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7. HRSC 1 > Module 2 Health Information Services > Flashcards

Module 2 Health Information Services Flashcards

1
Q

HIM vs Health Informatics

A

HIM - data entry/retrieval/analysis

HI - database management/creation/mining, more technical

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2
Q

What are the four domains of practice in HIM?

A
  1. Data Quality
  2. Privacy
  3. e-HIM
  4. HIM Standards
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3
Q

Design, development, adoption, application of IT based innovations in health care services delivery, management, and planning.

A

Health Informatics

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4
Q

HIMs are responsible for management of health information through:

A
  1. Collection
  2. Organization
  3. Storage and retention
  4. Access
  5. Dissemination
  6. Analysis and interpretation
  7. Destruction
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5
Q

Key concepts for HIM

A
  1. Privacy
  2. Security
  3. Confidentiality
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6
Q 
– Records Management 
– Access and Disclosure
– Coding Specialist (HIM I)
– Data Analysis
– HI Manager (HIM II)
A

Traditional HIM Roles

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7
Q

– Deals with paper and electronic format (currently hybrid)
– form creation/management, documentation standards
– assembly and quantitative/qualitative analysis
– chart tracking
– storage, retrieval, protection, retention, and destruction of health info

A

Records Management ($19)

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8
Q

– May also be called Release of Information (ROI)
– Responsible for analyzing requests for patient information from various sources and responding appropriately
– Must be experts in all privacy laws, not just health privacy laws

A

Access and Disclosure ($28)

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9
Q

– Use software to classify patient information
– In some large facilities, coders will “specialize” in certain areas, but the move is away from this and towards “cross training”

A

Coding Specialist ($35)

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10
Q

Search ____ in job postings for HIM careers

A

HLTH

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11
Q

– Not an entry to practice position, but a career transition with experience
– Analyze patient information to answer questions posed by doctors, researchers, government, management, etc. regarding health trends, quality of care, patient outcomes, resource utilization statistics, wait times, and so on

A

Data Analysis (competitive)

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12
Q

– Often posted as HIM II

– May include regular HIM duties, but also includes managing staff and processes in an HI department

A

HI Manager ($32)

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13
Q

Most important stage as it provides direction for all HIM activities

A

Information Management Planning

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14
Q

Articulating a HIM strategy that links to the organization’s strategic plan and IT plan

A

First step in information management planning

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15
Q

What are the 7 phases of the health information cycle?

A 
information management planning
capture and collection
preservation
access, use, and dissemination
maintenance and protection
disposition
evaluation
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16
Q

What 8 factors should a HIM strategy address?

A
  1. security, access and privacy of HI
  2. legislations and regulations
  3. disaster recovery plans
  4. information sharing
  5. documentation and data collection requirements
  6. migration plan to EHR
  7. IT infrastructure requirements
  8. staff competencies and training needs
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17
Q

8 types of data collected in the capture and collection phase:

A
  1. clinical data
  2. administrative data
  3. research
  4. education
  5. risk management
  6. professional practice assessments
  7. legal events
  8. legislative data
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18
Q

Involves data integrity and data quality

A

the preservation phase

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19
Q

T or F. Data quality = accuracy of content, while data integrity = accuracy of chart context; right patient, right location, etc

A

True

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20
Q

One way to ensure preservation of data

A

data quality audits

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21
Q

Sharing of information that involves granting authorization to retrieve or receive data and then act on it

A

access in the access, use, and dissemination phase

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22
Q

Phase that ensures HI is kept current and secure

A

maintenance and protection phase

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23
Q

_______ have forced hospitals to take careful inventory of all the physical locations and HI systems where health information is stored

A

hybrid records

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24
Q

Involves setting retention schedules compliant with legislation, as well as setting physical and technical safeguards

A

maintenance and protection phase

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25
Q

The destruction phase of a health record

A

disposition

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26
Q

Disposition must include policies for ______ information stored electronically in medical equipment

A

resetting

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27
Q

Permanent and ongoing phase

A

evaluation

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28
Q

Phase that looks at the effectiveness of IM strategies, and incorporates changes in standards or legislation and IT

A

evaluation

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29
Q

Became an emerging field with computing advances where early applications were put into use in the 60s

A

Health Informatics

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30
Q

What are the goals of HI?

A

The well being of patients and efficiency in health care

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31
Q

HI may also be called MI, BMI, BMHI. Expand.

A

Medical Informatics (MI), Biomedical Informatics (BMI), and Biomedical and Health Informatics (BMHI)

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32
Q

What are the three domains and disciplines of HI?

A
  1. Biomedical Science
  2. Computer Science
  3. Behavioral Science
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33
Q

What are the four fundamental concepts of HI?

A
  1. data
  2. knowledge
  3. information
  4. modelling complex realities
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34
Q

observations and measurements

A

data

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35
Q

the relationships between data

A

knowledge

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36
Q

the result of interpreting data using knowledge

A

information

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37
Q

T or F. HI deals with direct and indirect data collection

A

true

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38
Q

information you may not get from the patient themselves; family, third party, etc

A

indirect data

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39
Q

machine acquired data (biosignal acquisition)

A

direct data

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40
Q

human acquired data

A

indirect data

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41
Q

Processing of health data can be divided into which 2 parts:

A
  1. applications designed to create knowledge

2. applications capable of degrees of use knowledge in decision-making processes

42
Q

Application that analyzes data in data warehouses

A

clinical data mining

43
Q

Applications like the Human Genome Project

A

bioinformatics

44
Q

Applications that increase the efficiency and quality of care

A

intelligent systems

45
Q

Applications with an “intelligent” approach to decision support in medicine

A

knowledge-based systems

46
Q

Applications that automate planning tasks

A

case-based reasoning

47
Q

Application that uses natural language processing to code from documents

A

automated coding

48
Q

Application that is more effective than human monitoring of repetitive tasks

A

monitoring and control system

49
Q

Study of the standards of right and wrong in human behavior

A

ethics

50
Q

The criteria we use to determine which actions are right and wrong

A

ethics

51
Q

What a person believes to be right or wrong

A

morals

52
Q

Beliefs important to an individual that guide their conduct and decisions

A

values

53
Q

May be external or internal

A

duties

54
Q

Duties where others depend on you to fulfil your responsibilities in your profession

A

external duties

55
Q

Duties based on your values and dictates the way you do something; accomplishing duties in a way that makes you proud or in the best way you can

A

internal duties

56
Q

Showing kindness to or doing good for others

A

beneficence

57
Q

Causing no harm

A

nonmaleficence

58
Q

Honoring an individual’s right to autonomy, being truthful, not withholding information from a patient about their own health (unless legally required), and honoring an individual’s decisions

A

respect

59
Q

What are the ethical principles of healthcare?

A
  1. beneficence and nonmalificence
  2. respect
  3. autonomy
  4. truthfulness
  5. fidelity
  6. justice
60
Q

A person’s right to self-determination (provided they are mentally competent and have all the facts)

A

autonomy

61
Q

Contributes to trust

A

truthfulness

62
Q

Withholding the truth works against ____.

A

autonomy

63
Q

Faithfulness or loyalty and adherence to your professional code of ethics

A

fidelity

64
Q

Proper and equitable distribution of healthcare resources

A

distributive justice

65
Q

Paying of compensation for wrongdoings

A

compensatory justice

66
Q

Acting in a fair and impartial manner

A

procedural justice

67
Q

What are three boundaries for health professionals?

A

patients, colleagues and hospital setting

bonus: gifts

68
Q

List the 6 ethical issues related to HIM Professionals.

A
  1. protection of confientiality and privacy
  2. documentation
  3. access and disclosure
  4. coding
  5. quality management
  6. EHR
69
Q

What is the standard used for concepts of privacy and confidentiality?

A

CSA Model Code for the Protection of Personal Information

70
Q

What are the principles of the CSA Model Code?

A
  1. accountability
  2. identifying purposes
  3. consent
  4. limiting collection
  5. limiting use, disclosure, and retention
  6. accuracy
  7. safeguards
  8. openness
  9. individual access
  10. challenging compliance
71
Q

Health Canada has developed the _______ to help guide organizations that manage personal health information as a guide for good practice

A

Pan-Canadian Health Information Privacy and Confidentiality Framework

72
Q

manipulating data that is reported in health indicators (ie wait lists)

A

performance data

73
Q

What is the full name of CHIMA?

A

Canadian Health Information Management Association

74
Q

What is the full name of AHIMA?

A

American Health Information Management Association

75
Q

What is the full name of HIMAA?

A

Health Information Management Association of Alberta

76
Q

What is the full name of IFHIMA?

A

International Federation of Health Information Management

77
Q

What is the full name of AMIA?

A

American Medical Informatics Association

78
Q

What is the full name of CAHIIM?

A

Commission on Accreditation for Health Informatics and Information Maanagement Education

79
Q

What is the full name of HIMSS?

A

Health Information Management Systems Society

80
Q

What is the full name of CNIA?

A

Canadian Nursing Informatics Association

81
Q

What is the full name of IMIA?

A

International Medical Informatics Association

82
Q

How many phases are there in the health infomation life cycle?

A

7 phases

83
Q

Involves data quality and integrity; may use audit to ensure this phase

A

preservation

84
Q

Ensures health information is current and secure; involves setting retention periods that are compliant with legislation, as well as setting safeguards

A

maintenance and protection

85
Q

Most important stage as it provides direction for all HIM activities; must articulate a HIM strategy that links to the strategic plan and IT plan of the organization

A

information management planning

86
Q

Granting authorization to retrieve or receive data and act on it

A

access, use and dissemination

87
Q

Includes retrieval of types of health data, including clinical, administrative, research, education, risk management, professional practice assessments, legal events and legislative

A

capture and collection

88
Q

Evaluates the effectiveness of HIM strategies; permanent and ongoing phase

A

evaluation

89
Q

Destruction phase

A

disposition

90
Q

List the four components of the HI pyramid.

A

data > integrity > knowledge > wisdom

91
Q

Which organization developed the Code of Ethics for HIM professionals?

A

CHIMA

92
Q

Provide an example of applications designed to create knowledge.

A

eCPS, textbook

93
Q

Provide examples of applications capable of degrees of use knowledge in decision making processes

A

decision making software that can help clinician consider next steps; an extra level of information application

94
Q

T or F. You may be morally opposed to the idea of a DNR note, but are ethically required to abide by the patient’s decision.

A

True.

95
Q

How are ethics and morals different?

A

Ethics refer to rules provided by an external source (codes of conduct; principles in religion) while morals refer to an individual’s own principles regarding right and wrong

96
Q

Provide other examples where ethics and morals may not agree.

A

Contraception, abortion, assisted suicide, etc.

97
Q

In what ways can documentation be an ethical issue?

A
  1. backdating progress notes

2. changing documentation to reflect outcomes of care vs what was actually done at the time

98
Q

In what ways can access and disclosure be an ethical issue?

A
  1. violation of the “need-to-know” principle
  2. secondary release of information
  3. storage of and access to charts with sensitive information
99
Q

In what ways can coding be an ethical issue?

A
  1. upcoding
  2. cherry picking easy charts
  3. workload expectations
100
Q

In what ways can quality management be an ethical issue?

A
  1. manipulating data that is reported on health indicatiors
  2. misrepresenting negative outcomes
  3. incomplete health records hidden in preparation for accreditation visits
101
Q

In what ways can EHR be an ethical issue?

A

protection of electronic data

7. HRSC 1 (7 decks)

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