HEALTH INFORMATION C800 2 ETHICS/MANAGEMENT

AHIMA Code of Ethics

Promotes high standards of HIM practice. Identifies core values on which the HIM mission is based. Summarizes broad ethical principles that reflect the profession's core values. Establishes a set of ethical principles to be used to guide decision-making and actions. Establishes a framework for professional behavior and responsibilities when professional obligations conflict or ethical uncertainties arise. Provides ethical principles by which the general public can hold the HIM professional accountable. Mentors practitioners new to the field to HIM's mission, values, and ethical principles.

Data flow diagrams (DFDs)

A DFD is a diagram that shows how data flows within the database.

query

A HIM director needs to pull a report that shows delinquent physicians by service line (for example, cardiology or internal medicine). Which database function should be used to extract this data from the HIM chart deficiency system?

File (Structure of Table)

A collection of data. It can be compared to a file cabinet that has multiple files within a drawer in the cabinet.

data mining

A data analyst is attempting to locate duplicate records in the master patient index (MPI). Which algorithm should the analyst use to ensure the highest accuracy rate?

probablistic algorithm

A data analyst is attempting to locate duplicate records in the master patient index (MPI). Which algorithm should the analyst use to ensure the highest accuracy rate?

Request for information (RFI)

A formal document requesting information on IS. The _____ asks the IS vendor for basic information about the product and how their IS would meet the requirements outlined in the ___. The ____ can be used to select minor IS, or the information gathered in the ____ can be used to determine who will receive the more rigorous _____.

beneficence

A hospital has a policy that allows a medical record to be copied free of charge if the patient cannot afford the processing fees. Which ethical principle is illustrated in this scenario?

initiation

A hospital is planning to upgrade its electronic medical record software. The planning committee chair summarizes the scope, objectives, and budget before preparing the project charter. Which phase of the system development life cycle (SDLC) is this director addressing?

scope creep

A hospital's chief executive officer (CEO) begins to attend project team meetings related to the purchase of a new EHR system. The project plan has already progressed to the point of sending out requests for proposal (RFPs) when the CEO suggests that the project team also look for systems that can be implemented in the rehabilitation centers affiliated with the hospital. Which scenario will occur if the CEO's advice is followed?

improving patient quality of care

A hospital's emergency department has been tasked by hospital administration to speed up service. Emergency department patients should not have to wait more than one hour to be seen by an emergency department provider. To help the department reach its goal, a warning appears on the dashboard of the emergency department's provider; reception staff, and nurses' computers if a patient has been waiting more than 45 minutes. What is the purpose of the data used by the real-time data analytics application that provides this information to the dashboards?

Primary Key

A key field that is a unique identifier that ensures that each entry in the database table is different. You can only have one per table.

Force Majeure

A legal term that refers to "an event or effect that cannot be reasonably anticipated or controlled. This contract clause is designed so that the parties of the contract cannot be held accountable to a deadline if there was an "act of God" that prevented compliance.

PERT chart

A management tool that evaluates the tasks, the dependencies on other activities, the activity sequence, and the time required to complete the task. Because the ____ shows interdependencies between tasks, it will help determine whether the implementation date is slipping due to delinquent tasks.

Face validity

A method of evaluating the quality of data that involves looking at data to determine if it makes sense.

system development life cycle SDLC

A model used to represent the ongoing process of developing (or purchasing) IS (Information System).

The office finds a valid authorization from the husband before releasing his record.

A patient stops by a primary care physician's office to pick up a copy of her husband's medical records to take to his appointment with a specialist. Which action demonstrates that the physician's office has an appropriate policy in place to comply with HIPAA regulations on release of information?

patient's provider

A patient wants to keep his medical information out of the health information exchange (HIE). The patient resides in an opt-in state for participation in the HIE. Which entity is required to tell patients that information will be shared and give them the opportunity to opt in or opt out?

Autonomy

A patient with advanced renal disease decides not to undergo dialysis care. Which ethical principle is illustrated in this scenario?

security rule

A physician practice manager tells the HIT consultant that the log-in and password information for employees, students, and visiting consultants are all the same. The consultant advises that this needs to change immediately. Which law or regulation should the consultant explain requires this change?

design

A project team meets weekly to discuss system objectives, specifications, and functionality for a new information system. Which phase of the system development life cycle (SDLC) is the project team addressing?

Query

A search for data that meet specific criteria the user requests within subsets of the database.

Altruism .

A selfless concern for others

Escrow

A situation in which a third party holds a copy of the software in case the vendor goes bankrupt. This means that if the vendor goes out of business, the healthcare facility can obtain access to the code behind the software so that they can maintain the system themselves or hire someone else to do so. Both parties prefer to use ______ rather than obtaining access up front. The vendor prefers this method as well because it does not want its trade secrets to be widely available.

coding standards

A supervisor reviews claims prior to submitting them to the insurance providers and observes that an orthopedic surgeon and the assistant on a procedure both submitted claims as the primary surgeon on the procedure. The supervisor decides to file both claims with the insurance provider. Which type of ethical issue did the supervisor violate?

Alphabetic data type

Accept only alphabetic characters. Data elements of this field type include patient name.

Data manipulation language (DML)

Accesses, makes changes to, and retrieves data from the database. Controls access to data within a database.

Beneficence

Action that is done for the benefit of others

Least Harm

Actions cause least harm.

National Committee on Vital and Health Statistics (NCVHS)

Advisory committee to the HHS. Their major purpose and role is to advise and recommend guidelines for the EHR in all areas, including data standards, data sets, and terminologies.

Record (Structure of Table)

All of the information that has been collected on an individual patient or a specific transaction. It can be compared to a file within the drawer of the file cabinet.

Questionnaires

Allow for a large number of users to provide input about the needs of the system.

Natural language queries

Allow the user to use common words to tell the database which data are needed.

data standards

Allow us to share data in a standardized way. Includes data content and data exchange ________.

Interface engine

Allows two applications to exchange information without having to build a customized interface for each application. Is a type of middleware.

Alphanumeric Data Type

Alphanumeric fields accept alphabetic characters, numbers, or a combination of the two. They are never calculated. Examples of alphanumeric fields include street address, zip codes, phone numbers, and such.

Big bang method

Also called the cutover method, this is the most risky. With this method, the facility stops using the old system and starts using the new system. It is the riskiest because the facility may not have the old system as a backup and the new system is being used all over the hospital.

Postimplementation

Also known as maintenance, this is the final step of the implementation process. In this stage, the system is operational and the goal is to provide ongoing maintenance and improve the system where needed. In the immediate postimplementation period, problems may be found that were not revealed during the system testing and will need to be resolved.

Integrity

An HIM data analyst discovers that a patient's ePHI (electronic protected health information) was altered during transmission across a network. Which aspect of the HIPAA Security Rule was compromised?

attritube type

An HIM director has found multiple physician ID numbers entered as physician names in the credentialing database. This creates errors and confusion in reports. Which database characteristic should be used to eliminate this problem?

information governance

An HIM director writes a policy defining how documents should be edited and deleted in the EHR. Which type of management of the EHR does this policy represent?

budget

An IT project manager determines the number of data analysts needed to complete a project. Which project constraint is this task attempting to minimize?

Breach

An act of breaking or failing to observe a law, agreement, or code of conduct.

Data Steward

An individual appointed with responsibility and accountability for data, usually in a specific domain.

Organize a specific IT project into phases.

Analysis; Design; Implementation; Maintenance/Evaluation

Healthcare abuse

Any practice that creates unnecessary cost to federal healthcare programs

Coding Standards

Apply accurate, complete and consistent coding practices that yield quality data.

Probabilistic algorithms

Are able to identify transpositions and name changes and can use phonetic search capabilities, digit transposition and rotations, alternate name cross-referencing, distance editing, and enhanced phonetic searching capabilities. Has the highest accuracy rate.

Content standards

Are clear guidelines for the acceptable values for specified data fields.

Aggregate data

Are data that are grouped together in a way that the individual patients, employees, or others are not identifiable. Examples of reports that use ________ include top 10 diagnosis-related groups or the monthly statistical reports

Abbreviations

Are extremely easy to use and can speed up data entry. However, ___________ should be uniform so there is no confusion over the meaning of the abbreviation.

Status reports

Are periodic updates on where the project is, what has been accomplished, and what problems have been encountered. Solutions for the problems should be identified in the report. Status reports are typically directed to the IS project steering committee to keep that group informed on the project's progress.

Ad hoc reports.

Are reports that are needed only once. They may be used for a special report, a research program, or other purpose

Routine reports

Are those that are needed repeatedly. These reports may be daily, weekly, monthly, semiannually, or annually.

Each Entity has ___________. Facts and data about the entity deals with information of specific fields, data, format, size and relationships.

Attribute type

DG council

Authorized by the DG steering committee, is usually responsible for establishing DG policy and standards and monitoring their implementation.

Post-implementation

Begins immediately after implementation is complete. The team must evaluate itself to prepare for the next project. It should also include an evaluation process to determine if the objectives of the project were met and how the process could have been improved.

Data consistency checks

Built into software systems help ensure the documentation is complete for every health record.

Define how technology impacts business intelligence.

Business Intelligence (BI) comprises the strategies and technologies used by companies for the data analysis of business information. Technology like data warehouse impacts BI by making the data analysis easier and more efficient for the company.

Four major Sources of External Data?

CDC, NCHS, AHRQ, joint commission

Algorithms

Can be used to help prevent duplicate medical record numbers when admitting a patient.

Best of Breed

Choosing the best product for your organization regardless of vendor

When the system operates on a computer that is owned and maintained by a vendor. This system is located at the vendor's location, not the healthcare facility, so the system must be accessed remotely.

Cloud computing

External data

Come from outside the facility and can be used to compare the facility with other similar facilities.

Internal data

Come from within the healthcare facility and includes both administrative and clinical data.

Information Governance

Concerned with governing the output (information) of an information system.

Database Management System (DBMS)

Controls and manipulates the database to meet the needs of the user. It controls the ability to create, read, write, and delete data stored in the database. The parts of the DBMS include data definition language (DDL), data manipulation language (DML), data control language (DCL), and data dictionary.

Auto-numbering Data Type

Create a unique number that will never be assigned again. This could be the medical record number.

Mask

Data element is entered one way and displayed another. Data can be entered without dashes, slashes, or other characters, but the data are displayed with it. For example, a social security number could be entered as 123456789 but is displayed as 123-45-6789.

Secondary Data

Data taken from a primary source and abstracted into another database or registry. Examples of ______ sources are the cancer registry, master patient index, and disease index. ________ may or may not be patient identifiable. For example, patient identifying information is in the cancer registry, but reports generated from the registry may not contain patient identifiable information.

Object-oriented database

Database model that handles text, images, audio, video, and other objects. In the model these images and other nontext items are stored as objects with hierarchy and a navigational style of programming. An object is "a logical grouping of related data and program logic that represents a real world thing" such as a patient, physician, or test. Each data element is called a variable.

Project Plan

Describes each task to be completed, how it will be completed, who is responsible for its completion, when a task should begin, and when the task should be finished.

Data Dictionary

Describes the data used by the system and controls the quality of the data. Used to improve data consistency. Standardizes descriptions, permissible values and formats to optimize reliability, consistency and portability

Computer-aided software engineering (CASE)

Designed to create many of the diagrams and other tools used in the data model.

Business care

Desired outcome of implementing a business change.

project definition

Determined during the project planning process to tell the facility exactly what it is trying to do with the system being implemented and the expected outcomes.

Scope

Determines exactly what work is and is not—to be included in the project based on resources available. Identifying the project's _______ is important to prevent scope creep.

Data type

Determines what type of value an object can have and what operations can be performed.

Planning in the IT Department

Develop an IT strategy that supports the organization's business objectives and helps build a strong competitive advantage.

The Joint Commission

Developed performance standards known as ORYX.

Project Plan

Dividing the project into specific activities or tasks. Describe each task to be completed, how it will be completed, who is responsible for its completion, when a task should begin, and when the task should be finished.

copying and pasting

During a quality review in the HIM department, the analyst notices that a patient has been listed as 69 years old in the history and physical reports for the past three years. Further review uncovers almost verbatim text describing the patient's history of present illness (HPI) across this same time period. Which provider activity does the analyst believe is taking place?

Entity-relationship diagram

Entities are linked together to show relationships between the two.

Agency for Healthcare Research and Quality (AHRQ)

Federal agency whose mission is to research the quality of care provided to Americans, the costs associated with that care, the outcomes, and patient safety

Application Integration

Figuring out the best way to integrate applications.

Phase 4 "Requirements Analysis Phase" of SDLC

Functional user requirements are formally defined and delineate the requirements in terms of data, system performance, security, and maintainability requirements for the system. All requirements are defined to a level of detail sufficient for systems design to proceed. All requirements need to be measurable and testable and relate to the business need or opportunity identified in the Initiation Phase.

Rollout strategy

Generally refers to how an application will be implemented throughout an organization (such as, departmental sequencing). Three types of roll-out strategies: phased, pilot, and big bang.

Federal Rules of Evidence

Govern the introduction and use of evidence in federal civil and criminal actions.

Assigns the diagnosis and procedures codes entered into the encoder into the appropriate. Medicare severity diagnosis-related groups (MS-DRG) or other diagnosis-related group (DRG). The most common ____ is the MS-DRG.

Grouper.

Object-oriented database

Handles text, images and other objects.

Data Warehouse

Hold an abundance of data from many different source systems. __________ is designed for specific types of analyses. _______________ is updated periodically rather than in real time.

Data in the IT dept

IT teams develop tools to collect, store, manage, secure and distribute data to employees who need access to the latest information to make decisions about strategic, financial and operational issues.

Patient-specific data

Identifies the patient. When executing a query, the user generally retrieves a single patient's information such as discharge summary, laboratory tests, and list of patients who had blood transfusions. Patient-specific data are generally connected through the use of a medical record number or other unique identifier.

Predictive Modeling

Identify patterns. Once a pattern is identified, the model is able to calculate the odds that a specific action will occur.

Aligning an organization's business mission and goals with its IT generally improves the company's overall performance. It can lead to more efficient processes, the development of better products and services, cost reductions, faster response times, and more efficient supply chain management.

Identify the importance of aligning IT goals to a specific business's mission and goals.

Planning, network, data, security, support

Identify the purpose of an IT department in an organization.

Auditing

Identify which users are accessing, inserting, updating, or deleting data, and when.

Emergency Medical Treatment and Labor Act (EMTALA)

Imposes obligations on hospitals (including critical access hospitals) that offer emergency department (ED) services.

Phased approach

In this method, the implementation starts with one module of the system and then gradually other modules of the system are added.

Security

Information security management is now one of the most important IT functions in an organization. IT teams must protect the IT infrastructure and corporate data against attacks from viruses, cyber criminals and other threats.

10 STAGES OF SDLC

Initiation, system concept development, planning, requirements analysis phase, design, development phase, integration and test, implementation, operations and maintenance, disposition.

Healthcare Fraud

Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.

The products are not designed to work together, but rather are linked through an ____________. Acts as a bridge between two systems or databases to translate data into each system's respective language. An interface has to know what data to retrieve, where the data are located in the first database, whether any data manipulation has to be performed (and, if so, what that manipulation is), and where the data will be entered into the second database.

Interfaced system

Are powerful tools for obtaining information. There are three types of _________: Name the three.

Interviews - structured, unstructed and semistructured

Logical data model

Is a "complete representation of data requirements and the structural business rules that govern data quality in support of project's requirements. For example, the nursing department would look at the data differently than the HIM department and the HIM department would look at it differently than the marketing department.

Qualitative analysis

Is a detailed review of a patient's health record for the quality of the documentation contained therein.

Structured Query Language (SQL)

Is a domain-specific language used in programming and designed for managing data held in a relational database management system. Is used to query data.

Clinical Data Repository (CDR)

Is a large database within a healthcare facility that is the central repository for health information. Common electronic means of collecting data within healthcare. CDR can be used as the database for the EHR.

Entity

Is a person, location, thing, or concept that is to be tracked in the database. In healthcare, entities would include items such as patient, physician, or laboratory.

Gnatt Chart

Is a project management tool that records specific tasks, their start and end dates, the person responsible for the tasks, and any connections between tasks. Can easily show which tasks are behind schedule, which are on target, and which are ahead of schedule.

computer assisted instruction (CAI)

Is a software program designed to use multimedia and interactive technology to teach a topic. Multimedia can use audio, video, simulation, self-quizzes, and other tools to engage the learner. The benefit to _______ is that it has been proven to increase learning in a shorter period of time

Duplication

Is a specialized data compression technique for eliminating duplicate copies of repeating data.

Data Mart

Is a subset of the data warehouse designed for a single purpose or specialized use. _________ does the same type of analysis as data warehouse but the target area is narrower. Cost of managing a ________ is lower than data warehouse.

Automated codebook encoder

Is an encoder that lists diagnoses and procedures in alphabetic order much like the alphabetic index located in the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT) codebooks. This similarity eases the transition from the book to the encoder. Mimics a codebook.

Peer review

Is at its best whenever a discipline can review its own members.

Normalization

Is breaking the data elements into the level of detail desired by the facility. For example, last name and first name should be in separate fields as should city, state, and zip code.

Implementation plan

Is carried out according to the project manager's specifications. The team member's skills will vary according to the needs of the project.

Data Governance

Is concerned with governing the input (data). Is the enterprise authority that ensures control and accountability for enterprise data through the establishment of decision rights and data policies and standards that are implemented and monitored through a formal structure of assigned roles, responsibilities, and accountabilities.

Release of Information (ROI) system

Is designed to manage the processing of requests for protected health information (PHI) received and processed by the HIM department.

Chart locator system

Is designed to track the paper medical record. This tracking is important because paper records are moved from place to place for patient care, quality reviews, coding, and many other purposes.

Reengineering

Is reevaluating the way the facility does business in order to improve efficiency and is often overlooked.

Middleware

Is software and hardware that connects applications.

Accountability

Is the duty of an individual, group, or organization to be answerable for specific activities.

Data reliability

Is the measure of consistency of data items based on their reproducibility and an estimation of their error of measurement.

Data Mining

Is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships. May also be called database exploration or information discovery. Used to analyze data to identify patterns that would be unnoticed without the analysis.

Archiving

Is the process of moving data that is no longer actively used to a separate storage device for long-term retention.

Risk management

Is the process of planning, organizing, directing, and controlling resources to achieve given objectives when events are possible.

Foreign Key

Is the second primary key. If the primary key of a specific table is also in a different table then it would be referred to as the foreign key of that different table. You can have many foreign keys in per table.

HTML

Is the standard markup language for creating Web pages.

Encoder

Is used by coders to select the appropriate code for the diagnosis (es) and procedure(s) supported by the medical record. Two types of encoders are Rules-based Encoders and Automated Codebook Encoder.

Quantitative analysis

Is used by health information management professionals as a method to detect whether elements of the patient's health record are missing.

DG steering committee

Is usually composed of representatives from various business or functional organizational units. This group serves as the coordinating body for the DG program. It develops the goals of the DG program, identifies and sequences project and task priorities, coordinates the data steward committees, monitors DG program outcomes, recommends policy and standards, and reports the status of the DG program to the executive data governance council.

Observation

Is watching an action being performed. It is useful in determining what employees are actually doing. The use of __________ is a way to validate what the interviewee has been told.

Deterministic algorithms

Look for exact matches. The algorithm looks at data elements such as name, birth date, gender, and social security number.

Expanders

May also be called macros. Allow transcriptionists to type an acronym such as "CHF" and the full phrase "congestive heart failure" will automatically be spelled out, thus saving keystrokes and time.

Flowcharts

May be used to illustrate the flow of information within the organization. Problems and inconsistencies may be identified through the development and analysis of the flowchart.

Pilot method

Method where only one nursing unit, department, or other entity starts using the new system at a time. Once consistently successful, the next group is implemented.

Relational database

Most common database model. A relation is created by sharing a common data element. The data are stored in rows and columns much like a spreadsheet. Each row in the table is called a record and each column or field is a single piece of data. A relational database must have two or moretables to be a relational database; otherwise, it would be a flat file

what is the ONC

National Coordinator for Health Information Technology

Accepts only numbers that can be calculated. This would include charges, but would not include zip codes and the medical record number, as these are not being used as numbers that can be manipulated.

Numeric data type

manager

On a project, one team member is responsible for directing project objectives while guiding resources, coordinating the scope, budgeting, and maintaining quality and communication throughout the implementation life cycle. Which project role describes this team member?

Phase 2 "System Concept Development" of the SDLC

Once a business need is approved, the approaches for accomplishing the concept are reviewed for feasibility and appropriateness. The scope of the system is further explored and identified. Which Phase is this in the SDLC?

Define how technology can be used to combat scope creep.

Online Project Management software is an important tool in managing scope creep. Scope creep (also called requirement creep, or kitchen sink syndrome) in project management refers to changes, continuous or uncontrolled growth in a project's scope, at any point after the project begins. This can occur when the scope of a project is not properly defined, documented, or controlled.

Incremental backup

Only copies files that have changed since the last backup.

Healthcare waste

Over utilization, under utilization, or misuse of resources. Waste is typically not intentional or criminal in nature; however, waste does have a financial impact on services.

Is a family of script programming languages that are similar in syntax to the C language.

PERL

Parallel testing as described in the testing section. Although parallel start-up works well, it is labor intensive and therefore expensive. Because the old system is in place and current, this approach provides a safety net and has the least amount of risk involved.

Parallel processing

National Center for Health Statistics (NCHS)

Part of the CDC. Their mission is to collect information on healthcare in the United States that can be used to improve the quality of the citizens' health.

ORYX

Performance standards developed by joint commission. Collects core measurement data from their accredited hospitals and uses that data to monitor and compare the quality of care provided.

Change Management

Performs impact analysis before changes are made, implement changes, test changes, and document them.

The various components of the system are integrated and systematically tested. The user tests the system to ensure that the functional requirements, as defined in the functional requirements document, are satisfied by the developed or modified system. Prior to installing and operating the system in a production environment, the system must undergo certification and accreditation activities.

Phase 7 Integration and Test of SDLC

Privacy

Practice of maintaining the security and confidentiality of patient records.

Tables

Preprogrammed lists and options for a user to select from, can be used to save time and improve data quality. For example, only approved locations would be programmed into the "Locations" table. As a result, the user would choose the location desired from a drop-down box.

Comes directly from the source of the data. A medical record is a _________ data source because the information comes directly from the patient and the healthcare providers who provide the care being recorded.

Primary data

Includes system selection and implementation expenses as well as the cost of maintaining the system for a specified period of time, such as two to five years. Include items such as cost of software, upgrading infrastructure, hardware, training, renovations to the physical plant, maintenance of the system, project management, consultant expenses, and travel expenses for site visits.

Project budget

Backup and Recovery

Protect the organization's data. Making periodic backups of data and keeping it safe from accidental or intentional destruction. In addition, a well-developed recovery plan needs to be implemented and tested so that when problems do arise, data can be restored quickly.

Relational database

Relation is created by sharing a common data element.

May also be called fuzzy logic. Rules-based algorithms may use phonetic searching in order to identify potential duplicates. 50 to 80 percent of the potential duplicates are identified.

Rule-based algorithms

Requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic protected health information. Deals with PHI

Security Rule

Integrated systems

Separate applications that are designed to work together. Data is entered into one system and then is accessible to the other applications. This type of system is much easier to manage than an interfaced system because of the lack of interfaces.

electronic data interchange

Six organizations have been appointed by the Department of Health and Human Services (DHHS) to develop and maintain healthcare standards. Which process makes healthcare run more efficiently due to the implementation of these standards?

Hierarchical database

Structures data in a hierarchy similar to an organizational chart.

Executive data governance council, committee, or board.

The DG program is led by this council. This group of executives and senior level managers are responsible to make the business case for the DG program, provide the authorization for the DG program, establish the program's mission and scope, set the program's strategic direction, secure funding and resources for the program, and evaluate and measure the overall program success.

Breach Notification Rule

The HIPAA ________________ requires covered entities to notify affected individuals, HHS, and in some cases, the media of a breach of unsecured PHI

The Privacy Rule

The HIPAAPrivacy Rule establishes national standards to protect individual's medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. This rule deals with PHI directly.

Resources

The _________ plan identifies the _________ needed in order to meet the objectives of the plan. This includes money, time, staff, space, and other resources.

Transition

The _____________ phase prepares the facility for the conversion from the old system to the new. This stage includes not only the actual conversion of data, but preparing staff for the change.

Accessibility

The ability to get medical care and services when needed.

Accessibility

The availability of the data collected.

Phase 3 "Planning" of SDLC

The concept is further developed to describe how the business will operate once the approved system is implemented, and to assess how the system will impact employee and customer privacy. To ensure the products and / or services provide the required capability on-time and within budget, project resources, activities, schedules, tools, and reviews are defined.

Best of Fit

The decision to purchase software from a single vendor

Phase 10 of the SDLC - disposition

The disposition activities ensure the orderly termination of the system and preserve the vital information about the system so that some or all of the information may be reactivated in the future if necessary.

credentialing, health information management, and nursing

The hospital executive team has approved the purchase of an upgrade to the healthcare quality indicators software system. Which teams should be assembled to review the functionality of any system proposals?

Database Model

The logical constructs used to represent how data are stored and the relationships between the data. Four _______ can be used, relational, hierarchical, network, and object-oriented

Phase 5 "Design" of SDLC

The physical characteristics of the system are designed during this phase. Everything requiring user input or approval must be documented and reviewed by the user. The physical characteristics of the system are specified and a detailed design is prepared. The design should include system objectives, output specifications, input specifications, database design, and expected costs of the system.

What is the definition of computer security and privacy.

The protection of computer systems from the theft and damage to their hardware, software or information, as well as from disruption or misdirection of the services they provide.

Authenticity

The quality of being genuine and valid.

Confidentiality

The right of an individual to have personal, identifiable medical information kept private.

Autonomy

The right of competent adults to make informed decisions about their own medical care.

Deontology

The study of the nature of duty and obligation.

Phase 9 "Operations and Maintenance" of SDLC

The system operation is ongoing. The system is monitored for continued performance in accordance with user requirements, and needed system modifications are incorporated. The operational system is periodically assessed through In-Process Reviews to determine how the system can be made more efficient and effective. Determines what went well in the implementation.

Phase 8 "Implementation" of SDLC

The system or system modifications are installed and made operational in a production environment. The phase is initiated after the system has been tested and accepted by the user. This phase continues until the system is operating in production in accordance with the defined user requirements. Includes Training.

Cardinality

The uniqueness of data values contained in a particular column (attribute) of a database table. The lower the _________, the more duplicated elements in a column.

Data Models

There are three levels of ______. Conceptual ______ (basis for the logical and physical), logical __________ (complete representation of data requirements and the structural business rules that govern data quality in support of project's requirements), and physical _________ (how the data are physically stored within the database).

design

This month, the IT team is defining the output and input specifications of a new EHR system. Which phase of the system development life cycle (SDLC) is this organization addressing?

Hardware and software procurement

This stage includes ensuring that the facility has all of the hardware and software needed and that any missing components arrive in a timely manner. For example, hardware delivery may take six weeks, so ordering needs to be done early in the process.

Feasibility study

This study defines the objectives and need for the project and justifies the plan. Determines if a proposed IS is an appropriate option to meet the objectives of the organization. For example, the organization could investigate the feasibility of implementing an EHR to support an objective to improve the quality of care.

support

To enable employees to make the most effective use of IT resources, the IT team provides various forms of user support.

Business Intelligence/Data Warehousing

To mine all the information they can in order to make better business decisions.

Cancer registry information system

Tracks information about the patient's cancer from the time of diagnosis to the patient's death.

Cancer registry information system

Tracks information about the patient's cancer from the time of diagnosis to the patient's death. For Example a TNM (Tumor, Node, Metastasis) stage.

Registry

Tracks patients who meet criteria for inclusion such as a specific disease or treatment

Disclosure management system

Tracks the disclosures made throughout the healthcare organization for reporting purposes. May be part of the ROI system or it may be a separate system used by HIM and non-HIM departments. May also track requests for amendments to PHI as well as restrictions to disclosures.

Data definition language (DDL)

Translates how data are stored in the computer from the physical view (physical structure of the database) to the logical view (one that is understandable by the user). _____ controls the security of the database. Define relationships between data.

Network database

Uses pointers to connect data.

Gnatt chart

Using a chart, a project manager tracks the status of a project's tasks, the start and end dates, and each team member responsible for the tasks. Which project management chart is this manager utilizing?

Chart deficiency system

Utilized by both staff and management. Used by staff to record what deficiencies a physician, or other clinician, has on specific records. When these deficiencies are completed by the physician, the ______________ is updated to reflect the change. Will identify the incomplete records by physician so that the physician can be notified for completion.

network

What does the IT team develop and operate to support effective communication and collaboration.

Office of the Inspector General (OIG) Compliance Goals

What goals do the following? •fights fraud, waste, and abuse; •promotes quality and safety; •secures the future; and •advances innovation

compare facilities mortality rates

What is the purpose of the data used when the Centers for Medicare and Medicaid Services (CMS) performs a risk-adjusted mortality analysis?

SQL

What is the standard programming language used to retrieve data from relational databases?

secure messaging

What should be built into a patient portal to protect the exchange of communications between patients and providers?

director

Which HIM department member should be the project sponsor for a team implementing a major upgrade to a hospital's EHR?

security

Which HIPAA rule provides the framework for safe transmission of protected health information across electronic systems?

scalability and universal access

Which Office of the National Coordinator for Health Information Technology (ONC) interoperability principle encourages progress in the health information exchange initiative?

data dictionary

Which aspect of the relational database model controls quality through standardization?

quality

Which data management domain addresses the accuracy, completeness, and timeliness of data to meet business needs?

data dictionary

Which database component uses standardized descriptions, permissible values, and formats to optimize reliability, consistency, and portability?

primary key

Which key serves as the unique identifier in a relational database?

Phase 1 Initiation of SDLC

Which phase of the SDLC begins with initiation of a system (or project) which begins when a business need or opportunity is identified. Summarizes the scope, objectives and budget and comes before preparing for the project charter. A Project Manager should be appointed to manage the project.

Phase 6 "Development Phase" of SDLC

Which phase of the SDLC is ... The detailed specifications produced during the design phase which are translated into hardware, communications, and executable software. Software shall be unit tested, integrated, and retested in a systematic manner. Hardware is assembled and tested.

implementation plan

Which project management document would include columns titled Task Details and Resources Required?

security rule

Which section of the HIPAA legislation requires the protection of a patient's diagnosis and treatment plan from unauthorized access to the health information system?

established principles to guide decision making and actions

Which term is defined as ensuring that the data is not subject to unauthorized alteration either during transmission across a network or while at rest?

integrity

Which term is defined as ensuring that the data is not subject to unauthorized alteration either during transmission across a network or while at rest?

Network database

Which type of database has nodes called owners and members?

start and end dates

Which type of project information should be found on a Gantt chart?

breach

Which type of unethical access is an employee's unauthorized access of a coworker's patient record

Wildcard

Would be used to indicate that the query should identify data that meet the partial information provided. For example, a query of 0F140D* would retrieve all codes that start with the specified characters such as 0F140D3, 0F140D4, 0F140D5, 0F140D6, and so on.

Fraud

Wrongful or criminal deception intended to result in financial or personal gain.

Contains all data related to a particular subject or concept such as a patient and is made up of the records and fields.

a table

Time and date Data Type

contain only a date or time.

The ____________ shows the longest amount of time to complete the project within the PERT Chart. Slippage is shown by review of the

critical path

Standards that are "clear guidelines for the acceptable values for specified data fields. These standards make it possible to exchange health information using electronic networks. The use of _______ make it possible to share information in a way that users are able to interpret data in the same way.

data content standards

A predetermined area within a healthcare database in which the same type of information is usually recorded. Examples of ___________ are patient name, health record number and date of birth.

data field

Data are generally broken down in two different ways: primary and secondary ?

data sources

The HIM professional has an obligation to demonstrate actions that reflect values, ethical principles, and ethical guidelines. The American Health Information Management Association (AHIMA) Code of Ethics sets forth these values and principles to guide conduct The code is relevant to all AHIMA members and CCHIIM credentialed HIM professionals regardless of their professional functions, the settings in which they work, or the populations they serve. These purposes strengthen the HIM professional's efforts to improve overall quality of healthcare.

describe the role of professional associations and ethics standars in the healthcare IT profession

In this stage, the project team identifies the specific details required to implement the plan. For every task identified, the plan must provide a start and end date and a person responsible. f the project requires programming, the team must establish the standards that will be used in writing the program.

design

Used to illustrate the flow of information within the organization. Standardized symbols to demonstrate the steps performed. Problems and inconsistencies may be identified through the development and analysis of the _______. Identify critical points in the process as well as problem areas.

flow chart

Structures data in a ______ similar to an organizational chart. Data starts at the top of the ________ and moves downward. The relationship can be described as one-to-many. Each piece of data in the database is called a node. Pointers indicate where in this tree structure the data are stored. A parent-child relationship is created by the relationships developed by the pointer.

hierarical

The _______________ stage includes the steps to be taken to prepare for the _____________ and the actual conversion to the new system.

implementation

No maleficence

means non-harming or inflicting the least harm possible to reach a beneficial outcome.

Centers for Disease Control and Prevention (CDC)

mission states in part that they will work "through health promotion, prevention of disease, injury and disability, and preparedness for new health threats

Allow the user to use common words to tell the database which data are needed.

natural language queries

Which details all required system functionality including functional, technical, training, and implementation requirements. It is a much more detailed document than the RFI and is critical to the selection process. The purpose of the ____ is to give the vendor all the information needed to propose an IS that meets the needs of the facility. The ___ describes what system is needed, description of the organization, description of the desired functions.

request for proposal (RFP)

Rules-based encoders

require the user to type in the name or portion of the name of the diagnosis or procedure. This entry into the encoder generates a list of suggestions from which the coder selects. For example, if the coder types in pneu-, the encoder may suggest pneumonia and pneumonitis. From there the coder scrolls down until the proper code is selected.

Happens when items not included in the original scope are added after the project has begun.

scope creep

Means developing screens of an IS to meet the needs of the user and to promote job efficiency. Include designing computer views for various types of users. Screens should be simple to use and have a standardized terminology across screens to facilitate data entry, training, and data quality.

screen design

An exact duplicate of the system in use, excluding data. In this test environment, changes can be made to the system and tested to see what happens. The software changes can be tested without worrying about problems resulting from the changes. This will enable support staff to solve problems before the update is live; once the system is working appropriately in the test environment, it can be implemented into the live one.

test environment

Network database

what type of data uses Pointers to connect data. The nodes are called owners and members rather than parent and child nodes as in the hierarchical model. A node in the network data model can have more than one parent, unlike in the hierarchical data model