HI Exam 1 Flashcards
(101 cards)
1
Q
Autonomy-
A
The right to choose your own options
2
Q
Autonomy, Justices , Benefic ence, Non-Maleficence
A
What are the 4 ethics?
3
Q
Justices
A
Equality of resources
4
Q
to do what is right for others
A
Benefic ence
5
Q
Non-Maleficence
A
Do no harm
-Means not to hurt anyone
5
Q
What are some examples of Autonomy?
A
-Choosing dr
-Choosing procedure
-Choosing where you go to school
-Choosing who you give med records to
5
Q
Electronic Medical Record
A
EMR
5
Q
Is EHR a legal document?
A
Yes
5
Q
Electronic Health Records
A
EHR
5
Q
IS PHR a legal document?
A
No, It isnt
5
Q
This exist is healthcare as a result of using different words but having the same meaning
A
Semantic Gap
5
Q
Why can’t we follow a personal document
A
The information isn’t always accurate
5
Q
HIE
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Health Information Exchange
5
Q
Health Information Technology
A
This includes the technical aspects of processing health data and records including classification and coding, abstracting, registry, and storage
5
Q
Health Informatics
A
A science concerned with the cognitive, information processing and communication tasks of healthcare practice, education and research including the information task
5
Q
Used primarily during patient care
A
Primary Data
5
Q
In the SDLC process evaluating what the organization is currently doing is done in the “planning” phase. In what phase would you identify the gaps in what is currently being done
A
The analysis phase
5
Q
Secondary data
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Data used AFTER patient care. Used for research
5
Q
High Tech Act (Health information technology for economic and consumer health)
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This act designed funding to modernized the healthcare system by promoting and expanding the adoption of health information technology
5
Q
-Picture archiving communication systems.
-In Radiology Department
A
What is a PACS? What area in hospital would you need a PACS?
5
Q
Data Acumen
A
Data literacy has evolved to refer to not just data management skills but the ability the ability to make good judgement about the use of data to support evidence based decisions
6
Q
The ability for health information systems to work together with and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities
A
Interoperability
6
Q
Defined as he actual exchange of health information electronically between providers and others with the same level of interoperability; such as labs and pharmacies
A
HIE (Health information exchange)
6
Q
A complicated HIE model to to implement. It allows the patient to choose up front what data is included, Who can have access to it and for what purpose it can be used
A
Opt in with restrictions
6
Direct recording of care on individual patients
Primary use of EHR
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This is not for profit standards developing organization provided a comprehensive framework and related standards for the exchange, integration,sharing and retrieval of eHealth information that supports clinical practice and the management, delivery and evaluation of health services
HL7
6
Classification of diseases is used internally for reporting diagnosis
ICD10-CM (10->international)
6
Is an inpatient EHR. Is the use of technology and barcoding to track medications from when ordered til given to patient.
eMAr (electronic medication administration records)
6
Implementing what means ensuring that systems are implemented in the least proprietary, most cost-effective and most user-empowered way possible to facilitate organizational benefits
Adaptable solutions
6
Electronic Health Records(EHR):
Platforms that integrate the data and functions of specialized CIS solutions in hospitals and other healthcare fields
6
Early stage:
Focuses on the technical data infastrucure.
6
Long term EHR
Involve many niche vendor system. EHRs used with this enhance digital communication with hospital facilities.
6
Practice management system (PMS)
Supports scheduling, financial, and billing activities. Usually include patient registration, scheduling, verification, and billing.
6
The ambulatory record is longitudinal rather than episodic, has fewer practitioners documenting in the record, may not have in-house diagnostics (lab, x-ray, and such) and so requires a link to this information, and has more referrals made to outside practitioners than seen in the hospital.
Main differences between ambulatory and inpatient?
6
Involve applying data to improve the delivery of healthcare
Secondary use of EHR
6
Clinical Information Systems(CIS):
Tech platforms including software, servers, databases, and devices that administer clinical care and support clinical organizations.
6
Impatient EHR Stages:
Early stages, Later stages, Final Stages
6
Focuses on personal health record connectivity
Final Stages:
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Abulatory EHR
These functions before and after visits. The patient generally moves themselves from setting to setting when receiving services from multiple providers
8
Before in Abulatory EHR
Scheduling online, insurance verify, document care
9
CPOE
Process where clinician enters and sends care instructions
10
Picture archiving and communicating systems (PACS)
Allowed viewing of radiology/EKG's outside of the radiology department. They provide storage of electronic images and reports
11
Clinical Decision Support Software:
Used in clinical setting to help decide the right treatments for their patients
12
Labatory Information Systems (LIS):
A system for the integration of Labatory information related to the processing and storage of medical tests
13
Radiology Information Systems (RIS):
Bring together patient radiology data with images. These often include patient tracking, scheduling, and reporting results.
13
Tethered PHR Benefits:
Satisfied patients, reduces delays in patients, Improved clinical safety,
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Tethered PHR
PHR software that is engineered into the database of an EHR
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Tethered PHR Cons:
PHR Cons:
Clinicians must open schedule's online, Organizations must build interfaces to and from building systems, Offices need to adapt to new workflow and service models
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Care is generally provided in the hospital setting with many levels of providers and services concentrated within one setting
Safety Orientations: Clinical provider Order Entry
(CPOE): IS a process where clinician enters and sends care instructions.
Impatient EHR
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E-scribing
Sending orders to pharmacy and checking patients' insurance formulary
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Later stage:
Focus on safety functions like CPOF and documentation that supports medical billing.
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Clinical decision Support (CDS)
System designed to assist in prescribing drugs and detect disease outbreaks
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Systemized Nomenclature of Medicine Clinical Terms (SNOMED)
-Ordered by formal decription logic-benefits from the classifying reasons developed by computer science
-Each entry in SNOWMED CT contains a concept identifier
-Largest, most complex, and comprehensive terminology about clinical medicine.
18
HITECH ACT
Health Information Technology of Economic and Clinical Act. This program created tax funded incentives for eligible hospitals, offices, and clinic's to use EHR's
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Opt-Out Model
-Allows predetermined set of data to be automatically included in HIE
-Not much flexibility
19
HIPPA
Health Insurance Portability and Accountability Act. Used to help protect and secure information of patients.
19
Opt-In Model
Requires patients to affirm their data made available within HIE (Patients HAVE to confirm)
19
Opt-Out With Exception Models
-Make patients information available in exchanges, BUT allows patient to exclude data from HIE (patients are able to decide)
20
Federated HIE's
-Isn't a specific place where data is stored
-Works like a network and allows providers to talk back and forth directly.
-Everyone has their own but shares data
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What are the Patients Consent options?
-No-Consent Model
-Opt-Out Model
-Opt-Out With Exception Models
-Opt-In Model
-Opt-In with Restrictions
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The process of sharing important health information.
Health information Exchange(HIE)
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Opt-In with Restrictions
-Provides the most autonomy for patients.
-Allows patients to restrict how much data is available.
-They have to opt- in to data being included; there May be specific rules and restrictions
Ex: Selecting what healthcare providers can see and can't see.
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-The entity that manages and ensures the success of the exchange.
-Organization that is in charge of the facilitation of exchange
Health Information Exchange Organization(HIO)
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Recommends polices, standard implication specifications, and health information
HITAC
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Logical Object identifies Names and COdes (LOINC)
A dictionary of laboratory codes and clinical test descriptors
-Primarily seen in lab diagnoses
-Important for lab and clinical codes
~Has two sections: Lab and Clinical
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-Provides codes for procedures provided to impatient to enable greater compatibility
-Seven character alphanumeric structure:
~Each character have different possible values
~First character can be algebraic or alphabetical
~The digits 0-9 and lettr A-H, J-N, P-Z used only
~Letters O& I are not used because it could cause confusion with 0 & 1
ICD-10-PCS
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-Reporting diagnosis, procedures, and services in health settings
-Maximum of 7 charaters per code
-Use "X" as place holder whenever neccessary.
ICD-10-CM
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Lab and Clinical codes
Clinical: Clinical codes examples are vital signs, EKG, and cardiac echocardiogram
Lab: Use proprietary test codes and an exchange standard for lab results was needed.
LOINC 2 sections and what they mean
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The MU recommendation for pharmaceutical names and codes in the United States
-Standardized coding for clinical drugs already ordered
-codes identify if medicine is effective
RxNORM
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FHIR(Fast Healthcare Interoperability Resources)
-Set of code resources used to combine sys. from mobile phones, cloud resources, and EHRs
-Provides the framework to share data
-Implements restful web services as the backbone of technology.
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Health Level 7 (HL7)
-Utilized for providing healthcare data structure and healthcare-specific perspectives
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Aggregated and Federated
What are the two main HIE's ?
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-Combines all of the data into a centralized repository with a master patient index or record locator service. (MPI separates it)
-Preferred by persons of local govt. trying to maximize the public health benefits of HIE
-Present greater risk to privacy and data
Aggregated HIE's
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Public HIO:
-This is entirely supported and ran by the govt.
-Aims to make HIO's similar to public infrastructure such as roads system
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Cooperative HIO:
-Arise when relationships are formed between otherwise competing healthcare providers for the purpose of exchanging information.
-Financial stability rests on community or geographic region concerns (finances are split by competitors)
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What makes up the HIO structure?
Public, Cooperative, and Private
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-Planning(identifying what you need)
-Analysis (what you already have going)
-Design (evaluating the technology to see what's available and how it fits)
-Implementation (utilize as vendors)
-Evaluation
What are the steps in SDLC?
30
Private HIO:
-Involves single integrated delivery system (IDS)
-Connects all different providers within the healthcare entity
Ex: The V.A. has a system where they share information throughout V.A. in U.S and other practices that isn't V.A.
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evaluating the technology to see what's available
Design Phase:
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Step of implementation involves gathering and verifying data needed to input into software or hardware for the system to function.
System building and development:
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People or groups outside of the company who are indirectly affected by the company's decisions and outcomes
What does an External stakeholders mean?
33
Program
This group of projects with interdependencies and relationships between project work and goals
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Sustainment Phase:
-People, processes, technologies, and associated resources needed to ensure that solutions are managed effectively on an ongoing basis make up this
-Is broken down into three areas: support, maintenance, and upgrades.
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Scalability or volume testing
Often done in an automated fashion
35
Testing has three stages. What are they?
-Unit testing, integration testing, and scalability or volume testing.
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Internal and External
Two types of stakeholders:
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An individual, formal role such as chief nursing officer or groups of individuals or entities.
-Have a vested interest in both the implementation of a technology solution and the capability for a solution to provide valuable data to meet the objectives of the organization.
Stakeholder
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Staff associates, providers, management team, executives, board of directors, advisory boards
Internal Stakeholder
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What are the 5 steps of the SDLC?
Planning, Analysis, Implementation, Sustainment
39
What's does internal stakeholder mean?
means they are people or groups within a company who are directly involved in the company's work
39
Implementation
The process of delivering technology, data sets, and processes to a business function.
-Technologies such as EHRs are implemented through a series of steps for use in various settings of clinical care; platforms such as human resources systems are implemented to support administrative functions such as recruiting and payroll in the same settings of care.
40
Champion
is a specialized stakeholder who has a defined role to provide one-on-one support to influential groups of stakeholders.
41
Sponsors
Stakeholders could be groups or individuals who provide financial resources that enable successful and sustainable implementations of health system solutions.
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External Stakeholders
customers, vendors, investors, governments, communities
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Adaptable Solutions
Means ensuring that systems are implemented in the least proprietary, most cost-effective, and most user-empowered way possible to facilitate organizational benefits
43
-Includes collecting information about existing data requirements, functional and technical requirements, and business workflows.
-Data regarding types of end users who will use the technology is also collected during this time
-Time in the implementation process where it is important to determine what type of hardware is needed.
-Questions for end users regarding the need for specific types of organizational computers, printers, handheld devices, kiosks, or bar code devices are discussed in this phase of the SDLC.
- The data gathered during this phase are turned into meaningful information to support building the system solutions,
Analysis Phase:
43
-Involves developing the appropriate IT-based approaches to support the organization's strategies.
-This stage is a precursor to further work that will lead to effective implementation of health system solutions.
-Encompasses activities such as surveying the market for viable technology solutions and evaluating technology partners.
Planning Phase:
44
-Involves ensuring that the device or software system performs as it should.
Unit Testing
44
SDLC
A framework for describing the phases involved in developing and maintaining information systems
44
-An individual who has business operations knowledge and whose part-time or full-time role is to receive additional training and support and maintain technologies during and after implementation.
-Crucial activities that they address are related to nontechnical level one support issues, additional training of end users, writing and running reports and analytics dashboards, and initial unit testing and review of new products eligible for implementation upgrades.
Superuser
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-Distinct phase of the SDLC involves building or developing, testing, and implementing the solution, whether it is software, hardware and devices, network upgrades, or new data sources.
-There are several steps involved in implementing technology solutions.
-Although presented in a linear fashion, some of the steps might overlap in the interest of expediting project and program timelines.
-The important emphasis is that each step is critical and that there are dependencies between certain steps.
Implementation Phase
