Health Information Tech. end of semester exam 15'

voluntary

Currently, participation in the Physician Quality Reporting Initiative is:

annually

Data security ploicies and procedures should be reviewed at least?

CDA

Developed by HL7, this document markup standard specifies the structure and semantics of clinical documents such as discharge summaries, operative reports, etc.

licensure

Documentation standards can be found in four major sources. Healthcare organizations must be given this by government entities such as the state or county in which they are located and must maintain this as long as care is provided in the facility. This definition is for what standard?

Structured

Drop-down lists, check boxes, radio buttons, and other forms of controlled data entry is used in what type of data entry?

1996

HIPAA (Health Insurance Portability and Accountability Act) came into existence in?

umbrella

HIPAA is the "_______" term that covers both privacy and security of the health record.

technological

Health informatics is basically the_______ part of managing health information.

permanently

How long should a facility's MPI be kept?

Data mart

I will be conducting some analysis of data, but I only need a limited amount of data that are contained in the data warehouse. What system should I utilize?

All of the above

In order for hospitals or physicians to earn meaningful use, their EHR technology must be: Certified Used in a meaningful way Interoperable All of the above

Medication Orders

In the Medicare Core Objectives, Stage 1 of the CPOE standards only addressed:

All of these

In the event of a breach of confidentiality, who may be held responsible for that breach? Providers Office staff Facility all of these

BC-MAR Barcode medication administration record

Many hospital today are moving to the ____ system.

EDMS

Notifying a coder that the physician has completed the discharge summary is an example of workflow in the

Periodic schedule

Ozarks Technical Community Hospital receives a report each morning listing all of the admissions from the day before. This is an example of what type of report?

breach of confidentiality

Releasing information without proper authorization is called a/an?

insurance verification

Revenue Cycle Management includes all of the following except: Fincance Charge Capture Case Management Insurance verification

ACO Accountable Care organization

The ____ intention is to pay providers as an encouragement to collaborate with other providers and to reqard high quality care to the patient and iscourages supplier induced demands.

interoperability

The ability of one computer system to exchange data with another computer system is the definition for?

makes the appointment

The actual claim process begins when the patient?

productivity

The biggest complaint physicians have with using an EHR already installed relates to

Health information and data Result management Order management Decisions support Electonic communication and connectivity Patient support Administrative processes and reporting Reporting and population health

The core functions to assure patients have better safety, quality and efficiency in their health care delivery by and orgaization with a EHR system are?

OIG

The essential elements of a Corporate Compliance Program are defined by?

confidentiality

The expectation that information shared by an individual with a health care provider during the course of care will be used only for its intended purpose is the definition for?

laboratory infromation systems (LIS), radiology information systems (RIS), and the pharmacy information systems

The first departments to utilixe a department specific EHR were?____, these three key departments help support clinical decision making and clinical processes for the patient.

managed care plan

The form of insurance that monitors patients, care, and performance to ensure quality is the definition for

EOB

The insurance company sends a statement to the patient explaining charges for services rendered and payment made to the provider for those charges is called the

Public, private

The internet is _______ and the intranet is _______________.

fee schedule

The list of how much is charged per service by CPT code is the definition for which term?

SNOMED CT

The most widely recognized nomenclature in health care is?

Assessment

The physicians interpretation and evaluation of the problem ?

Plan

The physicians prescription and treatment for the problem or what next?

encryption

The process that encodes textual material, converting it to scrambled data that must be decoded, is call

security

The protection measures and tools for safeguarding information and information systems is the definition for?

Privacy

The right of an individual to limit access to information about themselves. It can also be described as the quality or state of being hidden from, or undisturbed by, the observation or activities of other persons, or freedom from unauthorized intrusion. In a nutshell, this means the patient has a right to control the disclosure of their personal health information.

1. Threats from employees who make honest mistakes. 2. Threats from employees who exploit their access to data. 3. Threats from employees who use their access to data for malicious or financial gain. 4. Threats from external individuals who attempt to access data or steal hardware or other equipment. 5. Threats from angry employees or others who attack the information systems of the organization.

There are five (5) types of threats to data security that can result from individuals. They are:

Wireless connection

There must be a/an _____________ available in order for providers to use portable devices to access health information.

Administrative safeguards

These are documented, formal practices that manage data security measures throughout the organization. They require the facility to establish a security management process and details how this will be managed from the organizations' perspective via policies and procedures. There are nine safeguard standards that must be implemented by covered entities.

RCM (Revenue Cycle Management)

These are major function of ___ includes: admitting, patient access management Case management charge capture health information management patient financial services, business office finance compliance and information technology

Clinical Data Repository (CDR)

This EHR database helps manage data that comes from many different sources, ancillary systems in the hospital, or other provider settings as well as from direct entry of structured data by the clinician. What is the name of this database?

e-Prescribing

This had been a meaningful use requirement from the HITECH act. It reduces/eliminates the wrong patient wrong dose, wrong meication that happened within the pharmacy ream when they could not read the providers handwriting.

Technical safeguards

This has five broad categories that includes items that can be implemented utilizing technology and the computer software. They are: access control, audit control, integrity control, person/entity authentication, and transmission security.

Physical safeguards

This includes the protection of the computer system (s) from natural and environmental hazards and intrusion. These include facility access control, workstation security and device/media control.

Clinical Decision Support (CDS)

This is a key component of an EHR, it helps all health care professionals as well as the patient make infromed decisions about the type of care a patient needs to receive.

RCM (Revenue Cycle Management)

This is so important in both acute care setting and in thephysician practices. Without it you cannot adwquately determine how productive your practive is nor how financially sound you are n order to provide the care and services your patient expects from you.

ACO

This organization is a health care model whereby a group of physicians, hospitals, and/or other health care providers form a partnership that provides high-quality, coordinated care to a population of patients. What is the name of this organization?

SNOMED CT

To provide a controlled vocabulary for coding the contents of the patient record and for facilitating the development of computer-based patient records is the function of what classification system?

Human users

Unintended consequences from using EHR technology are primarily due to issues with:

1) The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital's commitment to compliance (e.g., by including adherence to compliance as an element in evaluating managers and employees and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals; 2) The designation of a chief compliance officer and other appropriate bodies, e.g., a corporate compliance committee, charged with the responsibility of operating and monitoring the compliance program, and who report directly to the CEO and the governing body; 3) The development and implementation of regular, effective education and training programs for all affected employees; 4) The maintenance of a process, such as a hotline, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation; 5)The development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations or Federal health care program requirements; 6) The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem area; and 7)The investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals.

Whar are the seven elements that the OIG states is the minimum necessary for a comprehensive compliance program?

R-ADT (registrations, admission, discharge and transfer) and patient fincacial systems (PFSs) help revenue cycle management (RCM)

What administrative and financial systems that have been around for awhile were some of the first electonic systems used within a healthcare system?

Results Management

What allows diagnostic reports to have data that not only can be reviewed, but can also be reported and the data processed? e.g. information presented can be used interactively (not waiting for a flag or hard copy of a report) or the national diabetes crisis.

1) results management 2) clincial documentation 3) closed loop medication management 4) clinical decision support 5) analytics and reporting

What are the 5 main components needed for and effective EHR?

Cllinical decison support system (CDSS)

What is a system that works in conjunction with the EHR but is a stand alone system it is referred to as a ______?

Analytics and Reporting

What is considered the final core of the EHR application. It allows us to not oly collect the information required for federal and state reporting requiremenst (cancer registry, meaningful use), but is also allows the providers of health care to determine if a change is needing in the way a disease process is treated.

The executive information system is designed to be used by high-level management

What is the difference between the executive information systems and the decision support system?

HL7

What is the name of the SDO that allows different software packages to interface with one another?

EHR

What takes months and sometimes years of planning, reviewing, accessing, and training before an ___ for an organization can be chosesn and implemented fully?

Objective

What the physician observes and physical finding and labs readiology reports?

Clinical Documentation

What type of clicnical data is often performed by a licensed nurse or personnel to determined how a patient is treated.

Vocabulary

What type of standard establishes common definitions for medical terms?

HL7

Which SDO develops messaging, data content, and document standards to support the exchange of clinical information?

assigning passwords that limit access to computer stored information

Which of the following is an example of a technical measure?

To identify a new service for the hospital to implement

Which of the following is an example of when an executive decision support system should be used?

Human resource system

Which of the following systems would be used to manage productivity?

availability

Which term is defined as ensuring timely and reliable access to and use of information?

Administrative and clinical

Which two major types of data are contained in the health record?

Data can be in structured or unstructured form

Whis is not true of ACO's? There are currently two models: Medicare Shared Savings and Advance Payment Model Sharing of patient information through an EHR is necessary Data can be in structured or unstructured form Participation in an ACO is voluntary

Licensed hospital personnel

Who documents the care provided to the patient during their encounter in the organiations facility?

the provider

Who gets a remittance advice (RA) to explain the payments made.

the patient

Who gets the EOB (explanation of benefits) explaining what was billed what was paid by the insurance company and the balanced owed to the healthcare facility?

Patient

Who is responsible for maintaining a personal health record?

The HITECH Act

Who revised the Social Security Act in 2009 and established a monetary penalty for HIPAA violations.

HITECH

Who states that a qualifier EHR "indludes patient demographic and clinical health information such as medical history and problem lists, and has the capability to provide clinical decision support, support physician order entry, capture and query information releveant to health care quality and to exchange electronic health information with the intergrate such information form other sources"?

Chief Security Officer (CSO)

Who within the covered entity, must ensure that on-going monitoring or privacy and security is taking place. They must also assure that breaches are properly reported, investigated, and processed.

Registry

You are reviewing a report which shows the patients born at Memorial Hospital from January 1, 2011 through December 31, 2011. The report is sorted by date and includes patient name, name of mother, time of birth, and name of obstetrician. Which type of report are you reviewing?

HIPAA

_______ privacy and security standards had reinforcements come in 2009 with the development of the HITECH (Health Information Technology for Economic and Clinical Health) Act; which was part of ARRA (American Recovery and Reinvestment Act).

risk management

__________ encompasses the identification, management, and control of untoward events.

General Rule

provides the objective and scope for the HIPAA security rule. It gives specifics on what a covered entity must develop regarding a security program and it must include a range of security safeguards that protect the PHI maintained or transmitted.

confidentiality

refers to the expectation that the information shared by an individual with a health care provider during their course of care will be used only for its intended purpose. In other words, a physician cannot disclose any medical information revealed by a patient or discovered during their course of treatment. This is part of the patient-physician relationship and is upheld by the AMA's Code of Medical Ethics.

electronic records

A definition of what constitutes a record, recording where each component is located, and noting dates of format changes are particularly important in:

Evidence-based medicine

Care providers use____________ as a way to support their decisions and diagnoses.

Consolidated

In what form of HIE are data centrally located but logically separated?

Source-oriented health record

Per the IOM, all of the following are core functions of the EHR except:

human, intentional activity, and natural disasters.

There are three sources where security threats come from:

Virtual private network

What does VPN stand for?

Revenue cycle management

What means it is the management of the accounts payable and accounts receivable on a daily basis by the facility.

Subjective

What the patient states in their own words?

Flag

Within the EHR is a tool created to serve as a reminder to the staff and care providers that has a specific meaning. What is the name of this electronic tool?

Outdated

A facility needs to make sure that the information on their intranet does not become:

Security

AHIMA states ________ has two definitions: (1) The means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from unauthorized alterations, destruction, or loss. (2) The physical protection of facilities and equipment from theft, damage, or unauthorized access; collectively, the policies, procedures, and safeguards designed to protect the confidentiality of information, maintain the integrity and availability of information systems, and to control access to the content of these systems.

10 years

According to the AHIMA practice brief, how soon does the e-HIM taskforce think industry will transition from paper-based to EHR?

both demographic and financial data that has been collected

Administrative data is?

Lack of health care organizations

All of the following are external forces that affect HIM except:

data security

An HIT's ____________________ role includes being aware of security threats and other measures to protect data.

remittance advice

An insurance company submits payment to a medical practice, along with a document that details the patients and the accounts for which payment is made. This document is called the?

MPI

Anna Jacobs presented to the ER of OTC Hospital three times in the past year. What tool will the staff at OTC Hospital use to locate Anna's record?

Uniformity, Accuracy, Authenticity

Basic principles of health care documentation addresses all of the following except:

fraud

Billing for services that are not medically necessary or that did not happen at all is?

Closed Loop medication management

CPOE is a part of ___; it helps assure patient safety when medications are ordered. Helps a pharmacist assure the medication ordered is not contraindicated for patient due to drug incompatabilities, allergies, or wrong patient wrong dose issues. Also e-Rx, E-MAR, or barcode medication.