Electronic Health Records (EHR)

How many ways are there to locate information?

Two; searching by topic or using the User's Guide. You may search for a topic or look it up in the User's Guide.

The ____ is a form used to bill inpatient claims.

UB-04

PrimeSUITE: * has mobile applications * assists in information exchange *all of the above * allows for ePrescribing

all of the above

What feature of PrimeSUITE allows practitioners to access clinical trials and other research?

PrimeRESEARCH.

Point of care

Procedures that take place at the time of care, rather than at a remote location or at a point in time after care is complete

Where would you go to write a letter to a specialist to whom a patient is being referred?

Referral Letters Referral letters are composed in the Referral Letters section of PrimeSUITE.

Check- In

The first face-to-face step in the patient encounter

What is PrimeSPEECH?

The speech recognition technology available in PrimeSUITE. PrimeSPEECH is a speech-recognition tool.

A patient is admitted to the hospital with a constant, severe migraine headache. After numerous tests, no cause for the headache can be determined. Discuss how EHRs might help diagnose this patient

Their system keeps track of all of their patients health records for any problems that they have been seen for. If the hospital can't figure it out maybe going through their records will help you understand

A patient is entered into the Patient list:

once

The process of moving a patient from appointment-making through check-out is called

patient flow

Provider

person, usually a physician, who performs health care services requiring specialized education and training

The ____ is an example of clinical information that is collected through an EHR.

plan of care

Clinical documentation of a patient's visit is known as the:

progress note

The electronic Superbill is automatically generated from the __________.

progress note

One factor that might contribute to slow acceptance of EHRs is:

security fears

PrimeSUITE uses a ________ database, allowing for interoperability.

single

An encounter form is also known as a/an:

superbill

List three advantages of ePrescribing.

1. A physician can submit an prescription electronically instead of paper based. 2. It gives an accurate, and permanent record, and 3. the prescription is ready to be picked up when a patient arrives.

List the steps included in patient flow of information.

1.Appointment Scheduling 2.Front desk/ Check- In 3.Nursing/Clinical Support 4.Care Provider 5.Check-Out Desk 6.Business Office/Billing 7.Clinical Staff/ Care Provider

Contrast a typical day in a paper-based office with a day at an office that uses practice management software.

A day in a paper-based will be much longer and tiresome. At the end of each day you are stuck to file paper work, and finish incomplete paper work. A day at an office that uses practice management software will be much quicker. The patient flow will be swifter because every thing is electronic and it moves as the patient does.

What is the CMS-1500 form?

A form generated after each visit that contains patient, insurance information, and ICD -9- CM and CPT codes.

Encounter Form

A form generated at the completion of an office visit, a portion of which details diagnosis, procedures and services, performed for each procedure/service.

Interoperability

A single database to sync multiple unrelated functions or systems

Demographics

Documented patient information such as age, sex, and race

Using the Help feature, describe how to add a new allergy to a patient's chart.

Access the Help feature from the screen you are on; enter "add allergy" into the search box or look up "add allergy" in the topic list. There, you will find the directions you are looking for. You find the directions you need by either looking up "add allergy" or searching for the information.

What does PrimeSUITE's PrimeEXCHANGE function do?

Allows for the sharing of clinical information between providers or other parties who have a need to know the information. The PrimeEXCHANGE function allows users to share, or exchange, information.

What is the first step in the patient flow of information?

An appointment is made

Put the following steps in the flow of information into the correct order: Care Provider; Front Desk/Check-In; Business Office/Billing; Check-Out Desk; Appointment Scheduling; Nursing/Clinical Support; Clinical Staff/Care Provider.

Appointment Scheduling, Front Desk/Check-In, Nursing/Clinical Support, Care Provider, Check-Out Desk, Business Office/Billing, Clinical Staff/Care Provider (if necessary). The flow of information begins with appointment scheduling, moves through front desk check-in, nursing/clinical support, care provider, and check-out, and finished with billing; the clinical staff and care provider are cycled back to as necessary.

Is PrimeSUITE a practice management tool or an electronic health record?

Both. PrimeSUITE functions as practice management software as well as an EHR.

If you needed to use PrimeSUITE's Help feature to look up how to register a patient, how would you do it?

Click help, and it opens the user guide. You can search a topic by using the index or glossary.

List the types of insurance companies that need to be provided with a billing claim form.

Commercial insurance (BCBS, etc.); Medicare; Medicaid; Workers' Compensation; TRICARE. Commercial insurance carriers, as well as government-sponsored plans, need to be provided with billing claim forms

List at least three main applications found in a typical practice management program.

Complete a Billing Claim Form for Each Visit Scheduling Appointments Entering Each Patient Seen into a Master List

What is electronic claims submission? Why is this preferred method of claims submission?

Electronic Claim Submission means that the information is sent by wire to a clearing house. It is the preferred billing method because it cuts down on biling errors, and cuts down on processing time, which results in faster payments

Electronic Submission

Filing of a healthcare claim using by computer rather than paper

Denisse Cruz arrives at your office for her annual check-up appointment with Dr. Smith. Discuss what will happen with Denisse as she moves through each step of patient flow.

First Denisse is going to arrive to the office on the day and time of her appointment, and she will be checked in. Any information that she has not yet given or has changed will be collected at that. After she is checked in she will be asked to take a seat until she is called to the back. Once she is called to the back all of her vitals will be checked. She will then be asked questions about her visit as well as her medical history. Now the physician steps in for the actual exam. Once the exam is complete and the doctor has came up with the a plan of action, the billing process will begin.

How do you access the Help feature in PrimeSUITE?

From the Help tab on the menu bar, accessible from any screen in the program. You can access the Help feature from any screen in the PrimeSUITE program.

PrimeSUITE's User Guide is accessed through the ____ feature.

Help

Your medical office is preparing to transition from a paper-based office to an electronic one; you are really excited about this change. One day you receive an email from one of your some colleagues negatively discussing the change, and wondering why things could not stay how they are now. Your colleague is looking to you and asking your opinion. What would you say to them to convince them this transition is a good thing?

I know that we are all use to doing this on paper, but as a growing company we need to implement procedures that could help use move more quickly and sufficiently and I feel that moving forward as an electronic-based office would absolutely help us do just that.

Which of PrimeSUITE's many EHR applications do you feel is the most beneficial or useful? Explain your answer.

I think that all of them are going to be beneficial and useful. I really like the Interoperability because it will help to reduce error count and is much quicker than the paper mode.

Where would you look to determine if a patient has had a polio vaccine?

Immunizations List The Immunizations List would should you whether a patient has had a polio vaccine.

Mobile EHR applications are currently available on what mobile devices?

PDA's, iPhone, iPod touch, and iPad.

User Guide

Included in the HELP feature of PrimeSUITE and allows office staff search for assistance in using the software

When transitioning to EHRs, which costs are higher: initial costs or long-term costs?

Initial costs. Long term, there are actually cost savings compared to the current paper/manual systems once training has taken place and staff members become more comfortable with the new processes. Initial costs are highest when moving to an electronic system.

____ is not easily attained when using a manual record system.

Interoperability

Discuss three advantages to electronic health records as discussed in the text.

Interoperability is an advantage that can't be used easily or at all in a manual system. It means that many functions can take place and information can be shared using a single data base. This ensures that regulatory compliance is made easier through the use of electronic health records (EHR). Using (EHR) allows for collection and use of large amounts of clinical data for use in medical research and epidemiology from a global perspective.

Define interoperability and give an example of how it might be used in the health care field.

Interoperability means that through a single database, many different functions can take place and information can be shared. Ex. Prescription medications.

Is a paper-based system of records more secure than an electronic one?

No; they both have some security issues, but an electronic system is actually safer. An electronic system is safer than a paper-based one.

The medical office you work in recently transitioned into an electronic office and is implementing practice management software. You are excited about this change and are learning all you can about the new technology. However, some of your coworkers are having trouble grasping the basics, and are now saying they don't want to use the software at all. What steps could you take to assist your struggling coworkers?

Offer to help them after work for about an hour so that I can get them to understand the new software; so that we all will be on board.

When would the clinical documentation steps need to be repeated?

Only in cases where the provider ordered diagnostic procedures, such as x-rays or laboratory tests. The clinical documentation process is only repeated if extra procedures were ordered for a patient.

What is practice management software?

Software like many others that carry out functions and operations

Practice Management Software

Specialized computer software that performs administrative and billing procedures in medical offices

What is the final step in the Front Desk/Check-In process?

Start Patient Tracking ----> Patient Tracking Automated/ Manual Start

Where would you go to send tasks or make requests of physicians or other practice staff?

Task Management You will use the Task Management section to assign tasks or make requests of practice staff.

Speech Recognition

Technology that digitally transcribes spoken words

PrimeSUITE is ___________ in meaningful use standards.

certified

In the long-term, costs will ____ when transitioning to an electronic health record system.

decrease

EHR/EMR software is more comprehensive than practice management software because it:

includes clinical documentation.

The Superbill includes charges, diagnosis, and ___________ for the patient.

instructions