Health Informatics Final

Fraud, waste and abuse divert significant resources away from necessary care that is covered by federal and commercial program rules. A common potential waste of the healthcare system is to admit a patient to the hospital when an observation or outpatient setting would have been sufficient. Which of the following types of information would be most appropriate to identify claims that might have been overpaid due to the patient being in an inappropriate setting? (a) Inpatient length of stay, admission type, primary diagnosis code (b) Patient age, admission type, primary diagnosis code (c) Inpatient length of stay, discharge status, patient gender (d) Admitting physician type, principal procedure code, primary diagnosis code

(a) Inpatient length of stay, admission type, primary diagnosis code

Under the traditional fee‐for‐service (FFS) health care reimbursement models, doctors and other health care providers are paid for each service performed. Alternatively, bundled payment models cover all aspects of the care that a patient receives during the course of treatment for a specific illness, condition or medical event. Which of the following can be a source of savings if using a bundled payment model instead of a FFS reimbursement model? (a) Negotiated total cost that is less than the sum of the disparate services (b) Additional charges can be applied for complications that may arise from the care (c) Providers can decide which services are included or excluded in an episode of care (d) Any savings that arise from the lower cost for the bundle benefit the payer only

(a) Negotiated total cost that is less than the sum of the disparate services

From a young age we are conditioned for the threat of physical crime, we are now faced with a whole new type of criminal activity and it happens through technology. The first step in Security Awareness is being able to ________ a security threat. A. Avoid B. Recognize C. Challenge D. Log

B. Recognize

What are challenges for screening and diagnostics of congenital heart diseases in low and middle income countries? A. lack of availability of health worker trained in auscultation or echocardiography B. lack of clinical guideline C. lack of government and non‐government support, payer coverage D. All of the above

D. All of the above

Which of the following related to the patient and family perspective of care concerns and safety reporting is true: a) A patient or family perspective of safety threats may differ from a clinician's perspective of safety threats b) Fear of retaliation never occurs for patients or families that have safety incidents or threats they want to report c) Only patients and families with low health literacy need to be educated about how to report safety threats d) Care concerns from the patient and family perspective are narrow in scope and are not safety threats

a) A patient or family perspective of safety threats may differ from a clinician's perspective of safety threats

We have formed the Clinical Informatics Research Collaborative (CIRCLE) to address EHR issues by creating a network of applied clinical informatics researchers who are committed to improving our understanding of these issues. CIRCLE members are involved in various aspects of the design, development, implementation, use and evaluation of all aspects of health information technology with a particular emphasis on EHRs. CIRCLE members are encouraged to... a. Use the CIRCLE mailing list to exchange jokes and political commentary. b. Use the CIRCLE mailing list to conduct surveys regarding important EHR‐related issues. c. Use the CIRCLE mailing list to ask for contributions to their favorite charity. d. Use the CIRCLE mailing list to seek retirement investment advice.

b. Use the CIRCLE mailing list to conduct surveys regarding important EHR‐related issues.

What is the biggest concern when we do healthcare knowledge extractions from social media? (a) The credibility of healthcare knowledge extracted from social media is not high. (b) Patients may not like to reveal their personal health information to others. (c) The noise in the social media is so high that the processing is challenging. (d) The server may be unstable so that information on line may be gone.

(a) The credibility of healthcare knowledge extracted from social media is not high.

The increasing volume, detail, and availability of digital health data offers an unprecedented opportunity to learn richer, data‐driven descriptions of health and illness. This principle has driven the rapid development of computational phenotyping, i.e., discovering meaningful data‐driven characteristics and patterns of diseases from increasingly large and complex medical data sets. Deep learning models, such as deep neural networks, are an emerging solution for many computational phenotyping problems. Which of the following is true in general for deep neural networks? (a) Features learned by Deep Neural Networks are easily interpretable (b) Deep Neural Networks can learn representations of data (c) Deep Neural Networks can only learn linear relationship across features (d) Deep Neural Networks are only supervised algorithms

(b) Deep Neural Networks can learn representations of data

The Centers for Medicare and Medicaid (CMS) Comprehensive Joint Replacement (CJR) initiative: (a) Was created by the Affordable Care Act to test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children's Health Insurance Program (CHIP) expenditures (b) Is a bundled payment model that is mandatory in 67 geographic regions, and aims to support better and more efficient care for Medicare beneficiaries undergoing the most common inpatient surgeries (c) Is designed to increase access to patient‐centered medical homes and support retrospective episode‐ based payments for acute medical events (d) Is a voluntary bundled payment model that incentivizes increased coordination of care among hospitals, physicians, and post‐acute care providers

(b) Is a bundled payment model that is mandatory in 67 geographic regions, and aims to support better and more efficient care for Medicare beneficiaries undergoing the most common inpatient surgeries

The Triple Aim is: (a) A framework developed by the Institute for Healthcare Improvement (IHI) for accelerating improvement by rapidly diffusing innovations and new ideas within and between organizations. (b) An analytic framework quality developed by the Institute of Medicine (IOM) for assessing effectiveness and safety, timeliness and patient‐centeredness, and efficiency or equity of care. (c) A framework developed by the Institute for Healthcare Improvement (IHI) for optimizing health care including improving patient experience and population health, and reducing the cost of care. (d) A framework developed by the National Quality Forum (NQF) to identify key drivers of population, opportunities to align quality improvement programs, and measures to fill gaps associated with population health and affordability.

(c) A framework developed by the Institute for Healthcare Improvement (IHI) for optimizing health care including improving patient experience and population health, and reducing the cost of care

Potentially Avoidable Complications (PAC) include events such as post‐surgical infections, blood transfusions, pressure ulcers, or unplanned readmissions, and associated costs can contribute to the overall cost of an acute care episode. With respect to creating a payment bundle, the financial risk associated with PAC costs is considered: (a) The burden of the healthcare payer (b) An equal "shared cost" between the payer and the provider (c) The burden of the healthcare provider (d) An equal "shared cost" among the overall risk pool based on the health care recipients

(c) The burden of the healthcare provider

Screening for early signs of dementia in the absence of an effective treatment is advantageous because early diagnosis of dementia can: (a) give the patient and family extra time (b) improve quality of life of a patient by reducing isolation from social and family activities (c) reduce the healthcare costs associated with dementia diagnosis in emergency settings (d) All of the above

(d) All of the above

Which of the following are components of any episode construction logic: (a) Provider rate schedule, trigger event, procedure codes (b) Trigger event, patient co‐morbidities, geographic region (c) Risk score calculation, provider rate schedule, trigger event (d) Trigger event, complication codes, provider assignment

(d) Trigger event, complication codes, provider assignment

What are some of the challenges of investigating drug interaction signals using large medical record databases? (a) Defining the longitudinal relationship between drug exposure and adverse drug events in both cases and controls. (b) Controlling the confounding variables for the drug interaction signals. (c) Estimating the false discovery rate of drug interaction signals. (d) Defining the proper adverse drug events. (e) All of the above.

(e) all of the above

You are the chief nursing information officer (CNIO) of an integrated system of seven hospitals all of which store their electronic health record data in a system wide centralized data repository (CDR). The CDR (approximately 10 million patient records covering a span of 8 years) is comprised of structured data from discrete fields such as demographics, flow sheets, vital signs, provider orders, and test results. Narrative nursing notes are present, but in unstructured text format and not coded using a standardized nursing language. As the CNIO you are interested in developing a model that predicts patients at high risk for developing pressure ulcers and alerts providers through the EHR. However, the pressure ulcer data is stored in a mix of structured flowsheets and unstructured text in notes. And the health system does not have data scientists with the skills to build such models. As the CNIO which of the following is the most appropriate first course of action to take? A. Build consensus and create a pressure ulcer information model B. Recruit and hire a data scientist who can build predictive models C. Purchase additional hardware and software to allow processing of big data D. Identify all patients with a ICD9/10 diagnosis code of pressure ulcer and preprocess the data

A. Build consensus and create a pressure ulcer information model

Meaningful Use Stage 2 Rule requires use of SNOMED CT for which purpose? A. Clinical knowledge representation B. Transport of data between systems C. Process interoperability D. Translation from research to practice

A. Clinical knowledge representation

HHS set a goal of tying 30 percent of traditional, or fee‐for‐service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements in 2016, and tying 50 percent of payments to these models by the end of 2018.This is the first time in the history of the Medicare program that HHS has set explicit goals foralternative payment models and value‐based payments. Which of the following best explains how a CDI program can impact government regulations? A. Connect the entire care team to increase knowledge and visibility of the working DRG B. Create commitment, build competence, and achieve results such as at‐risk revenue C. Hire additional FTEs to focus on care coordination and Centers for Medicare and Medicaid Services (CMS) readmission measures D. Review all payers, and help establish an ACO/shared risk with a certain payer E. Educate skilled nursing facilities and other post‐acute facilities in your provider network on these initiatives

A. Connect the entire care team to increase knowledge and visibility of the working DRG

What technical standards were included in FHIR 2.0 to enable security and authentication? A. Existing ISO standards B. HL7 developed security standards C. Proprietary standards

A. Existing ISO standards

What are the requirements for use of FHIR in open‐source or commercial products? A. FHIR is provided through a creative commons license. B. HL7 membership C. A license fee based upon utilization.

A. FHIR is provided through a creative commons license.

Historically, in the inpatient setting, data collection occurred after the patient was discharged. After discharge, HIM professionals checked the record for discrepancies that could hinder code assignment. HIM professionals would then query the provider for clarification either by paper queries or other disconnected systems that were not part of the permanent medical record. Assuming national reporting initiatives require the specificity and accuracy of clinical documentation, which is the most vital role a CDI program would play within an organization? A. Investigate the progression of the patient through the healthcare system, making sure all acute and chronic conditions treated during hospitalization are reported and supported via clinical indicators within the EMR for the most accurate medical record. B. Investigate the progression of the patient through the healthcare system solely for the purpose of optimal reimbursement C. Improve the quality of care through advanced care coordination to in‐network facilities in order to prevent revenue leakage D. Reduce paper and inefficiencies while complying with Centers for Medicare and Medicaid Services (CMS) readmission measures E. Hire additional Full‐Time Equivalents (FTEs) to review more payers post ICD‐10 implementation

A. Investigate the progression of the patient through the healthcare system, making sure all acute and chronic conditions treated during hospitalization are reported and supported via clinical indicators within the EMR for the most accurate medical record.

The value of constructing information models from flowsheet data for research is to... A. Map similar data to concepts for research B. Standardize all notes into structured documentation C. Assure all clinicians document in the same manner. D. Inform vendors how they should implement EHRs

A. Map similar data to concepts for research

You are embarking on a redesign of your hospital's venous thromboembolism (VTE) prevention order set. The new version will dynamically tailor the prophylaxis options to be presented to the clinician based on the patient's VTE risk category, using an accepted risk scoring system. You have the following User Story: "As a clinician, I want to be provided guidance on the most appropriate VTE prophylaxis measures to order for a given patient, so that I can institute the recommended DVT prophylaxis interventions, and ultimately reduce my patients' chances of suffering a DVT and/or pulmonary embolus." You want to measure effectiveness of the redesigned order set as part of your CDS Benefits Realization program, by selecting one or more metrics to measure before and after implementation. Given this User Story, which one of the following potential measures is most appropriate to select? A. Percent of inpatients on risk‐appropriate VTE prophylaxis B. VTE order set usage as a percent of total order set usage C. Frequency distribution of order selection within the VTE order set D. Ratio of VTE prophylaxis orders placed via the order set versus placed outside the order set

A. Percent of inpatients on risk‐appropriate VTE prophylaxis

A resident is in the emergency room and is seeing a post‐operative patient for pain and swelling at the operative site. The wound has erythema and there is drainage from the incision. She is uncertain if the patient should be admitted or simply be given oral antibiotics and sent home. She chooses to send a photo to her attending from her personal cell phone using her iPhone's native messaging app. This is a very efficient way to communicate. What are some steps that would be required to make photo sharing HIPAA compliant in this scenario? A. Photo should be encrypted at rest, in flight (during transmission) and the resident needs permission from the patient to take the photo. B. There are no HIPAA compliant solutions available for the resident to use her personal phone. C. The resident needs to have a Business Associate Agreement (BAA) in place with the patient. D. The resident should use the patient's phone to take the photo and send to her attending.

A. Photo should be encrypted at rest, in flight (during transmission) and the resident needs permission from the patient to take the photo.

Your department is migrating from a predominantly paper‐based to an electronic system for triaging patients. You have been tasked with mapping the current workflows and determining how best to implement them using electronic means. One of the goals of implementing this electronic system is to improve operational efficiency. Which of the following may jeopardize this goal? A. Simply computerizing existing (manual practices) leading to unnecessary sequencing of tasks B. Not allowing scope creep C. Allowing a resource to practice its specialty and use its specific qualities D. Leveraging new developments in networking and distributed databases to eliminate barriers between geographically scattered resources

A. Simply computerizing existing (manual practices) leading to unnecessary sequencing of tasks

Why did CHL think that the stethoscope program will help develop cardiac services in LMIC? A. The program will provide a link between referring providers in communities and cardiology specialists in the LMIC cardiac center B. Cardiologists in the US can find patients who need operations to boost numbers C. The high profile procedure will attract more donors D. Telemedicine is sexy

A. The program will provide a link between referring providers in communities and cardiology specialists in the LMIC cardiac center

Model‐based statistics depend on the specification of a probability model for the random process that generates the data (for example, a Normal Distribution). On the other hand, design‐based statistics depend on a researcher specifying a fixed population and the random process of selecting a sample is completely under the control of the researcher. Which of these studies would require a design‐based statistical approach? A. A readmission study consisting of all patient encounters within a two‐year period B. A patient satisfaction study consisting of randomly selected samples from each nursing unit of a hospital within a two‐year period C. A longitudinal study of pain consisting of pain intensity scores of all inpatient encounter within a one‐ year period D. A survival analysis of all patients with Chronic Heart Failure within a five‐year period

B. A patient satisfaction study consisting of randomly selected samples from each nursing unit of a hospital within a two‐year period

Even with increasing emphasis on capturing clinical information in standard and structured format to enable down streaming meaningful use of EMR applications, what is the primary reason that we still have much of the clinical information in clinical narratives in EMR? A. Not all EMR systems support structured data entry. B. Clinical narrative is human friendly while the primary function of EMR is to facilitate the care communication among the care team. C. It is not possible to capture clinical information in standard and structured format.

B. Clinical narrative is human friendly while the primary function of EMR is to facilitate the care communication among the care team.

In accordance with public policy and private groups, the use of health information technology is tightly related to improving patient safety and quality(1). The growth of mobile health information technology, in particular, shows promise for streamlining clinical workflow. Despite these promises, there are concerns and a lack of research demonstrating the impact of health information technology (HIT) on clinical workflow(2). Concurrently, the existing research is difficult to interpret as there are over one hundred definitions of workflow (3). The definition of workflow used in HIT research and implementation is important as it guides the investigator in selecting the appropriate measurement tool (4). You are chartered to conduct a constructive analysis of workflow to inform the design and implementation of a body‐worn mobile device for continuous vital sign capture in general care wards. The focus is on "efficiency" in vital sign data capture as measured by time savings. What are the most appropriate steps to define workflow? A. Define workflow focused on the nature and impact of interruptions as this time impacts task time B. Define workflow using a definition focused on how much time tasks consume C. Define workflow focused on the information needs and cognitive processes of workers D. Define workflow focused on the dimension of time, the relationship among routine tasks, and interactions among workers

B. Define workflow using a definition focused on how much time tasks consume

Which of the following is NOT one of the major factors physicians commonly report about health information and communications technologies that contribute to their job stress: A. Slow or unpredictable system performance B. Having all patient information together in one place C. Ergonomic consequences such as eye strain, back pain, or hand/wrist pain D. Not enough time in clinic to complete patient documentation.

B. Having all patient information together in one place

Is health care data "big data"? If not, why do we need a big data environment to process health care data? A. Health care is big data and many times bigger than social media and astronomical data B. Health care data is not big data in a strict sense, but the big data technology stack helps in processing data to deliver near real‐time solutions for clinical care needs. C. Health care data is not big data and we do not need big data technology to solve health care problems D. Health care data is not at all big data but big data infrastructure is being used as it is a hot topic.

B. Health care data is not big data in a strict sense, but the big data technology stack helps in processing data to deliver near real‐time solutions for clinical care needs.

A health care system wishes to improve appropriate antibiotic prescribing practices for the treatment acute bacterial rhinosinusitis (ABRS) in the virtual care (e‐visit) setting by improving clinician adherence to an evidence‐based clinical guideline. The initial baseline data demonstrated clinician adherence to the ABRS 95.2% of the time. Data analysis revealed that the most common reasons for as being identified as not adherent to guidelines were short duration of patient sinus symptoms and a lack of ABRS specific symptoms. Given the above information, which is the most appropriate intervention to improve adherence to the evidence‐based ABRS clinical guideline? A. Add a link to the Infectious Disease Society of America web site on the clinician screen. B. Incorporate clinical decision support by highlighting patient history text related to the duration of ABRS symptoms and specific symptoms consistent with ABRS, and display a summary of the guideline criteria within the clinician workflow. C. Provide a variety of pop‐up reminders and alerts reminding clinicians of the importance of antibiotic stewardship. D. Disable e‐prescribing functionality for antibiotic medications to prevent clinician over‐prescribing.

B. Incorporate clinical decision support by highlighting patient history text related to the duration of ABRS symptoms and specific symptoms consistent with ABRS, and display a summary of the guideline criteria within the clinician workflow.

Another Element of the TOC Framework is "Scope." This refers to the expectations of all parties about what the receiving party is supposed to do. Confusion, error and harm result when the sending, receiving and transitioning parties are not clear about goals and contingencies. Healthcare professionals generally have a "loose" understanding about the differences between a "referral for specialized advice or testing," a "consultation with the potential for a procedure," a "transfer of responsibility for ongoing care," and similar categories. What process seems most likely to reduce misunderstandings between providers? A. Create a high‐level, inter‐professional commission with participation from all major specialties, to propose a uniform definition of the most common types of transition scenarios, with standardized language and terminology to assure optimal understanding by all parties. B. Make determining "Scope" part of TOC workflow, and incorporate a statement verifying understanding by sender and receiver into the documentation process. C. Lobby state legislatures to include a requirement for a "Scope" statement in every TOC form. D. Explain the purpose and goals of every TOC to the patient or family. E. Create a reimbursement code that covers the effort spent communicating with colleagues and patients.

B. Make determining "Scope" part of TOC workflow, and incorporate a statement verifying understanding by sender and receiver into the documentation process.

Which of the following is true about the fundamental shift to the 4th paradigm or big data research? A. Having more data means increased sampling error B. Pattern discovery and hypothesis generation are primary goals C. Big data requires a theory‐based analysis D. It is relatively simple to show causation because of the sheer magnitude of the data

B. Pattern discovery and hypothesis generation are primary goals

What is the principle objective of the FHIR Foundation? A. Accelerate development of FHIR resources and profiles. B. Provide a collaborative environment for FHIR implementation. C. Enable a funding source for subject matter experts.

B. Provide a collaborative environment for FHIR implementation.

You have been asked to constitute a division of analytics that will support quality improvement initiatives across your health care system. Which of the following is an accurate statement regarding data, analytics and quality improvement? A. The medium (for example, an interactive dashboard vs. a static report) via which information is presented is as important as the relevancy of the information. B. Real time analytics must include indicators aligned to the strategic/performance goals and have built‐in signals to suggest that an action is needed. C. From an analytics perspective, data and process are distinct entities and should be kept separate in their development cycle. D. Quality cannot be quantified, and therefore is not amenable to measurement, monitoring and analysis.

B. Real time analytics must include indicators aligned to the strategic/performance goals and have built‐in signals to suggest that an action is needed.

An automated acceptance test is written before development of a clinical decision support alert, specifying the decision logic it should employ when evaluating whether to display to clinicians. The automated test is red (fails) initially, and then becomes green (passes) once the EHR analyst has successfully finished their development. Which best describes this use of automated testing? A. Regression testing B. Test‐driven development C. Exploratory testing D. Unit testing

B. Test‐driven development

On rapid‐cycle agile development projects, requirements are often kept lightweight, for example, with a User Story and associated Acceptance Criteria. The most typical template for a User Story is: "As an X , I want Y,sothatZ". When using this template to write a User story for a clinical decision support (CDS) tool which will be displayed to clinicians in an EHR, the best entry for the placeholder is: A. The executive sponsor of the project B. The clinician who will see and use the CDS tool C. The EHR analyst building the CDS tool D. The patient who will ultimately benefit from best practices promoted by use of CDS

B. The clinician who will see and use the CDS tool

After assessing the three vendor products, the practice selects System X. Features of the selected system include: integrated collaborative longitudinal care planning for individuals with a chronic disease, secure messaging for the care team and the patient, patient portal features focused on chronic disease management, and modules for collection of patient‐generated health data. The system is gradually deployed across the various clinics. Over the next few weeks, complaints are received from patients and healthcare teams about delays, miscommunications, and problems with the new system. Which of the following best explains this observation? A. People are resistant to change and do not have rational reasons for being concerned about the new system. B. The new system requires new perspectives on care, and will require changes in care processes and possibly also in staffing to improve support for chronic disease care. C. Despite their best efforts at system evaluation, the clinic leadership picked the wrong system for this clinic practice. D. A "big bang" implementation is empirically better than a gradual system deployment; the clinic should have implemented the system across all clinical areas at one time.

B. The new system requires new perspectives on care, and will require changes in care processes and possibly also in staffing to improve support for chronic disease care.

Which of the following statements is accurate? A. Variables that are statistically significant in univariate statistical models are guaranteed to retain their statistical significance in a corresponding multivariate model consisting of additional variables B. Variables that are statistically significant in univariate statistical models may lose statistical significance in a multivariate model consisting of additional variables C. A model with a large number of variables is always desirable D. If a variable is statistically significant in a multivariate logistic model in which all known potentially confounding variables have been controlled for, the variable may be said to be a cause of the event under consideration

B. Variables that are statistically significant in univariate statistical models may lose statistical significance in a multivariate model consisting of additional variables

In the Transition of Care Framework, the Element labeled "Information Payload" refers to relevant information that should accompany the person being transferred. This item is among the most often deficient in practice. Missing information during transitions is a significant cause of patient harm, provider inefficiency and irritation for everyone. Which best explains why this component of care transitions is so difficult to execute? A. There is currently no standard format for patient transfer and referral information. B. Necessary TOC information can't be effectively transmitted until there is better electronic interoperability between EHRs. C. "Summary" information generated by EHRs is generally poorly formatted, inadequately filtered, usually incomplete and often untrustworthy; a reliable "transition of care message" must be manually created, involving significant provider effort. D. There is currently no reimbursement code for generating patient transfer and referral information. E. State Boards of Medicine do not consider transferring patients without adequate information to be "unprofessional conduct."

C. "Summary" information generated by EHRs is generally poorly formatted, inadequately filtered, usually incomplete and often untrustworthy; a reliable "transition of care message" must be manually created, involving significant provider effort.

A recent study demonstrated a reduction in inappropriate urinary cultures in ICU patients with indwelling urinary catheters through the use of clinical decision support. The study integrated several clinical decision support techniques into the process. Which technique was not utilized in this study? A. A real‐time decision support alert window at the time of ordering B. A real‐time e‐mail message to quality oversight if the order is overridden C. A phone number imbedded in the alert that the provider must call to override the alert D. Educational information and a reference imbedded in the alert E. Ability to cancel the order from the alert window

C. A phone number imbedded in the alert that the provider must call to override the alert

Grace is a 56‐year old cancer patient. She receives care from four different specialists, local hospital, cancer center, and you, her PCP and an eligible professional by meaningful use standards. Grace frequently accesses her records, results, and medications through a patient portal that is offered through a local HIE. All of Grace's caregivers happen to be participants in this HIE and use this HIE's portal to make information available to their patients. The HIE itself has been certified as an EHR Module for this purpose and has the ability to identify and verify the information that a particular provider may have contributed. In situations such as this, where multiple eligible professionals or eligible hospitals contribute information to a shared portal, how is it counted toward the meaningful use measure of View, Download, or Transmit when the patient accesses the information on the portal? A. None of the caregivers can take credit whether or not Grace views online, downloads, or transmits to a third party any of her health information from the shared portal B. All caregivers may count Grace in the numerator for this measure, even if one or more of them have not contributed any of the information to the portal C. All caregivers may count Grace in the numerator for this measure as long as they all have contributed at least some of the information to the shared portal, but not necessarily the particular information that was viewed, downloaded, or transmitted by Grace D. A caregiver may count Grace in the numerator if and only if Grace has specifically viewed, downloaded, or transmitted the particular information that the caregiver has contributed to the shared portal

C. All caregivers may count Grace in the numerator for this measure as long as they all have contributed at least some of the information to the shared portal, but not necessarily the particular information that was viewed, downloaded, or transmitted by Grace

Drolet (2008) states that the use of a single term, "registry," to refer to databases of clinical information ranging from biomedical informatics, clinical research, public health, to evidence‐based practice impedes the ability to locate and learn from the literature about specific types of registries. In what way would an ontology help to remedy this problem? A. An ontology would define once and for all what a registry is and is not. B. An ontology would help researchers identify registries of observational data. C. An ontology provides a specification written in a formal language that defines a shared conceptualization and vocabulary. D. An ontology would define a method for assessing data quality in a registry.

C. An ontology provides a specification written in a formal language that defines a shared conceptualization and vocabulary.

ONC is offering three major funding opportunities for FHIR developers, including the creation of FHIR‐ based solutions and an open FHIR Registry. Who is eligible for these grants? A. HL7 members. B. Argonaut participants. C. Anyone.

C. Anyone

A community health worker provides clinical care to patients in her remote community. The community health worker has approached the CMIO of their base clinical hospital to inquire about possible changes to the interface to improve data collection in the field. The electronic health record was traditionally designed to facilitate the recording of community‐collected data using standardized human factors techniques endorsed by the vendor. What is the best way to develop and include the needs of the community health worker within the end product using an agile software development process? A. Develop a community health worker persona that reflects the needs of the CHW B. Use a standard requirements process to identify the data fields that are needed by the community health worker C. Ask the Community Health Worker to join the development team and provide ongoing input into the agile development process D. Have a programmer develop wireframes that include the data fields that the CHW indicates are needed

C. Ask the Community Health Worker to join the development team and provide ongoing input into the agile development process

The average typing speed of primary care providers measured in a small study in a multi‐clinic health system was ____ wpm. The range was _____ to _____. The number of documents that were generated using self entry/structured documentation doubled in the providers that had a keyboarding speed measured at above _____ wpm. A. These numbers don't matter because providers are not secretaries and will not do "clerical work." B. Average typing speed was 74 wpm, ranging from 43 - 121 wpm. A notable increase in success was noted if the provider typed more than 85 wpm. C. Average typing speed was 42 wpm, ranging from 19 - 101 wpm. A notable increase in success was noted if the provider typed more than 50 wpm. D. Average typing speed was 22 wpm, ranging from 11 - 43 wpm. A notable increase in success was noted if the provider typed more than 20 wpm. E. This study proves that a provider can generate more documents with self‐entry/structured documentation if they increase their typing speed using typing tutor programs.

C. Average typing speed was 42 wpm, ranging from 19 - 101 wpm. A notable increase in success was noted if the provider typed more than 50 wpm.

Chemotherapy‐induced nausea and vomiting (CINV) is one of the most dreadful and unpleasant side‐effects of chemotherapy. Antiemetic treatments are provided before chemotherapy to prevent CINV. There are several antiemetic guidelines for the management of CINV. However, they are solely based on the emetogenicity of the chemotherapies. Several patient‐related risk factors affect the risk of CINV but none of the guidelines considers those factors. As a result, physicians rely on their personal experiences for CINV treatment, which leads to inconsistent managements of CINV. As a clinical informatician of your hospital, you have been given the task to help the physicians with personalizing the CINV treatment recommendations based on patient‐specific risk factors. Which of the following is the most appropriate informatics solution? A. Identify the list of patient‐specific risk factors by data analysis and provide the list to physicians B. Tell physicians to consider the patient's specific risk factors C. Develop a prediction model that determines the combined effect of multiple patient‐specific factors for predicting the risk, and integrate the model with the clinical decision support system D. Tell physicians to consult with their experienced colleagues about their experiences on managing CINV

C. Develop a prediction model that determines the combined effect of multiple patient‐specific factors for predicting the risk, and integrate the model with the clinical decision support system

What individuals may contribute to FHIR development? A. HL7 members. B. Argonaut Project members. C. FHIR development is open to anyone who registers

C. FHIR development is open to anyone who registers

Mr. Grant is an 82‐year old retired mechanic. He sees you, his PCP, at a community health center. A year ago, you started managing his care via a portal, and you both agree that it has been helpful. He also has separate portals with: ophthalmology at a specialty eye center; cardiology and orthopedics at a multispecialty group; and walk‐in clinic in his neighborhood. Recently, his healthcare insurance company and his pharmacy each gave him online access, too. Today, Mr. Grant is in your office after being admitted to a community hospital while traveling out of state. He knows that he had some medication changes. At discharge, they gave him a new portal. When he logged in for the first time, he noted that much of the information on the portal was wrong or missing. He has decided to close every portal, stating "If I close them all, then at least the records won't be wrong." After listening to his concerns, the best advice for him is which? A. He should shut down all his portals. Older adults with multiple medical conditions are not good candidates for using patient portals. B. He should keep all the portals open. Unused portals do not represent any risk. He should routinely contact all his providers individually to update the information. C. He should close infrequently‐used portals, such as the one with the out of state hospital. He should keep the portal with you, his PCP; your staff will work with him to make it as complete and accurate as possible. His multispecialty group portal is optional. D. He should sign up with a centralized portal company that will aggregate the data from all other portals. The central portal will always be reliable, complete, and accurate.

C. He should close infrequently‐used portals, such as the one with the out of state hospital. He should keep the portal with you, his PCP; your staff will work with him to make it as complete and accurate as possible. His multispecialty group portal is optional.

Despite extensive efforts to monitor and prevent surgical site infections, real‐time surveillance of clinical practice has been sparse and expensive or non‐existent. Which of the following reasons best explains this? A. Currently there is a lack of measurement and reporting of surgical site infections. B. Surgical site infections are very complicated for clinicians to identify. C. Lagged abstraction of surgical site infection due to manual chart review and delay from capture to access data. D. The definition of surgical site infections is not well aligned with clinical practice.

C. Lagged abstraction of surgical site infection due to manual chart review and delay from capture to access data.

Which of the following are examples of research that can be facilitated by inclusion of nursing flowsheet data? A. Number of medications received within 24 hours B. Lab test results for diabetes C. Pain management for patients D. Comorbid conditions

C. Pain management for patients

To promote more consistent care of patients undergoing colorectal surgery, you've been asked to lead a project to develop new pre‐op and post‐op note templates and order set(s) in your EHR specifically for these patients. The targeted go‐live date is in 3 months. Several surgeons are important stakeholders, and although they've all agreed to the idea of using the same set of EHR tools to help standardize care and collect better data, no unanimity exists yet about note or order set content. On previous projects you've taken a traditional method of getting up‐front "sign‐off" on all exact requirements before beginning work. For this project, you decide instead to use an iterative, incremental development approach, with time‐boxed development "sprints"; you plan to demonstrate the latest version of EHR tools to a surgeon's meeting every 2 weeks for feedback. Which of the following best explains why use of this agile development approach is more likely to be successful here than traditional project management? A. Your team has experience building note templates and order sets. B. The deadline is short, only 12 weeks away. C. Requirements are likely to be discovered and undergo change during order set and note template development. D. The number of stakeholders is too high.

C. Requirements are likely to be discovered and undergo change during order set and note template development.

Physicians have long been urged to place the indication for the medication on the prescription for drugs they are ordering. With paper prescriptions, physician acceptance has been poor, but with near universal adoption of electronic ordering (CPOE) there are renewed opportunities to promote utilization of this feature. However, there remain numerous challenges in designing and incorporating indications into prescribers' workflow. Which of the following is not a prerequisite for developing a system to incorporate indications into the prescribing process? A. Needs to be flexible and not require extra time B. Needs to accommodate off‐label prescribing C. Requires prescribers to choose a drug first and then add the indication from a pull down list of indications D. Provides "smart" drug suggestions based on medication and patient characteristics E. Makes it easy to put indication on the label for patients, as well as suppress if sensitive conditions

C. Requires prescribers to choose a drug first and then add the indication from a pull down list of indications

What was the most common murmur that was heard in the "HeartLink" Project? A. Austin Flint rumble B. Murmur of small muscular VSD C. Still's murmur D. Venous hum E. Mitral valve regurgitation

C. Still's murmur

Morgan is a patient who has 9 different providers who each have their own portal login. She is being referred to a specialist and wants to be involved in her care coordination. She does not want to rely on her memory, fill out a lot of forms, or find out that the new doctor doesn't have any of her recent x‐rays, MRIs or primary doctor's records. She has seen three other doctors for issues that are related to her upcoming visit. She cannot imagine logging into so many portals to try to figure out how to share that information with her new doctor. She does not want to have tests repeated or have her treatment delayed due to coordination issues. What is the best advice for her to prepare for the visit? A. Personally get copies of all important documents from her various providers/portals and bring all of them with her to the visit. B. Download data from her Fitbit and Apple Health account and bring the Excel files with her to the visit C. Use a single, consolidated report that explains relevant history, current health information, the x‐ rays and MRI ahead of the visit through a personal health record app and/or care coordination service. D. Tell her new physician the name and contact information for the three other doctors E. Do the best she can to memorize and share the information with the doctor

C. Use a single, consolidated report that explains relevant history, current health information, the x‐ rays and MRI ahead of the visit through a personal health record app and/or care coordination service

Clinical narratives can be structured and codified by a state‐of‐the‐art NLP system with results stored for down streaming applications. Why do we need real‐time late‐binding NLP solutions in practice? A. Late‐binding NLP solutions are needed since different down streaming applications have different performance requirements. B. For delivery NLP in practice, the latest clinical information in EMR is needed for clinical decision making. C. The advance in big data technology has made it possible to deliver real‐time late‐binding NLP solutions. D. All of the above

D. All of the above

The IOM Charter and Vision Statement for the Learning Healthcare system states, "that, by the year 2020, ninety percent of clinical decisions will be supported by accurate, timely, and up‐to‐date clinical information, and will reflect the best available evidence." What types of health IT were deployed at the local level that supported the HIV quality outcomes predictive of a public health impact? A. Sustainable Timely Operational Registry in the EHR (STORE) B. Bulk ordering and messaging C. Risk scoring D. All of the above

D. All of the above

What are the training opportunities for FHIR implementers? A. FHIR‐based application development is taught as a component of undergraduate and graduate school courses at many colleges and universities. B. The FHIR Institute offers hands‐on workshops for both HL7 members and non‐menbers. C. FHIR Tutorials are provided at every HL7 work group meeting. D. All of the above.

D. All of the above.

An ambulatory clinic practice is considering several new technology options focused on improving support for individuals with a chronic disease and their healthcare teams. The clinic leadership does an initial assessment of the options and decides to have three vendors provide in‐person demonstrations of their chronic disease care modules. The vendors have agreed to present system features and allow hands‐on interaction with their products. Which of the following groups are most appropriate to include in the systems demonstrations and further assessments? A. Only clinic leadership B. Clinic leadership and physicians C. Clinic leadership and all clinical staff (e.g., nurses, nurse practitioners, physicians) D. Clinic leadership, clinical staff, and patients/families

D. Clinic leadership, clinical staff, and patients/families

What is the biggest vulnerability to computer information security? A. Instant Messaging, Peer‐to‐Peer (P2P) applications B. Malware ‐ virus, worms, spyware C. Spam, Phishing attacks D. End Users

D. End Users

Cybercriminals are looking for commodities that can be quickly sold to the highest bidder. In 2015, what type of commodity were cyber thieves targeting for theft and receiving the highest payout for? A. Credit Cards B. Bank Account information C. Social Media profiles D. Health care records

D. Health care records

The costs for transcription are a significant percentage of overhead in running a medical clinic. These costs need to be analyzed as the healthcare dollar becomes increasingly tight. Which one of the following statements is true regarding the costs of transcription? A. Both US trade law and HIPAA privacy rules forbid transcription companies from outsourcing transcription to off shore (non‐US) work‐staff. B. In a typical primary care office the transcription costs for a document average about 5 cents per document/encounter. C. In a typical primary care office the transcription costs for a document average about 50 cents per document/encounter. D. In a typical primary care office the transcription costs for a document average about $5 per document/encounter. E. When determining costs of documentation one can consider structured documentation as a NO COST option for documentation creation when comparing to transcription.

D. In a typical primary care office the transcription costs for a document average about $5 per document/encounter.

You are a researcher in an academic health center and want to investigate how well family nurse practitioners comply with evidence based guidelines for outpatient care of type II adult onset diabetes on a national level. Of the following databases available to you, which database is the best to conduct your analysis? A. Medicare Claims Database (Medicare inpatient hospital insurance claims on patients over 65 years of age) B. AHRQ HCUP Database (Cost and quality data from 7 million hospitals) C. CDC National Center of Health Statistics: Vital Statistics (US annual births and deaths only) D. Optum Labs Data Warehouse (commercial health insurance claims linked to inpatient and outpatient EHR data - all ages) E. A clinical data repository from your university medical center (2 million lives of hospital inpatient EHR data)

D. Optum Labs Data Warehouse (commercial health insurance claims linked to inpatient and outpatient EHR data - all ages)

Your liver specialists want to increase the rate at which patients with cirrhosis are screened for hepatocellular carcinoma, in line with published guidelines. Accordingly, a clinical decision support alert has been reminding providers to order a liver imaging test if one has not been performed within the recommended screening interval. The alert checks for presence of cirrhosis on the Problem List, and for a completed order in your EMR for any of a list of imaging procedures. Your CDS monitoring program recently detected a sharp rise in the frequency at which this alert is displaying to providers. What is the most likely cause for the abrupt increase in frequency of alert display? A. The national society guidelines were recently updated to eliminate the screening recommendations, and the physicians' practice reflects the new guidelines. B. Your local physicians have collectively decided that the screening practice is low‐yield and not cost‐ effective, and have abandoned it. C. A recent operating system software security patch on your workstations has caused the CDS alert to display inappropriately D. Radiology has begun using a new orderable in your EMR which is not contained in the "Liver imaging" procedure list used by the CDS alert, causing it to display inappropriately.

D. Radiology has begun using a new orderable in your EMR which is not contained in the "Liver imaging" procedure list used by the CDS alert, causing it to display inappropriately.

Why is information in unstructured data sources such as clinical notes important for a clinical decision support system like MayoExpertAdvisor? A. Structured data have completely wrong information B. Structured data sources contain no information C. Unstructured data contain the most right information D. Structured data need to be reconciled with information in unstructured data sources to provide the right context to make the right care recommendations

D. Structured data need to be reconciled with information in unstructured data sources to provide the right context to make the right care recommendations

A large community hospital is implementing a new technology system designed to improve patient engagement. Research has shown patients who are engaged in their care are more likely to have better patient outcomes and reduced health care costs. It has also been suggested that user acceptance is a significant barrier to full system adoption. This new system will be piloted on the telemetry unit where the majority of patients have been newly diagnosed with congestive heart failure. Training has been scheduled for all nursing staff. To fully utilize the benefits of the new patient technology system, which of the following is the most appropriate? A. The training plan should be reviewed for common troubleshooting tips B. The training schedule should be distributed amongst the nursing staff C. Contact numbers for staff super users and vendor trainers should be collected D. The training plan should be reviewed for adequate training time and clinical nursing practice applicability

D. The training plan should be reviewed for adequate training time and clinical nursing practice applicability

Epidural catheters for pain control are frequently placed by anesthesiologists for patients primarily managed by other services. Administering anticoagulants to patients with an epidural catheter may be associated with increased risk of epidural hematoma and neurologic damage. You've been asked to create an alert for anyone ordering an anticoagulant or antiplatelet medication for a patient with an epidural catheter, to alert them of this risk. As you listen to the experts discuss when the alert should fire, you learn that exception conditions apply, e.g., for low‐dose VTE prophylaxis. You want to capture the logic to define unequivocally for which sets of conditions the alert should and should not appear. The optimal model for depicting this logic is a: A. Swimlane Workflow Diagram B. User Interface (UI) Storyboard C. Use Case Diagram D. Object Diagram E. Decision Tree

E. Decision Tree

Task‐Oriented Medicine is the approach to care management that organizes patient care plans around future needs. To be effective, the Task List must be attached to the patient, rather than tethered to any provider. While each provider may have a local reminder ("Tickler") system to track follow‐up items for its own purposes, the Task List must be visible to the patient, caregivers and all providers. What is the biggest challenge in transmitting a Task List to the receiving provider, as part of a care transition? A. There is no standard format for a Task List. B. There may be items on the Task List that the patient or family should not see C. There will be items on the Task List that are irrelevant to the receiving provider D. The Task List potentially creates liability for sender and receiver, by implying a duty to follow up E. It is essentially impossible to reconcile separate Task Lists among multiple providers without some kind of "master list" that can be continuously updated on a shared network

E. It is essentially impossible to reconcile separate Task Lists among multiple providers without some kind of "master list" that can be continuously updated on a shared network

The distribution of EHR skill scores from an EHR skill assessment tool in a primary care health system resembles the predictable pattern as described by Everett Rogers in his "Diffusion of Innovation" theory. This theory describes sub‐groups as innovators, early adopters, early majority, late majority and laggards. When evaluating these sub‐groups of providers in this study the authors found which one of the following statements to be true? A. The Diffusion of Innovation predicts and the study found a majority of providers fit in the innovator and early adopter sub‐groups. B. The age and gender of the provider were strongly related to the level of adoption and EHR skill. C. The outcome measures for the patients receiving care from the more adopted sub‐groups were statistically better than the outcomes measured for the late majority and laggards. D. The average score for EHR satisfaction in each distribution group incrementally increased as one progressed from laggard to higher innovator sub‐group. E. The dissatisfaction rate was significantly higher for the sub‐groups with lower adoption and skill level (laggards and late majority).

E. The dissatisfaction rate was significantly higher for the sub‐groups with lower adoption and skill level (laggards and late majority).

Comparative effectiveness research (CER) on Electronic Health Records (EHRs) is designed to generate evidence to help inform decisions regarding the design, development, configuration, implementation, use, and evaluation of EHRs. It seeks to accomplish this by gathering evidence on the safety and effectiveness of various features, functions, uses, and outcomes associated with implementation and use of different EHRs across different healthcare organizations. Before conducting such studies one should... a. Work with your local human subjects protection committee (IRB) to obtain permission to review medical records, if required, and provide protection for the IT professionals or doctors (a.k.a. human subjects) you are interviewing to identify best practices. b. Ask your boss if it is ok to talk to some of your friends about different EHR configurations. c. Ask your EHR vendor if they can provide you with access to other organizations' EHR so you can look for yourself to see how they have configured various applications. d. Just make the calls, it is always easier to ask for forgiveness than permission.

a. Work with your local human subjects protection committee (IRB) to obtain permission to review medical records, if required, and provide protection for the IT professionals or doctors (a.k.a. human subjects) you are interviewing to identify best practices.

The investigation of change over time is key to empirical research in many disciplines. Is systolic blood pressure related to the development of coronary heart disease? What factors are associated with the risk of progression of type 2 diabetes? How do different groups of students in my state compare to each other in terms of academic achievement over the course of college? Does my data exhibit distinct trajectory patterns? These research questions are best answered through the collection and analysis of what type of data? a) Cross‐sectional data b) Longitudinal data c) Time series data d) Observational data

b) Longitudinal data

Which of the following statements is true with regard to the Patient safety checklist? a) The Patient safety checklist is designed for use by care coordinators to promote a continuum of transition of care b) The Patient safety dashboard is a patient centered communication tool to provide actionable plans for patients and family to prevent adverse events during their hospital stay c) The Patient safety dashboard provides information regarding hospital acquired harm as well as adverse events reported by a hospital incident report d) The Patient safety checklist uses data that is put into the patient safety dashboard to communicate with care team members

b) The Patient safety dashboard is a patient centered communication tool to provide actionable plans for patients and family to prevent adverse events during their hospital stay

Most classification methods assume that the training data are drawn independently and identically from an unknown distribution (i.i.d), although this assumption is violated in in many real life situations. The implicit assumption by the machine learning and data mining communities is that even if the i.i.d assumption is violated, the algorithms would work well in practice. When would this not be the case? a) When we have cross‐sectional data with weak or no correlations between observations. b) When the observations in the data are systematically correlated. c) Small sample size data. d) Large sample size data.

b) When the observations in the data are systematically correlated.

Assessing and responding to many patients' risks of chronic diseases and related complications are complex, high‐dimensional information processing problems faced by time‐constrained clinicians. Innovative algorithms and tools which combine statistical machine learning, information visualization and electronic health data may reduce clinicians' information processing load and improve their ability to assess risk of disease onset and related complications. A critical element in visualization is the incorporation of flexibility in customizing assessments to the needs of unique patient populations. Suggested by this study, which insight can be obtained via a 2‐dimensional visualization of chronic disease risk that is contextualized by the risk factors? a. Confidence intervals for population‐level risk stratification b. Drivers of risk for the population and individual patients c. Best interventions for an individual patient d. Patient clusters that may benefit from an intervention

b. Drivers of risk for the population and individual patients

A hospital is concerned about its Hospital Compare ratings for AMI 30‐day mortality, compared to area hospitals. They have downloaded the spreadsheet available on the Hospital Compare web site. They have purchased IBM Watson Analytics. What data analytical processes can they utilize with this platform? a. Clustering, neural networks, visualization b. Exploratory data analysis, predictive analytics, visualization c. Neural networks, classification, regression d. Exploratory data analysis, clustering, visualization

b. Exploratory data analysis, predictive analytics, visualization

Implementing, configuring, and optimizing electronic health records (EHR) in large healthcare delivery systems involves making thousands of configuration decisions, hundreds of workflow changes, and development of hundreds of clinical content artifacts (i.e., order sets, alert logic, default values). Many of these decisions, changes, and artifacts have the potential to lead to unintended adverse effects on patient safety, clinician efficiency, and organizational performance. Which of the following is the best way to gather evidence to support various configuration decisions that your organization must make? a. Ask your colleagues at other organizations and see what they think is best b. Gather data from different organizations to figure out which organizations have the best performance and then compare and contrast the configuration decisions of the best organizations with those of the lower performing organizations. c. Ask your vendor what they think is best. d. Ask your favorite clinical champions in your organization what they think is best

b. Gather data from different organizations to figure out which organizations have the best performance and then compare and contrast the configuration decisions of the best organizations with those of the lower performing organizations.

Which of the following statements is false with regard to the measuring unit‐based risk to patient safety? a) Staffing of nurses below target levels has been associated with increased mortality b) High patient turnover has been associated with increased mortality c) Low nursing‐to‐patient staffing ratios decreases risk of hospital acquired adverse events (including falls, hospital acquired infections, pressure ulcers) and readmissions d) a and b

c) Low nursing‐to‐patient staffing ratios decreases risk of hospital acquired adverse events (including falls, hospital acquired infections, pressure ulcers) and readmissions

The Chief Nursing Officer of RBH wants to hire a Chief Nursing Informatics Officer (CNIO). She wants this person to be highly qualified. The CNIO must have: a. Completed a nursing informatics fellowship b. Passed a nursing informatics certification exam c. Possess an advanced degree in nursing Informatics d. Current in all nursing practice requirements

c. Possess an advanced degree in nursing Informatics

The CIO of RBH (Really Big Hospital) calls you into her office. She tells you the hospital is going to select a new EHR (Electronic. Health Record), implement it, and then optimize it. All to be done within the span of 24 months. She wants to hire a Chief Medical Informatics officer (CMIO). You advise her that the best candidate is: a. Physician with extensive EHR experience but very little Informatics education b. Physician with extensive Informatics education but limited EHR experience c. Physicians only but absolutely no PhDs, Masters d. Clinical Informatician educated in and experienced with Informatics

d. Clinical Informatician educated in and experienced with Informatics

An accountable care organization is concerned about their increased heart failure readmission rate. They have a data warehouse with two years of inpatient data. What is the standard data science process sequence to analyze their data? a. Exploratory data analysis, data pre‐processing, visualization, modeling b. Visualization, modeling, data pre‐processing, visualization c. Data pre‐processing, modeling, exploratory data analysis, visualization d. Data pre‐processing, exploratory data analysis, modeling, visualization

d. Data pre‐processing, exploratory data analysis, modeling, visualization

There are many Continuity of Care Document (CCD) software vendors that sell Electronic Health Record (EHR) products for an outpatient setting. While HL7 provides coding standards, it has been noted that there are vast inconsistencies with how data are reported among vendors. Furthermore, each software package is proprietary. What is likely the most difficult challenge in integrating data from a CCD? a. The vast number of potentially relevant number of concepts in an EHR b. Reconciling various coding systems (Snomed, CPT, RxNorm) c. Handling a variety of data types d. Inconsistent data structure

d. Inconsistent data structure

RBH has physician, nursing, pharmacy, and dental CCIOs (Chief Clinical Informatics Officers). The leadership of RBH wants to create an Office Of Clinical Informatics because: a. Space will be saved having these four share an office b. Communication will be improved by proximity and frequent interaction c. Four people are essentially doing the same job d. These professionals have knowledge, education, training and skillsets in common

d. These professionals have knowledge, education, training and skillsets in common