question

One of the earliest terms used to describe the EHR was ____.

answer

computer based patient record

question

This is a nonproft organization that provides advice to lawmakers and the public about health issues.

answer

Institute of Medicine

question

A system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support, links to bodies of medical knowledge and other aids.

answer

electronic health record

question

This group provides leadership for the development and implementation of an interoperable health information technology infrastructure nationwide to improve healthcare quality and delivery.

answer

Office of the National Coordinator

question

An electronic record of health related information on an individual that can be created and managed by clinicians and staff within one healthcare organization.

answer

electronic medical record

question

An electronic record of health related information on an individual that conforms to nationally recognized interoperability standards and that can be created and managed by clinicians and staff across more than one healthcare organization.

answer

electronic health record

question

This supports the collection of patient demographic and insurance information, scheduling visits, and billing.

answer

practice management system

question

Services that support sharing heath information across different healthcare organizations.

answer

health information exchange

question

This program provides incentives for making significant use of a certified EHR and enact sanctions on Medicare reimbursement for those who don't use certified EHRs.

answer

meaningful use

question

The practice of medicine utilizing guidance gleaned from research studies.

answer

evidence based medicine

question

To acheive meaningful use, clinicians must ____ with the EHR as they care for patients at ____. Information must be ____ as needed and documentation is made _____.

answer

interact directly, point of contact, accessed, directly into the system

question

Data that is dictated, keyed as text, or scanned.

answer

unstructured

question

Data that are discrete facts, figure, observations or findings entered via templates that are able to be processed by the computer.

answer

structured

question

The EHR combines _____ from many sources which can then be processed into ____.

answer

structured data, alerts

question

The development of an EHR system most often begins in a healthcre organization with acquisition of ______.

answer

source systems

question

These supply the EHR and other application with data.

answer

source systems

question

These are among the first systems implemented by healthcare organization.

answer

administrative and financial systems

question

Administrative and financial systems include _______, ______, and _____.

answer

registration, admission, discharge and transfer, patient financial systems, form creation system

question

Billing systems aid in _______.

answer

revenue cycle management

question

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

answer

revenue cycle management

question

Revenue cycle management use a _____ to collect information about services performed by ancillary systems and EHR.

answer

charge capture

question

Revenue cycle management includes _____, ____, _____, posting ______, and receiving ______.

answer

charge capture, claim generation, claims status inquiry and response, remittance advice, electronic funds transfers

question

Ancillary systems for the EHR include ____, _____, and ____ information systems.

answer

laboratory, radiology, pharmacy

question

HIM departments manage some of the _____ systems, support ____ that complement the EHR, and retain responsibility for _____ and ____ of EHR.

answer

administrative and financial, applications, content, quality

question

What are the five core EHR applications required for earning meaningful use incentives?

answer

results management, clinical documentation, closed loop medication management, clinical decision support, analytics and reporting

question

This is an application that enable diagnostic study results to be both reviewed in a report format and the data to be processed. Allows reports to be used in interactive ways.

answer

results management

question

These only allowed reports of results to be viewed and printed

answer

results retrieval

question

Clinical documentation is also called ____ systems.

answer

point of care charting

question

These systems direct what documentation needs to be recorded for the patient and is the means to supply CDS.

answer

clinical documentation

question

These systems supply templates to the user to be completed primarily via point and click, drop down, type ahead, and other data entry tools.

answer

clinical documentation

question

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.

answer

closed loop medication management

question

The closed loop medication management system includes ____, _____, _____, _____, and _____

answer

CPOE, e-prescribing, EMAR, medication reconciliation systems, automated drug dispensing machines

question

Many hospitals in the past implemented ____ last because it is difficult to get physicians to use such systems.

answer

CPOE

question

This systems is used for entering all orders such as patient admission, laboratory tests, x-rays, nutrition, nursing, referrals, medication, etc.

answer

CPOE

question

Some of the problems providers have with CPOE is the performance of _____, _____, and _______.

answer

clerical tasks, annoying alerts and reminders, standard order sets

question

This is a special type of CPOE used to make prescriptions and transmit them electronically to pharmacies.

answer

e prescribing

question

This system allows the nurse to scan a bar code on the patient's wrist band to automatically date and time stamp the entry of drug administration.

answer

bar code medication administration record

question

These systems help assure that a nurse administers the right drug, in the right dose, through the right route, at the right time, to the right patient.

answer

electronic medication administration record

question

This key component of the EHR sets the EHR apart from simply automating paper documents.

answer

clinical decision support

question

This system helps providers and patients make decisions about patient care.

answer

clinical decision support

question

Statistical processing of data to reveal new information.

answer

analytics

question

Benefits of analytics include _____, _____, ____, _____

answer

genomic research, personalized medicine, business intelligence, disaster response

question

Statistical analysis can help improve ____ and reduce ____.

answer

quality, costs

question

Analytics and reporting may be used for ______, ______, _____.

answer

health plans, quality or research studies, rule based lists for patient follow up

question

Physician's can earn incentives through quality reporting to ______.

answer

physician quality reporting system

question

In addition using required program elements, ______ is also a requirement for earning MU incentives.

answer

clinical quality measures

question

These systems support documentation of patient care in areas such as intensive care units, emergency services, therapy services, rehabilitative care, hospice, etc.

answer

specialty systems

question

These systems capture digital images from various modalities such as xray ultrasound, etc. to provide special viewing capabilities of these images via computer.

answer

picture archiving and communications

question

Hardware and software that allows various applications to work.

answer

supporting infrastructure

question

These systems enable the exchange of data across separate information systems both withing a healthcare organization and across organizations.

answer

connectivity

question

This allows software from different vendors to share a single patient's data with multiple entities.

answer

connectivity

question

Connectivity systems are required to contribute patient data to _____ to conduct quality measurement and reporting.

answer

registry

question

The laboratory information system is considered a _____.

answer

source system

question

The pharmacy information system is or is not considered a core EHR component.

answer

is not

question

This assists in assuring that the specific patient is not allergic to a drug.

answer

drug knowledge database

question

What provides alerts and reminders to clinicians?

answer

clinical decision support system

question

Point of care charting systems in hospitals are primarily used by ____.

answer

nurses

question

E MARs that utilize barcode or RFID support ____.

answer

Medication Five Rights

question

______ is the most difficult function of close loop medication management system to implement.

answer

medication reconciliation

question

The meaningful use incentive program requires ____ medication management components to be present and used in a hospital.

answer

all

question

A transition technology used by many hospitals to increase access to health record content during the evolution to EHR.

answer

EDMS

question

The EHR component that is often the most challenging for which to gain adoption in a hospital.

answer

CPOE

question

A system that is used by all intended users for at least basic functionality.

answer

adopted

question

Unintended consequences from using EHR technology are primarily due to issues with ______.

answer

human users

question

The biggest complaint physicians have with using an EHR already installed relates to ____.

answer

productivity

question

Cloud computing can reduce cost of EHR if _______ is not required.

answer

customization

question

By the end of 2011, over _____ of hospitals had most, if not all, of the EHR components to be able to earn MU incentives.

answer

25 percent

question

Many physicians eased into acquiring an EHR by starting with _____.

answer

e-prescribing

question

Hospitals find some _____ in ____ with EHRs. They also generally find improvements in ______ and can reduce the number of _____, ___, and _____

answer

cost savings, administrative functions, increased charge capture, denied claims, bad debt, collection services costs

question

Notifying a coder that the physician has completed the discharge summary is an example of ________ in EDMS.

answer

workflow

question

Exchange of a standard set of health information content between providers and with patients is facilitated by _____.

answer

personal health record

question

In what form of health information exchange are data centrally located but physically separated?

answer

consistent federated

question

The function used to provide access controls, authentication, and audit logging in an HIE is ____

answer

identity management

question

For hospitals or physicians to earn meaningful use, their EHR technology must be ____, ____, and _____.

answer

certified, interoperable, used in a meaningful way

question

To participate in the nationwide health information network, providers must _____.

answer

sign a special participation agreement

question

A database for online analytical processing is otherwise know as a ____.

answer

clinical data warehouse

question

A computer that has minimal processing capability of its own is a _____.

answer

thin client

question

This technology would reduce the risk that information is not accessible during a server crash.

answer

server redundancy

question

Part of storage management that assures documentation is retained about changes.

answer

change control

question

Online analytical processing typically requires a _____ database.

answer

relational

question

This type of message format standard deals with claims.

answer

ASC X12

question

This type of vocabulary standard deals with clinical drug names.

answer

RxNorm

question

This type of messaging standard deals with drug inventory.

answer

NDC

question

This type of messaging standard deals with data exchange.

answer

HL7

question

This type of messaging standard deals with clinical images.

answer

DICOM

question

A plan to provide access to content of previous visit information in an EHR.

answer

chart conversion

question

A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in healthcare organization.

answer

migration path

question

Copy and paste can make data entry ____ but harm _____.

answer

easier, data quality

question

Potential problems with the reuse of data in an EHR is ______, ______, and _____.

answer

correcting entries, documentation compliance, privacy

question

An ideal EHR system supports _____.

answer

clinical decision making

question

A transition strategy to achieve an EHR is the _____.

answer

electronic document management system

question

To ensure that a computerize provider order entry system supports patient safety, you need a _____.

answer

pharmacy information system

question

The concept of the EHR was first conceived in _____.

answer

1960s

question

A CDR support ______ for EHR.

answer

management of data

question

The federal government envisions a nationwide health information network to manage a _______ of all ______.

answer

central data bank, patients health information

question

Electronic prescribing is a special case of ____.

answer

CPOE

question

What includes the content of information that should be exchanged among referring providers?

answer

continuity of care record

question

A vocabulary is considered ______ when it establishes meaning for terms used in the EHR.

answer

controlled

question

This terminology is used for coding lab results and other observations.

answer

LOINC

question

EDMS can manage ____, ____, and ____.

answer

document images, email, PACS

question

A critical element of data retrieval planning is designing _____.

answer

screen layout

question

Structured data may be entered into an EHR via _____, _____, and _____.

answer

macro, point and click, voice command

question

This helps to convert narrative information to structured data.

answer

natural language processing

question

A local area network using Internet based protocols is _____.

answer

intranet

question

A tool that helps identify all costs associated with implementing an EHR is ______.

answer

total cost of ownership

question

Before contracting for an EHR product, ______ should be done to vet the vendors.

answer

due diligence

question

The process where data tables are loaded and screen layouts are customized.

answer

system build

question

Type of testing where a team tests whether or not all of the components will work together.

answer

system testing

question

Deciding what paper based content should be automated is called ____.

answer

chart conversion

question

Elements of data quality include _____, _____, and _____.

answer

accessibility, precision, relevancy

question

The primary user of CPOE is _____.

answer

physician

Sayles Ch 16 – EHR – Flashcards

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