Deck 6: 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

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

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

Answer 2

Knowledge.

Question 3

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

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

Answer 3

Image

Question 4

Which is a transaction-oriented information system?

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

Question 5

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

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

Question 6

Which of these standards is not related to the others?

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

Question 7

Which data type is a discharge summary?

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

Question 8

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

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

Question 9

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

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

Question 10

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 11

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

Question 12

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 13

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 14

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.

Question 15

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 16

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 17

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 18

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 19

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 20

Which is a communication system?

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

Question 21

Which of these depend on the requirements and design features of the EHR product?

A) Legibility
B) Chronology
C) Understandability
D) Data organization

Question 22

There have been a number of barriers to successful health information exchange. Which of the following is tied to technology?

A) Business case
B) Privacy and security
C) Lack of funding
D) Competitive disadvantage
E) All of the above

Question 23

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

Question 24

Models for health information exchange have been designed to facilitate and share information between organizations. The HIE model that uses a point-to-point transport through a secure inexpensive connection is known as

A) Partner access.
B) End-to-end.
C) Internet.
D) Direct

Question 25

System migration plans are developed to

A) Plan electronic health record system upgrades.
B) Establish and implement communication strategies to prepare users for technology innovation.
C) Map out building blocks of IT applications moving toward organizational technology goals.
D) Move legacy systems out in a planned manner to accommodate new systems.

Question 26

According to a 2013 report to the Office of the National Coordinator, progress in health information technology, the pace of commitment to the adoption of electronic health records is

A) Moving forward at a steady pace.
B) Continues to accelerate.
C) Continuing to advance in hospitals, but more slowly in other settings.
D) Slowing in some settings in order to understand unexpected challenges better.

Question 27

There are several definitions of electronic health records. The definition that states "A qualified electronic health record is an electronic record of health-related information on an individual that include patient demographics and clinical health information, such as medical history and problem lists, and has the capacity to provide clinical decision support, support physician order entry, capture and query information relevant to health care quality, and exchange electronic health information with and integrate such information from other sources" is defined by

A) HIMSS.
B) Institute of Medicine.
C) AHIMA.
D) Federal Register: 45 CPR 170 Subpart B

Question 28

Examples of quality improvement benefits cited in electronic health record systems research include decreases in medication errors. This benefit is derived with implementation of

A) Clinical data repository.
B) Computerized provider order entry.
C) Provider communication system.
D) Pharmacy inventory system.

Question 29

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

Question 30

Computer processing of a natural language is called ___________________________________.

Question 31

Meaningful use is using certified EHR technology to accomplish the following with one exception, Identify the exception from the following.

A) Improve quality, safety, efficiency, and reduce disparities.
B) Engage patients and their families in their health care.
C) Improve population and public health.
D) Demonstrate applied standards.

Question 32

From a quality perspective, EHRs have resulted in which of the following?

A) System alerts prompt nursing staff to meet their schedule.
B) Medication processes are more streamlined.
C) Reductions in illegible order have been reduced.
D) Nurse time on direct patient care is increased after EHRs are in place.
E) a, b, c
F) All of the above

Question 33

Information contained in patient records continues to expand in content and form as the electronic health record replaces the paper record. Today records may contain which of the following types of information?

A) Text
B) Wave forms
C) Imaging studies
D) Chest films acquired and displayed in digital form
E) Monitoring data such as ventilator data
F) All of the above

Question 34

The paper record continues to be used as the health care industry slowly moves to health information technology. Many organizations will be transitioning to EHR products. In addition, many organizations will be working with hybrid records on their way to electronic versions. The paper record's weaknesses in legibility, chronology, understandability, and data organization are difficult to overcome. Which of these are most likely to be solved easily by technology? Check all that apply.

A) Legibility
B) Chronology
C) Understandability
D) Data organization

Question 35

Standards organization most known for their work in information transfer from one system another is

A) ASTM.
B) X12.
C) HL7.
D) NCPDP.

Question 36

What are prescribed statements called that are usually written as computer procedures, sets of conditions, or formulas and are useful to de?9?ne what roles certain individuals are allowed to carry out?

A) Policies
B) Procedures
C) Business Rules
D) Processes

Question 37

A(n) ____________ is an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part, or accessory which is recognized in the official National Formulary, or the United States Pharmacopoeia and is intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or is intended to affect the structure or any function of the body of man and does not achieve any of its primary intended purposes through chemical action within or on the body or by metabolic means.

A) reagent
B) medical device
C) antibiotic
D) MDS

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

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

Question 40

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

Question 41

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

Question 42

Name one use of secondary data.

Question 43

Write a definition of an electronic health record.

Question 44

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

Question 45

Health informatics is the science that deals with _________________, its ____________, ________________, and its _______________.

Question 46

An electronic health record system includes rules and procedures.

Question 47

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

Question 48

While many electronic health record systems include clinical data repositories, extracting data from the repository is difficult due to the way data is stored. Today, health care organizations employ data warehouses as alternative ways to store clinical data to make it more easily retrieved to meet enterprise analytics.

Question 49

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

Question 50

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

Question 51

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

Question 52

Name three key diagnostic or treatment devices that are not yet necessarily part of an organization's electronic health record system.

Question 53

The Medicare and Medicaid EHR Incentive Program is designed to engage providers to move forward with electronic health records and demonstrate they are used in a meaningful way. The program called for staged objectives, criteria, and measures to be met. Failure to meet all of the objectives within the specified time will ultimately mean the loss of federal reimbursement.

Question 54

Infrastructure refers to hardware, software, systems, __________________________, and data integration.

Question 55

An _________________ for a correction must be written by the document's author and includes additional information from the source document. An ______________is something that the patient requests.

Question 56

Explain how CPOE and Results Management work with ancillary applications within a functioning electronic health record.

Question 57

Meaningful use requires those who use an electronic health record to be able to collect data and report that data in line with quality of care measures identified by the provider organizations.

Question 58

Contrast a decision-support and an executive information system.

Question 59

Define "users" as related to health information systems.

Question 60

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

Question 61

There is no easy way to check for data and information consistencies in paper records.

Question 62

Health informatics and health information management professionals are challenged to understand, lead, and manage transition from paper records to hybrid records to a full electronic health record system.

Question 63

A key belief of PHR proponents is that patients who keep their own complete, updated, and easily accessible health records are taking a more active role in their own health care and participate in shared decision-making with their physicians.

Question 64

The most challenging and rewarding benefit from implementing electronic health record systems is improved workflow. Workflow can be described as the patient's step-by-step process used for the patient experience working through their health care visit.

Question 65

Medical devices can be portable or fixed.

Question 66

A medical device data system (MDDS) is able to transfer, store, or display medical device data.

Question 67

When printing from an EHR, the volume of paper used decreases.

Question 68

It is important to save different versions of documents because care decisions can be made at any point when the document is viewable.

Question 69

Producing an integrated health information system that does everything well is now easy to accomplish.

Question 70

Syndromic surveillance is the process of monitoring data that can identify when specific epidemiologic syndromes have been identified and action taken.

Question 71

Copy and paste refer to duplicating selected text or graphics and inserting it in another location, leaving the original changed.