NHA - Certified Electronic Health Record Specialist (CEHRS) Study Guide AVTEC

Medical Staff Committee

A committee formed to discuss and recommend practices, policies, and other activities specific to the medical staff.

Centers for Disease and Control and Prevention (CDC)

A division of the Department of Health and Human Services.

Encounter Form

A form the provider fills out as she sees the patient; lists the service charges and how much the patient paid for the services; can be submitted for billing.

Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT)

A medical reference vocabulary that serves to standardize the naming of terminology used in medicine and health care.

National Practitioner Data Bank (NPDB)

A national database created in 1986 to collect information on licensed providers.

Current Procedural Terminology (CPT)

A nomenclature or naming system the American Medical Association (AMA) publishes and maintains; allows providers to code for services provided and submit bills for reimbursement.

Healthcare Common Procedure Coding System (HCPCS)

A numeric and alphabetic coding system used for billing and pricing of procedures, medical supplies, medications, and durable medical equipment.

Hybrid Record

A record that is partially paper and partially electronic.

Third-party Vendor

A separate business that handles a specific task for a facility; common third-party vendors include billing companies, transcription companies, and coding firms.

National Health Inpatient Quality Measures

A set of specific data that hospitals must collect and report to CMS and the Joint Commission to document quality patient care.

Practice Management System

A software designed to assist in the office workflow by streamlining scheduling, insurance information, patient demographics, and billing.

Face Sheet

A standard structured document that contains patient information, such as name, date of birth, insurance information, reason for seeking medical care, and religious preference;

National Provider Identifier (NPI) number

A unique 10-digit number assigned to providers in the U.S. to identify themselves in all HIPAA transactions.

Health Insurance Portability and Accountability ACT of 1996 (HIPAA)

Addressing security and privacy protections for health care information.

CPOE

Allows a provider to order medications, diagnostic testing, rehabilitation, and other services for inpatients.

Computerized Provider Order Entry (CPOE)

Allows providers to order prescription medication, including IV therapies, laboratory tests, imaging studies, rehabilitation services, dietary requirements in the inpatient environment.

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes

Alphanumeric codes used to classify injuries, diseases, symptoms, and cause of death.

Continuity of Care Record (CCR)

An early form of a document developed to make communication about patients' course of care available across facilities; CCD replaced it.

Business associate

An organization or individual who provides specific services to a covered entity involving the use or disclosure of PHI; for example, an off-site storage company that houses EMR data.

Electronic Medical Record (EMR)

Another generic term for a digitized medical record; this term has evolved to most often refer to the single, standalone records systems that providers' offices and other smaller outpatient settings use; the term EMR is most often used in reference to the electronic records used by providers in their private practice and outpatient settings; many EMR's can exchange data with larger hospital-based EHR systems through the use of a Continuity of Care Document (CCD)

Payers

Another word for insurance companies or the responsible party who will pay for the medical services patients receive.

Release of Information (ROI)

Appropriate and legal release of patient health information that includes PHI; HIPAA outlines the requirements for proper release of information in various circumstances.

CCHIT

Approves and certifies EHR technology and is the required standard for facilities and providers wanting to participate in the Meaningful Use incentive program.

Compliance

As it relates to paper or electronic medical records refers to the completion of the record and the adherence to medical records and documentation requirements set forth by state and federal law, as well as accreditation and regulatory agencies.

Diagnosis-related groups (DRGs)

Assigned to inpatients based on the principal diagnosis; determines the hospital's reimbursement; based on the prospective payment system.

Incomplete Charts

Charts that are missing signatures, reports, or other required elements as outlined in either CMS Conditions for Participation for Medical Record Services or the Joint Commission accreditation guidelines for information management.

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Coding and classification system that groups diseases, disorders, and procedures into similar categories; there are three volumes in ICD-9-CM.

Hospital Information System (HIS)

Collection of systems that collect, store, and allow manipulation and management of data generated in the daily operations of a facility.

National Ambulatory Medical Care Survey (NAMCS)

Collects data on ambulatory medical care provided in the U.S.; the data is collected from visits to office based providers who provide direct patient care.

American Recovery and Reinvestment Act of 2009 (ARRA)

Consists of three major goals: create and save jobs, spur economic activity and invest in long-term growth, and support accountability and transparency in recovery spending.

Role-Based Access Controls (RBACs)

Control the ability to access certain areas of the system, based on the person's role in the facility, which is associated with their login ID and password.

Health Information Management (HIM) department

Department responsible for the care and management of all patient information; as electronic records began to replace paper-based records, HIM professionals became key players in the transition to the EHR or EMR system; previously known as the medical records department.

Legacy Information System

Department-specific systems that pre-date the implementation of EHRs by several decades; sometimes referred to as legacy systems.

Comorbidity

Disease that exists at the same time as a primary disease that a patient is being treated for at the time; for example, a patient who has cancer is receiving cancer specific treatment and is also a diabetic - diabetes mellitus would be considered the comorbid condition.

Health Information Technology for Economic and Clinical Health (HITECH)

Encourages the adoption and meaningful use of health information technology.

Certification Commission for Health Information Technology (CCHIT)

Established to evaluate and approve EHR and EMR systems; to participate in incentive programs for EHR adoption and use, facilities must use a certified EHR or EMR product.

Record Destruction Policy

Facilities that maintain medical records of any form must have a record destruction policy in place.

Centers for Medicare and Medicaid Services (CMS)

Federal agency charged with administration of the Medicare and Medicaid programs, as well as the Children's Health Insurance Program; operating division of the Department of Health and Human Service (HHS).

Patient Care Unit (PCU)

For the purpose of census data, a PCU has a defined number of beds and is staff assigned; also called floors, units, or wards.

Fully-integrated EHR

Functionality that has replaced paper records entirely; few hospitals or health care systems in the U.S. have achieved this yet, but many are moving in this direction.

Health Information Technology

General use of computers and related devices to manage the day-to-day functions in a health care environment.

Benchmarks

Goals or metrics a facility wants to meet; for example, if the industry standard is 90% of patients should have advance directives entered into their patient record within 24 hour of admission, and a hospital was only meeting this for 45% of the patients, they would use the external benchmark of 90% as a goal and track performance toward that goal by month or quarter.

Service Lines

Groups of patient services by specialty; hospitals define these individually, and they vary by facility with some similarities, such as obstetrics; examples include cardiology, neurology, thoracic surgery, general surgery, and the gynecology; some facilities choose to combine similar or related lines, such as obstetrics and neonatology, obstetrics and gynecology, and cardio-thoracic surgery; they are useful for compiling financial, compliance, and other in-house reports.

Record Retention

How long to retain medical records is a policy decision based on state and federal laws and regulatory and accreditation agency guidelines

Protected Health Information (PHI)

Information that can individually identify a person; includes demographic data or any common identifier, such as Social Security number, date of birth, address, or phone number.

eFax

Is a software application that allows EHR specialists to send a document from the computer to a fax machine.

ePrescribing

Is the tool providers use in the outpatient setting to send prescriptions to the patient's pharmacy. It replaces the paper prescription pad.

Chief Executive Officer (CEO)

Leader of a facility who reports to the Board of Directors.

Chief Financial Officer (CFO)

Leader who oversees all financial and fiscal decisions and issues for a facility; generally reports to the CEO.

Affordable Care Act

Mandates comprehensive health insurance reform.

HIPAA Privacy Rule

Mandates the protection of patients' personal health information by hospitals and health care facilities.

Meaningful Use

Meaningful use is both a program and a definition; the Meaningful Use program are the federal incentives established by CMS for facilities to use EHR technology in a meaningful way; meaningful use, the definition, refers to using EHR technology in a manner that makes a meaningful impact on patient care and safety.

Copayment

Money the patient must pay toward the bill as contracted between the insurer and provider; amounts range from $5 to $50, and $75 for emergency room and specialist visits; provider's office visits are often in the $10 to $35 range.

Computer on Wheels (COW)

Most often refers to a laptop computer that sits on a cart with wheels that can be rolled from patient room to patient room and facilitates real time documentation or charting of patient care; often called COW's.

National Center for Health Statistics (NCHS)

Nation's primary statistics organization; it works to compile, analyze, and disseminate information on the nation's health to influence and guide health policy and practice in a manner that best serves the population.

Institute of Medicine (IOM)

Non-governmental, independent, and nonprofit organization that provides unbiased, expert advice to governmental and private decision-makers, as well as the public.

Joint Commission on the Accreditation of Health Care Organizations

Not-for-profit and independent (non-governmental) organization that accredits and certifies more than 19,000 health care facilities and programs in the U.S.

Current Procedural Terminology (CPT) codes

Numeric codes developed by the America Medical Association (AMA) to standardize medical services and procedures.

Off-site Location

Off-site refers to remote or distant from the place of business; data recovery and storage options are often off-site.

Database

Organized collection of pieces of information or data; electronic version of file cabinets with folders and files; the term generally refers to data collected and stored in an electronic environment.

Accounts Receivable

Patient bills for services that have already been provided that legally are due to a facility.

Patient Care Orders (PCOs)

Patient interventions that are ordered by a provider for a nurse to carry out.

Reimbursement

Payment for services rendered; refers to the end result of the revenue cycle.

Templates

Pre-designed forms for the capture of data and information.

Department of Health and Human Services (HHS)

Principle agency for protecting Americans' Health

Commercial Insurers

Private, non-government insurers; these are often the insurance options available through employers.

Medication Reconciliation (Med Rec)

Process of gathering and documenting a complete list of a patient's medications when he is admitted to a care environment, which includes medications he was taking when he came into the facility and medications the provider prescribed as new and sending the list to the next care provider when the patient leaves the facility.

Credentialing

Process used to document a provider's education, licensure, and qualifications in order to allow for the assignment of privileges to practice in a hospital health care system.

Insurance verification

Process used to make sure the service received by the patient is approved and paid for by the insurance company.

History and Physical (H and P)

Providers document a patient's history and perform a physical exam when she presents for health care services.

Covered entities

Providers who transmit PHI in an electronic format, health plans, and health care clearinghouses.

Master Patient Index (MPI)

Record of every patient who has been treated, seen, or evaluated in a facility.

Morbidity

Refers to disease

EHR technology

Refers to the conceptual EHR, including the basic structure, functionality, and expected outcomes users expect from any system identified as being an electronic health or medical records system.

Garbage-in, garbage-out (GIGO0

Refers to the fact that poor documentation or data entry results in poor output from a computer or informations system.

HIS

Refers to the sum total of all information systems that support operations in a facility.

Discharge Summary

Report written b y the provider when a patient is being discharged from inpatient care; summarizes the patient's chief complaint or whey they are were admitted to the hospital, diagnostic test results and other findings, treatments administered and how the patient responded to them; outliners recommendations for continued care and follow up, as well as dietary, medication and activity instructions; the provider must sign the final copy in the record before the record can be marked complete.

Ad Hoc Reports

Reports created or programmed in response to an inquiry or issue that comes up; they are not normally scheduled reports.

Database Queries

Reports run on records stored in a database to find specific information; an ad hoc report is set up as a query.

Authorization

Required for any release of patient PHI; consists of specific elements that make it legal and appropriate to release information.

HIPAA Security Rule

Sets forth the administrative, physical, and technical safeguards for covered entities in order to protect the confidentiality, integrity, and availability of PHI that is stored electronically.

Conditions of Participation (CoPs)

Specific practices that CMS mandates for facilities to follow if they treat patients covered under Medicare or Medicaid; similar to the Joint Commission's accreditation requirements.

Redundant Data Storage

Storing data from your facility in more that one location so if one area is hit with a disaster event, the data is restored from a copy located elsewhere.

Prospective Payment System (PPS)

System initially implemented by Medicare in the early 1980's that replaced fee-for-service payments for the provision of health services with predetermined payments based on the principal diagnosis of the patient.

Information Technology (IT) Department

The IT department in facilities has emerged as a necessary response to the transition from a paper-based world to one that increasingly reliant on technology.

Point-of-care (POC) Charting

The ability of providers to document the care and treatment they render in real time, when they are with he patient.

Daily Census

The count of how many patients are in beds by patient care unit for an inpatient facility.

Medical Terminology

The language of medicine, which encompasses terms to describe anatomy, physiological processes, disease, treatment, and other terms related to the human body and the care provided in terms of health and disease.

Total Inpatient Service Days

The number of inpatients receiving care each day summed for the days in the period under study; for example, if you are reviewing the total inpatient service days for the month of September, which has 30 days, add the patients for Sept 1 (125), Sept 2 (119), and so on; the total is the sum of all patients per day. az

Autopsy Rates

The percent of autopsies performed on patients who die in the hospital; reasons for not performing an autopsy in the hospital may include legal inquiry or family preference.

Mortality (death) Rate

The percentage of all discharged patients who are discharged due to death within a prescribed period; for example, if a hospital has discharged 30 patients in a month, and of those 5 were deaths, the mortality rate for the month would be expressed as 5/30 or 16.7%.

Occupancy Rate

The percentage of licensed beds in a hospital that have a patient assigned to them, and thus are generating revenue.

Average Length of Stay (ALOS)

The total number of patient days in a period divided by the number of patients; for example, the ALOS for cardiology services in February was 6.1 days.

Continuity of Care Document (CCD)

The widely-accepted and federally-mandated document for sharing patient health information across facilities; replaced the CCR and CDA, which were earlier attempts at addressing the continuity of patient care between facilities.

Which of the following describes the impact on legacy systems when implementing an EHR system?

They were not built to work with other health information technology solutions.

Physician's Desk Reference (PDR)

Traditionally this is a large, bound book that lists all prescription medications available on the market and includes prescribing information from manufactures, now available in a electronic format.

Digitize

Transform information from a paper-based document into an electronic format; some systems use document scanning that includes Optical Character Recognition (OCR) capabilities, which transforms a scanned document from a static image to a searchable document.

Complications

Unexpected events or circumstances that happen to a patient during the course of his care; hospital-acquired infections, such as those involving MRSA, are considered to be complications, as are reactions to medications or an adverse response to any treatment.

Wireless on Wheels (WOW)

WOWs are the same as COWs; in some environments, patients may be sensitive to the casual use of the word cow, so some facilities prefer to use the WOW acronym to avoid any patient misunderstanding.

Electronic Health Record (EHR)

While this term is generic, its use denotes a system-wide record that involves inputs from many systems and is used across a diverse environment of care with multiple location; although not strictly defined as such, EHR often refers to the electronic records in a hospital or integrated health care delivery system.