HIM 230 Test 3 Chapter 16 Part 1

rad2329's version from 2018-03-21 16:52

Section 1

Question Answer
EHR Definition (don't need to memorize)“a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support, links to bodies of medical knowledge, and other aids”
CCDContinuity of Care Document
*Continuity of Care DocumentA set standard that physicians have agreed upon to exchange referral information between providers.
*Define HospitalistA physician dedicated to hospital-based care services.
Health Inrofmation Technology (HIT)Term used to describe the use of information technology in healthcare (interoperability)
*Source System A system of applications that supply the EHR with the different types of applications and data needed to operate/populate/build the EHR
*What are the Source Systems on the Administrative or Financial applications that feed and provide the data for the EHR?1. Registration, admission, discharge and transfer syste (R-ADT) - 2. Patient Financial systems (PFSs) -
Registration, admission, discharge and transfer syste (R-ADT)Feeds the data for that master patient index.
Patient financial systems (PFSs) ?Aid revenue cycle management (RCM) used for Billing, claims, remitance payment.
First type of Clinical systems that will populate the EHR Laboratory Information system (LIS)

Section 2

Question Answer
1a..Laboratory Information system (LIS)Take in orders for the lab tests, perform all of the lab tests, and electronically send out the results, keep an inventory of equipment/supplies
Radiology Information SystemAssist in documentation of procedures that have been conducted in radiology, manage supplies,
Pharmacy SystemOrders the drugs, checks for allergies, directs staff in componding any drugs, Aids in despensing the drug (right dose and route.
***Know for test 3 Main clinical systems that populate the EHR1. Laboratory Information system (LIS) 2. Radiology Information System 3. Pharmacy System
Admin financial taling aboutADT,
**Must know for test - 5 main components to have a fully EHR system?Results Management - Clinical Documentation - Closed-loop Medication Management - Clinical Decision Support - Analytics and Reporting
**The first main necessary component to be able to run an EHR isResults Management
Results Management isAny type of diagnostic studies that have been processed (May use graphs). Need to be able to retrieve and print results.
Results Management is able to have 24/7 week access to those results of any type of precedure that has been processes, interpreted, given meaning. A powerful, very important part of the EHR
Clinical Documentation (Point of Care Charting)Those that supply templates to the user to be completed primarily via point-and-click, drop-down, type-ahead, and other data-entry tool, so that all staff can access it.

Section 3

Question Answer
***Closed Loop Medication ManagementA system that ensures patient safety, because the physcian has put in the order and links directly to the e-prescribing (RX system), Pharmacy will check for allergies/dosage, and will interact with the eMAR barcode system
**Clinical Decision SupportAssists physicians, nurses, and other clinicians make decisions about patient care such as: Provides documentation of clinical findings and procedures
Clinical Decision SupportProvides documentation of clinical findings and procedures
Protocols help to assess the patient for certain health maintenance procedures
Analytics and ReportingFinal core EHR applicaion. Analytics refers to statistical processing of data to reveal new information. (data mining, forecasting)
What is the 5th core EHR application? page 967Using statistical processing (data mining), to run reports to see what types of patients are in the facility what they were seen for and what type of outcomes. ***Helps us improve quality and reduce costs.
If facility is accredited what type of reports might you have to run to benchmark your facility?Analytics and Reporting
PACSsPicture archiving and communications systems
PACSs areA specialty information that captures digital images from various modalities, such as x-ray, ultrasound etc. May connect directly with a radiology information system.

Section 4

Question Answer
Name a source system.Laboratory information system
TextualNarrative of clinical documentation
ContextualThe condition of depending on the parts of a written or spoken statement that precede or follow a specified word or phrase and can influence its meaning or effect.
What is a transition technology used by many hospitals to increase access to health record content during the evolution to EHR?EDMS
What are the IOM key capabilities of an EHR system?1. Health information and data 2. Results management 3. Order entry/management 4. Decision support 5. Electronic communication and connectivity 6. Patient support 7. Administrative processes 8. Reporting and population health management
HIE requires:Policies and Procedures for exchanging health information - Security utilities - Matching algorithm - Record locator service.
What are the Federal government initiatives and framework for the EHR?Health Insurance Portability and Accountability Act (HIPAA), Office of the National Coordinator (ONC), Health Information Technology for Economic and Clinical Health Act (HITECH)
The ONC (Office of the National Coordinator) supports ___?National health information network.
*What are the Source Systems on the Clinical side that feed and provide the data for the EHR?1. Laboratory Information system (LIS) 2. Radiology Information System 3. Pharmacy System
CPOE - Can be used for entering all kinds of tests, (xrays, therapies, consults), has alerts/reminders built in for the physician.