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Enterprise Health Systems > 2. HIS Fundamentals > Flashcards

2. HIS Fundamentals Flashcards

1
Q

what is the definition of EMR, EHR and PHR& their levels

A

EHR = national –> more than ONE
EMR = institution –> accessed by authorised clinicians in ONE healthcare org
PHR = personal –> multiple sources accessed by INDIVIDUAL

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2
Q

what is CPOE

A

computerised physician order entry (CPOE)
- replaces hospital paper based ordering system
- record instructions for patient treatment
- trigger safety alerts

benefits:
- full range of orders
- medication record
- communication of successive personnel

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3
Q

what are some similar systems to CPOE

A
  • pharmacy information system
  • pharmaceutical decision support system
  • electronic prescription
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4
Q

what is eMAR

A

electronic Medication Administration Record
- automates documents for administration of medication into certified EHR tech using tracking sensors (RFID, barcodes)

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5
Q

how does communication occur between HIS

A
  • every dept may have their own version of a HIS and standards e.g. CPOE and PACS
  • all are integrated via EHR
  • governed by HL7 & DICOM
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6
Q

what differentiates PHR from EMR & EHR

A

Whereas an electronic health record (EHR) is a computer record that originates with and is controlled by doctors, a personal health record (PHR) can be generated by physicians, patients, hospitals, pharmacies, and other sources but is controlled by the patient.

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7
Q

what does EHR connect to

A

Patient Management. The patient management component facilitates the capture, storage and retrieval of up-to-date information related to new patients. …
Clinical Component. …
Secure Messaging and Alerts. …
Financial Dashboards. …
Revenue Cycle Management (RCM)

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8
Q

what are the benefits of EHR

A
  • reminders & alerts
  • compliance
  • reduced errors
  • accessibility
  • cost reduction
  • efficiency
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9
Q

what is the usability value of EHR

A

systems communicate with each other rather than department personnel manually exchanging information

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10
Q

name some EHR trends

A

basic without clinician notes –> basic with clinician notes –> comprehensive
- moving to cloud
- doing EHR analytics
- using AI
- mobile –> tablets & smartphones

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11
Q

why is blockchain technology applicable to PHR

A
  • it uses ledgers
  • data is distributed and available everywhere but only the owner has the key
  • record of every time a ledger is accessed
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12
Q

what is SDPR is it an EHR

A

yes it’s an EHR

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13
Q

what is included in SDPR

A
  • PAS = patient admin system
  • EMR = electronic medical record
  • LIMS = laboratory information manegement system
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14
Q

what is HealtheNet

A
  • eHealth NSW program that connects disjointed systems
  • NSW clinicians can get access to NSW LHD EMR & EHR and PHR
  • consistent and accurate info to deliver best care
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15
Q

is eMR institution based, and what is eMR2

A

yes, EMR2 is integration of all EMRs implemented across the state

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16
Q

what are 2 goals of the australian digital health strategy

A

interoperability & data quality

17
Q

what is interoperability

A

the ability of IS to communicate, exchange and utilise exchanged data while still preserving the meaning and context of data

18
Q

what is semantic interoperability

A

preserving the original meaning of the data sources

19
Q

what is the purpose of a data standard

A

ensuring every system can communicate

20
Q

what is the relationship between data standards and DQ

A
  • seamless exchange
  • confidence in meaning & context
  • less mistakes
  • better quality patient care
  • patient safety
21
Q

what are the different types of data standards development processes

A
  • adhoc: no formal adoption process
  • defacto: vendor or other has large mkt segment
  • government mandated: legislative
  • consensus: volunteers from different orgs to come together to reach a formal agreement
22
Q

what are some data interchange standards

A
  • HL7
  • DICOM (digital imaging and communications in medicine)
    from ISO (International organisation for standardisation)
  • ANSI (american national standards institute)
23
Q

what is the purpose of HL7

A
  • system integration & interoperability
  • tools to build standards
  • messaging & document standards
  • EHR functional models & profiles
24
Q

what are some primary standards of HL7

A
  • version 3 messaging standard
  • CDA = clinical document architecture
  • FHIR = hl7 fast healthcare interoperability resources
  • context managment spec
25
Q

examples of HL7 CDA

A
  • DisplayName shall be accurate
  • Identifiers shall be unique
  • each entry shall contain at least one text reference
26
Q

what is FHIR

A

fast healtchare interoperability resorces

interoperability standard to facilitate the exchange of information between anyone involved in the HC ecosystem

27
Q

what are some non-priority HL7 standards

A
  • mobile health
  • CCD (continuity of care document)
28
Q

what PHR developer has integrated HL7

A

Apple

29
Q

what is NCVHS & what do they recommend

A
  • national committee on vital & health stats
  • systematised nomenclature of medicine
  • federated drug technologies e.g. RxNorm
30
Q

what is SNOWMED

A

Systematized Nomenclature of Medicine Clinical Terms
- comprehensive clinical terminology to facilitate electronic storage & retrieval of detailed clinical info
- facilitates efficiency and consistency

31
Q

what is NCIRD and is it compatible with HL7

A
  • national centre of immunization & respiratory disease developed a CVX (clinical vaccines administered table)
  • yes
32
Q

what are some HL7 DQ requirements

A
  • unique patient ID
  • confidential & secure authentication & accountability
  • interoperability across systems
33
Q

what are some causes of poor quality data

A
  • unclear data definitions
  • programming errors
  • no or lacking test cases
34
Q

do EMRs require structured data input and why

A

no, because patient data can come from anywhere e.g. overseas

35
Q

how is dq improved using prevention

A
  • data checks
  • user friendly data entry forms
  • training
36
Q

how is dq improved using detection

A
  • dq audit e.g. ask clinicians and registrars
  • review of data collection protocols/procedures
  • automatic data checks
37
Q

how is dq improved using improvement methods

A
  • provide users with dq reports
  • give feedback of dq with results and recommendations
  • implement identified system changes
38
Q

what is the process for improving dq

A

prevention –> detection –> improvement

39
Q
A

Enterprise Health Systems (12 decks)

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