Electronic Health Records

Question 1

Electronic Health Record (EHR)

Answer 1

Electronic record of health-related information on an individual
Conforms to nationally recognized interoperability standards
Can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.

Question 2

Qualified EHR

Answer 2

Includes patient demographic and clinical health information
AND
has the capacity to:
provide clinical decision support
support physician order entry
capture and query information relevant to health care quality
able to exchange electroni health information with and integrate such information from other sources

Question 3

Functions of EMR

Answer 3

1. Captures and enables use of data at POC
2. Health Information Exchange
3. Quality measurement, reporting, and improvement
4. Supports clinical decision makeing
5. Collects and integrates source data

Question 4

3 Components of MU incentive program

Answer 4

1. Certification Program whereby EHR technology is tested and certified as meeting standards and criteria.
2. Standards and Criteria that certified EHR technology must meet
3. Objectives and measures for earning incentives

Question 5

Certification of EHRs

Answer 5

Oversight by ONC (Office of the National Coordinator for Health Information Technology)
Testing Laboratories are accredited by
*Americant National Standards Institute (ANSI)
*National Voluntary Laboratory Accrediaton program (NVLAP)

Question 6

Standards that EHRs must meet

Answer 6

Address specifications for exchanging health information content,
vocabularies for representing health informaiont,
protection of health information created, maintained, and exchanged by EHR technology

Question 7

Objectives and meausre for earning incentives

Answer 7

Defined by Centers for Medicare and Medicaid Services (CMS)

Question 8

Stages of MU implementation

Answer 8

2011: Data capture and sharing
2013: Advanced clinical processes
2015: Improved outcomes

Question 9

Priorities for adoption of EHR Technology

Answer 9

1. Improve quality, safety, efficiency, and resude health disparities
2. Engage patiens and their families in their healthcare
3. Improve care coordination
4. Improve population and phblic health
5. Ensure adequate privacy and security protections for personal health information

Question 10

Specific outcomes for EHR

Answer 10

• Improve quality of healthcare
• Enhance patient safety
• Support health maintenance
• Increase productivity
• Reduce hassle factors
• Support revenue enhancement
• Support predicitive modeling
• Maintain patient confidentiality

Question 11

Improving quality of Health care with EHR

Answer 11

Data availability

Links to knowledge sources

Question 12

Enhancing paitient safety with EHRs

Answer 12

Context-sensitive reminders and alerts
clinical decision support
automated surveillance
Chronic disease managment
Drug/device recall capability

Question 13

Support of health maintenance by EHRs

Answer 13

Preventive care and wellness with reminders
Health summaries
Tailored instructions
Educational materials
home monitoring/tracking

Question 14

Increased productivity with EHRs

Answer 14

Data capture and reporting formats tailored to users
streamlined workflow supprot
patient-specific care plans, guidelines, and protocols

Question 15

Reduction of hassle factors with EHRs

Answer 15

Improve satisfaction for clinicians, consumers, and caregivers by managing:

• scheduling
• registration
• referrals
• medication refills
• work queues
• auto generation of administrative data

Question 16

Support of revenue enhancement by EHRs

Answer 16

Eligibility and benefit information
Cost-efficiency analysis
Clinical trial recruitment
Rules-driven coding assistance
External accountability reporting/outcome mx
Contract managment

Question 17

EHR System components

Answer 17

Hardware
Software
People
Policy
Process

Question 18

4 main categories of information systems that comprise the EHR

Answer 18

1. Sources systems that collect data, including administrative, financial, and clinical
2. Core clinical systems that enable use of data at the point of care
3. Supporting infrastructure that integrates data from applications internalk to a given care delivery organization
4. Connectivity systems that support the integration of data across different organiatons and with patients or their caregivers

Question 19

MPI

Answer 19

Master patient index

Question 20

R-ADT

Answer 20

Registration - Admission, Discharge, Transfer

Question 21

PMS

Answer 21

Practice Management System (ambulatory)

Question 22

PFS

Answer 22

Patient Financial Services

Question 23

HIM

Answer 23

Health Information Management

Question 24

EDMS

Answer 24

Electronic Document Management Systems

Question 25

DIMS

Answer 25

Document Imaging systems

Question 26

ED/CM

Answer 26

Electronic Document content management

Question 27

OC/RR

Answer 27

Order Communication/Results Retrieval Systems

Question 28

LIS

Answer 28

laboratory information system

Question 29

RIS

Answer 29

Radiology Information System

Question 30

PIS

Answer 30

Pharmacy Information System

Question 31

PACS

Answer 31

picture archiving and communications systems

Question 32

POC charting systems and types of data

Answer 32

Clinical documentation systems Structured data = discrete data : data tht have been predefined in a table or checklist or uses drop down menus Unstructure data = narrative data

Question 33

POC charting systems

Answer 33

``` Smart phones Tablets wireless on wheels /workstations on wheels laptops PDAs ```

Question 34

CPOE

Answer 34

computerized provider order entry

Question 35

CCR

Answer 35

Continuity of Care Record

Question 36

CCD

Answer 36

Continuity of care document rendered in xml or pdf using HL7 Clinical docuemtn Architecture

Question 37

CDR

Answer 37

Clinical Data Repository Relational database intended to support direct care delivery functions Can process many kinds of transactions

Question 38

CDS

Answer 38

Clinical Decision Support Software that porocesses infoirmation to provide assistance with making a clinical decision Embedded in EHR

Question 39

CPT

Answer 39

Current Procedural Terminology

Question 40

Executive decision support

Answer 40

``` Standalone system that analyzes a large volume of aggregated data and provides trending information Typically retrospective Quality miprovement Procutivity Staffing ```

Question 41

CDW

Answer 41

``` Clinical Data Warehouse Advanced component of EHR Database that has been optimized for analysis Used for data mining Used for predictive modeling ```

Question 42

PHR

Answer 42

Personal Health Record Systems designed to suppport patient-entered data. May be standalone or linked to provider

Question 43

Telemedicine

Answer 43

Use of medical informtion exchanged from one site to another via electronic communications to improve,l maintain, or assist patients health status. Closely associated with telehealth May include home monitoring

Question 44

HIE

Answer 44

Health Information Exchange Seamless exchange of health informaton across disparate organizatons. May be part of a format HIO - Health Information Organization Maybe local, regional, or state Supports the development of the nationwide health infomation network (NWHIN)

Question 45

AHIMA

Answer 45

American Health Information Management Association

Question 46

Integration

Answer 46

The task of linking inforamtion system comp0onents together to that they communicate and act as a uniform entity. Information systems built on same platform are built to be integrated Other wise systems integrators use various programming and process techniquest to integrate disparate systems.

Question 47

Interoperability

Answer 47

The ability of differen information systems and softare applications to communicate and exchange data

Question 48

Electronic Medical Record (EMR)

Answer 48

Electronic record of health related information on an individual Created, gathered, managed, and consulted by authorized clinicians and staff withon one healthcare organization