test 3 Medical informatics chp 15, 16, 19, 20

Captures the level of detail necessary to document specific items at the point of care

A classification system is used to categorize the details of the clinical encounter. Which of the following does a classification system not do?

A. Entering medical history B. Entering allergies C. Entering present medication alerts D. Entering past social history E. Entering family history

Which of the following functionalities can be found with the personal health record (PHR)? Select all that apply.

Palo Alto Medical Foundation

Which of the following health systems was an early pioneer adopting the PHR?

Access

Which of the following is a barrier associated with patient use of PHRs in rural regions?

Clinical Care Classification (CCC) System

Which of the following is a nursing classification designed to document the six steps of the nursing process across the care continuum?

Information inputted by the patient

Which of the following is considered a core personal health record element?

Insurance claims

Which of the following is not a PHR concern?

The Electronic Signatures in Global and National Commerce Act

Which of the following laws, signed by President Clinton in 2000, gives electronic signatures the same legal status as handwritten signatures?

The U.S. Department of Health and Human Services (USDHHS)

Which of the following organizations is the umbrella under which all regulatory agencies eventually fall because the health and welfare of the citizens of the nation are ultimately deemed to be federal responsibility?

The system rewards physicians and other health care professionals when patients receive good results from that care.

Which of the following responses is not a benefit of Pay for Performance (P4P) legislation?

Medicare Part A has an annual deductible; Medicare Part A covers facility related expenses

Which of the following statements about Medicare Part A are correct? Select all that apply.

A. Nursing Management Minimum Data Set (NMMDS) B. Nursing Minimum Data Set (NMDS) C. Alternative Billing Codes (ABC Codes) D. Clinical Care Classification (CCC) E. North American Nursing Diagnosis International (NANDA-I)

Which of the following terminologies have been approved by the American Nurses Association? Select all that apply.

Standardized terminologies

Which of the following terms is defined as structured and controlled languages that have been developed according to terminology development guidelines?

MS-DRG

Which type of billing codes is used by Medicare to determine the level of severity and per diem rate?

Integrated

________________________ PHRs are extensions of physicians' offices

Nurse Informatics Specialist

____________________________ is a specialty in nursing that focuses on the technology aspect of patient care.

SNOMED CT

______________________________ is a globally recognized controlled health care vocabulary that provides a common language for electronic health applications.

If a patient has certain complications during the hospital stay

Medicare will not reimburse the hospital at the higher rate for the treatment., Which of the following statements is true about the do-not-pay list?

Outcome identification; Diagnosis; Nursing process data elements

The American Nurses Association established criteria for recognizing standardized terminologies. The terminologies must meet established criteria to be approved. Which of the following are instrumental in the approval process? Select all that apply.

Data review responsibility

As PHRs become the established norm, health care providers are aware of issues that can emerge from patient self-disclosure. Which of the following is a key concern associated with the patient-self entered data?

B. Some fully standalone applications are available commercially. C. The PHR is not tied to any particular health care system. D. Some fully standalone applications are available in formats such as smart card

CD, or flash drive. E. Standalone PHRs such as those on thumb drive devices have been found to have significant security risks., Which of the following are characteristics of stand-alone PHRs? Select all that apply

A. Diagnostic studies B. History and physical examinations C. Visit notes D. Ancillary department information E. Outcomes measures

Clinical terminologies consist of concepts that support which of the following facets of health care? Select all that apply.

The Clinical Care Classification (CCC) System facilitates patient care documentation at the bedside

During the orientation to the renal oncology unit, the head nurse demonstrated the usefulness of the Clinical Care Classification (CCC) System. Throughout the demonstration, the head nurse discussed the value of the system to patient care. Which of the following statements best reflects the usefulness of CCC?

Health care providers were forced to install EDI transmission programs in their billing and medical record systems.

Electronic data interchange (EDI) is an effort to help phase out paper claims except under extensive appeal circumstances. The result of this initiative is which of the following?

If data are encrypted

Healthcare entities, as well as their business associates, must notify individuals whose health information is breached within 60 days of that breach. In which of the following cases does the entity not have to notify the individual whose information has been breached?

Provided loans to physicians to purchase technology

Implementing an electronic health record in a small primary care practice can be cost prohibitive. To assist in the cost of the endeavor, the government has done which of the following?

A. Patients B. Providers C. Health care organizations D. Health care industry

Implementing standardized terminology has many benefits to multiple beneficiaries. Which of the following are benefits of standardized terminology? Select all that apply.

patient

In its simplest form, the PHR is a stand alone system where the _______________enters data.

Medicare Improvements for Patients and Providers Act

MIPPA is an acronym for ___________________.

A. PHRs permit easy exchange of information across health care systems. B. PHRs contain information from one's entire lifetime. C. PHRs contain information from all health care providers. D. PHRs are accessible from any place at any time. E. PHRs are private and secure.

Markle's Common Framework offers valuable guidance for the development and deployment of patientcentered PHRs. The Framework identifies seven attributes of an ideal PHR. Which of the following are considered attributes of the Common Framework? Select all that apply.

standardized terminologies

Meaningful use requirements mandate the use of _________________________ for data collection and reporting of established quality measures

Through tax dollars

Medicare is an age or disability based benefit. How is Medicare funded?

"I understand your concerns Mrs. Owens. It looks like you may qualify for Medicaid benefits."

Mrs. Owens has come to the clinic to see the nurse practitioner about her persistent cough. Recently, she was laid off from her job at the retail store and lost all benefits. She has had a fever and chills for several days. As the nurse begins the assessment, Mrs. Owens begins to cry and says: "I have no money to pay for medicine or this visit. Please do not order an antibiotic, because I cannot pay for it." The nurse's best response would be which of the following?

The ICD-10 transition is to better manage the quality of health care data through more precise and accurate diagnostic coding.

On October 1, 2015, the federal government implemented the mandatory transition to the International Classification of Diseases, Tenth Revision (ICD-10). Of the following responses, which is the most reasonable rationale for the upgrade?

May confuse and worry patients

PHRs and their functions are becoming more important in health care delivery systems. There are a multitude of benefits associated with the PHR. Which of the following is not a potential benefit associated with the PHR and laboratory tests?

A. Allows patients to check and improve quality of medication list (medication reconciliation) B. Encourages discussion with doctor to improve adherence C. Patient can share medication information with other providers D. Health care provider can access information on prescription refills E. Allows the health care provider and patient immediate communication with pharmacy

PHRs can enhance a health care provider's clinical practice in a number of ways. Which of the following are associated with the benefits of the PHR and medication management? Select all that apply. A

Decreased e-literacy

Patients bring a wide variation in their capacity to use information technology. Which of the following does not increase the usability of PHRs?

A. Financial viability B. Payment initiatives C. Effectiveness D. Ensuring access

Pay for Performance (P4P) otherwise known as value-based purchasing (VBP) system has been developed through ObamaCare. Which of the following are considered goals of this initiative? Select all that apply

The act guarantees health insurance for every citizen.

President Obama signed into law on March 23, 2010, The Health Care and Education Reconciliation Act of 2010 (Pub.L.111-152, 124Stat.1029), which amended the Patient Protection and Affordable Care Act (PPAC) and further strengthened the federal grip on health care regulation in the United States. Which of the following statements best reflects the intentions of the act?

Integration between a scheduling application and the PHR allows the patient to schedule an appointment without making a telephone call.

Some functionalities require integration between the PHR and a scheduling application. Which of the following is a benefit of this communication?

Evidence-based practice and decision support rules

Standard terminologies have been scientifically investigated for their effectiveness and impact on patient care. The use of standard terminologies can, therefore, facilitate the use of which of the following?

Reference; point of care

Terminologies can be incorporated within the electronic health record (EHR) thereby improving practice. Which of the following are considered uses for this technology in health care? Select all that apply.

The Omaha System is a problem classification scheme

The ANA has recognized the Omaha System and integrated the terminology into SNOMED CT. Which of the following best represents the value of the Omaha System?

Electronic Data Interchange (EDI).

The Centers for Medicare and Medicaid Services (CMS) mandated all providers, insurers and any middlemen involved in the health care industry submission of claims for reimbursement or registering of care, the verifying of eligibility, the precertification of services, or any other client- related information to adhere to a uniform format by October 2002. This action forced all providers to install_______________________ transmission programs in their billing and medical record systems

Researching quality and effectiveness

The Omaha System has a multitude of functions. The system can store data describing problems, symptoms, modifiers, interventions, and outcomes. One of the benefits of the stored data is which of the following?

consumer-centric

The PHR is considered a ________________________ lifetime health record.

Do Not Pay list

The __________________________ was developed by Medicare in an effort to control quality and cost and minimize preventable complications

Office of the National Coordinator for Health Information Technology (ONCHIT)

The _________________________________________ oversees information- technology standards, implementation strategies, and impact assessment.

The goal of meaningful use is to exchange clinical structured data in a manner that is accurate and complete to improve patient care in a cost-efficient way

The impact of standardized terminology throughout the U.S. health care system has grown exponentially. Medicare and Medicaid have begun to offer financial incentives to health care providers to promote adoption and meaningful use of interoperable health information systems and a qualified health record. Which of the following statements best describes meaningful use?

A. CPT codes were grouped into services by the first digit followed by four more digits that further described the procedure. B. The number 9 is reserved for visits related to evaluation and management procedures. C. The CPT code 99211 is an office visit and used for injections. D. Two digit modifiers are used to further distinguish services and procedures altering the billing process. E. Inaccurate code input will delay claims processing

The importance of billing codes and reimbursement for services cannot be overstated. Which of the following responses are true regarding accurate code input and claims processing? Select all that apply

Veterans Health Administration

The largest health system to deploy a PHR in the United States is __________________.

The need for nurse informaticians will increase in the future.

The need for informaticians who understand health care has grown. Which of the following best represents the future of nursing informatics?

Medicare and Medicaid

The ratification of the Title XVIII and Title XIX Social Security Acts in 1965 led to which of the following?

Value-based purchasing (VBP)

The system called Pay for Performance (P4P) is also known as which of the following?

A. Provides interoperable data collection that can be analyzed and used for evidence-based practice models B. and used for decision support rules C. and used in reporting quality measures D. and used for medication renewals E. and used for administrative billing

The use of SNOMED CT within electronic health records has multiple benefits. Which of the following are considered benefits of SNOMED CT? Select all that apply.

Standardized terminology

The use of which of the following is a means of ensuring the data collection is accurate and valid?

New plans must offer free preventive care.

There has been an impact of the Health Insurance Reform Act, also known as The Patient Protection and Affordable Care Act, on system use and design. Which of the following actions was enacted upon the president's signature?

Centers for Medicare and Medicaid

To receive financial incentives, hospitals and physician offices must meet designated criteria established by which organization?

Personal health record

What is a private, secure application through which an individual may access, manage, and share his or her health information?

HITECH

Which act eases the budgetary impact of EHR thereby facilitating implementation?

Health Information Technology for Economic and Clinical Health Act (HITECH)

Which act makes several significant changes to the current HIPAA Security and Privacy Rules and provides funds and incentives to increase the use of electronic health records (EHRs) by physicians and hospitals who meet eligibility criteria?

E-literacy; Lack of access in poor and rural regions; Cost

Which of the following are considered disadvantages of the PHR? Select all that apply.

B. Appointment request C. Medication management D. Appointment views E. Access to test results

Which of the following are considered patient benefits of EHR personal health information? Select all that apply.

A tethered PHR is inextricably linked to a single entity or health system

Which of the following best defines a tethered PHR?

A. Accurate

consistent meaning of data is collected and shared across the health care system. C. Clinical terminology enables the capture of data at the level of detail necessary for patient care documentation. D. Standardization in nursing documentation supports research across settings on patient outcomes and interoperability., Multiple benefits have emerged from the use of structured terminologies within health care records. Which of the following are considered benefits of the health information technology (HIT)? Select all that apply.

A. The standards are insufficient to enable collection

management, and exchange of the mandated data. B. Technical standards are needed to assure that structured and codified terminologies C. Technical standards are needed to sufficiently capture all of health care D. Standards must be widely available E. Technical standards should be easily exchanged within and across organizations, HIPAA and HITECH have designated some technical standards as mandatory. Which of the following are associated with the implementation of standards? Select all that apply.