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Terms in this set (178)what does HITECH stand for Health Information Technology for Economic and Clinical Health what larger act does HITECH belong to ARRA- American Recovery and Reinvestment Act
define CCD continuity of care documemt- provides content and format specifications for exchanging referral informaion between providers (ASTM and HL7 together made the CCD) phr- define personal health record- electronic record of health -related info that can be accessed from multiple sources while being managed and controlled by the individual that conforms to national interoperability standards remote patient monitoring device- define device that enables provider to monitor and treat a pt from a remote location HIEO- define Health information exchange organization- organization that governs the exchange of health-related info among organizations according to nationally recognized standards consent directive -define allows patients to opt in or opt out of having their data exchanged in the HIE ACO- define accountable care organization- organization of providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned in the traditional fee-for-service program. A health reform mechanism that ties reimbursement to quality and costs. Patient-Centered Medical Home -define program to provide comprehensive primary care that partners physicians with the patient and their family to allow better access to healthcare and improved outcomes system -define set of components that work together to accomplish a goal IOM- define they provided early description of EHR---branch of the National Academy of Sciences whose goal is to advance and distribute scientific - knowledge with the mission of improving human health who developed the EHR-System Function Model HL7 ONC Office of the National Coordinator for Health Information Technology- provides leadership for the development and implementation of an interoperable health info technology infrastructure nationwide to improve healthcare quality and delivery (their task) the ONC falls within what governmental department? HHS- department of health and human services What is the difference between the EMR and EHR "EMR= electronic record of health-related info that can be created, gathered, managed, and consulted by authorized clinicians within one healthcare organization HIT - define technical aspects of processing health data includes classification and coding, abstracting, registry, development, storage. Encompasses not only the HER but other broader uses of into tech such as applications that support insurance info, billing, drug ordering, collection of pt demographics HIS hospital information sys. Comprehensive database containing all clinical, administrative, financial and demographic info about each pt PMS Practice management system- software designed to help physician practices run more smoothly- example = MEDISOFT collects pt demographic, insurance info, scheduling, and billing HIE define health information exchange- services that support sharing health information across different healthcare organizations telehealth- define delivers healthcare services remotely - remote monitoring devices, videoconferencing meaningful use - define ARRA/HITECH's rules that providers must follow in order to qualify for incentive payments for using the EHR when were meaningful use incentives started..what about the date set for sanctions incentive payments were started in 2011 and sanctions are set for 2015 EBM- define evidence-based medicine the practice of medicine utilizing guidance from research studies....in the absence of research practice guidelines may be used practice guidelines -define draws info from experts in the field who reach consensus on best practices (they use EHR at the POC (point of care) development of an EHR most often begins with acquisition of source systems source system -define systems that supply the EHR with data name the source systems administrative, financial, departmental (ancillary) systems why are financial/administrative systems not considered departmental systems they manage patient-specific data needed for all other applications and do not process data that aid in the management of the departments as departmental systems do list the financial/administrative systems R-ADT, PFS- patient financial systems, form creation systems what functions does a R-ADT do " for inpatient hospital: what is the physician's office equivalent o a R-ADT PMS- practice managemnt system or simply a scheduling system what is the function of the PFS(patient financial system) they aid RCM (revenue cycle management)- charge capture to collect info about services performed in departmental systems, claim generation for reimbursement, claims status inquiry and response- posting RA reflecting actual fees reimbursed and receiving electronic funds transfers RCM define revenue cycle all process relating to creating, submitting, analyzing, and obtaining payment for services given define business intelligence integration of financial and clinical data that supports business decisions what functions does a forms creation systems do automates some of the authorization, consent, advance directive, and other forms used. Captures e-signature, provides info to pt, and supplies a copy of the signed form to the pt what is the funciton of departmental/ancillary systems primarily to manage the department while at the same time prividing key clinical data for the EHR What are the 3 main departmental/ancillary systems necessary for an EHR to function in a hospital LIS (laboratory),RIS (radiology), pharmacy info sys what is the function of a LIS collects, stores, and manages lab tests and their results. It also performs quality control, maintains an inventory of equipment and supplies, and manages info on departmental staffing/costs.Speeds up access to test results. is blood-banking and clinical pathology part of the LIS no what is the function of a RIS collects, stores, and provides info on radiological tests. After receiving order it schedules the procedure, notifies the pt/personnel how to prep for the procedure, tracks procedure's performance, performs quality control, maintains inventory of equpment/ supplies, and manages staffing/costs what is the functions of a pharmacy info sys "info sys that aids: does the HIM department have its own information system? no..they manage some financial, admin, and support applications what are systems that HIM use that are not addressed by the EHR and so will remain chart deviciency sys, RIO sys, coding/abstracting sys what are the 5 main components/applications of an EHR results management; clinical documentaiton; closed-loop medication management; clinical decision support; analytics and reporting does meaningful use include E-MAR, barcode medication administration record, or support for E/M coding? no does meaningful use include CPOE yes what is the difference between results retrieval and results management systems results retrieval systems only allow results to be viewed and/or printed while results management systems allow the user to compare, trend, graph the results how must data be stored if the results management application is to be used data must be stored in a structured form and ideally stored together in one data repository define results management application that enables diagnostic study results (primarily lab) to be both reviewed in a report format and allows the user to process (trend,share, graph, compare) the data within the reports. what is another name for clinical documentation applications? point-of-care charting is a nursing information system considered a clinical documentation system? no it is considered a departmental system..similar to LIS or RIS because it manages the nursing department including staffing, training, budgeting and other managerial functions define clinical documentaiton system those applications that supply templates to the user to direct documentation that needs to be recorded for the patient to be completed primarily via point-and-click, drop-down, type-ahead, and other data-entry tools and that also provides a way to supply CDS at the time when the clinician is most responsive to alerts/reminders Is CPOE part of clinical documentation system? no..its considere part of the medication management system (pg 961) define closed-loop medication management system applications that help assure patient safety from the point a drug is ordered to the point it is administered what applications are considered part of closed-loop medication management systems CPOE, e-prescribing (e-Rx..which is a special type of CPOE), electronic medication administration record (E-MAR), or barcode medication administration record (BC-MAR), medication reconciliation systems, and automated drug dispensing machines......as well as policies/procedures and workflows associated with ensuring proper drug ordering, dispensing, administering, and monitoring of reactions. what is CPOE used for? used for entering ALL orders..not just medication orders (orders for pt admission, lab tests, consults, referrals, discharge of pt and medication orders) define alert fatigue providers ignoring alerts when there are an excessive number of them define unintended consequence and give an example unanticipated and undesired effect of implementing and using an EHR . A physician accepting a standard order when his patient's needs require something different and a bad result happens Which system generates a patient's medication list? CPOE What are some problems with CPOE use? physicians feel they now have to perform clerical duties and so don't use CPOE, alert fatigue, unintended consequences due to the CPOE being based on standard order sets what is e-Rx special type of CPOE used exclusively to make a prescription and transmit it electronically to RETAIL pharmacies what is included in the e-Rx medication alerts/reminders (like CPOE) formulary information that identifies whether the patient's health plan covers the cost of the drug and what co-pay may be required (unlike CPOE) what is a BC-MAR system that requires the hospital to have each patient identified with a barcode (wristband) and to package drugs in unit dose form , each with a barcode or radio-frequency identification tag that identifies the drug, dose, and route. When the nurse logs onto the BC-MAR system and scans the pt's wristband and unit dose pkg the system automatically time and date-stamps the entry made does the BC-MAR system provide CDS yes..provides links to info about drugs does the BC-Mar system generate reports? yes...on the timely administration of drugs..also has ability for nurse to write notes to describe exceptions what are some issues with the BC-MAR system somme specially compounded drugs administered IV require special labels which not all hospitals pharmacy information systems can accommodate..requiring data to be entered manually into the system; you have to bring the computer, barcode wand, and medication to the patient...this can be done via wireless workstation-on -wheels (WOW..which is heavy to push) or carrying a sling with a tablet and wand; the hospital needs to define what constitutes a medication error...a wrong time may not be due to error...the pt may have been unavailable during the administration time what application sets an EHR apart from simply automating paper documents CDS What does Clinical decision support do helps providers make decisions about patient care examples of Clinical decision support alerts about drug contraindications and out of range lab results and standard order sets in CPOE, templates that help determine what documentation is required, suggest less expensive but equally effective drugs and alternate treatments/protocols is the Clinical decision support built into the core applications of an EHR or is it a separate system? both. CDS found in core EHR applications if rudimentary, more sophisticated CDS requires the integration of data from the other EHR components...these require separate applications why would you need a separate clinical decision support system to provide information about drug-lab checking? because it is not a routine function of the CPOE (drug) or LIS (Lab) but requires the combination of the data from both sources and the ability to dliver the alert back to the correct system. what are some examples of separate CDSS that are integrated into the EHR templates used in clinical documentation, standard order sets used in CPOE, clinical pathways for nurses what is an example of a CDSS used in a stand-alone fashion by physicians differential diagnosis system...compares images or data against a library of images or data to help in diagnosing a condition what is an example of a CDSS used in a stand-alone fashion by a hospital system to alert infection control nurses of a potential hospital-acquired infection... why are many physicians adverse to use CDSS? because it requires data to be entered in a structured fashion and physicians don't usually like that--its a workflow issue what does analytics and reporting applications refer to? the statistical processing of data to reveal NEW information...such as which form of treatment for a specific condition had the best outcomes why is the ability of the analytics and reporting application to produce reports important? they are used to improve quality and reduce healthcare costs(find more efficient ways of doing things) what functions do analytics involve? data mining, forcasting, and neural networks( mathematical modeling that makes connections between data to discover relationships) who uses analytics? academic and research institutions, health plans, pharmaceutical manufacturers, and public health departments analytics is used to create XXXXX XXXXX , such as predicting prescribing paterns of physicians, or the impact of a disaster on local emergency services business intelligence what part of an HER does not support analytics and reporting the nature of the database required for POC charting and CDS...it is often necessary to data from an HER system to a separate database that is optimized to perform analytics and reporting what is analytics used for? quality improvement, quality reporting (core measures PQRI), used by insurance companies to decide whether to grant facilities favorable discount rates on fees, consumers use analytics to decide which facility to have procedures done at (success rates of procedures), research for new/better outcomes for procedures/medications, can also be used to generate a patient follow-up list what is a specialty system system that supports documentation of patient care in specialty areas such as ICU, ED, respiratory therapy, rehab, behavioral and hospice care what is a type of speciality information system PACS- picture archival and communication system-captures digital images and provides special viewing capabilities of these images from a computer
what is medical device integration technology that would allow the integration of automated medical devices (fetal monitoring strip, vital signs monitors, cardiac output monitor, ventilators, infusion pumps) into an EHR. what is supporting infrastructure technology that allows the various applications to work (hardware, software, policies/procedures) connectivity systems define systems that enable the exchange of data across separate information systems both within and across organizations what provides connectivity services? systems integrators, registries, and health informaion exchange organizations what are the 'big 3' ancillary systems needed to support the majority of clinical processes LIS, RIS, and pharmacy information system define portal web page that offers secure access and allows data entry upon authorization of user what was EDMS called at first? DIMS- document imaging management systems what is EDMS electronic document management systems-involve scanning documents to turn them into digital documents. Some include barcoding. This system can manage many types of documents including e-mails and faxes is EDMS part of an EHR? no..it is part of a hybrid system what does it mean to say that EDMS has workflow support? EDMS will send notifications out when certain jobs need to be done at the correct time what is electronic signature authentication systems that requires the user to log into the system using a password and user ID, review the document to be signed, and indicate approval...the system annotates the date and time that the document has been signed define implementation system has been installed and configured but the staff are still experimenting with it/learning how to use it and the new workflows define adoption a state in which every intended user of the EHR is using the basic functions of the system define optimization activities that extend the use of the EHR beyond the basic functions....usually involves changes in clinical practice define clinical transformation profound change in how medicine is practiced due to significant changes in technology what are some challenges that must be over come for EHR adoption cost, questions about their true benefits, workflow changes, productivity impact, and unintended consequences define cloud computing delivery of computing resources (software) over a network and sold as a metered service..much like buying electricity why do some facilities prefer cloud computing for an EHR it lowers the cost...although customization is not possible at the lower cost can facilities expect much financial return for installing/using an EHR? no..they consider it a cost of doing business...the only area where hospitals see cost savings/return on investment is in administrative areas....storage of paper charts/warehouse costs are reduced, number temporary and overtime hours is reduced (to manage paper records) how is productivity affected by an EHR? productivity falls while people get used to the new system but after optimization productivity is elevated over past performance what is the purpose of the Safeguarding Access for Every Medicare Patient Act (SAFE Medicare Patient Act) give legal protection to medicare/medicaid providers who participate in the MU incentive program to help ensure patient safety due to unintended consequences. It would also create a system for reporting errors and potential errors that occur when using the EHR or HIE define HIE plan in which health information is shared among providers describe the function of an HIO manages patient identity, record location and security --including consent directives where patients opt in or opt out of having their data exchanged through the HIO list the types of HIE (HIEO) models federated, consistent federated, consolidated (centralized) describe the federated HIE model "*no central location of data describe the consolidated HIE model "*data is stored in one large database describe the consistent federated model "it's a hybrid model HITECH deemed the HIO as a ____ ____under HIPAA. business associate True /False the HIO requires all participants to sign a participation agreement that spells out the policies and procedures for exchanging information TRUE what is an identity matching algorithm? a way to match a patient with their data in an HIO what is voluntary universal health identifier unique patient identifier what are critical services an HIO must supply patient identification (identify matching algorithm), record locator service, identity management, consent management what is a record locator service? locates alll patient medical records for one person what is identity management? it is NOT patient identification. It provides security including determinating who or what information system is authorized to access information, authentication services, audit logging, encryption, and transmission controls what is consent management? allows patients to opt in or opt out of having their data exchanged in the HIE what is does a NHIN (national health information network) do provides technology to support the national health information infrastructure what act made the ONC permanent? HITECH when do sanctions for not having an EHR begin? 2015- they won't get the full medicare reimbursement rate meaningful use has 3 parts..what are they "standards for MU of EHR define meaningful use criteria, set by ARRA/HITECH that providers must meet in order to qualify for incentives for using EHR describe the first part of MU-standards for MU of EHR? a certified EHR is connected in such a way that allows for the electronic exchange of health information that includes vocabulary standards to ensure consistent meaning. describe the second part of MU- certification that EHR tech meets standards criteria EHR has to be certified by an entity approved by the ONC an ONC authorized testing and certifying body What is CCHIT certification commission for ehalth information technology...it certifies HER are products certified by the authorized ONC entity complete EHR? they can be complete or they can be modular...modular components meet one or more but not all of MU requirements and so providers must combines modular products to have a complete system to meet incentive criteria does meeting the MU requirements mean that you have a complete EHR system? no...the requirements do not include all the core components for an EHR ...examples include BC-MAR, ambulatory practices are not required to have physician progress notes, describe the third part of MU-criteria for earning MU incentives identifies the extent to which the functions of the EHR must be used in order for hospitals or physicians to meet meaningful use their ERH technology must meet 3 things..what are they technology must be certified, interoperable, and used in a meaningful way
who specified the criteria for the MU? CMS what is a patient portal? software that allows a patient to log on to a website from home or a kiosk in a providers waiting room to schedule appointments, pay bills, obtain educational material, sign informed consents, request ROI, or enter their own health history what is an e-visit existing patients can exchange e-mail in lieu of visiting the physisican for follow-up or recurring care needs PHR what is it personal health record- electronic record of health -related info that can be accessed from multiple sources while being managed and controlled by the individual that conforms to national interoperability standards what is the CCR/CCD continuity of care documemt- provides content and format specifications for exchanging referral informaion between providers (ASTM and HL7 together made the CCD) who made the ccr? ASTM international what was combined to make the CCD? ASTM's CCR along with HL7's CDA(clinical document architecture) What is HL7's CDA? an XML-based standard that provides structure (description of document content for users), vocabulary standards (SMOMED and LOINC), and codes for sharing clinical documents how may the CCD be transmitted? HL7 standard messages, email attachments, or standard internet file protocol (FTP) define DBMS database management systems are software applications that organize, provide access to, and manage a database what is a flat file earliest form of a database. Stored data in plain text where each line of text holds one record with fields separated by delimiters (tabs/commas). There are no folders/paths in which to organize files what is a relational database stores data in predefined tables that contain rows and columns similar to a spreadsheet. Each talbe is a set of rows and columns that relate to one another CDR what is it Clinical Data Repository a special kind of relational database What does a CDR do? it manages data from all sources in a facility--helps to combine data from multiple source systems into one location for easier processing what is another name for a CDR? transactional databases what is a CDW clinical data warehouse. May be a relational database but more often it is a hierarchial or multi-dimensional database. what is the purpose of a CDW to support online analytical processing (OLAP) what is the difference between CDR and CDW? "CDR= uses structured and unstructured data. It is optimized for online transaction processing (OLTP) which is transactions
relating to patient care. Is often included in EHR what does data storage refer to? the type of media, location, and length of time the contents of a database are kept define- data exchange standards/message format standards protocols/rules that help ensure data transmitted from one system to another remain comparable ex. 042187 will be recognized by both systems as the patient's record number NOT his birthday what is the difference between relational and hierarchial/multi-dimensional databases relational databases store each piece of data only once while hierarchial and multi-dimensional data may purposefully duplicate data HL7 Health Level 7 - message format standards that aid in the exchange of health data among hospital and physician systems. Used by almost every EHR vendor in the US DICOM message format standard that helps exchange clinical images such as x-rays, CT scans and so on NCPDP message format standard that helps the exchange of prescriptions from a physician practice e-Rx system directly to the retail pharmacy information system ANSI accredited standards Committee X12 ASC X12 is a message format standard for the health claims that professionals (physicians) send out to 3rd party payers define data comparability the meaning of a term is consistent across all users how is data comparability achieved? vocabulary standards what is the difference between message format and vocabulary standards message format standards are rules that ensure data transmitted from one system to another remain comparable while vocabulary standards ensure standardized meaning of terms define controlled vocabulary a specific set of terms for specified data is used and any changes must be formally approved...... SNOMED what is it a vocabulary standard that was originally developed by American College of Pathologists...it is now freely available to US vendors as the basis for clinical data dictionaries in EHR systems. LOINC what is it vocabulary standard that is used for lab test results RxNorm what is it standardized nomenclature (vocabulary standard) for clinical drugs and drug delivery devices NDC what is it vocabulary standard for drug inventories in pharmacies architecture define refers to the configuration and relationships of all components of a computer system two main types of hardware infrastructure/architecture in an EHR
"Client/server architecture-uses combination of computers to capture and process data...servers are powerful computers that house all application software that serve client computers data center define area where servers are kept...the area needs special temperature, humidity and power controls server redundancy with server failover...what does this mean? at least two if not more servers are performing the same processing on data simultaneously. If one server goes down, processing is still occurring at another server....users are not interrupted define client computer that users use to retrieve and enter data define thick client information system with full processing capabilities thin client computer with minimal processing capability but no storage(memory) list and describe 3 human-computer interfaces (technologies that make data capture easier) "structured data entry via point-and-click, structured templates. These devices include the mouse, and touch screens migration path...define strategic plan that outlines the major components and the order in which they are to be implemented (EHR) what are factors that should be considered when planning EHR implementation? "*total cost of ownership/budget- cost of hardware/software, cost of consultants, construction, furniture list and describe data quality entry issues "*copy and pasting- while this makes entering data faster it is easy to paste incorrect data into the record what is a plan to provide access to content of previous visit info in an HER? chart conversion what is a strategic plan that identifies applications, technology, and operational elements needed for the overall info technology program in a health organization migration path potential problems with reuse of data (copy/paste) in an HER correcting entries is required, documentation compliance, privacy Sets with similar termsSayles, HIMT Chapter 16 - Electronic Health Records80 terms KathyPotato Health Information EHR176 terms bmgilli HIM 229 TEST 193 terms jamienh24 Data Management and Health Care Technology102 terms howarja Sets found in the same folderElectronic Health Record Practice Exam62 terms Dextanesha Electronic Health Records Drill Questions49 terms PSTUBEOC NHA - Certified Electronic Health Record Specialis…150 terms catherine_canario Electronic Health Record121 terms sndelgado89 Recommended textbook solutionsPharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 388 solutions
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Which of the following EHR functions may contribute to unintended consequences for a patient Quizlet
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