HIT FINAL (A)
Identify the three levels of theory relevant to program evaluation. (select all that apply) a. diffusion of innovation theory b. scientific theory c. social cognitive theory d. cognitive engineering theory e. program theory f. implementation models
b, e, and f
American Health Information Management Association (AHIMA)
association of HIM professionals. Strives to foster the professional development of its members
The role of evidence-based practice (EBP) in developing informatics-based solutions for managing patient care includes solutions that generate support for clinical decisions through: a. identifying clinicians to use the EBP information b. designing EBP documentation screens, order sets, infobuttons, and clinical reminders c. purchasing journals and databases with EBP d. purchasing and adopting any electronic medical record with EBP
b
Hybrid health record
combination of the paper record and the EHR
Unit numbering system
commonly used in large healthcare facilities; patient is issued a health record number at the first encounter and that number is used for all encounters
Which information system will track information provided to a requester? a. Registry b. Quality improvement c. Chart tracking d. Release of information
d. Release of information
Which standard is attached to the data element smoking status contained in the Common Clinical Data Set? a. ICD-10-CM b. HCPCS Level II c. ICD-10-PCS d. SNOMED CT
d. SNOMED CT
Continuum of care
places an emphasis on treating individual patients at the level of care required by their course of treatment and extends their PCPs to specialist and ancillary providers
Overall changes in national health expenditures
population growth inflation for the economy as a whole higher prices real income increases
demonstrated link between use of HIT and quality
positive correlation between HIT and patient compliance w/RX -reduction in med errors when eMAR, CPOE used
long, healthy, productive lives
preventable mortality infant mortality life impacts of poor health
HC System change
payment will be more oriented toward the outcomes generated and will cover the costs of a full range of services necessary to treat the patient
protecting information privacy and confidentiality
physical security- hardware, data files technical safeguards- passwords, encryption, audit logs management policies- written security policy, employee training, disciplinary actions for violation
Skilled Nursing Facility (SNF)
primary provides inpatient skilled nursing care but does not provide the level of care or treatment available in a hospital
Government policy: Privacy
privacy act of 1974: established key provisions
Record reconciliation
process of assuring that all the records of discharged patients have been received by the HIM department for processing
transactions and code set standards
warrant additional commentary because they are so vital to the effective implementation and use of the electronic record
Overlap
when a patient has more than one health record number at different locations in an enterprise
Overlay
where a patient is erroneously assigned another persons health record number
Capture Collect Process
who, when, how, what, where?
Serial-unit numbering system
A combination of the serial and unit numbering systems
2. A key reason for general government intervention includes problems with which of the following? *
All of the above *
healthcare field
arguable most information-intensive sectors of the US economy
elements of confidentiality policy
assign rights release of information special handling for select information (HIV) special handling for select patients (VIP) availability and retention policy for medical information integrity of medical information methods for communication of medical information
information systems
assist in providing better access to care uninsured- post ACA
strategic decision support systems
assist the senior management team in strategic planning, managerial control, performance monitoring, and outcomes assessment -must draw data from internal clinical management systems as well as from external information on community health, market area demography, and activities of competitors -consequently, information system integration becomes very important
20. What is (are) the most important feature(s) of the Patient Protection and Affordable Care Act with respect to HIT? *
All of the above *
A key reason for general government intervention includes problems with which of the following?
All of the above: public goods, monopoly, externalities
4. National health spending reached approximately what figure in 2005? *
$2 trillion
In 1980, Goldsmith predicted what healthcare would look like in the future. Which of the following did he NOT forecast?
****Undersupply of physicians Expanded role of government financing Shift of financial risk from payers to providers Problems of the uninsured
Which of the following statements concerning HIPAA is NOT true?
***HIPAA compliance has always been voluntary. HIPAA pays the cost of medical care under a variety of federal programs, including Medicare and Medicaid. HIPAA allows individuals who change or lose jobs to maintain health insurance coverage for a certain amount of time. The final rules for HIPAA compliance took effect in April 2001.
Connectivity Goals
-FCC should continue to play a leadership role in advancing mobile health adoption -Federal agencies should increase collaboration to promote innovation, protect patient safety, and avoid regulatory duplication -The FCC should build on existing programs and link programs when possible in order to expand broadband access for healthcare -The FCC should continue efforts to increase capacity, reliability, interoperability, and RF safety of mHealth technologies -Industry should support continued investment, innovation, and job creation in the growing mobile health sector
Management of healthcare organizations is improved by intelligent use of information for:
-Financial management -Strategic planning -Operations management
Which of the following statements regarding healthcare costs are true?
-Hospital spending accounts for the largest portion of healthcare costs. -They have increased at a greater rate than inflation. -They are comprising a growing % of GDP. -They have increased at a greater rate than GDP
System performance measures to support national 'report cards' will
-Require new information to be collected, beyond traditional sources -Require increased efforts by HIT staff. -Require population-based data not usually collected by individual organizations
Which of the following is NOT predicted to happen in US healthcare?
-The Internet will facilitate communication between patients and providers. -Home-based monitoring systems will become more common and will reduce the need for repeated outpatient visits. ***Healthcare decisions will be more physician based. Patients will participate more fully in decisions about their care.
current challenges
-getting participation in application specifications from key clinical staff -MDs and HIT staff participation -having apps that meet workflow needs -documentation and billing requirements -federal requirements for participation in Medicare
current challenges
-healthcare costs -medical errors and poor quality -access and health disparities -evidence based medicine -broad organizational challenges
Future challenges for HC Information Systems
-healthcare system change -consumer empowerment -connectivity -transparency (honest, accurate, ....) -tourism
Consumer empowerment and participation research regarding social media suggests that in the future
-patients will share information regarding their healthcare experiences via social media -patients will be willing to trust and share information from the Internet -patients will seek second opinions and shop for hospitals and doctors using social media. -patients will share personal health information (positive and negative) via social media. ** All of the above
Enhanced websites sponsored by healthcare organizations are being used for all of the following EXCEPT
-provision of consumer health information. -marketing and promotion. ***-disclosure of patient information. -employee recruitment.
International and Regional tourism
-sent historical patient health information -receive patient health information -compete with centers of excellence -financial incentives from employers contracting for care on the basis of price and quality
3 reasons gove should be involved with HIT
-spend lots of money, business doesn't help people-government insurance -all providers need to get involved to be successful -medicare makes sure that hospitals cant line the pockets of those involved
President Bush's value-driven healthcare called for
-strict privacy of all provider cost and quality information. -establishment of Internet2 exclusively for healthcare applications. -better security through prohibition of the creation of information systems that easily share information. -free Internet access for all citizens. *** none of the above
healthcare costs
-trend upward costs for 45 years -Cost increases may make the US economy less competitive -gov't and private payers implement cost control -variance in use and sots provide indirect evidence that can control costs
Why did health informatics develop?
1. Growth and volume of medical knowledge, patient information, understanding of human health. 2. Increase in specializations has created and need to share and coordinate patient information. 3. Clinicians need access to medical information expeditiously regardless of time and day.
What are some of the challenges existing today that require an improvement in informatics?
1. Technology is advancing faster than healthcare professionals can assimilate into their practice. 2. Critical limitation of IT that manages data and not information. This creates a mismatch in what clinicians need (information) and what they have (ineffective ways to manage information).
Categories of Information systems
1. clinical information systems 2. operational management systems 3. strategic decision support systems 4. electronic networking and 3-health applications
uninsured
15.7% to 16% (50 to 48.6 million)
When did health informatics begin?
1950-1960
14. According to the US Census Bureau (2012), approximately how many people in the United States are uninsured? *
49 million
Classification
A clinical vocabulary, terminology, or nomenclature that lists words/phrases with their meanings, provides proper use of clinical words and symbols, and facilitates mapping standardized terms for broader classifications for administrative, regulatory, oversight, and fiscal requirements
3. Which of the following statements regarding the National Library of Medicine (NLM) is true? *
A major portion of the NLM's charge is helping healthcare organizations develop data systems to support clinical operations and health services research. *
Delinquent record
A record that remains incomplete longer than the time allowed by medical staff rules and regulations
19. Core measures required to demonstrate meaningful use involve which of the following standards? *
All of the above *
Nomenclature
A system of terms that follows pre-established naming conventions; includes clinical terminologies, classification, and code systems
Emeritus membership
AHIMA membership category for members who are 65 years old or older.
Addendum
Additional information provided in the heal record. It should be dated the day it was written
In addition to ensuring that individuals retain access to health insurance when they change jobs, HIPAA contains a second provision called
Administrative Simplification
7. In addition to ensuring that individuals retain access to health insurance when they change jobs, HIPAA contains a second provision called *
Administrative Simplification. *
12. Most healthcare organizations have established a HIPAA task force. Which of the following positions lead(s) the task force? *
All of the above *
16. Improving quality of care has which of the following implications for HIT? *
All of the above *
Hospital Standardization
American college of Surgeons in 1918; establish quality standards for hospitals with complete and accurate records
Code system
An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information
Clinical coding
Assigning codes to represent diagnoses and procedures
What is bioinformatics?
Bioinformatics is a sub-field of biomedical informatics that is concerned with biological data, DNA and genomic information as opposed to clinical, public health and other data.
Unified Medical Language System (UMLS)
Centralized location of health and biomedical terminologies and standards
Amendment
Clarification made to healthcare documentation after the original document has been signed
Diagnostic and Statistical Manual of Mental Disorders (DSM)
Classification for mental disorders
ICD-O-3
Classifies diseases for oncology. Used by cancer registries to report topography and morphology of neoplasm
What are some other names for health informatics?
Clinical informatics, medical informatics, and biomedical informatics. If the informations science deals primarily with actual application and programs and not theory, it is called applied informatics.
Outcome and Assessment Information Set (OASIS)
Collected on Medicare beneficiaries receiving skilled services from a Medicare certified home health agency. RN nurses and therapists collect the data
11. Which of the following dimensions is NOT one of Davis's (2004) six domains of quality from the perspective of the patient? *
Comfort *
For which of the following activities/programs should healthcare organizations establish enterprise-wide standards to maintain data security and protect the privacy and confidentiality of information?
Complete and accurate information; better access to information; patient empowerment
18. What are the three benefits of using the electronic health record? *
Complete and accurate information; better access to information; patient empowerment *
Metathesaurus
Contains codes and terms from over 150 terminology, classification, and code systems
Uniform Hospital Discharge Data Set (UHDDS)
Data is collected by acute care, short term stay hospitals to report inpatient data elements
Healthcare Effectiveness Data and Information Set (HEDIS)
Designed to collect administrative, claims, and health record review data. Data is collected by clinics and acute care hospitals from health records
In which of the following activities/programs should the information steering committee ensure that effective data backup and recovery procedures are implemented at all processing sites throughout the organization?
Disaster protection and recovery procedures
16. In which of the following activities/programs should the information steering committee ensure that effective data backup and recovery procedures are implemented at all processing sites throughout the organization? *
Disaster protection and recovery procedures *
Secondary purposes of health records
Education; legal, accreditation, and policy development; and public health and research
Which of the following areas do electronic networking and e-health applications support?
Electronic data interchange
In which of the following activities/programs should HIT leadership focus on being able to understand fully the operational and resource implications, while the internal team focuses on what extra manpower, expertise, technology, software, and time will be needed?
Environmental Scanning
15. In which of the following activities/programs should HIT leadership focus on being able to understand fully the operational and resource implications, while the internal team focuses on what extra manpower, expertise, technology, software, and time will be needed? *
Environmental scanning *
Common Clinical Data Set
Established by the ONC. A common set of data types and elements and associated standards for use across several certification criteria
Much of what is envisioned in today's healthcare reform represents brand new thinking, and approaches that have never been tried in the past.
False
1. Cost, quality, and access (the healthcare triangle) involve systems challenges faced by our governmental leaders and do not have a direct impact on healthcare organizations or HIT. *
False *
6. National health expenditure growth since 2000 poses a major challenge to the United States today because the rate of growth was much lower in prior decades. *
False *
Fellowship Program
For AHIMA members who made significant contributions to the HIM profession; open to active and senior members
Importance of clinical terminologies
Form the basis of coded data and provide the data structure required for semantic interoperability and health information exchange
13. Which of the following statements concerning HIPAA is NOT true? *
HIPAA compliance has always been voluntary. *
Management Implications:
HIT and leadership must collect, analyze and report clinical and administrative data -Includes conventional and new types of data demanded in the future
4. This major set of government legislative and administrative interventions has fundamentally changed HIT in the last decade and will likely continue to change it in the future. *
Health Insurance Portability and Accountability Act of 1996 (HIPAA) *
What is the central concern of informaticians?
Health information technology provides the tools to generate information from data that humans can turn into knowledge and wisdom, thus improving human decision making with usable information.
What factor is NOT a primary driver of change in the healthcare system?
Healthcare costs, quality, and access ***Global warming Evidence-based medicine Broad organizational change
Institutional uses of the health record
Healthcare delivery organizations; third party payers; medical review organizations; research organizations; educational organizations; accreditation organizations; government licensing agencies; and policy making bodies
Healthcare costs
Hospital services 31.4% Physician services 19.9% Prescription drugs 10% Nursing home 5.5%
CHAPTER 2
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CHAPTER 3
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What is biomedical informatics?
It's a broader term referring to medical, dental, nursing, public health, pharmacy, medical imaging and veterinary informatics.
14. Which of the following statements regarding the Privacy Act of 1974 is NOT true? *
Its main focus was to protect genetic privacy. *
What is the name for someone who practices informatics?
Informaticist or informaticians
What is information?
Information is meaningful data or facts from which conclusions can be drawn by humans or computers. Computers do not process information, they process data. This is a fundamental problem and challenge in informatics.
Health record
Information relating to the physical or mental health or condition of an individual, collected by a health professional
17. For which of the following activities/programs should healthcare organizations establish enterprisewide standards to maintain data security and protect the privacy and confidentiality of information? *
Information security policies and procedures *
What is the definition of informatics?
It is a science of information and the blending of people, biomedicine and technology.
What happened with the advent of EHR, health information exchange (HIE) and multiple hospital electronic information systems?
It provided the ability to collate and analyze large amounts of data to improve health and financial decisions.
Importance of classification
Key to secondary data use. Aggregate clinical data for healthcare statistics, design payment systems, monitor public health, and improve financial performance
What is knowledge?
Knowledge is information that is justifiably considered to be true. i.e. A rising PSA level suggests the likelihood of cancer.
Access problems- the ability to receive care when needed- can be caused by which of the following factors?
Lack of available transportation Living in a rural/remote area far from healthcare providers. Fear/ lack of awareness of public health programs. Lack of health insurance
AHIMAs Board of Directors
Leads the volunteer structure; manages the association
What are the different levels of data?
Level 1 paper forms with serious limitations in regards to sharing, storing and analyzing. Level 2 data could be scanned in documents. Level 3 data are entered into a computer and are data that are structured and retrievable but not computable. Level 4 data are computable, meaning electronic, capable of being stored in data fields and computable because it is in a format that disparate computers can share (interoperable) and interpret (analyzable).
Enterprise master patient index (EMPI)
Links the patient's information at different facilities
e-health applications
Many of the electronic networking applications are web-based, e-health applications
12. What is a leading cause of adverse health consequences and greater cost burden on society as a whole? *
Medical errors *
AHIMAs House of Delegates
Part of the volunteer structure that governs the profession
Which of the following areas do clinical information systems support?
Patient Care
Individual users of the health record
Patient care providers; patient care managers and support staff; coding and billing staff; patients; employers; lawyers; law enforcement officials; healthcare researchers and clinical investigators; and government policy makers
Primary purposes of health records
Patient care, managing patient care, and administrative purposes
13. Problems with quality of care in the United States will be resolved if the following occurs: *
Payment incentives change to reward efficient, effective, patient-centered care and greater use of HIT
Master Patient Index (MPI)
Permanent record of all patients treated at a healthcare facility
Coding
Process of assigning numeric or alphanumeric respresentaions to clinical documentation
Current Procedural Terminology (CPT)
Provides a uniform language for procedures. CPT has 5 characters, Catergory 1, 2, and 3, and modifiers
ICD-10-CM
Provides classification of diseases for morbidity. Contains 3-7 character codes and descriptions for patient conditions
17. Which of the following mechanisms to reduce or control healthcare costs will have an impact on HIT?
Reducing duplicate tests and procedures *
ICD-10-PCS
Reports procedures for inpatient claims. Contains 7 character codes and descriptions for procedures
Requisition
Request for the health record
Which of the following is NOT one of the 6 domains of quality from the patient's perspective?
Safety ***Convenience Patient-centeredness Efficiency
Document management system (DMS)
Scans paper records and stores it digitally. Used during the transition from paper to EHR
Clinical terminology
Set of standardized terms and synonyms that record patient findings, circumstances, events, and interventions with detail to clinical care, decision support, outcomes research, and quality improvement
SNOMED-CT
Standardize clinical phrases. Content includes concepts, descriptions, and relationships
Logical Observation Identifiers Names and Codes (LOINC)
Standardizes names and codes for the identification of laboratory and clinical test results or observation
8. Administrative simplification involves what four features? *
Standards for electronic health transactions, required use of standards, privacy of health information, and penalties for noncompliance *
Which of the following tasks is (are) a primary focus of medical research information systems?
Studying patterns of health and disease in populations
11. Which of the following tasks is (are) a primary focus of medical research information systems? *
Studying patterns of health and disease in populations *
Which of the following is NOT a major priority in system development?
Support for consumers through development of home applications **Disuse of wireless devices to improve data entry and access Interoperability among systems Protection of information security/HIPAA compliance
Which of the following is (are) a primary focus of public health information systems?
Supporting disease prevention and surveillance programs
10. Which of the following is (are) a primary focus of public health information systems? *
Supporting disease prevention and surveillance programs *
A recent study found that healthcare providers that had adopted HIT (Electronic Health Records, primarily) had patients who were more likely to take recommended medications than patients of providers who had not adopted HIT/EHR.
TRUE
Which of the following are reasons that the U.S healthcare spending is more than twice as much per capita as that of other OECD nations?
The US is at least a decade late in making HIT a national priority. The US invests significantly less per capita on HIT. The US has not relied on a centralized government role in motivating HIT adoption.
6. Government intervention in HIT can be justified for all but which of the following reasons?
The United States needs to be a leader in HIT adoption for its national pride *
5. Which of the following statements regarding government intervention and involvement in the healthcare sector is NOT true? *
The homeless population is growing rapidly. *
Abstracting
The process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome, or extracting elements of data from a document and entering them into an automated system
15. The uninsured tend to exhibit poor health outcomes and high overall costs for all of the following reasons EXCEPT: *
They are often undocumented residents who were sick and came to the United States to obtain quality healthcare. *
MPI Quality Control
To maintain the MPI, algorithms are used to match patients so patient information can be merged
__________ are activities involving the transfer of healthcare information for specific purposes
Transactions
9. __________ are activities involving the transfer of healthcare information for specific purposes. *
Transactions *
10. Interoperability, the ability of health information systems to work together within and across organizational boundaries, is a vital movement for the development of standards. *
True *
3. The government recognizes the challenges that the healthcare industry faces regarding cost, quality, and access to care. *
True *
9. If health spending continues to increase, the quality of care for even the best-insured Americans will be threatened. *
True *
reasons for adverse international comparisons concentrate on HIT and other challenges
USA is a decade late in making HIT a national priority USA has not relied on centralized government role in supporting HIT adoption USA invests less per capita on HIT than other countries
RxNorm
Used to communicate drug related information
Healthcare Common Procedure Coding System (HCPCS) Level II
Used to meet operational needs for Medicare and Medicaid reimbursement programs. Required for reimbursement of ambulatory services provides in healthcare settings
International Classification of Functioning (ICF)
Used to report health and disability
What is wisdom?
Wisdom is the critical us of knowledge to make intelligent decisions and work through situations of signal versus noise. I.e. A rising PSA could mean a prostate infection and not cancer.
Allied health professional
a credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietitian, social worker, or occupational therapist)
Serial numbering system
a patient is issued a unique numerical identifier for every encounter at the healthcare facility; this method is inefficient and costly
Managed Care Organization (MCO)
a type of healthcare organization that delivers medical care and manages all aspects of patient care or the payment for care by limiting providers of care or limiting access to care
The centers for disease control and prevention provides a six-step framework for program evaluation of a locally developed... select steps for program evaluation. (select all that apply) a. justify conclusions by comparing to standards and expert review b. test a hypothesis and research questions c. generalize to larger population d. assess usefulness, feasibility, ethics, and accuracy e. engage stakeholders to contribute to goals and metrics f. describe, manipulate and measure variables
a, d, and e
The use of the health record by a clinician to facilitate quality patient care is considered ____________. a. A primary purpose of the health record b. Patient care support c. A secondary purpose of the health record d. Patient care effectiveness
a. A primary purpose of the health record
The formal approval process for academic programs in health information management is called which of the following? a. Accreditation b. Certification c. Registration d. Standardization
a. Accreditation
What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization? a. Accreditation b. Certification c. Licensure d. Deemed status
a. Accreditation
Which of the following is an example of administrative information? a. Admitting diagnosis b. Blood pressure records c. Medication records d. Patient's address
a. Admitting diagnosis
A classification provides clinical data to ______________. a. Allow collection and reporting of healthcare statistics b. Indicate smoking status in the Common Clinical Data Set c. Facilitate electronic data collection at the point of care d. Use for primary data purposes
a. Allow collection and reporting of healthcare statistics
The Joint Commission places emphasis on ________________. a. Appropriate and standardized health record documentation b. Electronic health record technologies used to support documentation c. Clinical and operational practices related to the health record d. Statutes at both the federal and state level
a. Appropriate and standardized health record documentation
A healthcare provider organization, when defining its legal health record must ___________. a. Assess the legal environment, system limitations, and HIE agreements b. Determine what other healthcare provider organizations are doing c. Determine if a legal health record is needed d. Only include the paper components of the health record
a. Assess the legal environment, system limitations, and HIE agreements
Who has the primary responsibility for setting the overall direction of the hospital? a. Board of directors b. Chief executive officer c. Chief financial officer d. All employees of the hospital
a. Board of directors
Which group is responsible for AHIMA's certification exams? a. CCHIIM b. AHIMA House of Delegates c. AHIMA Board of Directors d. CAHIIM
a. CCHIM
The ___________ is responsible for the publishing and maintaining HCPCS Level II. a. CMS b. AMA c. NCHS d. ADA
a. CMS
HCPCS is made up of which code systems? a. CPT and HCPCS Level II b. Dental codes and HCPCS Level II c. ICD-10-PCS, CPT and HCPCS Level II d. CPT, HCPCS Level II and HCPCS Level III
a. CPT and HCPCS Level II
Which of the following is part of qualitative analysis review? a. Checking that only approved abbreviations are used b. Checking that all forms and reports are present c. Checking that documents have patient identification information d. Checking that reports requiring authentication have signatures
a. Checking that only approved abbreviations are used
Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words? a. Chief complaint b. Social and personal history c. Past medical history d. Present illness
a. Chief complaint
If data aggregation is the goal of collecting the data, ______ are the best choice. a. Classifications b. Code systems c. Clinical terminologies d. Nomenclatures
a. Classifications
A ___________ is a set of terms representing the system of concepts for the medical field. a. Clinical terminology b. Code system c. Nomenclature d. Classification
a. Clinical terminology
Which of the following qualify for CEUs? a. College course b. Applying for fellowship c. Being on the AHIMA Board of Directors d. Participating on an AHIMA national committee
a. College course
Student membership
any student who does not carry an AHIMA credential
Which of the following best describes the mission of AHIMA? a. Community of professionals providing support to members and strengthening the industry and profession b. Community of professionals whose major purpose is lobbying Congress to change laws c. Community of credentialed members who monitor the credentialing process d. Community of credentialed members whose purpose is to ensure jobs for their members
a. Community of professionals providing support to members and strengthening the industry and profession
The emphasis on traditional practice of HIM was to ensure: a. Complete and accurate health record b. Valid certification exams c. Retrieval of the health record for patient care d. Management of information
a. Complete and accurate health record
Which of the following places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers? a. Continuum of care b. Integrated delivery systems c. Case management d. Integrated delivery networks
a. Continuum of care
One group of patients that prefer treatment at urgent care centers are those whose insurance carriers treat urgent care centers preferentially when compared with physician offices. a. True b. False
a. True
How do patient care managers and support staff use the data documented in the health record? a. Evaluate the performance of employees b. Communicate vital information among departments and across disciplines and settings c. Generate patient bills or third-party payer claims for reimbursement d. Determine the extent and effects of occupational hazards
a. Evaluate the performance of employees
Which of the following is true of good forms design for paper forms? a. Every form should have a unique identification number b. Barcodes are never included c. Bright color paper should be used to identify forms. d. Paper size should be 8.5 inches by 14 inches
a. Every form should have a unique identification number
Written or spoken permission to proceed with care is classified as ___________. a. Expressed consent b. Acknowledgment c. Advance directive d. Implied consent
a. Expressed consent
Which of the following is an example of an acknowledgement? a. General consent to treat document b. Notice of privacy practices c. Consultation report d. Patient instructions document
a. General consent to treat document
The _________ is a system for classifying the topography and morphology of neoplasm. a. ICD-O-3 b. ICD-10-CM c. ICD-10 d. SNOMED CT
a. ICD-O-3
One of the functions of the board of directors is to approve the organization and makeup of the clinical staff. a. True b. False
a. True
The ___________ is responsible for the development and maintenance of ICD-10-CM. a. NCHS b. CMS c. ICD-10 C&M Committee d. NCHS and CMS
a. NCHS
Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? a. Operative report b. Anesthesia report c. Pathology report d. Laboratory report
a. Operative report
How long should the MPI be retained? a. Permanently b. 25 years c. 50 years d. 10 years
a. Permanently
Removing health records of patients who have not been treated at the facility for a specific period of time from the storage area to allow space for more current records is called: a. Purging records b. Assembling records c. Logging records d. Cycling records
a. Purging records
Which of the following types of facilities is generally governed by long-term care documentation standards? a. Rehabilitation b. Subacute care c. Behavioral health d. Ambulatory surgical center
a. Rehabilitation
Which type of microfilm does not allow for a unit record to be maintained? a. Roll microfilm b. Jacket microfilm c. Microfiche d. Micrographics
a. Roll microfilm
To qualify as a Critical Access Hospital one of the criteria is to be located in a rural area. a. True b. False
a. True
the total national cost associated with adverse effects
approximately 4 percent of national health expenditures in 1996
The management of health information is a fundamental component of which of the following? a. The overall information governance model b. The EHR workflows c. The documentation standards d. Cloud Computing
a. The overall information governance model
Critique this statement: Patient care managers are individual users of health records. a. This is a true statement. b. This is a false statement as they do not require patient information to do their job. c. This is a false statement as they require patient information to do their job. d. This is a false statement as patient care managers are institutional users.
a. This is a true statement.
Critique this statement: an RHIT must be at least 65 years old in order to qualify for emeritus membership. a. This is a true statement. b. This is a false statement because the member must be at least 60 years old to qualify. c. This is a false statement because the member must be at least 70 years old to qualify. d. This is a false statement because the member must be at least 55 years old to qualify.
a. This is a true statement.
Hospital-owned group practices are considered ambulatory care organizations. a. True b. False
a. True
Occupational Therapists are concerned with a patient's activities of daily living. a. True b. False
a. True
Two studies have reported that if fully using electronic health care records (EHR) within American hospitals, the volume of preventable fatal hospital-based events each year could be reduced by 78,800 to 132,000. What were the critical considerations to achieve such a significant improvement to patient safety? (select all that apply)
a. clinicians can document treatment completely within the EHR b. Healthcare providers who maximize their use of EHRs to care for patients d. Health informaticians fully involved in the design, selection, and implementation
CAHIIM
accrediting organization that establishes and enforces quality standards for programs
transactions
activities involving the transfer of the healthcare information for specific purposes
Social Media
adding to the ability to send and receive information
Health Insurance Portability and Accountability Act (HIPAA)
addresses issues related to the portability of health insurance after leaving employment, and national identifiers for providers, health plans, and employers. Also addresses the security and privacy of health information
1. The external environment and government have _______ roles in healthcare operations. *
all of the above *
evidenced based medicine
an information management and learning strategy that seeks to integrate clinical expertise with the best evidence available to make effective clinical decisions that will ultimately improve patient care -changing clinical process -use of information is essential but has both benefits and costs -
An emerging approach to knowledge building includes measuring the effectiveness of EBP guidelines. This approach requires steps to obtain clinical data through the application of PBE research design techniques. These techniques include: a. using a prospective research design to record information to characterize disease risk and generate theories about effective treatments or how well treatments work in practice b. using collected electronic data with cohort samples of patients with identified characteristics to detect subtle patterns within comprehensive standardized data about practice interventions and treatments c. using a standard research design for answering questions bout efficacy of treatment using an experimental design with random assignment of patients to treatment with controlled inclusion criteria d. using chart review with retrospective data generated before the study without controlled criteria to research practices with treatments
b.
The ACE Star Model of Knowledge Transformation is a model of five points to integrate evidence-based practice into informatics solutions. Which activities represent the five points of the star? a. Literature search, synthesize evidence, finding knowledge, building guidelines, and disseminating guidelines b. discovery research, evidence summary, translation to guidelines, practice integration, and evaluation of process and outcome c. find guidelines, identify champions, disseminate guidelines, perform academic detailing, and measure compliance d. identify problems, find solutions, share solutions, educate staff, and implement solutions
b.
The STEEEP recommendations and redesign principles reflected in health professional education programs to improve the quality of care are best described as: a. safety, timeliness, easy, explainable, excellence, and patient-oriented b. safe, timely, effective, efficient, equitable, and patient-centered c. simple, tested, education, effective, empirical, and practical processes d. safe, timely, evidence-based, efficient, economical, and patient preferences
b.
The use of opinion leaders and real-time feedback about patient outcomes are examples of which type of intervention? a. attend to process analysis and engineering workflows b. offer mechanisms to diffuse and adopt new knowledge and include innovation c. focus on EBP, research utilization, and knowledge transformation principles d. foster interactions among practitioners, researchers, policy makers, and consumers
b.
As of 2014, what percent of the U.S. economy was represented by healthcare spending? a. 10 b. 17.5 c. 21 d. 26
b. 17.5
State College is applying for accreditation of the new HIM program. How long do they have to complete their candidacy? a. 1 year b. 2 years c. 4 years d. 5 years
b. 2 years
What is the ideal ratio of medical generalist to specialist? a. 20:80 b. 40:60 c. 60:40 d. 80:20
b. 40:60
Someone who wishes to sit for the Certified Professional Coder (CPC) certification should contact which organization? a. AHIMA b. AAPC c. HIMSS d. AHDI
b. AAPC
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders? a. Mental Health Association b. American Psychiatric Association c. Mental Health Foundation d. World Psychiatric Association
b. American Psychiatric Association
Health information management departments are considered which of the following? a. Rehabilitation Services b. Ancillary Support Service c. Administrative Support Services d. Clinical Support Services
b. Ancillary Support Service
Which of the following is the formal process for conferring a health information management credential? a. Accreditation b. Certification c. Registration d. Standardization
b. Certification
The standardized HEDIS data elements are collected by _________. a. Acute care hospitals b. Certified survey vendors c. Healthcare purchasers d. Consumers
b. Certified survey vendors
Which system records the location of health records removed from the filing system and documents the return of the health records? a. Chart deficiency system b. Chart tracking system c. Abstracting system d. Registry system
b. Chart tracking system
___________ is a nursing terminology. a. International Classification of Procedures b. Clinical Care Classification c. International Classification of Functioning d. International Classification of Diseases
b. Clinical Care Classification
An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a ___________. a. Nomenclature b. Code system c. Concept system d. Data set
b. Code system
What standard does a hospital that participates in the Medicare and Medicaid programs have to comply with that hospitals who do not accept Medicare and Medicaid patients do not? a. Medical bylaws of the healthcare provider organization b. Conditions of Participation c. Accreditation organization d. Documentation standard
b. Conditions of Participation
Which of the following electronic record technological capabilities would allow a paper-based x-ray report to be accessed? a. Database management b. Documents imaging c. Text processing d. Vocabulary standards
b. Documents imaging
Medicare will pay the Medicaid premiums, deductibles, and coinsurance costs for some low-income Medicaid beneficiaries. a. True b. False
b. False
Registered Nurses are only formally educated at the bachelor's degree. a. True b. False
b. False
Rehabilitation hospitals are categorized as an acute care type of facility in treating patients. a. True b. False
b. False
Dr. Smith dictated his report and then immediately edited it. What type of speech recognition is being used? a. Back-end b. Front-end c. Physician d. Outsourced
b. Front-end
The accountability framework and decision rights to achieve enterprise information management is known as: a. Credential b. Information governance c. Certification d. Registration
b. Information governance
Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? a. Autopsy report b. Laboratory findings c. Pathology report d. Surgical report
b. Laboratory findings
What is the name of the type of beds in a hospital that are defined by those authorized by the state? a. Staffed b. Licensed c. Regulated d. Certified
b. Licensed
The medical staff operates according to a pre-determined set of policies called ___________. a. Policies and procedures b. Medical staff bylaws c. Medical staff credentials d. Legal guidelines
b. Medical staff bylaws
Deficiencies in a health record include which of the following? a. Mistake in the patient's age b. Missing document c. Contradictory content d. Illegible content
b. Missing document
Which professional organization sponsors the CTR certification? a. AHIMA b. NCRA c. AAPC d. HIMSS
b. NCRA
Which of the following is the health profession that focuses on the eyes and related structures? a. Occupational therapy b. Optometry c. Diagnostic sonography d. Dietetics
b. Optometry
Home health agency process and improvement outcome measures are based on data from the _____. a. Home Health Compare Data Set b. Outcomes and Assessment Information Set c. Uniform Hospital Discharge Data Set d. Common Clinical Data Set
b. Outcomes and Assessment Information Set
Which of the following is clinical data? a. Patient consent b. Physician orders c. Patient registration d. Name of insurance company
b. Physician orders
The Subjective, Objective, Assessment Plan (SOAP) came from the: a. Source-oriented health record b. Problem-oriented health record c. Hybrid health record d. Depends on facility policy
b. Problem-oriented health record
Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay? a. Physical examination b. Progress notes c. Physician order d. Medical history
b. Progress notes
Category I CPT includes which of the following? a. HCPCS Level II b. Surgery c. Drugs d. Durable medical equipment
b. Surgery
Which of the following is an institutional user of the health record? a. Patient care provider b. Third-party payer c. Coding and billing staff d. Government policy maker
b. Third-party payer
Which of the following materials is documented in an emergency care record? a. Minimum Data Set b. Time and means of the patient's arrival c. Patient's complete medical history d. APGAR
b. Time and means of the patient's arrival
Why is only the most current version of a document displayed? a. All previous versions are deleted b. To ensure there is no confusion on the correct document c. Only the physician has access to previous versions of a document d. The user decides which version to see
b. To ensure there is no confusion on the correct document
Which of the following is the most efficient filing system? a. Serial numbering system b. Unit numbering system c. Serial unit numbering system d. Middle-digit filing system
b. Unit numbering system
Choose the best two responses to describe evaluation research (select all that apply) a. wide scope, many outcomes b. methods selected and few targeted outcomes c. research with statistical evaluation of models d. similar scope, outcomes measured and methods to program evaluation e. planned focused questions
b. and c.
Which of the following functions governs the HIM profession? a. AHIMA Board of Directors b. AHIMA Commission on Certification for Health Informatics and Information Management c. AHIMA House of Delegates d. AHIMA Foundation
c. House of Delegates
Which health record format is most commonly used by healthcare settings as they transition to electronic records? a. Integrated records b. Problem-oriented records c. Hybrid records d. Paper records
c. Hybrid records
Research design involves a balance of internal validity (the validity of the causal inference that the treatment is the "true" cause of the outcome) and external validity (the validity that the causal inference can be generalized to other subjects, forms of the treatment, measures of the outcome, practitioners, and settings). The weaknesses of practice-based evidence observational designs include (select all that apply) a. external validity b. causality between treatment and outcomes c. selection bias effects d. internal validity e. associations between treatment combinations and outcomes
b. and d.
Healthcare system change
bundled payments, payment for outcomes, accountable care organizations, patient-centered medical homes, comparative effectiveness research -all challenge the conventional fee-for-service payment and focus on the care of an individual patient
Which characteristics of informatics interventions are measured during program evaluation? (select all that apply) a. compliance rates for rules and regulations b. unintended consequences c. effectiveness in decision support or identifying patients d. work-arounds e. resources for interventions f. reach of targeted people
c, f
The first professional association for health information managers was established in what year? a. 1900 b. 1905 c. 1928 d. 1970
c. 1928
The number of charter members of the ARLNA was: a. 35 b. 17 c. 58 d. 82
c. 58
Which of the following make up a virtual network of AHIMA members? a. AHIMA Board of Directors b. AHIMA Council on Certification c. AHIMA Engage d. AHIMA House of Delegates
c. AHIMA Engage
Which of the following is an arm of AHIMA that promotes research in health information management? a. AHIMA Board of Directors b. AHIMA CAHIIM c. AHIMA Foundation d. AHIMA Commission on Certification for Health Informatics and Information Management
c. AHIMA Foundation
The hospital standardization program was started by __________. a. American Health Information Management Association b. Commission on Accreditation for Health Informatics and Information Management Education c. American College of Surgeons d. Healthcare Information and Management Systems
c. American College of Surgeons
HITECH was a portion of which bill? a. Health Insurance Portability and Accountability Act of 1996 b. Patient Protection and Affordable Care Act of 2010 c. American Recovery and Reinvestment Act of 2009 d. Public Law 98-21 of 1983
c. American Recovery and Reinvestment Act of 2009
caregivers who are required to use best evidence-based practices
c. An interdisciplinary professional specialty and scientific discipline that integrates the health sciences, computer sciences, and information science as well as other analytical sciences with the goal of managing and communicating data, information, knowledge, and wisdom in providing care for individuals, families, groups, and communities
"Loose" reports are health record forms that: a. Are maintained separately from the health record b. Are not part of the legal health record c. Are received by the HIM department and added to the health record after it has been processed d. Are misfiled
c. Are received by the HIM department and added to the health record after it has been processed
One of the two major groups of LOINC content is _________. a. Clinical drugs b. Clinical diagnoses c. Clinical observations d. Clinical interventions
c. Clinical observations
The requirement for an HIM professional to comply with all laws, regulations, and standards governing the practice of HIM is in the AHIMA _________. a. Mission b. Vision c. Code of ethics d. Engage
c. Code of ethics
The ________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations. a. Outcomes and Assessment Information Set b. Healthcare Effectiveness Data and Information Set c. Common Clinical Data Set d. Uniform Hospital Discharge Data Set
c. Common Clinical Data Set
The ___________ is a core component of SNOMED CT. a. Identifier b. Hierarchy c. Concept d. Definition
c. Concept
ICD-10-PCS is a classification of _________. a. Emergency room procedures b. Nursing procedures c. Inpatient procedures d. Outpatient procedures
c. Inpatient procedures
In order to qualify for an AHIMA fellowship, what minimal educational level is needed? a. Associate degree b. Bachelor degree c. Master's degree d. Doctorate degree
c. Master's degree
Which of the following is a main goal in treating hospice patients? a. Curing the patient of their illness b. Relive the family of providing care c. Minimize the stress and trauma of death d. Reduce the costs for the patient's family
c. Minimize the stress and trauma of death
The federal Conditions of Participation apply to which type of healthcare organization? a. Organizations that are accredited b. Organizations that provide acute care services c. Organizations that treat Medicare or Medicaid patients d. Organizations that are subject to the Health Insurance Portability and Accountability Act
c. Organizations that treat Medicare or Medicaid patients
Documentation standards have become more detailed and have become focused on ________. a. EHR technology b. Licensure requirements c. Patient care quality d. Accreditation standards
c. Patient care quality
Categories of Healthcare Information Systems
clinical information operational management strategic decision support electronic networking
To be recognized as a profession, which of the following did HIM need? a. Certification b. Registration c. Preliminary training d. Accreditation
c. Preliminary training
Which of the following is a function of the discharge summary? a. Providing information about the patient's insurance coverage b. Ensuring the other healthcare providers know what to do next while the patient is hospitalized c. Providing information to support the activities of the medical staff review committee d. Documenting the patient's health history in detail
c. Providing information to support the activities of the medical staff review committee
Which of the following federal laws created Medicare and Medicaid? a. Social Security Act of 1935 b. Public Law 92-603 of 1972 c. Public Law 89-97 of 1965 d. Tax Equity and Fiscal Responsibility Act of 1982
c. Public Law 89-97 of 1965
If you were looking for a code for a medication taken orally, in which system is it found? a. ICD-10-CM b. HCPCS Level II c. RxNorm d. ICD-10-PCS
c. RxNorm
Which of the following numbering system assigns multiple health record number, or, one per visit? a. Unit b. Serial-unit c. Serial d. Alphabetic
c. Serial
In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers but the content is filed under the most recent health record number? a. Unit b. Serial c. Serial-unit number d. Alphabetic
c. Serial-unit number
Public Law 89-97 of 1965 created a number of amendments to which Act? a. Affordable Care Act b. Health Insurance Portability and Accountability Act c. Social Security Act d. Medicare and Medicaid
c. Social Security Act
The two components of AHIMA's management structure are which of the following? a. Staff and team b. Team and committee c. Staff and volunteer d. Volunteer and council
c. Staff and volunteer
Critique this statement: Data and information mean the same thing. a. This is a true statement. b. This is a false statement because data is used for administrative purposes and information is used for clinical purposes. c. This is a false statement because data is raw facts and figures and information is data converted into a meaningful format. d. This is a true statement because information is raw facts and figures and data is information converted into a meaningful format.
c. This is a false statement because data is raw facts and figures and information is data converted into a meaningful format.
Healthcare systems changes alter HIT data collection requirements because
care delivery will become more integrated across delivery locations
Integrated delivery networks (IDNs)
comprises a group of hospitals, physicians, other providers, insurers, or community agencies that work together to delivery health services
HC costs
consumed about 18% of the US gross domestic product (GDP)
Consumer Empowerment
consumers taking active role in care decisions -internet provides access to info, giving more control -need for uniform, national information infrastructure -generating need for information management in healthcare
Health Delivery
continues to be an information-intensive set of processes
The main challenges in US healthcare
cost quality access
healthcare triangle
cost, quality, and access -efforts to address the interrelated challenges of this triangle occupy much of the hc leadership's and researchers' time and energy.
International Comparisons
create stress on US healthcare delivery system
Public Law 89-97 of 1965
created amendments to the Social Security Act, which created Medicare and Medicaid
meaningful use
criterion used in incentive programs of the Centers for Medicare and Medicaid services; payments are made to eligible healthcare providers who demonstrate meaningful use of EHR technology
An RHIT who graduated from college 6 months ago is joining AHIMA for the first time. What membership is he or she qualified for? a. Student b. Emeritus d. New graduate d. Active
d. Active
The Office of the National Coordinator for Health Information Technology was created as part of which Act? a. Health Insurance Portability and Accountability Act b. Social Security Act c. Patient Protection and Affordable Care Act d. American Recovery and Reinvestment Act
d. American Recovery and Reinvestment Act
Which group focuses on accreditation of rehabilitation programs and services? a. HFAP b. Joint Commission c. AAAHC d. CARF
d. CARF
The "C" in CIO stands for: a. Corporate b. Corporate c. Clinical d. Chief
d. Chief
What is the process of ensuring that a record is available for every patient seen at the healthcare facility? a. Overlap b. Delinquent chart c. Abstracting d. Reconciliation
d. Reconciliation
equity
patient-reported influence of income on ability to receive care
Which of the following is true about document imaging? a. Data in the scanned documents can be manipulated b. Scanned documents can only be viewed by one person at a time c. Outguides are required d. Documents can be indexed
d. Documents can be indexed
Which of the following is a secondary purpose of the health record? a. Document patient care delivery b. Assist caregivers in patient care management c. Aid in billing and reimbursement functions d. Educate medical students
d. Educate medical students
The overall goal of documentation standards is to ______________. a. Ensure physicians have access to the health record information they need to care for the patient b. Ensure that the healthcare provider organization is reimbursed appropriately by payers c. Ensure that the Centers for Medicare and Medicaid Services (CMS) do not find reason to fine the healthcare provider organization d. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
d. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
Prior to hospital standardization, health records were: a. Valuable tools b. Strong communication methods c. Complete documentation of patient care d. Essentially worthless
d. Essentially worthless
The SNOMED CT _________ includes the semantic tag. a. Definition b. Preferred term c. Synonym d. Fully specified name
d. Fully specified name
Which of the following is the fastest-growing sector to offer services for Medicare recipients? a. Urgent care b. Long term care c. Hospice d. Home health
d. Home health
WHO defines ___________ as a reference classification. a. SNOMED CT b. DSM-5 c. ICF d. ICD-O-3
d. ICD-O-3
portability (HIPAA)
designed to enable individuals to retain insurance when they changed jobs
An HIM student asked an HIM director why the hybrid record is so challenging. What is the HIM director's response? a. It is because we are focusing on the EHR. b. It is because we have to maintain all of the traditional HIM functions. c. It is because HIM professionals do not have the skills to manage the EHR. d. It is because we have to manage both the electronic and paper media.
d. It is because we have to manage both the electronic and paper media.
Which of the following is considered an Allied Health professional? a. Physicians b. Physician Assistants c. Registered Nurses d. Licensed Practical Nurses
d. Licensed Practical Nurses
A patient's registration forms, personal property list, RAI/MDS and care plan and discharge or transfer documentation would be found most frequently in which type of health record? a. Rehabilitative care b. Ambulatory care c. Behavioral health d. Long-term care
d. Long-term care
Which of the following is the key to the identification and location of a patient's health record? a. Disease index b. Outguide c. Deficiency slip d. MPI
d. MPI
LOINC would be found in the UMLS ____________. a. Terminology Network b. SPECIALIST Lexicon c. Semantic Network d. Metathesaurus
d. Metathesaurus
The _______ is responsible for development and maintenance of RxNorm a. AMA b. ONC c. FDA d. NLM
d. NLM
Data and information within the EHR system provides opportunities to generate knowledge. Healthcare providers must have an understanding of health informatics. Which of the following statements best describes their role in knowledge generation?
d. The clinician supports the use of standardized languages to document patient care to allow others such as patients and other clinicians to search the terms to understand the assessments, diagnoses, treatment procedures, therapy, or intervention
Which of the following statements is true of the process that should be followed in making corrections in paper-based health record entries? a. Addendum should be backdated b. The reason for the change should be noted c. The incorrect information should be obliterated d. The phrase late entry should be noted on the entry
d. The phrase late entry should be noted on the entry
Critique this statement: Once someone has earned the registered health information technician (RHIT) credential, it is a lifetime certification. a. This is a true statement. b. This incorrect as it is valid only until you retire. c. This is incorrect as RHITs have to retake for the exam every 10 years d. This is incorrect as RHITs have to become recertified.
d. This is incorrect as RHITs have to become recertified.
How do accreditation organizations use the health record? a. To serve as a source for case study information b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards are being met
d. To determine whether standards are being met
Which of the following is a traditional HIM role? a. Managing interoperability standards b. Data manipulation c. Information governance d. Tracking record completion
d. Tracking record completion
What is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified. a. Case management b. Continuum of care c. Quality improvement d. Utilization review
d. Utilization review
Differences between formative and summative evaluation include: a. analysis of costs and events b. information collected c. methods d. assessments
d. assessments
When managing the interrelationships among the stakeholders to further develop EHR systems, health information technology (HIT) professionals need to facilitate life-cycle change. Select the foundational health informatics knowledge HIT professionals need to consider?
d. healthcare providers advocate for their involvements in selecting systems that directly and indirectly impact patient care
Information systems and applications for delivery of healthcare are addressing needs associated with health informatics. Three essentials to explore with each of these systems and applications would include:
d. purpose, functions, and internal and external structures.
quality measurement
data and information intensive
What is data?
data are symbols or observations reflecting differences in the world. Datum is the singular and is the lowest level of abstraction such as a number in a database. There is no meaning associated with data. Computers process data rapidly and accurately.
Aggregate data
data that has been extracted from individual health records and combined to form deidentified information about group of patients that can be compared and analyzed
patient safety
patient-reported medical error with serious health consequences
environmental scanning and organizational education
determine breadth and scope of impending or actual legislation assess current organizational readiness for impact perform gap analysis for organization outline timeline for implementation with key dates and milestones identify clinical and other resources w/in the organization that will be necessary to meeting standards
Administration Simplifications
did not have a high profile but became a big deal for HIT -establish national standards for e-health transactions -addressed the security and privacy of health data -goal of improving efficiency and effectiveness of healthcare system via electronic data interchange
Impact of Triangle of HIT
documentation of the value obtained for care delivered requires detailed data on outcomes and resources consumed improving quality requires greater accuracy, reliability, and timeliness of clinical information access: challenging population in terms of ability/ willingness to engage
transparency
driven by value-driven healthcare -inoperable HIT -public reporting of provider quality information -public reporting of cost information -incentives for value comparisons
Organizational change in market
driven payment reform (bundled parts for services)
physicians
drivers of consumption, yet resistant to deploy or use technology
2. Key dimensions of health system performance include all of the following EXCEPT *
economic growth.
American Academy of Professional Coders (AAPC)
educates and certifies medical coders; CPC, CPC-P... certification
Quality improvement organizations (QIOs)
ensure the quality, efficiency, and cost-effectiveness of the healthcare services provided to Medicare beneficiaries
HIT leadership roles
environmental scanning and organizational education information security policies and procedures disaster protection and recovery procedures protecting information privacy and confidentiality
Financial Information
essential for strategic planning and efficient operational support of the patient care process
patient care systems
information technology used in the course of providing care, services, or treatments
Healthcare Industry
information-intensive
CCHIIM
establishes and enforces standards for certification and certification maintenance
19. Delivery organizations will change their structure in the future to be better able to *
facilitate coordination of care across the continuum of care by greater investment in information technology. *
Home healthcare
fastest-growing sector to offer services for Medicare recipients
impose regulations
federal drug administration
removing barriers
financial physical -non-ambulatory -no car, no driver, no bus
-secure information
from physicians, hospitals, and post acute providers on cost, quality, and outcomes
National Library of Medicine NLM
funding for research and demonstration projects helping organizations get up to speed on HIT
-provide public goods
funding of medical research
-increasing patient participation in care decisions
good information expert input how will patient/provider interface?
20. The growth of managed care in the 1970s prompted all of the following organizational responses similar to today EXCEPT *
growth of accountable care organizations. *
information security policy and procedures
hc organizations must establish enterprise-wide standards to maintain data security and protect the privacy of health information (patient records)
5. National health expenditures almost doubled from 2000 to 2010, but *
health expenditure growth is a problem because the US population increased only slightly during this period. *
Health informatics definition- dynamic
health informatics is the field of information science concerned with management of healthcare data and information through the application of computers and other technologies. It is more about applying information in the healthcare field than actual technology (ie IT position). Technology merely facilitates the collection, storage, transmission of data.
specific hc legislations
health insurance portability and accountability act HIPAA health information technology for economic and clinical health act HITECH patient protection and affordable care act PPACA
Integrated Delivery System (IDS)
healthcare systems that combine financial and clinical aspects of healthcare and use a group of healthcare providers to provide comprehensive health services across the continuum of care
7. Cost control efforts routinely concentrate on the hospital sector because *
hospitals are the largest single category of health delivery in terms of total expenditures. *
Outguide
identifies where the health record is located and when it was removed
Government intervenes
if market fails to allocate resources effectively
tourism
international and regional tourism -send historical patient health information -compete with centers of excellence -financial incentives from employers (walmart) contracting for care on the basis of pricing and quality
Gov'ts role in HIT
justification of governmental intervention in business processes
equity
key roles in coverage, income, and race
Centers for Disease Control and Prevention (CDC)
leading federal agency charged with protecting the public health and safety through control and prevention
enforce antitrust laws
limit hospital mergers
Critical Access Hospital (CAH)
located in rural area; provide 24-hour emergency care services 7 days a week; located more than 35-mile distance from any other hospital
Dimensions of Health-care System performance assessment
long, healthy, productive lives quality access efficiency equity
Broad Organizational Change
market driven payment reform payment for outcomes v. providing services population v. episode management/ coordination/ provision of care
"To Err Is Human"
medical errors are a leading cause of adverse health consequences in hospitals
sponsor redistribution programs
medicare and medicaid
evidence based management
needs a foundation in empirical evidence evidence can partially replace experience, judgment, intuition, and political sense relies on systematically gathered, stored, analyzed, and reported information EBM can reduce variation in care
HIT may benefit from governmental involvement
no compelling business case exists for HIT potential savings from HIT benefit insurers and the public, not the providers
timeliness
patient-reported waiting time for hospitalizations, elective surgery, and physician appointment
-Coordination
of care
HITECH act: Meaningful use
offers incentives for adoption and implementation of e-health records comes in 3 stages
Subacute care
offers patients access to constant nursing care while recovering at home
Active membership
open to all individual's who are interested in AHIMA's purpose & willing to abide by the code of ethics
Association for Healthcare Documentation Integrity (AHDI)
organization dedicated to capture of health data and documentation; RHDI and CHDS certification
Health Information and Management Systems Society (HIMSS)
organization focused on better health through information technology
8. Decomposition of national health expenditure growth suggests that _________ accounts for the largest portion of overall growth from 2000 to 2010. *
overall inflation in the economy *
efficiency
overuse, inappropriate care, or waste access and efficiency variations in quality and cost insurance in administrative costs information systems to support efficient care
HITECH Act
part of the American Recovery and Reinvestment Act of 2009 that provides financial incentives to physicians and hospitals to adopt EHRs
access
participation affordability
Growing evidence that US does not compare favorably based on
patent overall perspectives outcomes access efficiency expenditures
patient-centeredness
patient assessment of quality of physician care, especially regarding involvement of the patient care decisions
Health and healthcare records: clinical information systems
patient care systems public health information systems medical research information systems
effectiveness
patient reported ability to follow up on care ordered by the physician
Davis reported 6 domains of quality (from patient perspective)
patient safety patient centeredness timeliness efficiency effectiveness equity
access
patient--> care
efficiency
patient-recorded coordination of care
Medicare
program that provides healthcare benefits to people 65 and older who are covered by Social Security
AHIMA Foundation
promotes education and research in HIM; philanthropic and charitable arm of AHIMA
American Recovery and Reinvestment Act of 2009 (ARRA)
provided stimulus funds to the US economy in the midst of a major economic downturn.
Medicaid
provides healthcare benefits to low-income people and children
HITECH Act
provides the authority to make changes that can improve healthcare quality, safety and efficiency through the us of EHR and the exchange of electronic health information
common reasons for intervention
public goods, correct externalities, imperfect information, monopolies
Types of Government Market intervention
purpose -> then government initiative
HIM functions include...
record processing; monitoring of record completing; transcription; clinical coding, abstracting, and clinical data analysis; birth and death certificate completion
Best practices
reducing duplicate tests and procedures, eliminating fraud and abuse, reducing excess administrative costs, and redesigning processes - all entail HIT involvement
ONCHIT
released regulations to define appropriate standards for the certification of EHR technologies and the means by which providers can receive financial incentives to adopt and use those systems
High quality patient care
relies on careful documentation of each patient's medical history, health status, current medical conditions, and treatment plans
access to care problems
remote rural locations lack of insurance transportation- physically, or no car, or... fear of public programs literacy and cultural competence
medical research information systems
repositories of medical diagnoses, health conditions, disease data, risk factors, and other health related details culled from patient records
National Cancer Registrars Association (NCRA)
represents cancer registrar professionals; CTR certification
Requisition
request for the health record
Public Law 92-603 of 1972
required concurrent review of Medicare and Medicaid patients
Errors
resulted in greater direct and indirect costs borne to society as a whole
quality
right care coordinated care safe care patient centered and timely care
International firms compete for patients by advertising that you can
save on medical costs avoid long waits for service receive better quality medical or diagnostic services protect patient privacy
-employing
scientific evidence for recommended treatment
CEUs
set of activities individuals holding any AHIMA credentials must complete
connectivity
social media adding to the ability to send and receive information -email, text, tweet, other
HIPPA simplification Provisions
standards for electronic health information transactions provider and health plan mandate privacy preemption of state law penalties
disaster protection and recovery procedures
steering committee must ensure that effective data backup and recovery procedures are implemented CIO develops backup plan disasters include: natural, terror attacks, computer virus, employee sabotage
public health information systems
support disease prevention and surveillance programs... protecting public health
operational management systems
support non-patient-care activities in the healthcare organizations ex. financial information systems, payroll, inventory control, ...
clinical information systems
support patient care and provide information for use in strategic planning and management ex. computerized patient records
electronic networking
supports dada interchange with external organizations and business partners for such activities as insurance billing and claims processing, accessing clinical information from regional and national databases, communicating among providers in an integrated delivery system, and communicating with patients and health plan members
triangle:overall
system approach- interrelated goals
correct for externalities
tax on alcohol and cigarettes
interoperability
the ability of health information systems to effectively transmit and share medical information across organizations
information system integration
the ability of organizational information systems to communicate electronically with one another
penalties
the bill imposes civil money to penalties and prison for certain violations
Code sets
the codes used to identify specific diagnosis and clinical procedures on claims and encounter forms
18. Unlike evidence-based medicine (EBM), evidence-based management may not become widespread because *
the complexity of healthcare organizations make discovery and dissemination of valid evidence time consuming and costly. *
Utilization review (UR)
the process of determining whether the medical care provided to a patient is necessary
National Quality Measures Clearinghouse
thousands of metrics collected Measures classified by scheme: -disease/condition -treatment/intervention -health administration
Improving the quality of healthcare in the U.S. requires greater ___, ____, and ____ of clinical information at the individual patient level
timeliness, accuracy, reliability
Negative behavior of people w/o insurance
use ER as regular source of care obtain fewer health screenings delay or forgo medical services typically sicker and die younger pay more for medical service
Organizational Change
use of information technology is needed to support...
If we manage patients and organizations without ___, ___ information then healthcare costs rise and quality falls (Fisher, Bynum and Skinner 2009)
valid, reliable
operate public enterprises
veterans administration hospitals
Engage
virtual network of AHIMA members
Accreditation
voluntary process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education