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health record

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The principal repository for data and information about the healthcare services provided to an individual patient

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Difference between data and information

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Data represents facts. Information represents meaning.

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EHR

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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

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PHR

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Personal Health Record - a health record initiated and maintained by an individual.

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NCVHS

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National Committee on Vital and Health Statistics

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ONC

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Office of the National Coordinator for Health Information Technology

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NHIN

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National Health Information Network

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Act signed in 2009 that accelerated EHR adoption

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American Recovery and Reinvestment Act (ARRA), an economic stimulus package that provides reimbursement incentives to providers and hospitals that are "meaningful" users of certified EHR technology

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Primary purposes of health record

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Relate directly to the provision of patient care services as well as the documentation of the patient's health status: Patient care delivery Patient care management Patient care support processes Financial and other administrative processes Patient self-management

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Secondary purposes of the health record

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Relate to the environment in which patient care is provided - they are not related directly to specific patient care encounters: Education Regulation Research Public health and homeland security Policy making and support Industry

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Primary users of health records

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clinical professionals who provide direct patient care

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Secondary users of health records

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healthcare managers and administrators, government agencies and policy makers, third-party payers, researchers, educators, accreditation organizations

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We had 324 Medicare patients last month. This statement represents which of the following: A. Information B. Data C. Content of the PHR D. Patient-specific information

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B. Data

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I am a patient. My medical history including information from myself and my physicians is stored on the Internet. This is an example of which of the following: A. Health record B. EHR C. PHR D. Data

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C. PHR

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Which of the following is an example of a primary purpose of the medical record? A. Education B. Policy making C. Research D. Patient care management

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D. Patient care management

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Examples of patient care delivery usage of the medical record includes which of the following uses? A. Developing of practice guidelines B. Communication between caregivers C. Reimbursement for patient care D. Getting patients involved in their own care

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B. Communication between caregivers

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Critique this statement: The PHR and EHR are synonymous. A. This is a true statement; both are controlled by the patient. B. This is a false statement as the PHR is controlled by the care providers and the EHR is controlled by the patient. C. This is a false statement as the PHR is controlled by the patient and the EHR is controlled by health care providers. D. This is a true statement; both are controlled by the healthcare provider.

answer

C. This is a false statement as the PHR is controlled by the patient and the EHR is controlled by health care providers.

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True or false: The health record is the principal repository for data and information about the healthcare services provided to individual patients.

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T

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True or false: The lab test "hemoglobin: 14.6 gm/110 ml" is considered information.

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F

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True or false: The primary purposes of the health record are associated directly with the provision of patient care services as well as the documentation of the patient's health status.

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T

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Submitting health record documentation to a third-party payer for the purpose of substantiating a patient bill is considered a secondary purpose of the health record.

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F

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Use of the health record to the study the effectiveness of a given drug is considered a primary use of the health record.

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F

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What is aggregate data?

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Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed

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What major healthcare legislation was passed in 1996?

answer

Health Insurance Portability and Accountability Act (HIPAA) of 1996

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What laws were passed that allowed law enforcement more access to health records?

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USA Patriot Act (2001) and The Homeland Security Act (2002)

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CMS

answer

Centers for Medicare and Medicaid Services

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Which of the following users of the health record is an example of an institutional user? A. Third-party payer B. Patient C. Physician D. Employer

answer

A. Third-party payer

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Which of the following users would utilize aggregate data? A. Patient care providers B. Billing and coding staff C. Law enforcement officers D. Patient care managers and support staff

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D. Patient care managers and support staff

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I work for an organization that utilizes health record data to prove or disprove hypotheses related to disease. I must work for what type of organization? A. Healthcare delivery B. Medical review C. Research D. Education

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C. Research

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Critique the following statement: A user of health records includes only care providers who document in the health record or refer to it for patient care. A. True, as defined by the IOM B. False, as the information is used for purposes such as analysis C. Trust, as defined by AHIMA D. False, as the information contained in the health record is also used for patients to document their own health record

answer

B. False, as the information is used for purposes such as analysis

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I work for CMS. How would I use the health record? A. Make decisions on healthcare reimbursement B. Medical research C. Issuing hospital and medical staff licenses D. Accrediting healthcare organizations

answer

A. Make decisions on healthcare reimbursement

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True or false: A physical therapist documenting in the health record is an institutional health record user

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F

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True or false: An auditor who is employed by Medicare is reviewing a health record for a mortality study. This auditor is an individual health record user.

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F

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True or false: CMS uses data to accredit hospitals.

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F

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True or false: A researcher uses data to determine the recommended treatment.

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T

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True or false: Patients do not have the right to add missing information to the health record.

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F

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The primary function of the health record is to

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store patient care documentation

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What are the attributes associated with the storage function of health care records?

answer

quality, accessibility, security, flexibility, connectivity and efficiency

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IOM

answer

Institute of Medicine

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What are the four domains of data quality management?

answer

- Data applications (the purposes for which data are collected) - Data collection (the processes by which data are collected) - Data warehousing (the processes and systems by which data are archived) - Data analysis (the processes by which data are translated into information that can be used for a designated application)

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What are the quality characteristics applied to the four quality management domains?

answer

accuracy accessibility comprehensiveness consistency currency definition granularity precision relevancy timeliness

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data accuracy

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means that the data are correct. The data should represent what was intended or defined by the original source of data.

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data accessibility

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means that the date are easily obtainable. Authorized users of the health record must be able to access information easily when and where they need it.

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data comprehensiveness

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means that all required data elements are included in the health record. In essence, comprehensiveness means that the record is complete.

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data consistency

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means that the data are reliable.

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data currency

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means that healthcare data should be up-to-date

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data timeliness

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refers to data being recorded at or near the time or the event or observation

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data definition

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means that the data and information documented in the health record are defined. Users of the data must understand what the data mean and represent.

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data granularity

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requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data. (Ex: lab results recorded to the correct decimal place)

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data precision

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the term used to describe expected data values. As part of data definition, the acceptable values for each data element must be defined. (Ex: gender could be M, F, U. Or year of birth could be a 4 digit number)

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data relevancy

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means that the data in the health record are useful.

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privacy

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the right of individuals to control access to their personal health information

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confidentiality

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the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purposes

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security

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the protection of the privacy of individuals and the confidentiality of health records. In other words, security allows only authorized users to access health records.

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flexibility

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the ability to display and present information in different ways

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connectivity

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the capacity of health record systems to provide electronic communication linkages and allow the exchange of health record data among information systems

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interoperability

answer

the ability, generally by adoption of standards, of systems to work together

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Three types of formats are commonly used in paper-based record systems:

answer

source-oriented problem-oriented integrated

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source-oriented health record

answer

organizes the information according to the patient care department that provided the care. For example, all lab tests are filed together, progress notes are filed together, etc. This format is mostly used by acute care hospitals that are still using a paper record.

question

problem-oriented health record

answer

the physician defines each clinical problem individually and all documentation related to that clinical problem is stored together. Information about the problems is organized into four components: the database, the problem list, initial plans and progress notes.

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integrated health record format

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organizes all paper forms in strict chronological order and mixes forms created by different departments.

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hybrid health record

answer

a combination of paper and electronic records

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EHR systems are introducing new formats and functionality.

answer

Results Management Order-Entry/Order Management Clinical Decision Support

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results management

answer

results retrieval technology that permits viewing of data by type and manipulation of several different types of data

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order-entry/order management

answer

systems that allow physicians to enter medication or other orders and receive clinical advice about drug dosages, contraindications, or other clinical decision support

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CPOE

answer

computerized provider order-entry

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clinical decision support

answer

the process in which individual data elements are represented in the computer by special code to be used in making comparisons, trending results and supplying clinical reminders and alerts

question

A physician just received notification from an EHR system that a patient's lab test had a dangerously high value. This is an example of what kind of clinical tool? A. Clinical decision support B. Electronic records C. Results management D. Order-entry/order management

answer

A. Clinical decision support

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I just told my physician something embarrassing about myself. I told him because I expect him to use this information for my care only. This concept is called: A. Data relevancy B. Security C. Privacy D. Confidentiality

answer

D. Privacy

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Someone suggested that we collect a patient's eye color. This was not implemented. What quality characteristic would be justification for not collecting this information? A. Accuracy B. Consistency C. Granularity D. Relevancy

answer

D. Relevancy

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It was suggested that we enter the patient's age manually in all of our information systems rather than having it entered once in one system and interfaced to the other systems. What quality characteristic would be justification for not doing this manual entry into each information system? A. Accuracy B. Consistency C. Granularity D. Relevancy

answer

B. Consistency

question

According to the AHIMA data quality model, what is the term that is used to describe how data is translated into information? A. Data applications B. Data collection C. Data warehousing D. Data analysis

answer

D. Data analysis

Sayles, HIMT – Chapter 2 – Purpose and Function of the Health Record – Flashcards

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