Introduction to Electronic Health Records

Password

A character sequence used to prevent unauthorized access to patient information contained in secure electronic files

Secure fax

A fax transmission sent via secure email

Copayment

A fixed sum of money usually paid at the time medical services are rendered

Minimum necessary standard

A key provision of the HIPAA privacy Rule requiring that disclosures include no more than the amount of information necessary to accomplish a given purpose

Hybrid

A medical practice in which health records are stored using some combination of paper and electronic media

Virtual private network (VPN)

A pathway that allows encrypted data to travel securely through an Internet connection to it's destination, where it is unencrypted

No-show

A patient who makes an appointment and neither shows up nor calls to cancel

Appointment slot

A period of time reserved for a patient to see a healthcare provider

Client-server model

A platform in which a powerful central computer serves a network of connected PC's or other workstations

Patient flow

A product of accurately estimated patient volume, a consistant provider pace, and efficient scheduling practices

Workflow

A set of related tasks necessary to complete a step in a business process

Controlled vocabulary

A standardized list of preferred terms and corresponding codes for medical diagnoses, findings, procedures, services, and treatments

Secure email

A system capable of transmitting an encrypted message and storing it in coded format until it is retrieved by the recipient via a secure web link

Encryption technology

A system that keeps data secure by converting it into an unreadable code during transmission and then unencrypting the information when it reaches the recipient

Secondary use

A use of health information for a business activity or other purpose that is not directly related to patient care

Used to describe an established patient who currently sees the physician.

Active patient

CPOE

An EHR function that facilitates automated prescribing - computerized physician order entry

Consumer reporting agency

An agency that sells or cooperatively exchanges consumer information and history in areas such as credit and healthcare

Legacy EHR

An existing, functional EHR system scheduled to be replaced with a newer software application

What tests are included in a TORCH panel?

CMV Ab, herpes simplex AB, rubella Ab, and Toxoplasma

Name four functions of the Front Office module.

Calendar, patient demographics, correspondence, and forms repository

True or False? A legacy EHR is a failed EHR system left behind when the staff gives up on learning how to use it.

False

True or False? Closed patient records are the records of patients who have not been seen in the past 6 months

False

True or False? HITECH requires that physician offices begin implementing an EHR immediately.

False

True or False? Information from the Internet is not reliable enough to use for patient education.

False

True or False? Interfacing has made incompatible systems a thing of the past because all systems are now interoperable.

False

True or False? Most medical assistants are employed in inpatient settings.

False

True or False? Over-documentation can leave a provider vulnerable to charges of fraud and abuse.

False

True or False? Patients are unlikely to notice the conversion from paper to an EHR.

False

True or False? Providers starting the meaningful use program in 2014 will not have to meet the stage 1 requirements before moving on to stage 2.

False

True or False? SCMO allows the user to enter up to three insurance carriers.

False

True or False? SCMO does not include the ability to create patient letters because it is easier to store these documents outside of the patient record.

False

True or False? SCMO is used to document clinical data and does not function as a practice management software (PMS) system.

False

True or False? Software vendors should be the practice's only source of information about the product because no one knows the application better.

False

True or False? The best approach to training is a sink-or-swim attitude because users learn best when they have to figure things out for themselves.

False

True or False? To simplify the preimplementation process, only key decision makers and a staff representative should be involved.

False

True or False? Unfortunately no two systems are the same, so knowing how to use one EHR will be little help in learning to use another.

False

True or False? When creating a new patient account, the user must randomly select a number to be the medical record number.

False

True or False? Workflow redesign will not be addressed until the EHR system goes live.

False

Trues of False? Automated sentence building is a means of electronic transcription.

False

Trues of False? EHR systems make it unnecessary for office staff to be familiar with medical terminology.

False

Trues of False? Professional organizations offer continuing education for the core skills of their discipline and do not have any opportunities for learning about the EHR.

False

Trues of False? The medical record contains legal documents but is not itself a legal document.

False

True or False? If erroneous information is found in a file, it can be removed at the patient's request.

False - they can have it noted in the record that it is false

Space allocated on a form for specific numeric or text data.

Field

Reporting and population health

One of the eight core functions of an EHR designated by by the IOM (Institute of Medicine)

Consent

Permission given to a covered entity for uses and disclosures of protected health information for treatment, payment, and healthcare operations

Template

Predefined, customizable forms that speed structured data collection

A specialized graphic element that toggles on and off and is used when only one response is appropriate because two of these buttons can't b depressed at the same time.

Radio button

The amount of time records must be kept in storage by a medical office.

Retention period

Ethics

Rules and standards of conduct that govern professional behavior and arise from our shared understanding of morality

Ledger

Screen the contains the amount owed and other billing details

Interoperability

The ability of electronic systems to share information in compatible formats

Chief complaint

The patient's stated primary reason for seeking treatment

Confidentiality

The patients right and expectation that individually identifiable health information will be kept private

Anonymity

The patients right to have a private health data collected in such a way that it can never be linked to him or her

Retention

The period of time patient records must, by law be maintained by the medical office

Authentication

The process of determining whether the person attempting to access a given network or EHR system is authorized to do so

Purging

The process of separating inactive patient health records from active ones

Organizational culture

The shared set of values, beliefs, and assumptions that governs behavior and decision making within a healthcare practice

Records management

The systematic control of patient records, from creation through maintenance and storage

Go live

To leave the practice mode and become operational

True or False? A computer can verify that a password is valid but cannot authenticate that the person using the password is authorized to do so.

True

True or False? A healthcare professional may speak to a patient's family or friends about the patient's general condition and location as long as the patient doesn't object or, if the patient is incapacitated, it can reasonably be inferred that he or she wouldn't object.

True

True or False? A screensaver is used to limit the view of patient information on a computer screen while the user is away from his or her desk.

True

True or False? Another name for a Patient Registry is a master patient index.

True

True or False? Audits should be conducted both randomly and at regular intervals under security plans.

True

True or False? Backing up data in the patient's EHR is mandated by HIPAA.

True

True or False? Client-server platforms are generally more expensive to start up than ASP licensing arrangements.

True

True or False? Covered entities - healthcare providers, health plans, and healthcare clearinghouses - are subject to the HIPAA Privacy Rule.

True

True or False? Electronic misfiling is the digital equivalent of physically misfiling a document.

True

True or False? Fraud can occur if an EHR is not properly designed to accommodate the practice's financial documentation.

True

True or False? HIPAA compliance and security features should be considered in choosing an EHR system.

True

True or False? HIPAA prohibits financial institutions from obtaining medical information.

True

True or False? The HIPAA Security Rule outlines the administrative, physical, and technologic measures covered entities must take in order to implement and comply with the HIPAA Privacy Rule.

True

True or False? The New Patient screen contains a patient's contact information and demographics.

True

True or False? The user must first perform a patient search before entering a new patient record.

True

True or False? When patient requests confidentiality regarding particular test results or diagnoses, the provider is obligated to hold that information in confidence.

True

Trues of False? An EHR system can help the provider and medical staff plan and coordinate care for a patient with a chronic illness.

True

Trues of False? An audit is performed by the office manager to investigate whether appropriate employees have viewed the contents of a high-profile patient's chart.

True

Trues of False? Clinical decision support tools are effective only if the provider chooses to use them.

True

Trues of False? Communication among various treating healthcare providers, pharmacies, and allied healthcare workers will be limited until EHR interoperability has been achieved.

True

Trues of False? It is possible for individuals to penetrate EHR systems despite security precautions.

True

Trues of False? Most EHR systems hold the ability to handle clinical and administrative functions without purchasing separate practice management software.

True

Trues of False? One of the core functions of the EHR includes the ability to assist providers with treatment protocols.

True

Trues of False? Reduced productivity is to be expected for a period of time during the conversion to an EHR system.

True

Trues of False? The medical assistant's typical duties will be modified with the implementation of the EHR.

True

A specialized graphic element that toggles on and off and is used when more than one option is correct.

Check box

Cloning

Copying and pasting information from a previous entry in the patient's record or from another patient's record

Electronic transcription

Data entry using structured data entry or voice recognition

Name the three types of correspondence generated by SCMO.

Email, letters, and phone message

Laws

Formal, enforceable rules and policies based on community standards of conduct

Unstructured data entry

Free-text keying of data directly into the electronic record

Disclosure

Giving access to, releasing , or transferring health information to another person or entity

Double-booking

Giving two or more patients the same appointment time with the same provider

Individually identifiable health information (IIHI)

Health information that clearly identifies an individual patient or could reasonably be used to identify the patient

Covered entities

Healthcare providers, health plans, and healthcare clearinghouses that transmit claims electronically

Protected health information (PHI)

Individually identifiable health information that is stored, maintained, or transmitted electronically

Name four insurance and billing documents found in the Form Repository.

Insurance Claim Tracer and Doctor First Report, Patient Statement, Prior Authorization, Referral

List the HPI elements identified in a chief complaint.

Location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms