Deck 5: Electronic Health Record Systems

Question 1

Select the best example of the electronic health record (EHR) documentation principle of integrity in action:

A) Physician is authenticated using a password each time he or she accesses the EHR system.
B) When a transcribed report moves from the vendor's dictation/transcription system to the facility's EHR system, the document's content remains the same as when it was transcribed.
C) The EHR system notifies the physician user of possible drug interactions when an order is placed.
D) The EHR data dictionary defines the fields used in a medical record review.

Answer 1

When a transcribed report moves from the vendor's dictation/transcription system to the facility's EHR system, the document's content remains the same as when it was transcribed.

Question 2

Internet-derived technologies are used in applications that communicate:

A) Between individuals in separate organizations using the public transport.
B) Between individuals and published Web sites of all kinds using public transport.
C) Internal and external applications using public transport and institutional Intranets.
D) All of the above.

Answer 2

All of the above.

Question 3

You are a clinical data specialist in an ambulatory care facility that has a newly implemented electronic health record (EHR). You notice that certain clinicians are copying and pasting discharge summaries written by others from partner hospitals into their patients' records. You are concerned and write an "issues brief" for the next EHR steering committee. Which of the following points will you include in the issues brief?

A) A definition of copy/paste
B) The benefits and risks of copy/paste
C) Medical record plagiarism
D) a, b, and c

Answer 3

a, b, and c

Question 4

In an electronic health record system, how are chest x-rays processed?

A) Image
B) Video
C) Drawing
D) Signal

Question 5

Which of these standards is not related to the others?

A) HTML
B) LOINC
C) XML
D) XForms

Question 6

A business rule applied to an electronic health record system would:

A) Specify who can make entries in the record.
B) Use judgment waive fees for release of information from the record.
C) Set the format for monthly record deficiency reporting.
D) Compare costs of care for similar diagnoses.

Question 7

You are a supervisor for the release-of-information unit in a medium-sized urban hospital. You notice that the unit is receiving an average of 100 requests a month from the Social Security Administration (SSA) for disability claims. What action and recommendation would you bring to the health information management director?

A) Analyze the work flow and amount of time it takes for a clerk to process an SSA request for information and calculate the extra amount of needed full-time equivalent time.
B) Analyze the work flow and distribute the SSA requests equally among the clerks.
C) Analyze the type of documents the SSA is requesting and create a designated record set to meet their needs.
D) Analyze the work flow and the type of documents the SSA is requesting and set up a time to meet with the SSA representative.

Question 8

Which data type are International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) codes?

A) Text
B) Alphanumerical
C) Image
D) None of the above

Question 9

Which of these languages is used frequently today for querying databases?

A) JAVA
B) MUMPS
C) Visual Basic
D) SQL

Question 10

Duplicate patient numbers management uses a deterministic method when it includes:

A) Full patient name and date of birth.
B) A specific data set in which all data elements must match.
C) Selected data elements.
D) Specified data elements that are either an exact match or a partial match.

Question 11

Which benefit can be realized from computerized health information systems?

A) Efficient use of personnel time
B) Improved presentation of data
C) Improved screening and tracking of patient care outcomes
D) All of the above

Question 12

Which is a transaction-oriented information system?

A) REG-ADT system
B) Decision-support system
C) Executive information system
D) Data security system

Question 13

All the following are types of electronic networks that link databases except:

A) Internet
B) E-mail
C) LAN
D) WAN

Question 14

Which data type is a discharge summary?

A) Text
B) Image
C) Numerical
D) None of the above

Question 15

Which is a communication system?

A) Electronic mail
B) Expert
C) Point of care
D) Encoder

Question 16

When determining how long you must retain paper or computerized health information and health records, you consult:

A) Your organization's legal counsel.
B) Your state laws.
C) Centers for Medicare and Medicaid Services guidelines.
D) All of the above.

Question 17

Expected electronic health record functions include:

A) 24/7 availability
B) Links to external databases
C) Computerized practitioner order entry
D) All of the above

Question 18

The formulation of the relationship among elements of information and data is:

A) Rules.
B) Alerts.
C) Knowledge.
D) Decision support.

Question 19

Which of the following systems generate patient data at the point of service?

A) Picture archiving and communication system (PACS)
B) EIS
C) REG-ADT
D) Expert system

Question 20

Which of the following combine data with analysis tools to facilitate "what if" questions for posing future optional scenarios?

A) Expert system
B) Executive information system
C) Decision support system
D) Both b and c

Question 21

A repository of selected electronic information from several transaction systems such as clinical laboratory and dietary is called a(n) ____________________.

Question 22

Contrast a decision-support and an executive information system.

Question 23

Persons who rely on computer systems to perform their job are called ____________________.

Question 24

Computerized health information systems have demonstrated a reduction in health care costs.

Question 25

Successful selection and implementation of electronic health records requires that key barriers be addressed. Identify three barriers.

Question 26

Write a definition of an electronic health record.

Question 27

Identify and discuss three overlapping benefits of health information systems in health care organizations.

Question 28

An electronic health record system includes rules and procedures.

Question 29

Name one use of secondary data.

Question 30

A repository of electronic information about a single patient compiled during an inpatient stay is called a(n) ______________________________.

Question 31

Knowledge-based systems are used for problem solving and patient monitoring.

Question 32

An information system that provides diagnostic assistance and expert resources to direct care providers is called a(n) ___________________________________.

Question 33

Infrastructure refers to ____________________________________________________________.

Question 34

Authorized users can access transcribed radiology reports and digital diagnostic images in radiology databases by a Web server using web browser.

Question 35

Computer processing of a natural language is called ___________________________________.

Question 36

What is meant by an on-line transaction processing system and what role does it play in achieving information systems benefits?

Question 37

A patient record contains selected data elements for nonclinical uses called ____________________ data.

Question 38

When considering how users retrieve information from an electronic health record (EHR), implementers should consider:

A) Document titles.
B) Templates.
C) Copying and pasting.
D) Timeliness.

Question 39

Define "users" as related to health information systems.