Deck 3: Electronic Health Records

Question 1

Clinical decision-making systems can assist in the patient care process by all of the following EXCEPT:

A) Information on drug interaction
B) The availability of generic drug ordering
C) Possible side effects from drug usage
D) Patient compliance.

Answer 1

Patient compliance.

Question 2

The goal of HITECH to encourage health care entities to achieve meaningful use is to:

A) Save time and money.
B) Improve the quality of patient care.
C) Secure patient health information.
D) Do all of the above.

Answer 2

Do all of the above.

Question 3

Which entity fosters collaboration of the public sector and private sector through the "Connecting for Health" initiative to improve patient care by promoting standards for electronic medical information?

A) Institute of Medicine
B) National Committee on Vital and Health Statistics
C) Markle Foundation
D) Consolidated Health Informatics

Answer 3

Markle Foundation

Question 4

Which is a career opportunity for HIM professionals in information technology?

A) Project management
B) Design and development
C) Marketing and sales
D) All of the above

Question 5

HL7 is working to develop standards that will aid the exchange of electronic data in and among health care organizations by assuring __________ among computer systems.

A) Analysis
B) Interoperability
C) Indexing
D) Timeliness

Question 6

Sapphire Medical Center is ready to implement an EHR system. Currently its clinical laboratory and radiology department have an electronic system that is well established and interfaces very well. What may be Sapphire Medical Center's biggest obstacle?

A) Training new users
B) The interoperability of the new EHR system with the current clinical laboratory and radiology department EHR system
C) Securing patient information
D) Obtaining the EHR license

Question 7

Interoperability means :

A) The ability of software and hardware on different machines from different vendors to share data
B) Incentives for electronic health record (EHR) adoption
C) Computers are not able to communicate with each other
D) Physicians can operate from within a surgical unit

Question 8

Which of the following technologies is approved by HIMSS for EHR use?

A) CPOE
B) Bedside terminals
C) Handheld computers
D) All of the above

Question 9

The American Recovery and Reinvestment Act of 2009 (ARRA) funded legislation to encourage all health care entities to meet meaningful use standards in computerized health care records; this part of the legislation is also known as:

A) HIPAA
B) HITECH
C) Social Security Act
D) CCHIT

Question 10

Sam, the HIM Director at Providence Hospital, suspects that some of his employees have been viewing patient files that they are not authorized to view. What can Sam do to investigate?

A) Encrypt all employee passwords.
B) Perform an audit trail.
C) Interview each employee and hope that the suspect confesses.
D) Block all users from viewing patient records until the suspect is discovered.

Question 11

Heritage Hospital's health information department uses EHR for its laboratory department, but uses paper health records for the emergency department. This hospital is currently using a _____ Medical Record System.

A) Hybrid
B) Computerized
C) Paper-Based
D) None of the above

Question 12

The HIMSS definition of an electronic health record includes:

A) Provides decision-making capabilities
B) Collection of data
C) Real-time, point of care
D) All of the above

Question 13

Why is the use of bar codes important in an electronic health record environment?

A) It increases productivity.
B) It decreases errors.
C) It allows for uniformity of electronic reports.
D) All of the above are correct.

Question 14

Which goal of the ONC includes unified public health surveillance architectures and accelerated research and dissemination of evidence?

A) Inform clinical practice.
B) Interconnect physicians.
C) Personalize care.
D) Improve population health.

Question 15

A process that tracks the activity of users in the system, storing what the user accessed and when the user accessed it, is:

A) Integrity
B) Scanning
C) Audit trail
D) Digitized

Question 16

An organization that stores patient records electronically for which an affiliated health care entity treating a patient can gain access is called:

A) CPOE
B) HIE
C) EDMS
D) CDA

Question 17

Health Level Seven (HL7) is a:

A) Committee working on electronic health records for federal entities only
B) Committee established by the President of the United States to investigate the use of electronic health records
C) Health clinic for seven boroughs in New York City
D) Standards development organization whose domain is clinical and administrative data

Question 18

The ONC's strategic plan has how many goals?

A) One
B) Two
C) Four
D) Eight

Question 19

The following are examples of security measures EXCEPT:

A) Encryption
B) Password administration
C) Locked cabinets
D) e-PHI

Question 20

The greatest obstacle to convert to an EHR system is:

A) Employee dissatisfaction
B) Start-up costs
C) Space for unit
D) Patient dissatisfaction

Question 21

All of the following about the COLD system is true EXCEPT:

A) It is considered an EHR system.
B) Images are downloaded into the EHR format.
C) Document imaging files are attached and incorporated into the EHR.
D) Allows many types of images to be used.

Question 22

Hospital B has a medical record that has computerized the progress notes, physician orders, ancillary reports, and nursing notes. The coders must review the record and enter abstracting data into the coding system. What type of record is being used at this facility?

A) Paper record
B) Hybrid record
C) Electronic record
D) All of the above

Question 23

A collection of information from different databases, organized to be used for ad hoc reports and analytical research that may not include patient identifying information, is called the ___________.

Question 24

The group working to establish uniform standards for the electronic exchange of clinical health information among federal health care agencies is:

A) CMS
B) Consolidated Health Informatics
C) HIPAA
D) HITECH

Question 25

The laboratory department and radiology department of Hospital B have their own computer software programs that generate their departmental reports that automatically move to the HIM electronic record. These software systems communicate with the HIM software system through a(n):

A) Algorithm
B) Longitudinal
C) Interface
D) Integrity

Question 26

A formula or set of steps for solving a particular problem is called an __________.

Question 27

Data that are valid and have not been altered by human error, viruses, or software crashes are said to have __________.

Question 28

Active knowledge-making systems which use two or more items of patient data to generate patient specific advice are called clinical ________________ systems.

Question 29

What procedure sorts the reports by different report types electronically?

A) Bar coding
B) Indexing
C) Algorithm
D) Both a and b

Question 30

The result of a patient's treatment is called the ___________.

Question 31

What is a benefit to an interoperable system?

A) Eliminate the need for redundant tests.
B) More health care employees will have access to patient information.
C) Less training will be required to use the EHR systems.
D) Physicians will have to spend more time entering orders in multiple systems.

Question 32

The interface which grants patients web-based access to their medical record is known as a patient ___________.

Question 33

Manipulation of an electronic file by "scrambling" data in order to safely send it across the Internet to its intended recipient is called __________.

Question 34

Which is not an advantage of the electronic health record?

A) Accessibility
B) Standardization
C) Improvement in quality of health
D) Cost

Question 35

A framework that enables interoperability by using standard operating nomenclature, specifications, or protocols against geographical boundaries and among various entities is the __________.

Question 36

An open database that stores data from various independent sources that can be integrated to enable viewers to see documents from several sources is a ___________.

Question 37

The major components of the Health Information Portability and Accountability Act (HIPAA) include the following EXCEPT:

A) Appointing a security officer
B) Training of personnel on security measures
C) Physical protection of data storage devices
D) EHR implementation incentive

Question 38

The goal of the Office of the National Coordinator (ONC) is to develop a strategic plan to guide the nationwide implementation of an interoperable EHR in _____ sectors.

A) Both public and private
B) Private
C) Public
D) None of the above

Question 39

A way to authenticate electronic data such as a password or pin number is with a _________.

Question 40

Data ________ is used for revenue, clinical, operational, and outcome management.

A) Repository
B) Warehousing
C) Algorithm
D) All of the above

Question 41

A nonprofit group composed of providers, vendors, payers, consultants, government groups, and others working to develop standards that will aid the interoperability of the exchange of electronic data in and across health care organizations is the _______.

Question 42

According to the Markle Foundation, the two barriers to EHR implementation are __________ and ____________.

Question 43

The recording of clinical data at the time treatment delivered to the patient is called ___________.

Question 44

Two independent systems configured to communicate with each other are known to be _________.

Question 45

Explain the difference between the paper, hybrid, and electronic health record.

Question 46

A method used to identify records in an electronic system is called __________.

Question 47

A series of steps to produce a final result or outcome, which describes how the electronic record moves from one electronic component or work area (queue) to another, is called _______.

Question 48

Explain the difference between the terms interoperable and longitudinal.

Question 49

A patient's health care experience or a unit of measure for the volume of ambulatory
care services provided is the _________.

Question 50

If an unauthorized user gains access to e-PHI, the event is known as a _________.

Question 51

What lessons did HIM departments learn about paper health records management after the Hurricane Katrina disaster? List at least two lessons.

Question 52

How can an EHR system improve patient care? List at least three ways.

Question 53

A health care record consisting of both paper and electronic data is a ___________.

Question 54

Use of a scanner or a fax machine to store the paper document electronically into a computer program or onto an optical disc is called ____________.

Question 55

Name the three of the characteristics of an electronic health record according to the HIMSS.

Question 56

Match the following terms with their definitions.
a. ONC
b. ARRA
c. HITECH
d. HL7
e. HIE
f. NHIN
g. EDMS
h. CPOE
1. A health information system in which physicians enter orders electronically
2. Computer software and hardware, typically scanners, that allow health record documents to be stored, retrieved, and shared
3. The database of a network of health care providers (physicians, hospitals, laboratories, and public health organizations) allowing access to patient records within the network from approved points of care
4. A health information systems compliance organization whose goal is to standardize the collection of patient information in the electronic health care record
5. An executive division of the U.S. Department of Health and Human Services that coordinates and promotes the national implementation of technology in health care
6. A system of nationally shared health data, comprised of a network of providers, consumers, and researchers, that aims to improve health care delivery through the secure exchange of information
7. Also called the stimulus bill, 2009 federal legislation providing many stimulus opportunities in different areas. The portion of the law that finds and sets mandates for health information technology is called HITECH
8. A subset of the American Recovery and Reinvestment Act (2009) legislation providing federal funding and mandates for the use of technology in health care

Question 57

Health care delivery that uses clinical research to make decisions in patient care is __________.

Question 58

A term used to indicate electronic processing of the physician order process or workflow, which allows for prompts, reminders, or alerts when the order is entered, is called ___________. Orders are sent to ancillary departments to be processed.

Question 59

The electronic use of information that can flow electronically from one type of provider to another along the continuum of care and over time is called ____________.

Question 60

__________ is the ability of the software and hardware on different machines from different vendors to share data.

Question 61

The federal level authority responsible for the coordination of the implementation of a National Health Information Network is the ___________.

Question 62

What are the three private groups involved in establishing standards for EHR?

Question 64

Why is indexing an EHR important?

Question 65

What is the goal for the Nationwide Health Information Network (NHIN)?

Question 66

Identify different types of career opportunities in Health Information Technology as more health care entities transition to EHR? Name at least three.

Question 67

List the four major goals of the ONC.

Question 68

What are the different types of interoperability as outlined by the Institute of Electrical and Electronics Engineers?

Question 69

Explain the HITECH meaningful use incentive.