Unit 4: EHR Formats and Data

Question 1

Digital Images

Answer 1

Digital X-rays, CT scans, pathology, and annotated drawings

Question 2

Text files

Answer 2

Word processing files, and transcribed exam notes

Question 3

Discrete Data

Answer 3

Fielded or coded data (structured data)

Question 4

Fielded data

Answer 4

each piece of information is stored in an assigned position called a field

Question 5

Coded data

Answer 5

Fielded data that also contains computer codes (for data mining and retrieval)

needs to adhere to a national standard for optimal interoperability

Question 6

Data capture

Answer 6

process of recording healthcare-related data in a health record system or clinical database

“garbage in, garbage out”
Ability of the EHR to function properly is dependent upon the quality and accuracy of data capture

Question 7

Direct data entry

Answer 7

keyboard, mouse, manual, etc.

Question 8

Hot spot

Answer 8

help message that is triggered when you hover your cursor over a data field

Question 9

Unstructured data fields

Answer 9

allow for free-text entry.

Ex: description of a procedure performed r a patients description of their medical history

Free-text complicates data retrieval, so structured data is preferred

Question 10

Structured data fields

Answer 10

guide the user during data entry and limit what can be entered in the field

Radio buttons, drop-down boxes, check boxes, etc.

Question 11

Drop down menus

Answer 11

offer pre-selected options so data entry is consistent between users and saves time so you don’t have to type out your selection

Question 12

Check box

Answer 12

allows multiple boxes to be checked

Question 13

Radio button

Answer 13

When only one of several option is allowed to be chosen

Ex: gender

Question 14

Numeric field

Answer 14

numbers that can be mathematically manipulated:
Age, weight, height
But not dates

Question 15

Date fields

Answer 15

allows valid, not correct, dates

Question 16

Time field

Answer 16

entry of valid times, preventing 26 hours in a day or 70 minutes in an hour, does not ensure the entered time is correct

Question 17

Auto-numbering

Answer 17

health record numbers are assigned to patients in numerical order

Question 18

Template based data entry

Answer 18

Cross between free text and structured

ex in a physical exam the field would direct the physician to enter review of symptoms, history of present illness, physical exam, impression, plan, and other required elements

The template helps to ensure that the required categories of data are captured

Question 19

Speech recognition

Answer 19

Technology that translates audio to text

The text may require editing since software isn’t perfect

Question 20

Data analytics

Answer 20

the science of examining raw data with the purpose of drawing conclusions about that information, which can then be used to make business decisions concerning services to provide and how to improve patient care

Question 21

Data analytics categories

Answer 21

descriptive, predictive, and prescriptive

Question 22

Descriptive data analytics

Answer 22

addresses the past to establish what has already occurred

Question 23

Predictive data analytics

Answer 23

addresses the future to predict what will likely occur

Question 24

Prescriptive data analytics

Answer 24

what to do with the information you have learned

Question 25

Data integrity

Answer 25

The extent to which health care data is complete, accurate, consistent, and timely About the data itself

Question 26

Data quality

Answer 26

reliability and effectiveness of data for its intended uses in operations, decision making, and planning All about data use

Question 27

Required Fields

Answer 27

a preset field in which data must be entered before the information system will allow the user to proceed Some fields may allow user override Required fields are the main reason EHRs are preferred over paper to avoid missing relevant data or information

Question 28

Edit checks

Answer 28

Pre-programmed definitions of each data field set up within the application Sometimes called flags Checks for illogical data such as a patients gender not matching a gender specific procedure (ask about trans patients?) ex: prevent a user from entering a body temp of 254C blood pressure as 543/87 flag as illogical

Question 29

Data quality management

Answer 29

the business processes that ensure the integrity pf an organization's data during collection, application, warehousing, and analysis collection refers to how data is gathered application is the reason for data gathering Warehousing refers to data storage Analysis refers to converting data to information

Question 30

Data Cleansing

Answer 30

process of checking internal consistency and duplication as well as identifying outliers and missing data check for errors such as duplicate patients

Question 31

Documentation integrity errors

Answer 31

when a revision is made to a report and it is not clear which is the most current version

Question 32

Patient identification

Answer 32

If patient A's info is mistakenly documented in patient B's record, potentially resulting in serious health problems

Question 33

Authorship

Answer 33

Data entry attributed to the individuals who recorded it. Important for tracking origin of mistakes and errors, legal purposes, also use of electronic signatures

Question 34

Dictation errors without editing

Answer 34

errors not edited out, incorrect words or medications

Question 35

Copying and pasting

Answer 35

Copy and paste speeds up data entry, but can accidentally be pasted into the wrong health record or not be correctly updated during a new visit for the correct patient

Question 36

Amendments to the health record

Answer 36

Files should be locked to changes and have to be unlocked to make amendments to prevent carryover info from incorrect patients Erroneous info should not be deleted but rather indicated and corrected with an indication as to who made the correction and when to keep a more complete record of mistakes for quality tracking and improvements Alternate versions of documents are the best way to do this, but must clearly indicate which is the most recent/up to date Previous versions can be important in court cases

Question 37

Copy and paste concerns

Answer 37

``` nullified entry entire record can be suspect health care practitioners may not notice extra or missing information if copying large amounts of text misrepresentation of a case patient harm fraudulent reimbursement claims ``` There must be checks and balances on copy paste, data integrity is ultimately more important that data entry speed