Chapter 12

Which are potential deterrents for implementing electronic health records?

- Maintenance costs - Possible damage to the system - Staff training requirements

What type of patients are more likely to adhere to agreed-upon care plans?

- Patients who are engaged partners - Patients who feel that their care providers listen to them - Patients who understand the rationale behind their care

Which must be taken into consideration when creating an appointment matrix in an electronic scheduling system?

- Physician's vacations - Hours when patients are not seen - Physician's meeting schedule

Identify the additional advantages of a fully functioning EHR program

- Physicians can access records from any computer with a secure access code - Providers in different locations can look at the same record at the same time

Which are advantages to billing and coding software within EHR programs

- Procedure and diagnostic codes can be automatically assigned - Alerts can produce flags notifying users of errors - Electronic claims can be submitted directly to insurance carriers

Which are advantages of electronic health records?

- Reduced storage needs - Increased access to educational materials - Efficiency in records transfers

Under the HIPAA privacy and security act, a medical office should maintain documentation of which of the following?

- Requests for patient information - Date when information was released - Patient permission for release of information

Careful key entry and regular backup of electronic files help ensure ____________ in electronic patient information

Accuracy

Most programs include a patient ____________ component so the administrative staff can produce a billing statement for the patient

Billing

To have better clinical outcomes, documentation should be which of the following?

Clear, concise and complete

An EHR software program may be ___________ to suit a specific specialty and style of a physician's office

Customized

What laws dictate that PHI cannot be disclosed without the patient's express written permission unless allowed by federal or state statute?

HIPAA

Which is a disadvantage of using an electronic scheduler?

If the computer is down, the day's schedule is not accessible.

When information such as the result of a laboratory test is entered into a patient's EHR, the information is available for viewing __________

Immediately

Which of the functions of the EHR program would be most helpful to the staff who schedules appointments for patients with specialists?

Insurance verification

An electronic health record must contain information that is created, managed, and gathered in a manner that conforms to ____________ standards

Interoperability

Part of meaningful use is to empower patients and families. How is that to happen?

Patients should be given reading material and providers should make sure patients understand all of their options

Information in a new patient template, such as name, address, and insurance information, appears in __________ fields

Required

Practitioners can engage patients in medical decision-making by sharing what kinds of information with them?

Risk factors, illness information and treatment options

Which of the following will not reassure patients about the privacy and security of the office EHR system?

Sharing "computer frustrations" with the patient.

Which of the following is not an acceptable method of reassuring patients and other staff members about EHR confidentiality and security?

Show patients that anyone can view their medical information

Which possible feature of an EHR/practice management system will likely require customization?

Specialty office

In addition to the recipient and patient information, what other information should be on the release of information form?

The reason for the request

Many EHR programs use the term ______ for a correction made to an electronic health record.

addendum

In order to find out which patients are not paying their office claims and statements promptly, you could ask the EHR report generator to create a(n) _________ report

aging

Electronic medical records and paper records are considered

legal documents

______________ improves the quality, safety, and efficiency of certified electronic health records

meaningful use

Dr. Ehrlinger and Dr. Copas are partners who own and operate a small medical practice in rural Kentucky. They are considering upgrading their practice to use electronic health records, but they are concerned about the costs involved. Including the initial startup cost and the estimated cost to maintain the system, how much will upgrading to an EHR system cost the practice in the next 5 years?

$156,000

The estimated cost for the initial establishment of an EHR program is __________ per full-time provider

$44,000

The estimated maintenance cost for an EHR system is approximately ____ per year per full-time provider.

$8,500

Which are strategies for focusing on the patient, not the computer, during a patient encounter

- Be comfortable with the system being used - Take notes and enter them in the computer later

In which ways can a medical assistant help reassure patients that the office EHR program and the information it contains are confidential and secure?

- Be knowledgeable about the confidentiality and security aspects of the program - Show patients their own medical records and how information is entered and maintained

Which are general guidelines for using EHR programs?

- Become familiar with the software and hardware used at your facility - Retrieve the patient record carefully - Keep your password information secure - Check your entries carefully before hitting the enter button - Secure the computer that maintains the electronic records

Which are advantages of EMR?

- Decreased transcription cost - 24-hour access - Easier billing processes

Which are objectives of Meaningful Use?

- Engage patients and family - Reduce health disparities - Improve care coordination - Better clinical outcomes

Identify the advantages of electronic health records

- Fewer lost records - Increased legibility of charts - Ease of chart access for multiple users

Which are advantages of electronic schedulers?

- It allows multiple users at any time - They can keep a list of patients who want an earlier appointment - They can easily look up a patient's appointment

Which apply to PHI?

- It stands for protected health information - It is protected by HIPAA laws - The patient's express written permission is required for non-federal or state disclosures

What are the functions of an electronic prescription writer

- Maintains a list of commonly prescribed medications and dosages - Flag an ordered prescription as a potential allergy interaction - Transmit prescriptions directly to the pharmacy

What are the advantages of ancillary programs for labs, X-rays, and other diagnostic services

- Results are transmitted back as soon as available - Results can be immediately uploaded to the patient's medical record

Which types of reports can be produced using the report generator in an EHR program?

- Revenue reports - Aging reports - Office accounts receivable - Patient statistics

What are tasks that a patient can do using a patient portal

- Scheduling an appointment - Accessing a child's immunization record - Paying a balance on an account

Which are characteristics of a customized EHR software program?

- Terms such as congestive heart failure may be quickly selected in a cardiologist's office - Templates allow the physician to add entire phrases with a few clicks of the mouse

Which can be tracked by an EHR program?

- The number of visits allowed by the referral - The time frame involved - The number of visits left on any given day

In which ways can computerized records also be useful as tickler files?

- They can alert staff to patients who require follow-up care - They can alert staff about patients who are due for yearly checkups

Steps in creating a new patient record with EHR software

1) Open the New Patient window of the EHR program 2) Enter the patient's full name 3) Carefully inspect all information entered for accuracy 4) Save the new patient information

Steps for creating an appointment matrix using an electronic scheduling system

1) Open the office appointment scheduler 2) Block the times and dates when the office or physician will not be available 3) Enter a reason that the time is not available for future reference 4) Specify time frames necessary for different types of appointments

Medical errors due to communication problems are the _____ leading cause of deaths in the U.S.

8th

Which item maintains each user's ability to work in certain areas of a patient's electronic health record?

Access code

All users of an EHR program must have individual

Access codes and passwords

How is security maintained if providers access EHR programs from home or other locations?

Access codes and passwords are used

Customized

An EHR software program changed to suit a specific specialty and style of a physician's office

What is the most appropriate action when an error or omission is found in an electronic record?

An addendum is made as soon as possible

Which function of an EHR allows for electronic test ordering and receipt of results?

Ancillary Order Integration

How often should passwords be changed in the EHR system?

As directed by the healthcare facility policies

Better _______________ occur when medical record documentation is clear, concise, and complete

Clinical outcomes

Electronic claims submission and coding of medical record is done through which component of an EHR?

Coding software

It is important that you follow HIPAA guidelines when releasing a patient's protected health information and do so without violating

Confidentiality regulations

You have received a request for a patient's medical records from a lawyer; the patient's cousin comes to the office to sign a release for the patient because that patient is critically injured and in the ICU. The cousins says he is the next of kin but is not listed in your records as the patient's next of kin. He also has a court document listing him as guardian for this patient. What should you do?

Copy the POA and let the cousin sign the release of information

Patient electronic health information created in a format meeting interoperability standards is defined as being in a(n) _______ format.

EHR (electronic health record)

EHR software programs allow for __________ transmission of referrals among the PCP, specialist, and insurance plan involved

Electronic

Electronic Medical Record (EMR)

Electronic record of health-related information for an individual patient that is created, compiled, and managed by providers and staff members in a single healthcare organization

Electronic Health Record (EHR)

Electronic record of health-related information for an individual patient that is created, managed, and gathered in a manner that conforms to nationally recognized interoperability standards

What are the materials needed to schedule an appointment using an electronic scheduler?

Electronic scheduler and a template outlining time frames for appointments types

personal health record (PHR)

Electronic version of the complete medical history and record of a patient's lifelong health that is collected and maintained by the individual patient

Which is not one of the expected outcomes of EHR interoperability mandates?

Increased responsibilities for medical assistants

A personal health record (PHR) is maintained by the

Individual patient

Which items are needed to create a new patient record in an EHR program?

Laboratory orders, patient information form and physician notes

Which is an advantage of EHRs?

Legibility of records

Which of the following phrases tells you that the record format is an electronic health record instead of an electronic medical record?

Meets interoperability standards

Which are examples of communication problems that may lead to medical errors?

Mislabeled laboratory orders and mishandled patient messages

At the provider's request, Tony is attempting to enter a prescription for Mrs. Johnson for her high blood pressure. The EHR system keeps reporting an error: Incompatible medication. What might this mean, and what should Tony do about it?

Mrs. Johnson is either allergic to the medication or is taking another medication that interacts with it; Tony should consult the physician

Which organization has defined the terms electronic medical record and electronic health record?

NAHIT

A template for a new patient record would most likely include which fields?

Name, insurance information and address

An EHR program can be used to verify a patient's insurance coverage

Online

Mr. Abrams is going to a specialist regarding an injury to his hand. He completes a release of information to have his records sent to the specialist. What information should be sent?

Only the information covered by the release form

An individual's lifelong health record is a(n)

PHR (personal health record)

Which is a true statement about a patient's personal health record (PHR)?

PHRs may be stored and maintained on secure internet sites

Which allows the entry of prescriptions, which can be transmitted directly to the pharmacy or printed and given to the patient?

Prescription writers

Files that need periodic attention are called ________ files

Tickler

In this morning's monthly financial status meeting, the office manager asked Cheryl for an analysis of how much revenue is generated by each of several procedures that are commonly performed in the medical office. To accomplish this in the most accurate and efficient manner, Cheryl should

Use the EHR software's report generator

If the patient is not available to sign a release of information, what may you do to release medical records?

Wait until the patient is available to sign a release of information form

Mr. Abrams decided he did not want the practice to release his information to another medical facility. What must he do?

Withdraw permission in writing

Although the medical record itself is the property of the medical practice, the information in the record

belongs to the patient and must be kept confidential.

What is the ultimate goal of EHR implementation and meaningful use?

better patient care

Many of the medical errors that can lead to a patient death can be traced to _________ problems

communication

The access codes that allow users to enter patient records in an EHR system insert a(n) ____ in the medical record, so that office administration can tell who is accessing each medical record.

date and time stamp

Many EHR programs can verify a patients insurance coverage and simultaneously capture the patients

demographic information

Many EHR programs make insurance verification ___________ by assisting with online verification

easier

What is the number one patient related issue to (hopefully) be decreased by the use of EHR programs?

illegible handwriting

In an effort to safeguard patient records, medical office employees should:

only be given access to records they need to perform their duties.

Once a signed release is obtained, you may copy and release

only those items of the record covered by the release of information.

A ______ allows a patient to access routine information and perform tasks such as making appointments online

patient portal

If an EHR's coding software detects a charge that does not match a diagnosis code, it may ____.

produce a flag to alert the medical office

The greatest concern of electronic health records is

protecting the confidentiality of patient record

Which of the following functions of the EHR program will be most helpful to the administration when reviewing the financial health of the practice?

report generator

Information that is mandatory in an EMR or EHR is denoted in the record by

required fields

When storing electronic documents on a computer, you should also:

store the files in a backup system.

What is the primary reason most providers give for not implementing EHRs in their offices?

to cost

Which is not an advantage of EMR?

training