C810 Quiz & Check Your Understanding

There are five pillars to the PCMH model:

-- a patient-centered orientation -- comprehensive and team-based care --coordinated care -- superb access to care -- a systems-based approach to quality and safety The patient-centered medical home = PCMH

Under the False Claims Act (31 USC 3729), claims may be brought up to __________ years after the incident; however, on occasion, the time has been extended to ___________ years.

7 10

What is a data dictionary? What is its importance in ensuring data quality?

A data dictionary is a set of descriptions of data items in a data model for system users to reference to promote data quality through data consistency across the organizations a set of descriptions of data items in a data model for system users to reference.

A ___________________ is a recognized system of terms used in a science or an art that follows preestablished naming conventions.

A nomenclature is a recognized system of terms used in a science or an art that follows preestablished naming conventions.

What is the difference between a primary data source and a secondary data source?

A primary data source is created by the healthcare professionals providing the care. The medical record is considered a primary data source. A secondary data source is made up of data taken from a primary data source and put in a different format, such as a registry.

Explain how you measure account receivable days.

Account receivable days are the average number of days between the provision of services discharge date and the receipt of payment for those services rendered.

List the 10 characteristics of data quality

Accuracy Accessibility Comprehensiveness Consistency Currency Definition Granularity Precision Relevancy Timeliness

For which healthcare setting is the patient's history and physical a required part of the health record?

Acute Care and behavioral health

What type of information would be listed in an organization-wide or enterprise-wide data dictionary?

An enterprise-wide or organization-wide data dictionary contains descriptions of common data and their formats.

How will the forms review process, including HIM oversight, change with implementation of electronic health records?

As health records move toward an electronic format, the forms' design process becomes the process of designing computer views and templates for entry of data, but the principles of control still apply. This transition requires extensive input and expertise from the HIM professional.

Generally, who develops and maintains healthcare data standards?

Both private organizations and government agencies such as ONC, CSM, FDA, the Agency for Health Care Policy and Research, the Office of the Assistant Secretary for Planning andEvaluation, and the CDC work collaboratively in the development and maintenance of these standards

Which method involves the recording of supplies and services and allows for monitoring costs and measurement of productivity?

Charge capture

clinical vocabulary, terminology, or nomenclature that lists words or phrases with their meanings; provides for the proper use of clinical words as names or symbols; and facilitates mapping of standardized terms to broader classifications for administrative, regulatory, oversight, and fiscal requirement

Clinical classification

A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement

Clinical terminology

What are common attributes used to help correctly identify patients?

Common attributes used to help identify a patient include: patient's full name, date of birth, address, gender, race, health record number, physician name, or billing account number.

What effect does the charge capture process have on the reimbursement received for services?

Complete and accurate charges must be posted to the claim because reimbursement rates are often related to individual charges, the charges posted to the claim can drive specific prices and reimbursement rates, and payers also use historical claim information to set current and future reimbursement rates. The charges reflect the resources that were used to provide the services and they help organizations measure labor costs and staff productivity

This field is devoted to informatics from multiple consumer or patient views. These include patient-focused informatics, health literacy, and consumer education. The focus is on information structures and processes that empower consumers to manage their own health.

Consumer health informatics

. Define interoperability and describe how terminologies play a role in interoperability

Basic interoperability relates to the ability to successfully transmit and receive data from one computer to another. The ability to understand or interpret the information being transmitted is not essential to basic interoperability.

If an attorney comes in to request medical records for a malpractice case, what documentation requirements are necessary to release the records, and what type of verification should be completed prior to releasing the records

Documentation to release records is an Authorization for Disclosure of PHI signed by the patient (or representative). Verification needs identification of the attorney and a link to the law firm by the attorney

What are the three types of advance directives and how do they differ from one another?

Durable power of attorney for healthcare decisions: Executed by a competent adult, designates another person (proxy) to make healthcare decisions consistent with the individual's wishes on the individual's behalf Living will: Executed by a competent adult, expressing the individual's wishes Do-Not-Resuscitate (DNR): Individual's wish not to receive treatment, specifically cardiopulmonary resuscitation.

Which best describes data governance (DG)? a. Enterprise authority ensures control and accountability for enterprise data b. Set of policies, procedures, and standards that manage data c. Decision rights and accountabilities for data d. Network of data stewards that functions collaboratively across the organization

Enterprise authority ensures control and accountability for enterprise data

Record retention time requirements: Federal? State? TJC? AHIMA?

Federal: 5 years State? 5 years after last encounter, 3 years after death TJC? Recommends the minimum of 5 by federal law, plus whatever is decided according to hospital policies AHIMA? Recommends 10 years

______________________ interoperability refers to sending messages between computers with a shared understanding of the structure and format of the message

Functional

What is the best definition of decision rights? a. Granting authority to specific individuals to make data-related decisions b. Granting responsibility for making policy decisions c. Granting permission to specific individuals to access data d. Granting individuals security clearance

Granting authority to specific individuals to make data-related decisions.

________________________ data are used for research on hospital utilization, access, charges, quality, and outcomes. This database can be queried for information when doing internal assessments related to the AHRQ QIs

HCUP Healthcare Cost and Utilization Project

What steps should an organization take to define its legal health record? What special considerations should be taken into account for defining a legal electronic health record?

HIM professionals and other designated individuals should consider state and federal laws that define health record content and the Federal Rules of Evidence (FRE).

_____________________________ pertains to responsibilities that best ensure appropriate use of health data

Health data stewardship

used to report services and supplies primarily for reimbursement purposes in the outpatient or ambulatory setting

Healthcare Common Procedure Coding System (HCPCS)

Why is data standardization so important in healthcare today?

Healthcare terminologies facilitate health information exchange by standardizing the data collected. Through this standard representation of data, terminologies provide shared meaning and a sense of context for the information being used. In simple terms, this ability to exchange information between computer systems is referred to as interoperability

An organization-wide framework for managing information throughout its lifecycle and supporting the organization's strategy, operations, regulatory, legal, risk, and environmental requirements

IG

How can HIM professionals play a role in health informatics and data standardizations?

In order to reach the full potential of health information exchange, HIM professionals must participate in the development, implementation, and maintenance of information systems that use standards for collecting and reporting data.

Which document provides the exact details of the treatment and must be signed by the patient or legal representative?

Informed Consent

1. What are the three related subsystems of government in the United States and what are their roles?

Judicial System: Enforces both rights and obligations through the court system Legislative System: Enacts the laws through statutes created by legislative bodies. Administrative System: Controls governmental administrative operations that enact regulations

. Identify the appropriate terminology, vocabulary, or standard that would be a good candidate to represent: (a) laboratory data, (b) nursing documentation, and (c) problem list documentation.

Laboratory data - Logical Observation Identifiers Names and Codes (LOINC) · Nursing documentation - International Classification of Diseases, 10th edition (ICD 10) · Problem list documentation - Systemized Nomenclature of Medicine Clinical Terminology (SNOMED CT)

exchange standard for laboratory results

Logical Observation Identifiers Names and Codes (LOINC)

This IG principle ensures that information assets have authenticity and reliability.

integrity

refers to the listings of words or expressions in a language (terminology) and information about the language such as definitions, related principles, and description of (grammatical) structure

lexicon

function that allows for the reuse of data captured for one purpose to be used for other purposes

mapping

A recognized system of terms used in a science or an art that follows pre-established naming conventions?

nomenclature

Refers to master data that an enterprise maintains about key business entities such as customers, employees, or patients, and to reference data that is used to classify other data or identify allowable values for data such as codes for state abbreviations or products

Master data management

. What is reported to the National Practitioner Data Bank?

Medical malpractice incidents Adverse effects It is required that providers report the following events to the NPDB: · Medical malpractice payments · Federal and state licensure and certification actions · Adverse clinical privileges actions · Adverse professional society membership actions · Negative actions or findings by private accreditation organizations and peer-review organizations · Healthcare-related criminal convictions and civil judgments · Exclusions from participation in a federal or state healthcare program

What is reported to the National Practitioner Data Bank?

Medical malpractice incidents Adverse effects Medical malpractice payment Federal and state licensure and certification actions Adverse clinical privileges actions Adverse professional society membership actions Negative actions or findings by private accreditation organizations and peer-review organizations Healthcare-related criminal convictions and civil judgments Exclusions from participation in a federal or state healthcare program Other adjudicated actions or decisions

What is often referred to as "data about data"?

Metadata

What are the three basic methods to address risk after a HIPAA risk analysis?

Mitigate the risk, transfer the risk, and accept the risk

--Disengaged and overwhelmed; --becoming aware, but still struggling; -- taking action; --maintaining behaviors and pushing further These are the four levels of what?

PAM Patient Activation Measure (patient's level of engagement in his own healthcare management)

Which type of health record has led to new challenges for HIM professionals interfacing with patients?

PHR

What is the term for "processes and steps involved in taking identified areas needing improvement and using actionable efforts to improve performance"?

Performance improvement

. Describe four types of AHRQ quality indicators.

Prevention indications identify hospital admissions that could have been avoided through high quality outpatient care. · Inpatient indicators reflect the quality of care inside hospitals, including inpatient mortality for medical conditions and surgical procedures. · Patient safety indicators reflect quality of care inside hospitals focusing on potentially avoidable complications and iatrogenic events. · Pediatric indicators use one or more of the previous three indicators and adapt them for use with children and neonates.

Describe the difference between, privacy, confidentiality, and security.

Privacy is the right of an individual to be left alone and refers to who should have access, what constitutes the patient's rights to confidentiality, and what constitutes inappropriate access to health records. Confidentiality is when data or information is not made available or disclosed to unauthorized persons or processes and establishes how the records (or the systems that hold those records) should be protected from inappropriate access.

Self-tracking of any biological, physical, behavioral, or environmental information. AKA mHealth Ex: Apple Watch, Fitbit, pedometers, exercise apps, etc.

Quantified Self movement

Differentiate between quantitative analysis and qualitative analysis. What purpose do they serve?

Quantitative analysis is a review of the record for completeness and accuracy Qualitative analysis is a more thorough review of the quality and accuracy of the documentation, ensuring it meets standards and regulations.

This type of database can be used to track patient care in the form of treatments, outcomes of those treatments, and critical indicators of a patient's current state such as blood pressure, heart rate, and blood glucose levels. _________________________ databases can also be used to interconnect with multiple informational systems throughout a healthcare facility.

Relational

Which component below does not fall under data governance?

Retention and disposal policies

standardized nomenclature for clinical drugs that provides information on a drug's ingredients, strengths, and form in which it is to be administered or used

RxNorm

Identify the major differences between RxNorm and MEDCIN.

RxNorm is a standardized nomenclature for clinical drugs that provides information on a drug's ingredients, strengths, and the form in which it is to be administered or used. MEDCIN was created with a strong focus on facilitating documentation by providing clinically relevant choices in a format consistent with the provider's clinical thought processes.

_____________________ is currently being used in EHR systems as a clinical reference terminology to capture data for problem lists and patient assessments at the point of care. It also supports alerts, warnings, or reminders used for decision support. A single clinical meaning is identified by a unique numeric identifier.

SNOMED CT

Why are secondary data sources developed?

Secondary data sources are created to put the information from the primary record into a format that is easier to query and manipulate. A database, which is a secondary record, can be queried to provide this information in a report from the secondary data that have been entered, thus accelerating the process. The secondary data provided to external users is generally aggregate data and not patient-identifiable data. Thus, this data can be used as needed without risking breaches of confidentiality

What are the main factors in determining how long to maintain a health record?

State law, CMS regulations, and other federal regulations, accreditation standards, and facility policies and procedures must be reviewed when establishing a retention schedule

Which healthcare technology is critical for patient engagement and is used to support long-distance clinical care and health-related education

Telehealh

What are two advantages of terminal-digit filing over straight numerical filing?

Terminal-digit filing allows for a more even distribution of files within the filing area and thus a more even distribution of work. In straight numerical filing, newer records are at the end of the file and most of the files work will be concentrated in the area with the new files.

handbook used by healthcare professionals as a guide to diagnose mental disorders and was first published by the American Psychiatric Association (APA) in 1952

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

How is the hospital case-mix index calculated?

The case-mix index is calculated by adding the Medicare DRG weight for every inpatient discharge and dividing by the number of discharges.

Why is the MPI considered the key index in the HIM department?

The master patient index (MPI) is the key locator for records in a numerical filing system because it contains the patient numbers by which the records are filed.

A model that attempts to improve care outcomes and reduce care costs by reorganizing how primary care is delivered:

The patient-centered medical home (PCMH)

Who is responsible for ensuring the quality of health record documentation?

The provider of care is responsible for ensuring entries made in the record are of high quality

What is the difference between a serial-unit numbering system and a unit numbering system?

The serial-unit numbering system assigns a different number for each episode of care and all information is brought forward to be filed under the last number issued. A unit numbering system assigns a number to a patient on the first encounter and keeps this number for all subsequent visits.

What data quality characteristics are listed in both AHIMA's data quality model and the MRI essential principles of documentation?

Timeliness and accuracy are listed in both AHIMA's data quality model and the MRI essential principles of documentation.

______________________ is a process the Joint Commission surveyors use during the on-site survey to analyze an organization's systems

Tracer methodology

What are the consequences of a patient having duplicate health record numbers?

When duplicate records are present in the EHR, data can become conflicted amongst providers, causing poor patient care and incorrect treatment. information and certainty for identification that are critical to the quality and safety of patient care.

Who are the internal users within a healthcare facility?

Within a healthcare facility, internal users include medical, administrative, and management staff

What are the four primary steps in a record retention program?

conducting inventory, determining storage format and location, assigning retention periods, and destroying unnecessary records.

The life cycle of records management begins when information is _______________and ends when the information is ____________________________.

created destroyed

. In which healthcare setting does CMS require specific documentation by the attending physician when updating the patient's plan of care?

home healthcare

Normally, who is the highest decision-making authority in a DG program? DG officer Data steward committee DG council Data steward

DG council

What is the difference between patient-identifiable data and aggregate data?

Data are categorized as either patient-identifiable data or aggregate data. The health record consists entirely of patient-identifiable data. Aggregate data include data on groups of people or patients without identifying information (for example, average length of stay for a diagnosis related group).

______________________________________is the set of policies and procedures that determine the who, how, and why of data management within the organization. _________________________supports compliance and legal efforts by organizing data for retrieval and retention, especially over the long term

Data governance

________________________ is characterized as a continuous process setting standards, building quality into the processes that create, transform, and store data, and measuring data against standards Content management Structured data Unstructured data Data quality management

Data quality management

________________________ is the process in which organizations implement protection measures and tools for safeguarding data and information from unauthorized, accidental, or intentional modification, destruction, or use. Unstructured data Data security Structured data Content management

Data security

Who is appointed with responsibility and accountability for data, usually in a specific domain? Data owner Data officer Data steward Data stakeholder

Data steward

What is the first step when establishing an audit and monitoring program?

Determine which systems produce audit logs.

. What are AHIMA's recommended guidelines for development of data dictionaries?

Develop an enterprise data dictionary · Ensure collaborative involvement · Develop an approvals process · Identify and retain details of data versions · Design for flexibility and growth · Design room for expansion of field values · Follow established International Organization for Standards (ISO)/International Electrotechnical Commission (IEC) 11179 guidelines for metadata registry · Adopt nationally recognized standards · Beware of differing standards for the same concepts · Use geographic codes and conform to the National Spatial Data Infrastructure and the Federal Geographic Data Committee · Test the information system · Provide ongoing education and training · Assess the extent to which the data elements maintain consistency and avoid duplication

record review process is ongoing while a patient is in-house to ensure documentation requirements are met?

open record review

Health-related data created, recorded, or gathered by or from patients (or family members or other caregivers) to help address a health concern

patient-generated health data (PGHD) EX: New patient packet, BP logs, Heart Rate monitoring

A HIM professional is asked by a patient if they can access their bill and make a payment online. Which technology could assist this patient?

patient/member web portal

Which form of connectivity might allow a patient secure and individual access to their most recent laboratory results?

personal health records

Which form of documentation is acceptable in an emergency situation when the formal report is dictated but not yet transcribed?

preoperative note

____________________ interoperability is when information being transmitted is understood. For example, the receiving system would not only recognize that what was being sent is a lab value but would also understand the method used to calculate the value and the reference ranges for a normal result.

semantic interoperability

What identifies the fundamental purpose, scope, and high-level goals of the DG program?

should be incorporated with the organization's strategic information management (IM) planning efforts. A strategic IM plan is developed so that all information management efforts are aligned with the organization's strategic plan and ensure that information management goals and strategies support the organization's high-level initiatives. An IM plan typically states the IM vision, mission, values, and high-level goals.

How does the HIM professional help providers complete health records?

supports the patient care process by ensuring quality and timely documentation in the patient record

universal product identifier for human drugs

the National Drug Codes (NDCs) directory

Why is it important for providers wanting a new form to go through the approval process?

to ensure control of the form, especially as the transition to imaging or computerized systems continues.

This IG principle is documented openly and verifiable and available to all interested and appropriate parties.

transparency

True or false? It is legal to release protected health information about a patient without the patient's signed consent if the released information is used for research purposes, and if an Institutional Review Board or Privacy Board has approved it.

true

What are the names of the federal initiatives that recognize healthcare information standards?

· AIIM · Accredited Standards Committee (ASC) X12 · American Dental Association (ADA) · ASTM International · European Committee for Standardization (CEN) · Clinical and Laboratory Standards Institute (CLSI) · Clinical Data Interchange Standards Consortium (CDISC) · Designated Standard Maintenance Organization (DSMO) · Health Level 7 (HL7) · Institute of Electrical and Electronic Engineers (IEEE) · International Organization for Standardization (ISO) · National Council for Prescription drug Programs (NCPDP) · National Information Standards Organization (NISO) · National Uniform Billing Committee (NUBC) National Uniform claim Committee (NUCC)

four sources of laws in the United States?

· Constitutional Law · Common Law · Statutory Law Administrative Law

What are five desirable characteristics of terminologies and classifications for data standardization?

· Content · Concept orientation · Concept permanence · Nonsemantic concept identifier · Polyhierarchy · Formal definitions · Reject not elsewhere classified. · Multiple granularities · Multiple consistent views · Context representation · Graceful evolution · Recognized redundancy. · Licensed and copyrighted. · Vendor neutral · Scientifically valid · Adequate maintenance · Self-sustaining

List five common registration errors that affect the revenue cycle

· More than one health record number per patient · Transposed digits: social security number, date of birth, policy number, group number · Misspelled name · Address verification failure (returned mail cost) · Observation patient with inpatient stay type

What are some of the reasons why incorrect information is obtained?

· someone other than the patient provided the information, · something was spelled incorrectly, · different names or initials are used for the same patient, · there were clerical mistakes, and there was a difference in language.

What is used to evaluate and validate a physician's qualifications for staff membership?

Credentialing process