Deck 14: The Electronic Health Record

Question 1

A hospital client sees the nurse documenting information into the computer. She asks the nurse why the computer is better than the "old patient chart like hospitals have always used." Which of the following points would be accurate to say about an electronic medical record?

A)It captures the information needed for billing purposes.
B)It is more secure than a paper record.
C)More than one person can access the record at any given time.
D)The record is available when and where needed.
E)Data are in real-time, as things happen.

Answer 1

It captures the information needed for billing purposes.
It is more secure than a paper record.
More than one person can access the record at any given time.
The record is available when and where needed.
Data are in real-time, as things happen.

Question 2

The U.S. Department of Health and Human Services indicated that the ________________ is a digital collection of patient's medical history.

Answer 2

EHR (Electronic Health Record)
Rationale : The U.S. Department of Health and Human Services indicated that the Electronic Health Record is a digital collection of patient's medical history. Items included are:
1. diagnosed medical conditions
2. prescribed medications
3. vital signs
4. immunizations
5. lab results
6. personal characteristics such as age and weight

Question 3

Consumers are the primary source of information about their health history and medications. The patient-carried record (PCR) addresses this. Which of the following are potential problems associated with the PCR?

A)Loss of the record
B)Legibility
C)Portability
D)Privacy
E)Liability

Answer 3

Loss of the record
Legibility
Privacy
Liability

Question 4

The Bush administration called for the adoption of the electronic health record (EHR) by 2014 as a means to help transform U.S. health care. Who owns the individual client record when an EHR is used?

A)The client
B)Ownership is unclear
C)The institution at which the record is created
D)The health care providers who enter the data

Question 5

Which of the following is a major component of the computer-based patient record (CPR)?

A)Results reporting including unstructured data reports
B)Legal record created in hospitals and ambulatory environments
C)Support for links to local or remote information resources
D)Integration of all pertinent patient information into one record

Question 6

Which of the following statements is true about the benefits of the electronic health record (EHR)?

A)It improves the quality of health care.
B)Health care executives have developed strong organizational structures around the EHR.
C)The EHR fosters continuity of health care.
D)Little scientific evidence now exists on what benefits are actually delivered.

Question 7

Which of the following topics must be addressed when giving a presentation to physicians on the benefits of the electronic medical record (EMR)?

A)Easier access to previous documented encounters
B)Facilitation of clinical pathways
C)Chart access speed
D)Trends and graphics are not available on demand
E)Reduced liabilities through accurate documentation

Question 8

The electronic health record (EHR) has the potential to integrate all pertinent patient information into one record. It also has potential to improve the quality of health information, patient safety, and productivity, contain costs, support research, decrease wait time for treatment and contribute to the body of health care knowledge. Which of the following are reasons why traditional paper records on clients no longer meet the needs of today's health care industry?

A)Paper records are episode-oriented with a separate record for each client visit.
B)Key information may be lost from one episode to the next, jeopardizing patient safety.
C)Only one person can access a paper record at any given time.
D)Different versions of the same information may be stored in several places.
E)Paper records cannot incorporate diagnostic studies that include images and sound.

Question 9

The EHR offers benefits to nurses, physicians, and other health care providers, the health care enterprise, and most importantly, the consumer. Much must be done before the benefits associated with the EHR can be realized. Which of the following is one action that has been proposed by experts?

A)Health care professionals should institute major changes in the way they work.
B)Consumers need education to choose providers based upon appropriate financial and insurance considerations.
C)Individual consumers should have lesser responsibility for data.
D)Government intervention should promote information exchange among software vendors and health care systems.

Question 10

For many years the EMR applied to a single encounter with no ability, or very limited ability, to carry information from one visit to another within a care delivery system. That situation has changed; it is now possible to bring information forward from prior visits within the organization or delivery system. Which of the following answers are basic components of the EMR system?

A)Clinical messaging and e-mail
B)Results reporting
C)Decision support
D)Clinical documentation
E)Order entry

Question 11

Healthcare Information and Management Systems Society (HIMSS) has defined and described the term electronic Personal Health Record (ePHR). Which of the following are included in the HIMSS definition and description?

A)Universally accessible
B)Owned and managed by the individual (or legal proxy)
C)Usually considered a legal record
D)Common data set of electronic health information
E)Lifelong tool for managing relevant health information

Question 12

Electronic medical record (EMR) result reporting and data repository components include unstructured data. Which of the following are examples of unstructured data?

A)Automated laboratory results
B)History and physical
C)Consultation findings
D)Magnetic resonance imaging
E)A social services text report

Question 13

Unlike other health records the _____________________is patient-centered, presenting a more-balanced view of an individual's health history.

Question 14

Information in the electronic health record (EHR) may be owned by the patient or stakeholder. Which of the following about the EHR is different than the electronic medical record (EMR)?

A)It does not provide interactive client access.
B)Clients may append information if desired.
C)Dental records components are not included.
D)The EHR records and manages only episodic information.

Question 15

While most hospitals have some level of automation, few have attained a fully electronic environment. Health care Information and Management Systems Society (HIMSS) analytics created an EMR adoption model that identifies eight levels of EMR capabilities. Your hospital has been designated as a Stage 3 facility. Which of the following is accurate about an organization at Stage 3 level?

A)Computerized provider order entry (CPOE) and better EBP clinical decision support is available.
B)Some clinical automation exists.
C)Basic clinical documentation is required.
D)Major ancillary clinical systems are all installed (laboratory, pharmacy, and radiology systems).

Question 16

Which of the following are major impediments to the development of an electronic health record (EHR)?

A)Development of an electronic infrastructure
B)Confidentiality
C)Cost
D)Lack of a common vocabulary
E)Information system vendors

Question 17

Personal health record (PHR) security issues relate to HIPAA and physical security of data. HIPAA only covers PHRs provided by covered entities such as health plans, health care clearinghouses, and providers. No governmental coverage exists for other sites unless it is at the state level. To avoid these types of breaches, the American Health Information Community's consumer empowerment working group made a recommendation. Which of the following was recommended for PHRs in order to avoid breaches?

A)Deletion of sensitive data
B)Educating the general consumer about PHRs
C)Restricting the number of authorized users
D)A PHR certification process

Question 18

The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties. The Institute of Medicine (IOM) identified major components of the CPR that are considered to be the "gold standard" attributes. Which of the following are CPR components?

A)Lack of confidentiality
B)Direct entry for physicians will be available
C)Tools cannot measure cost
D)Provides sporadic access to data
E)Provides a patient problem list

Question 19

An emerging technology related to electronic health record (EHR) progress is the use of the personal health record (PHR). PHRs store client information that will eventually contribute to the development of a comprehensive, longitudinal record. Which of the following are found in a PHR but not found in the EHR?

A)Periodic risk assessment survey results
B)Herbal supplements
C)Legal documentation created in a hospital
D)Decision support
E)Health status parameters such as exercise

Question 20

Which of the following are found with the electronic health record (EHR) but are not found with the computer-based patient record (CPR)?

A)Evidence-based decision support
B)Assists with the work of planning and delivering evidence-based care
C)Quality management
D)Public health disease surveillance and reporting
E)Comprehensive lifetime record that includes all information from all specialties

Question 21

The computer-based patient record (CPR) is a comprehensive lifetime record that includes all information from all specialties. Most of the data included in the CPR is which of the following?

A)Structured data
B)Unstructured data
C)Fragmented data
D)Complete data

Question 22

_________________________ would permit the uniform capture of data required to build a longitudinal record comprised of integrated information systems from multiple vendors.

Question 23

The relationship between meaningful use and the adoption of the EHR in hospitals, physician offices, and other settings is best described as which of the following?

A)The meaningful use requirement must be considered before beginning the development process.
B)The meaningful use requirement is achieved with the adoption and use of the EHR system as part of the daily routine.
C)The meaningful use requirement is unique to every health care provider.
D)The meaningful use requirement and use of EHR systems are unrelated.

Question 24

The mere implementation of an electronic medical record (EMR) does not guarantee that benefits will be achieved. Which of the following can affect data integrity?

A)System failure
B)Data analysis
C)Data downloading
D)Data mining

Question 25

Which of the following are considered impediments to a fully functional electronic health record (EHR) system?

A)Development of an electronic infrastructure
B)Cost
C)Common vocabulary
D)Caregiver compliance
E)Privacy

Question 26

The goals of implementing the EHR in all health care systems are fraught with a number of roadblocks. The largest barrier facing most institutions is which of the following?

A)The lack of fully trained professional staff
B)A technology committee that cannot agree on the institution's needs
C)Indecision regarding the choice of vendors
D)Cost

Question 27

Which of the following statements about meaningful use is correct?

A)Meaningful use will provide invaluable information that will define the numbers of staff members needed at the bedside.
B)Meaningful use will provide invaluable information that will improve patient outcomes and population health changing many current practices as we transform our health care delivery system.
C)Meaningful use is an ongoing process and not an issue associated with the EHR.
D)Meaningful use is an issue that must be addressed before implementing any upgrade.

Question 28

Which of the following best describes the electronic medical record (EMR)?

A)Legal record created in hospitals
B)Legal record created by vendors
C)An electronic stand alone database
D)Method to identify outcomes