Lesson 4 - Electronic Records

What are the drawbacks of paper files?

Hospitals and physician offices maintained hundreds and thousands of these files which took up a lot of space and time. More importantly, files at one hospital could not easily be shared with another hospital. This was not only a matter of distance. Different providers often used different record formats and filing systems.

What are the goals of the electronic record?

Improve accuracy, organization and management of medical information; improve accessibility to medical information; reduce medical errors; improve patient care; and reduce costs.

How does the ARRA define a qualified EHR?

It includes patient demographics and clinical health information, and has the capacity to provide clinical decision support; support physician order entry; capture and query information relevant to healthcare quality; and exchange electronic health information with and integrate such information from other sources.

What are the advantages of CPOE?

The advantages of CPOE include standardized, legible and complete orders, which will reduce medical errors.

What do the core set of terminologies include? a. CAC and NLP b. SNOMED CT and CAC c. NLP, LOINC and RxNorm d. SNOMED CT, LOINC and RxNorm

a. CAC and NLP

Which term is used to describe a computerized version of a medical record? a. CPR b. EDMS c. Encoded d. Encrypted

a. CPR

Which is a false statement of electronic records? a. Electronic records cannot be changed by healthcare professionals. b. Electronic records have the capacity of clinical decision support. c. Electronic records are able to exchange information with other sources. d. Electronic records capture and query relevant information.

a. Electronic records cannot be changed by healthcare professionals.

This allows health care professionals and patients to appropriately access and securely share a patient's medical information electronically. a. HIE b. EHR c. CPR d. EMR

a. HIE

_____ is meant to organize the contents of a medical record to capture, encode and use data for clinical care of patients and research. a. SNOMED CT b. EDMS c. Personal health record (PHR) d. HITECH

a. SNOMED CT

What is a drawback of the paper medical record? a. They take up a lot of space. b. The record formats are consistent. c. It is expensive to transition to EHRs. d. They are easily shared among hospitals.

a. They take up a lot of space.

Why was the Veterans Administration development of the DHCP important? a. It was the first time SRT was ever used in health care. b. It was the first time computers were used in health care. c. The DHCP linked together a network of healthcare providers in different facilities. d. The DHCP got the Veterans Administration involved in health care for the first time.

c. The DHCP linked together a network of healthcare providers in different facilities.

In the technology of information exchange and in the structure of data, _____ are necessary in vocabularies. a. interactive b. comparability c. standards d. interoperability

c. standards

In general, in hybrid systems, information contained in the dictated-transcribed narrative document is _____. a. not useful for patient care b. accessible only by the transcriptionist c. made up of only discrete, quantifiable data d. "invisible" to the facilities that share the EHR

d. "invisible" to the facilities that share the EHR

Providing better, more timely services to patients also helps the efficiency of a healthcare organization. Which of the eight core functions does this apply to? a. Decision support b. Order management c. Result management d. Administrative processes

d. Administrative processes

Which is a drawback to the original computerized health records? a. They were specific to single institutions. b. They limited the use of such databases for patient care. c. The data the electronic records contain could not be easily shared by providers. d. All of the above are drawbacks to the original computerized health records.

d. All of the above are drawbacks to the original computerized health records.

Pulse 130, blood pressure 122/80 and temperature 100.6 °F is an example of this. a. Standards b. Discrete data c. Laboratory data d. Narrative information

d. All of the above statements are true.

Which is true of an EHR? a. The patient's entire medical record is in a computerized database. b. With an electronic record, there are no paper records to generate, store or retrieve. c. The electronic record provides a completely electronic system to create, store and access medical records. d. All of the above statements are true.

d. All of the above statements are true.

Which is a true statement of controlled vocabulary? a. It is needed to assign the correct ICD code. b. Providers need controlled vocabulary to interact with nurses. c. It is needed for proper reimbursement from third-party payers. d. Controlled vocabulary is needed to index, store and retrieve EHR information.

d. Controlled vocabulary is needed to index, store and retrieve EHR information.

Early computerized health records systems tended to be specific to institutions. What was the result because of this? a. Providers did not need to share data b. Doctors did not like certain hospitals c. Some institutions provided inferior care d. Data could not be easily shared among providers

d. Data could not be easily shared among providers

The use of controlled vocabulary to allow for electronic exchange of health information is required by _____. a. SNOMED CT b. EDMS c. Personal health record (PHR) d. HITECH

d. HITECH

Suzy reported to her doctor that the "extreme heat made her feel agitated, so she shaved her head." What is this an example of? a. Standards b. Discrete data c. Laboratory data d. Narrative information

d. Narrative information

This presents data in a completely machine-readable format. a. NLP b. CAC c. Encoder d. SNOMED CT

d. SNOMED CT

A statement, such as "the patient's knee feels weird when she walks," is difficult to incorporate into the EHR. Why is that? a. The statement may not be true b. The statement is not useful for diagnosis. c. Discrete, structured data is part of this statement. d. The statement is narrative information, difficult to put into a structured format.

d. The statement is narrative information, difficult to put into a structured format.

Which is a true statement of the earliest computerized health records? a. They were specific to single institutions. b. They could share data among different providers. c. They were the creation of private insurance companies. d. They had the ability to incorporate free-form narratives.

a. They were specific to single institutions.

The Institute of Medicine report, The Computer-based Patient Record: An Essential Technology for Health Care, focused on this as the primary beneficiary of the EHR. a. Patient b. Physicians c. Insurance companies d. Healthcare organizations

a. Patient

This refers to information that consists of separate and limited values, such as distinct points on a numeric scale, with distinct intervals between any two values. a. discrete data b. interoperability c. clinical information d. unstructured narrative

a. discrete data

To assist healthcare providers in making decisions about patient care, electronic records use _____ features. a. interactive b. comparability c. standards d. interoperability

a. interactive

The advantage of this system includes standardized, legible and complete orders, which reduces medical errors. a. XML b. CPOE c. HTML d. SNOMED CT

b. CPOE

According to the IOM, a CPR should include this aspect which can aid in drug interactions/ prescriptions/prevention, detection of disease outbreaks and evidence-based guidelines. a. patient support b. Decision support c. order management d. result management

b. Decision support

Many large healthcare providers have implemented this type of "hybrid" system for their medical records. a. IOM b. EDMS c. LOINC d. SNOMED-CT

b. EDMS

The _____ uses standard word-processed documents in conjunction with the electronic record. a. SNOMED CT b. EDMS c. Personal health record (PHR) d. HITECH

b. EDMS

Data _____ standards are necessary to ensure quality payment. a. interactive b. comparability c. standards d. interoperability

b. comparability

Which core function provides warnings and reminders to assist providers in making decisions in patient care? a. patient support b. decision support c. order management d. result management

b. decision support

Pulse 120, blood pressure 120/80 and temperature 101.7 °F is an example of this. a. standards b. discrete data c. laboratory data d. narrative information

b. discrete data

This refers to the ability for different electronic record software to communicate among multiple machines. a. discrete data b. interoperability c. clinical information d. unstructured narrative

b. interoperability

When did it became a national goal in the United States for healthcare providers to replace all paper records with computer-based systems? a. 1991 b. 2003 c. 2010 d. 2018

c. 2010

The Institute of Medicine originally created the term CPR, and it also established how many core functions that a computer-based patient record should perform? a. six b. five c. eight d. seven

c. Eight

Which best describes discrete data? a. Clinical narratives b. Not included in the EHR c. Numerical and easily structured d. The only kind of information necessary in the medical record

c. Numerical and easily structured

A medical record which the patient has access to and control over is referred to as this. a. PPO b. PVP c. PHR d. HMO

c. PHR

Medical information maintained by the patient is known as the _____. a. SNOMED CT b. EDMS c. Personal health record (PHR) d. HITECH

c. Personal health record (PHR)

In 2010, the U.S. government renewed a national commitment to the EHR by providing this. a. Enrollment in Medicare b. Mandatory dates for EHR implementation c. Courses with more information about EHRs d. Financial incentives for healthcare entities that transition to the EHR

d. Financial incentives for healthcare entities that transition to the EHR

Different electronic record software communicates among multiple machines due to _____. a. interactive b. comparability c. standards d. interoperability

d. interoperability