Chapter 12 Review Healthcare Information

DNR

(Do Not Resuscitate) An order that tells medical professionals not to perform CPR.

Justice

- equal distribution (in society) of burdens and benefits of a treatment - Legally permissible and fair to all parties involved - consider the following in evaluation: competing needs, rights/obligations, legal challenges, equitable distribution of scarce resources

Autonomy

- right to self-determination - Helping to prevent or remove harms - Rooted in respect for person's as agents of choice and decision-making

Three elements of a data security program

1. Ensure data availability 2. Protection - Protecting the privacy of data 3. Ensure the Integrity of data

data dictionary

A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology

data element

An individual fact or measurement that is the smallest unique subset of a database

Non-maleficence

Avoidance of harm or hurt; choosing the least harmful intervention that will provide the most benefit

DEEDS

Data Elements for Emergency Department Systems - A data set designed to support the uniform collection of information in hospital-based emergency departments.

Aggregate Data

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

EMPI

Enterprise Master Patient Index - a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility.

ONC

Office of the National Coordinator for Health Information Technology (ONC) is at the forefront of the administration's health IT efforts and is a resource to the entire health system to support the adoption of health information technology and the promotion of nationwide, standards-based health information exchange to improve health care. ONC is organizationally located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information

Institutional Users

Organizations that need access to health records in order to accomplish their mission such as third-party users, educational organizations, healthcare delivery organizations, accreditation organizations, government licensing agencies, medical review organizations, and policy-making bodies, and research organizations.

OASIS

Outcome and Assessment Information Set

Data granularity

The level of detail at which the attributes and values of healthcare data are described.

Data Precision

The term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined.

UACDS

Uniform Ambulatory Care Data Set- used to compare data in an ambulatory setting

4. ___________ is a tool used for extracting data from a database. a. Data mining b. Back-end speech recognition c. Point-of-care charting d. Data abstraction

a. Data mining Rationale: Data mining is the process of extracting and analyzing large volumes of data from a database. Back-end speech recognition is where the recognition process occurs after the completion of dictation by sending voice files through a server. In point-of-care charting the information is entered into the health record at the time and location of service. Data abstraction, or the identification of data elements by an individual through health record review

3. What is the second stage of transforming raw data into meaningful analytics? a. Data provisioning b. Data capture c. Data analysis d. Data mapping

a. Data provisioning Rationale: The second stage is data provisioning, which ensures that the data is in a format that can be manipulated for data analysis.

17. Which system would be used to pull together operational and clinical information in order to uncover a problem with readmissions? a. Executive information system b. Decision support system c. Clinical decision support system d. Electronic health record system

a. Executive information system Rationale: The EIS is the source for identifying high-level strategic, operational, financial, or clinical issues. Rather than managing at the individual departmental level, an EIS can pull together financial, operational, and clinical information, with enterprise-wide policies and guidelines, to help the executive find actionable insights to drive enterprise performance.

12. Editors correct misrecognitions after the physician completes dictation when _______ is used. a. Front-end speech recognition technology b. Natural language understanding technology c. Back-end speech recognition technology d. Natural language processing technology

a. Front-end speech recognition technology Rationale: The physician corrects misrecognitions at the time of dictation wen front-end speech recognition is employed.

14. What role in consumer informatics is HIM filling in the following situation: Creation of policies and design workflows for accepting and managing patient-generated health information. a. Patient information coordinator b. Patient portal representative c. PHR liaison d. Consumer advocate

a. Patient information coordinator Rationale: This scenario describes the work of a patient information coordinator.

5. Data from a wearable monitor, such as an exercise-tracking device, is an example of? a. Patient-generated health data b. Device-generated health data c. Wearable-generated health data d. Patient to provider health data

a. Patient-generated health data Rationale: Health-related data created, recorded, or gathered by a patient is patient-generated health data.

Benefience

action that is done for the benefit of others

2. "What happened?" is answered by _______ analytics. a. Prescriptive b. Descriptive c. Diagnostic d. Predictive

b. Descriptive Rationale: Descriptive analytics answers the question "what happened," prescriptive analytics answers "how can we make it happen," diagnostic analytics answers the question "why did it happen," and predictive analytics answers "what will happen."

8. The clinical data ___________ is a central database that focuses on clinical information. a. Warehouse b. Repository c. Record d. Depository

b. Repository Rationale: The clinical data repository is a central database focusing on clinical information whereas the clinical data warehouse allows access to data from multiple databases and combines the results into a single query and reporting interface.

10. The _________ reports outcomes measures. a. Dashboard b. Scorecard c. Benchmark d. Quality metric

b. Scorecard Rationale: A scorecard reports outcomes measures. The dashboard is a management report of process measures. In order to track the process measure over time, metrics or benchmarks are established.

21. A _______ accepts data patients' select from external sources, which is then stored on their computer. a. Merged PHR b. Standalone PHR c. Secure PHR d. Tethered PHR

b. Standalone PHR Rationale: Standalone PHRs are patient driven. They accept data from external sources, such as healthcare providers and laboratories, and store it on computers. Patients choose with whom they share the information. Tethered is a type of PHR that is linked to a specific healthcare organization's EHR. A tethered PHR allows patients to access their own records through a secure portal.

6. The use of a dropdown list to select a patient's diagnosis is an example of _________. a. Discretionary data b. Structured data c. Non discrete data d. Unstructured data

b. Structured data Rationale: Structured data are binary, machine-readable data in discrete fields. The structured data's entry fields and the potential entries in those fields are controlled, defined, and limited

16. The problem being solved with the use of DSS is typically _______. a. Repetitive b. Unstructured c. Routine d. Structured

b. Unstructured Rationale: A decision support system (DSS) is a computer-based system that gathers data from a variety of sources and assists in providing structure to the data by using various analytical models and visual tools in order to facilitate and improve the ultimate outcome in decision-making tasks associated with nonroutine and nonrepetitive problems. In DSS and CDSS, typically the problem in need of solving is unstructured or the circumstances are unknown.

20. Scheduling appointments is an example of a patient portal feature having a(n)_______. a. Billing orientation b. Patient care orientation c. Administrative orientation d. Provider orientation

c. Administrative orientation Rationale: Features that support engagement are those having a problem-solving orientation, interactive decision tools, and personalized messages. Scheduling appointments is an administrative function.

11. Tracking a _______ can help detect problems and identify opportunities for performance improvement. a. Baseline b. Best practice criterion c. Key indicator d. Benchmark

c. Key indicator Rationale: A key indicator is a quantifiable measure used over time to determine whether some structure, process, or outcome supports high-quality performance measured against best practice criteria. A benchmark and baseline are a point of comparison for each indicator tracked.

18. If consumers were looking to interact and receive support from others with similar diseases via electronic means, which tool might they use? a. Mobile medical app b. Patient portal c. Social media d. Tethered personal health record

c. Social media Rationale: Healthcare-focused social networks set up to connect individuals in order to interact and receive support from others are available to consumers.

9. Which of the following data visualization tool is used to organize quantitative data? a. Diagram b. Graphs c. Tables d. Text

c. Tables Rationale: Tables display exact values. A diagram is a general term for a drawing that explains or shows the parts of something. Graphs show trends. Text is not a data visualization tool.

25. All definitions of HIE mention which of the following? a. The capacity exists for the exchange of information to maintain the meaning of the information being exchanged b. The capacity exists for different information systems and software applications to receive data c. The capacity exists for different information systems and software applications to exchange data d. The capacity exists for different information systems and software applications to send data

c. The capacity exists for different information systems and software applications to exchange data Rationale: All definitions of HIE note that the exchange of information is done electronically and the capacity exists for different information systems and software applications to exchange data.

23. ____________ in order to maintain patient identity data integrity. a. The data must be accurately normalized b. The data must be accurately coded c. The data must be accurately entered d. The data must be accurately exchanged

c. The data must be accurately exchanged. Rationale: Data must be accurately collected, entered, and queried in order to maintain patient identity data integrity.

7. Sharing the contents of a PHR with providers creates an opportunity to ____________. a. Establishing a secure combined record b. Ensure privacy of the contents c. Create a single legal medical record d. Improve patient safety

d. Improve patient safety Rationale: Sharing the contents of a PHR with providers can enhance existing data, fill in information gaps, and provide a more complete picture of a patient's health, creating an opportunity to improve patient safety.

15. A smart phone app that analyzes and interprets blood pressure readings to detect irregularities is a _________ according to FDA guidance. a. Personal health monitor b. Medical product c. Mobile device d. Medical device

d. Medical device Rationale: The FDA guidance states a mobile app intended for use in performing a medical device function is a medical device.

19. The eHealth Exchange is a _______________ of exchange partners. a. Worldwide community b. Regional community c. Local community d. Nationwide community

d. Nationwide community Rationale: The eHealth Exchange is a nationwide community of exchange partners. The community of federal and state agencies, care delivery organizations, consumer organizations, pharmacies, tech vendors, payers, and others agree to securely share information via the Internet using a common set of standards and specifications

24. A _______ can assist a provider in obtaining a health record on a patient who is visiting from another state, resulting in more informed decisions about the care of the patient. a. Provider-mediated exchange b. Data exchange c. Consumer-mediated exchange d. Query-based exchange

d. Query-based exchange Rationale: Query-based exchange allows providers to request information on patients from other providers.

1. The ONC's goal of advancing secure and interoperable health information requires_______. a. Collecting data from a variety of sources such as mobile devices b. Analyzing data from federal, state and local agencies c. Using information to improve individual and community health d. Sharing information among individuals, providers and the community

d. Sharing information among individuals, providers and the community Rationale: Sharing information is needed to advance secure and interoperable health information. Collecting the data is tied to the goal of expanding adoption of health IT, using information to strengthening health care delivery, advancing the health and well-being of individuals and communities, and advancing research, scientific knowledge and innovation.

22. When exchanging information about a patient's problem, a ________ would be used. a. Content and structure standard b. Transport standard c. Services standard d. Terminology standard

d. Terminology standard Rationale: A terminology standard represents the meaning of the clinical data. A content and structure standard defines the syntax conventions, a transport standard defines the way in which information is moved, and a service standard the infrastructure components used to achieve specific interoperability requirements.

13. ___________ is a possible outcome of point-of-care charting. a. Discretionary or non-discretionary data b. Structured data c. Unstructured data d. Unstructured or structured data

d. Unstructured or structured data Rationale: The outcome of point-of-care charting can be unstructured or structured data.

mds

minimum data set