can be used?
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practice guidelines
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source systems
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supply the EHR and other applications with data -may include administrative and financial systems as well as ancillary or departmental systems
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accountable care organization
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a health reform mechanism that ties reimbursement to quality metrics and reduced costs in an assigned population of patients
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practice management system
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support collection of patient demographic and insurance information, scheduling visits, and billing
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what are 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
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medical devices
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meaningful use
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initiated in 2011 under regulations issued by CMS ultimate goal is to provide a seamless exchange of information among providers at all levels of the healthcare continuum and provide support for fully integrated evidence based medicine
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What are the two types of EHR system applications
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administrative and financial clinical applications
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What two categories fall under the broad category of administrative and financial
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R-ADT Patient financial systems
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Describe Radt and patient financial systems
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R-ADT- tracks when patients are admitted and opens an account for them. It also tracks transfers within the hospital, such as to and from an intensive care unit. Patient Financial Systems-aka billing systems and revenue cycle management. refers to the entire process of creating, submitting, analyzing, and obtaining payment for healthcare services
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What falls under the broad category of clinical or ancillary/departmental systems?
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-laboratory information systems-receives orders for lab test, generates a work list for specimen collection, labeling, retrieve results from an auto analyzer; perform quality control -radiology information systems-receiving order for procedure, scheduling it, notifying hospital personnel or the patient if performed outpatient how to prepare for procedure, tracking preparation for report -pharmacy- receives order for drug, aids pharmacist in checking for contraindications, directs staff in compounding, maintains inventory -dietary/food and nutrition-receive orders and supply results to users
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What are the core EHR applications?
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results management, clinical documentation, closed-loop medication management, clinical decision support, analytics and reporting
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what is an application that enables diagnostic study results to be both reviewed in a report format and the data within the reports to be processed?
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results management -results review systems only allow reports of results to be viewed/and or printed
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clinical documentation
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aka point of care charting supply templates to the user to be completed primarily via point and click, drop down, type ahead, and other data entry tools.
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closed loop medication management
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refers to the use of certain systems that help assure patient safety from the point a drug is ordered to the point it is administered -uses cope, e-prescribing, e-mar
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What can happen when alerts are over used?
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alert fatigue
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what can happen when a physician accepts the standard orders or may make an error in modifying them?
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unintended consequences
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Define Medication Five Rights
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a nurse administers the right drug, in the right dose, through the right route, at the right time and to the right patient
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What helps physicians, nurses, and other clinical professionals, collectively referred to as clinicians, as well as patients themselves make decisions about patient care?
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clinical decision support
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What are the four types of clinical decision support?
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data display data retrieval workflow data entry
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what is statistical processing of data to reveal new information
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analytics and reporting
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what are those systems which support documentation of patient care in specialty areas such as intensive care units, emergency services, respiratory and other therapy services. They may be like mini EHR's for the specialty area
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specialty systems and automated medical devices
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What are a few specialty systems?
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PAC- which captures digital images
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What is technology that allows the various applications to work, this includes hardware and additional software?
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supporting infrastructure
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What systems enables the exchange of data across separate information systems both within a healthcare organization and across organizations?
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connectivity systems
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Connectivity systems range from what and refer to what?
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connectivity systems range from legacy structures, such as interfaces using message format standards to new web based services and XML
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document imaging management systems
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involve scanning documents created on paper and making their images available on a computer monitor
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Cold system-computer output to laser disk aka ERM-electronic or enterprise report management
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these systems capture print images of lab results and the documents that are in standalone electronic systems and make them available for viewing on a computer monitor
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Electronic document management systems
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more sophisticated DIMS, they can manage many types of digital documents, including emails and efaxes. When EDMS are well indexed, certain content within the documents can be uniquely retrieved. -may include barcoding on the forms to identify specific content, such as the name of the form
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What system requires the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval?
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Electronic signature authentication
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Digital dictation
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dictation files could be accessed for listening by clinicians prior to being transcribed
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speech recognition
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dictation automatically converts to text
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discrete reportable transcirption
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combines speech recognition with basic natural language processing techniques to create structured data from the dictation
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What is the ability for a computer to evaluate narrative information and structure it given the sophisticated rules for addresing context?
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natural processing language
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what is a secure means to exchange email, either through a portal or simply using e fax or encrypted email?
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clinical messaging
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What is implementation of EHR
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-refers to a sytem having been installed and configured to meet a specific organizations needs -a period of time in which the organization is still working on some aspects of deployment before every use has become fully acclimated ot the system and the changes in workflows and processes that accompany use of the EHR
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What is adoption of theEHR
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-refers to the state of EHR wherever every intended user is using the basic functionality of the system -frequently requires a period of acclimation where users need time to work though how they are going to use the system and what futher personal configurations may be discerned -may also require retrainining, reinforcement, further redesign of workflows and processess and eve a system of rewards
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What is optimization of EHR
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-includes activities that extend use of EHR beyond the basic functionality -optimization of technology frequently includes changes in the clinical practice of medicine
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what is a profound change in how medicine is practiced due to significant changes in technology
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clinical transformation
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certification process
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vender products evaluated against a set of published criteria to ensure that such EHRs would be sufficiently robust as to provide value
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federated model
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there is no central location of data
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What is the role of HIO in the federated model?
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-serves to manage patient identity, record location, and security including consent directives where patients may opt in or opt out of having their data exchanged through the HIO
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Health information is exchanged in what manner?
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point to point
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Which model is less efficient?
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the federated model may be less efficient, with the potential for not finding all desired information about a patient -most consider this a more secure and private model of HIE, even though it may be necessary to often review patient records before identifying the correct patient
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consolidated model
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-there is a central store of data in one large database -logically separated with access controls requiring specific authorization to gain access to any data -because security controls are centralized they can be made stronger by a single rather than dispersed investment -the fear is that the consolidation model could be used to compile massive amounts of data about individuals to be used against them, or hacked and wrongfully accessed or disclosed.
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consistent federated model
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-could be hybrid -independent vaults or databases are managed by the HIO, so that data are centrally managed but both logically and physically separated
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how is the hybrid or consistent federated model necessitated?
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-The hybrid structure or consistent federated model is often necessitated by how data are supplied and used.
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identity matching algorithm
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specified patient demographic information is compared to select the patient for whom information is to be exchanged
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voluntary universal health identifier
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being promoted as a solution that combines an enumeration and a registration process
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What is a process that seeks information about where a patient, once identified, may have a health record available to the HIO?
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record locator service
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What provides security functionality, including determining who is authorized to access information, authentication services, audit logging, encryption, and transmission controls?
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identity management
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consent management
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patients may opt in our opt out of having their health information exchanged
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national health information infrastructure
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-proposed by NCVHS -would be a set of technologies, standards, applications, systems, values, and laws that support all facets of provider healthcare, individual health, and public health - a comprehensive knowledge-based network of interoperable systems of clinical, personal, and public health information would improve decision making by making health information available when and where it is needed
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health information exchange organization
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an organization that supports, oversees, or governs the exchange of health-related information among organizations according ot nationally recognized standards
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ancillary systems aka departmental systems
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serve primarily to manage the department in which they exist, while at the same time providing key clinical data for the EHR
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What is workflow support?
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workflow support has been added to EDMS it means that the EMS facilitates various functions that must be performed simultaneously or in a specific sequence
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What are other facilities that have adopted EHR?
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long term care, post acute care, behavioral healthcare providers, dentists
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What is the state of EHR where every intended user is using the basic functionality of the system
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adoption
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What is optimization?
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includes activities that extend use of EHR's beyond the basic functionality.
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what is a profound change in how medicine is practiced due to significant changes in technology
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clinical transformation
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What are some challenges to EHR?
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-cost it very expensive -benefits-not many as far as money is concerned but it is helping with patient safety and quality -workflow process can be interrupted which can cause a lack of better results -productivity-may decrease
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Health information exchange has 3 models?
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federated-no central location of data, includes consents where patients can opt in or out of having their data exchanged through the HIO consolidated- there is a central store of data in one large database, data is separated with access controls requiring specific authorization to gain access consistent federated model- independent vaults or databases are managed by the HIO so data are centrally managed but logically and physically separated
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identity matching algorithm
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specified patient demographics information is compared to select the patient for whom information is to be exchanged
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What is the process that seeks information about where a patient, once identified, may have a health record, or more than one record, available to the HIO?
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record locator service
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What is a national health information infrastructure
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-like a highway - set of technologies, standards, applications, systems, values, and laws that support all facets of provider healthcare, individual health, and public health
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CCHIT
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certifies EHR's
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patient portal
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special software that enables patients to log on to a website from home or a kiosk
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CCD or CCR
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clinical summary that can be transferred electronically BETWEEN providers
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What provides a protocol for writing software applications?
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data exchange standards
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What are 4 common message format standards used in the US healthcare system?
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HL7, DICOM, NCPDP, ANSI
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controlled vocabulary
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means that a specific set of terms for specified data is used and that any additions or changes to the terms and/or meanings must be formally approved
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What term refers to the configuration, structure, and relationships of all components of a computer system?
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architecture
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What are the two main types of architecture that may be used in creating an EHR?
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client/server- uses a combination of computers to capture and process data web services architecture- an emerging architecture that utilizes web based tools to permit communication among different software applications
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What is a thick client?
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has full processing capability
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what has minimal processing capability?
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thin client
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Define readiness assessment
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helps an organization prepare users to better adopt and EHR. starts at the top, with an assessment of the organizations leadership and culture
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What is migration path?
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strategic plan that outlines the major components to be implemented
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What are the steps in acquiring an EHR?
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-readiness assessment -migration path -hire a physician champion to persuade physicians -communicate with stakeholders
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communicating to stakeholders involves what?
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communication about the status of the project and true engagement of as many stakeholders as possible
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What is natural language processing?
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the ability for a computer to evaluate narrative information and structure it given sophisticated rules for addressing context.
