Integrated Electronic health records (Key Terms) Chapter 1-2

Flashcard maker : Tiffany Hanchett
Application
Software that has a special purpose, such as word processing, spreadsheet, or for a particular industry such as practice management or electronic health record software.
Care provider
Term used to refer to physicians, physicians’ assistants, dentists, psychologists, nurse practitioner, or midwife.
Clearinghouse
A service that processes data into a standardized billing format and checks for inconsistencies or other errors in the data.
Current Procedural Terminology (CPT)
Coding system used to convert narrative procedures and services into numeric form. CPT is used to code procedures and services in a physician’s office; in a hospital setting, it is used for outpatient coding (emergency room, outpatient diagnostic testing, or ambulatory surgery, for example).
Save Changes
Demographic information
Administrative data that identifies the patient. Consists of name, date of birth, sex, and social security number (may vary by facility policy).
Electronic claims submission
Submitting insurance claims via wire to a clearinghouse or directly to the insurance carrier.
Electronic Health Record (EHR)
Comprehensive record of all health records for a patient, which is able to be shared electronically with other health providers as necessary.
Electronic Medical Record (EMR
The legal patient record that is created within any healthcare facility (hospital, nursing home, ambulatory surgery facility, physician’s office, etc.). The EMR is the data source for the electronic health record (EHR).
Encounter form (Superbill)
A document (paper or electronic) that is used in medical offices to capture the diagnoses and services or procedures performed and from which the CMS-1500 billing form is completed.
International Classification of Diseases-10th revision, Clinical
The classification system used to convert narrative diagnoses and procedures into numeric codes. Effective October 1, 2015, replaces ICD-9-CM.
Modification/Procedure Coding System (ICD-10-CM/PCS)
The classification system used to convert narrative diagnoses and procedures into numeric codes. Effective October 1, 2015, replaces ICD-9-CM.
Interoperability
Many different functions can take place and information can be shared between computer systems, or within applications of the same computer system, which is not possible with a manual or paper record system.
Master Patient (Person) Index
( Patient List or Master Patient (Person) Index )
A permanent listing of all patients who have received care in a hospital (inpatient or outpatient). In physicians’ offices, more often referred to as Master Patient List or Patient List.
Point of care
Documentation, dictation, ordering of tests and procedures that occur at the same time the patient is being seen.
Practice Management (PM)
Software used in physicians’ offices to gather data on every patient and perform administrative functions from the time an appointment is made through the time the bill for each visit is paid.
Speech recognition
Software that recognizes the words being said by the person dictating, and converts the speech to text.
Is PrimeSUITE a Practice Management tool or an electronic health record? Support your answer.
PrimeSUITE is both a PM and EHR solution using a single database.
List the types of information that insurance companies need to be provided with on a billing claim form.
This is done by compiling the patient’s identifying information, insurance information, and the ICD-10-CM/PCS and CPT codes into a form called the CMS-1500, which is used by physicians’ offices, or the UB-04, which is used to bill hospital claims.
otorhinolaryngologist
ear, nose, and throat specialist
How do you access the Help feature in PrimeSUITE?
PrimeSUITE help text can be accessed through any screen. By clicking on Help, you will gain access to the entire user’s guide (Figure 1.9). How many ways are there to locate information?
How many ways are there to locate information?
Three ways. How many ways are there to locate information?
What is PrimeSPEECH?
a form of speech recognition technology.
What does PrimeSUITE’s PrimeEXCHANGE function do?
Exchange of clinical information between medical providers or other entities
PrimeEXCHANGE solution.
Exchange of clinical information between medical providers or other entities with a need to know, through the PrimeEXCHANGE solution.
ePrescribing solution.
Prescribing medications electronically to the patient’s pharmacy of choice through use of the ePrescribing solution.
PrimeRESEARCH solution
The ability to access clinical trials, evidence-based medicine, and pharmaceutical research to improve patient care, and access to clinical and financial benchmarking services to enhance financial management by using the PrimeRESEARCH solution
PrimeMOBILE.
Mobile EHR applications available on personal digital assistants (PDAs) or smartphones to allow providers instant access anytime and anywhere through PrimeMOBILE.
The Flow of Information from Registration through Processing of the Claim
1:Appointment scheduling
2: Front desk check-in
3: Nursing/clinical support
4: Care provider
5: Check-out desk
6:Business office/billing
7: Clinical staff/care provider
Under what circumstances would clinical documentation steps need to be repeated?
In cases where the care provider ordered diagnostic procedures such as x-rays or laboratory tests, then the clinical documentation steps would be repeated
Describe Practice Management applications.
What is Practice Management?/Practice Management applications
-Master Patient Index/Patient List
-Scheduling appointments
-Assign ICD-10-CM/PCS and CPT codes
-Complete billing claim form
-Send insurance claims to carriers
List the advantages and disadvantages of an electronic health record
Disadvantages
-Increased security functions
-High cost of implementation
-training requirements

Advantages
-Possibly more secure than paper records
-Return on investment is high
-All information in one place
-Interoperability
-Assures regulatory compliance
-Exchange of information with those who have a need to know

Describe EHR applications.
-Clinical documentation
-Electronic prescribing
-Exchange of clinical information
-Research evidence-based medicine, pharmaceutical research, clinical and financial benchmarking studies

-Speech recognition

Chart the flow of information from registration through processing of the claim
-Appointment scheduling

-Front desk check-in
*Verify demographic information
*Sign authorization/administrative forms, if necessary

-Patient taken to examining room
*Height, weight, vital signs are taken
*Patient states the reason for today’s visit (chief complaint)

-Care provider meets with the patient
*Provider verifies reason for visit; updates history
*Provider examines patient
*provider makes referrals, if necessary
*Prescriptions are electronically sent to pharmacy, if necessary
*Provider completes the chart, which then starts the coding and claims process
*Provider completes the visit and provides patient with a Superbill or encounter form

-Patient stops at the check-out desk
*Superbill is given to staff member at the check-out desk
*Patient pays co-pay, if not paid during check-in process
*Patient leaves the office

-Business office/billing
*Insurance claim form is completed electronically
*Insurance claim is submitted electronically
*Insurance payment (or notice of denial) is received
*Payment is entered in the system
*Patient’s account is updated
*Statement is sent, if necessary

-Follow-up
*Results of diagnostic tests received, if applicable
*Record is updated with results
*Provider reviews results
*Patient is contacted, if necessary

Use the help feature in PrimeSUITE.
Use of Help from menu bar

Other means of accessing help feature

User’s Guide

American Recovery and Reinvestment Act of 2009 (ARRA)
Signed into law by President Obama on February 17, 2009; this economic \”stimulus plan\” includes provisions for the Health Information Technology for Economic and Clinical Health (HITECH) Act.
Clinical decision support
Allows access to current treatment options for a disease, through electronic or remote methods. Alerts the care provider to possible medication interactions, gives treatment options based on results of clinical trials or research, alerts provider that a patient may have a particular diagnosis based on the data found in the patient’s electronic record.
Certification Commission for Health Information Technology (CCHIT)
A nonprofit, nongovernmental agency whose purpose is to certify electronic health records for functionality, interoperability, and security.
Data
A single, raw fact such as a patient’s name, height, or weight. Often used interchangeably with information, though they are not synonymous terms.
Healthcare administrator
A leadership position within a healthcare facility, including chief executive officer, chief operating officer, chief financial officer, chief information officer, or other higher level management positions. May also be referred to as healthcare manager or health systems manager.
Health information exchange (HIE)
The movement or sharing of information between healthcare entities in a secure manner, and in keeping with nationally recognized standards.
Healthcare systems administrator
A leadership position specifically responsible for the information technology (IT) functions within an organization or facility.
Health Insurance Portability and Accountability Act (HIPAA)
Passed in 1996, this act includes regulations that afford people who leave their employment the ability to keep their insurance or obtain new health insurance even if they have a pre-existing medical condition. Also sets standards for storing, maintaining, and sharing electronic health information while ensuring its privacy and security.
Health Information Technology for Economic and Clinical Health (HITECH) Act
A portion of the American Recovery and Reinvestment Act (ARRA) that is meant to increase the use of an electronic health record by hospitals and physicians through a monetary incentive program.
Information
Raw facts that, when viewed as a whole, have meaning. Example: a report of all patients treated at Memorial Medical Center with a primary diagnosis of streptococcal pharyngitis (strep throat), sorted by patients’ age.
Institute of Medicine (IOM)
An independent, nonprofit, nongovernmental organization that works to provide unbiased and authoritative advice to decision makers and the public.
Meaningful use (MU)
Part of the requirements of the Health Information Technology for Economic and Clinical Health (HITECH) Act which is meant to increase the use of an electronic health record through monetary incentives provided the EHR is used in a meaningful way to improve patient care.
National Health Information Network (NHIN)
A set of standards, services, and policies that enable the secure exchange of health information over the Internet.
National Provider Identifier (NPI)
A unique identifier that must be used on insurance claims to identify the care provider and/or group practice that rendered care to the patient.
Office of the National Coordinator for Health Information Technology (ONC)
The principal federal entity charged with coordination, implementation, and use of health information technology and the electronic exchange of health information.
Personal health record (PHR)
A record, kept by the patient, that contains a person’s health history, immunization status, current and past medications, allergies, and instructions given by a care provider; it often includes patient education materials as well.
Picture Archiving and Communication Systems (PACS)
Computerized system for enhanced viewing and sharing of images such as x-rays, scans, ultrasounds, and mammograms.
Protected health information (PHI)
Any piece of information that identifies a patient, including a patient’s name, date of birth, address, email, telephone number, employer, relatives’ names, social security number, medical record number, account numbers tied to the patient, fingerprints, photographs, and characteristics about the patient that would automatically disclose his or her identity. PHI also includes any clinical information about an identified patient.
Regional extension center (REC)
An organization that assists healthcare providers with the selection and implementation of electronic health record systems.
Regional Health Information Organization (RHIO)
Healthcare organizations in a geographic area that exchange health information with the goal of improving patient care, reducing duplication, and reducing unnecessary costs.
Structured data
Data that fits a particular model or format, which can be tracked and may be part of a database. Examples include ICD-10-CM/PCS codes, CPT codes, a patient’s temperature, or a patient’s age.
Unstructured data
Data in the form of words or audio files that cannot be tracked. Examples include emails, written narratives, and audio files from speech recognition technology.
In the inpatient setting, the healthcare administrator may be a
chief executive officer (CEO),
chief operating officer (COO),
chief financial officer (CFO), or
chief information officer (CIO).
The office administrator Is also called the
(manager)
(AHIMA)
American Health Information Management Association
(AAMA)
American Association of Medical Assistants
(AMT)
the American Medical Technologists,
(HIMSS)
Healthcare Information and Management and Systems Society
(POMAA)
the Physician Office Management Association of America
What roles might be held by a healthcare administrator?
may be a chief executive officer (CEO), chief operating officer (COO), chief financial officer (CFO), or chief information officer (CIO). These individuals typically have a bachelor’s or master’s degree (preferred) in healthcare administration and are responsible for overseeing several departments (or the entire organization).
What is the difference between a medical assistant and an office administrator?
Medical assistant is required to enter and retrieve data quickly yet accurately whereas an office administrator (manager) will be gathering information from the practice management and EHR systems to ensure claims are filed and paid accurately and in a timely manner, to ensure requirements of managed care organizations are met, and to ensure compliance with Meaningful Use (MU) requirements.
What is data
A single raw fact such as a persons name, height or weight.
Differentiate between structured and unstructured data.
unstructured data are a dictated report, a written progress note, voice files, or scanned images of original documents. difficult to track or share.
Structured data allow computers to process the data into usable information.
What does a A PHR contain
a person’s health history, immunization status, current and past medications, allergies, and instructions given by a care provider; it often includes patient education materials as well.
The acronym HIE stands for:
health information exchange.
An advantage of using screen-based data collection tools is that the layout of the information on the can be:
customized.
The ____ defined the eight core functions of an EHR.
Institute of Medicine
Which of the following is a goal of HIPAA?
establish standards for keeping of health information
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
the patient calls to make an appointment.
In a physician’s office, patient data collection begins when:
An advantage of EHRs is that patients are now able to ____ about procedures they are undergoing.
view videos
Knowing that Jim Smith had a heart attack when he was 53 is an example of:
data.
When patients are finished with their encounter at a hospital, they:
are discharged.
If a hospital uses information gathered through their EHRs to justify the purchase state-of-the-art equipment to improve patient care, they are:
engaging in mean
Dr. Glover’s office has one vendor for their Practice Management software and another for their electronic health record, but the systems are able to communicate with one another without duplicating data entry. The systems are able to:
interface
.In order to file a claim to Medicare, a physician’s office submits a ___________ form.
CMS-1500
You are about to enter the marital status of a patient, and upon clicking in that field, the following appears:

These possible values are derived from a _____________ within the system.

Library
Susan is collecting data from a patient, and she asks him for his address. The patient asks whether she means his P.O. box number or his physical street address. Susan would find the meaning of the field permanent address in the practice’s ______________________.
Data dictionary
Demographic data is a subset of ____________________ data.
administrative
.Clinical Documentation Architecture (CDA) and Quality Reporting Documentation Architecture (QRDA) are both specific data standards of the broader _________ standards.
Health Level Seven (HL7)
A major goal of use of an electronic health record is the sharing of important clinical information about a patient. The use of ________________________ is directly related to this goal.
Continuity of Care Documents (CCD)
The name, address, NPI number, and telephone number of a physician is known as ____________ information.
provider
The subscriber and patient information section of a claim form includes all of the following except:
assignment of benefits authorization
The setting where services took place is known as ______________________.
the place of service code
There are certain pieces of data that must be collected in order to meet Meaningful Use requirements. Which of the following data does that?
race
Michael Malone’s health (medical) record number at Memorial Medical Center is 482638. This is an example of a/an _______________
unique identifier
The required code set for documenting diagnoses on all patients in any care setting is known as:
ICD-10-CM
Accountable Care Organization
Greenway Medical Center has partnered with five area physician’s offices as well as a rehabilitation facility nearby for the purpose of offering high quality, coordinated care to patients in that geographic area. This partnership is known as a/an _________________.
In order for ACOs to prove that they have provided quality care while controlling costs, what is necessary?
data
Where does the data originate that is used to prove Accountable Care Organization (ACO) success?
the patients’ health records
The master patient (person) index is:
An index of all patients ever treated in a hospital
In a hospital, what piece of data included in master patient (person) index (MPI) which allows a hospital to locate the corresponding health (medical) record for each patient?
medical (health) record number
Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many times will Daniel Allen’s name and demographic information be entered in the MPI of Greenway Hospital?
one
Daniel Allen has been a patient at Greenway Hospital for the following ailments: January 8, 2012, inpatient for appendicitis; April 16, 2012, emergency department for an asthma attack; May 12, 2013, urgent care for a viral illness, May 13, 2013, inpatient for pneumonia, and once on June 4, 2013 in the emergency department for a sprained arm. How many encounters for Daniel Allen will be found in the MPI of Greenway Hospital?
five
In a physician’s practice, the index of all patients seen in that practice is most commonly known as the:
Patient list
A patient at Heller Memorial Hospital, Lisa Ford, was a patient in the emergency department in 1998, has had outpatient lab work in 2003 and 2005; she was then married. Her name changed to Lisa Ford Haver, and she had her twins at Heller County Memorial Hospital in 2010. How many times will her name and demographic information appear in the hospital’s MPI?
once
The MPI and patient list should be kept:
Permanently
In which healthcare setting is a patient not registered prior to receiving care?
patients are registered in all of these settings
At Heller Memorial Hospital, all patients regardless of the type of patient, emergency department, inpatient, outpatient diagnostics, etc., are registered through the same department. This is known as:
Centralized registration
The amount of time allotted for a patient’s office appointment is largely dependent on the
reason for the visit
Virginia Reed called Greensburg Medical Center to make an appointment for her annual physical exam. This step in the process is called:
Scheduling
Amy Shaw arrives for her appointment at Dr. Rodriguez’s office. She has moved since her last visit and her last name has changed due to her marriage. The healthcare professional will __________ the patient’s demographic information.
edit
When certain fields are clicked, the most common response to that field may appear. This is known as a _________ value.
Default
The step that occurs after a patient is seen by the care provider is:
patient stops at the cashier or check-out desk
Each time a patient presents for care, the ______________ should be viewed or copied to ensure accurate information is on file for billing purposes.
insurance card
An on-screen item of data is known as a:
field.
It is important to keep the design of paper forms:
logical.
Birth
Which of the following is NOT a required patient history?
Family
Of the following, who will benefit from thoroughly completed paper forms?
Care providers
Patients
Receptionists
All of these
The patient’s ____ history could possibly help predict a future health condition.
family
A patient’s vital signs are entered via PrimeSUITE’s ____ screen.
Facesheet
Which of the following is an acceptable way of gathering a patient’s history?
Interview
Which piece of information might be included multiple times on a form?
Allergies
What information should you see on all forms in a patient chart?
Name
DOB
Medical record number
All of these
A patient’s past surgical history includes the:
approximate date of the procedure.
For ease of completion, related information should be ____ on a form.
adjacent
What does BMI stand for?
body mass index
Which of the following would include a patient’s exercise regimen?
Social history
Any discrepancies in patient information need to be:
documented.
Which of the following is an element of the history of present illness?
Duration
Which of the following would most likely require a complete review of systems?
Annual exam
Notes about a prescription ordered for a patient would appear in the ____ section of a SOAP note.
plan
An ROS covers information likely documented in the:
medical history form.
PrimeSUITE has the capability to ____ the status of an order.
generate
The biggest advantage of voice recognition software over manual transcription is:
speed of turn-around time
Information gathered during a provider’s physical exam would appear in the ___ section of a SOAP note.
objective
The more voice recognition software is used, the:
more it learns voice inflections.
There must be a ____ to perform any tests or treatments.
care provider request
A person hired to manually record a physician’s spoken words is known as a
transcriptionist.
Which of the following elements of an HPI are collected at a visit?
Only those that apply to the patient’s chief complaint
The extent of a physical exam largely depends upon which of the following?
Patient’s chief complaint
Meaningful use regulations require the keeping of an up-to-date:
problem list
The use of ePrescribing is part of the requirements for:
HITECH
The information contained in the encounter form is eventually transferred to the ________ form for submission.
claim
Only services deemed medically ________ can be billed to insurance
necessary
What does the \”CM\” stand for in ICD coding?
Clinical modification
The amount of a patient’s co-pay may vary by:
insurance plan.
Charges begin to accrue once the
MA or care provider interacts with patient
A remittance advice is typically given to a/an ________ , whereas an explanation of benefits is typically given to a/an ________ .
provider; patient
In PrimeSUITE, a red \”X\” on a Superbill summary indicates:
an invalid code assignment.
To avoid negative consequences, a compliance plan should be ____ in every hospital and medical office.
followed
The ________ is usually the person to set up information libraries within Practice Management software programs.
office manager
Who is the only person authorized to make a diagnosis?
Care provider
To check if a claim has been paid, which menu will the healthcare professional look at?
Accounts receivable
Which of the following is true of the advance payment ACO model?
It is an incentive model.
Depending on the terms of a patient’s insurance coverage, the balance remaining after insurance has paid may be:
written off as paid in full or sent to collections.
Expected methods of payment are discussed when a patient:
makes an appointment.
In the event of a breach, who may be held responsible?
Providers
Office staff
The facility
Which of the following would be considered a covered entity?
Healthcare provider
Of the following, which factor contributes to the access rights allowed a user?
Job description
It is critical that backup files be stored:
offsite
HITECH regulations require that ____ information releases are accounted for.
all
According to HIPAA regulations, healthcare providers must use ________ as opposed to written documentation to store and transmit
information to insurance carriers.
CPT codes
ICD-10 codes
HCPCS codes
Meaningful use standards require offices to select an EHR that is:
certified
Releasing information without proper authorization is called a/an:
breach of confidentiality
When a document is amended or changed in an EHR, the original documentation is:
hidden.
An office’s compliance manual should be kept in a/an ____ location.
accessible
The sharing of health information must be done in a ________ environment.
secure
Under a care provider’s order, medical assistants and nurses ________ allowed to send an ePrescription or call in a refill prescription to
a pharmacy.
might be
To help guard against security breaches, emails containing protected health information should be
encrypted.
The mission of CCHIT is to:
increase the implementation of EHR systems.
Abuse
Coding and billing that is inconsistent with typical coding and billing practices.
Accountable Care Organization (ACO)
A reimbursement model where hospitals, physicians, other healthcare providers form partnerships whereby all are accountable for the quality of care, efficiency of medical services (to contain costs), and patient satisfaction. A pay for performance model of healthcare reimbursement.
Accounts payable
Monies being paid from the medical practice, for instance to pay for supplies, rent, utilities, payroll,
Accounts receivable
Monies coming into a medical practice, for instance insurance payments or payments made by patients.
Affordable Care Act (ACA)
Signed into law in 2010, the ACA resulted in improved access to affordable healthcare coverage and protection from abusive practices by healthcare insurance companies. Gives consumers more control over their healthcare coverage and ties reimbursement to quality, patient satisfaction, and
Co-payment (co-pay)
The amount due from the patient at the time of the office visit; typically a requirement of managed care plans.
Compliance plan
A formal, written document that describes how the hospital or physician’s practice ensures rules, regulations, and standards are being adhered to.
Deductible
The out-of-pocket payment amount that a policyholder must meet before insurance covers the service(s).
Evaluation and Management (E&M)
The CPT codes used to capture the face-to-face time between a patient and the care provider; takes into consideration the extent of the history, extent of the physical exam, and the level of medical
Explanation of benefits (EOB)
An explanation of the charges for services, the amount paid by the insurance company, and the amount due by the subscriber, which is sent to the subscriber (and also to the provider, in some instances).
Fee schedule
The amount charged for services rendered in a physician’s office by Current Procedural Terminology (CPT) code.
Fraud
Intentional deception, which in healthcare takes advantage of a patient, an insurance company, Medicare, or Medicaid.
Healthcare Common Procedure Coding System (HCPCS)
Coding system required by Medicare and Medicaid to document services and procedures (Level 1, Current Procedural Terminology, CPT) and equipment, supplies, and transport (HCPCS Level 2).
Insurance plan
The medical insurance contract under which a patient is covered; the extent to which services are covered. Also referred to as \”the plan.\”
Insurance verification
The process of contacting the insurance carrier and receiving validation of coverage for that patient, deductible status, and co-pay amount.
Managed care plan
Insurance plans that promote quality, cost-effective healthcare through monitoring of patients, preventive care, and performance.
Medical necessity
The fact that there is a medical reason to perform a procedure or service. Documentation exists in the patient’s record to show there are sufficient signs, symptoms, or history to warrant the
Remittance advice (RA
A detailed accounting of the claims for which payment is being made by an insurance company. The remittance advice accompanies the payment from the insurance company.
Subscriber
The primary person covered by an insurance plan.
Transactions
Posting of charges and the payment of claims in the Practice Management system to update patients’ accounts.
\”written off\”;
patient does not pay
Therefore, a process, or to be specific, a written claims management process, is necessary. Each step of the process must be carried out efficiently and effectively. This process includes written policiesā€”how much is charged per service (fee schedule), the timing of filing claims, follow-up on unpaid claims, and collections procedures when claims are not paid must all be in writing. The importance of written policies will be addressed in the compliance section of this chapter.
patient portal
A method of accessing portions of one’s own health information from the care provider’s or hospital’s electronic health record.
Cloud computing
The housing of data in a clout environment, which is a commercially main-tained site on the Internet

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