CHAPTER 3 & 4 STUDY GUIDE

Question 1

Know the difference between fee for value and fee for service

Answer 1

Fee for Value- value-based reimbursement models compensate providers not for the quantity of procedures performed, but rather for the quality of the care they provide, measured by patient health outcomes.

Fee for Service- billing for healthcare services after the services have been provided (retrospectively) according to the facility’s or office’s actual fees for each service.

Question 2

Be able to identify health informatic activities

Answer 2

Health Informatics- the practice of information and knowledge management across clinical healthcare and public health domains

Require technical expertise such as project management, systems management, programming, and database management. Other positions analyze and use the data created in an integrated computerized healthcare system. These include data analysts, reporting specialists, and biostatisticians.

Focuses on the processes of electronic exchange, digital storage, and the computerized manipulation of health data

Question 3

Know how medical records are filed

Answer 3

On-site Client/ Server solutions

Cloud-based solutions

Question 4

Know terminal digit filing

Answer 4

Terminal Digit filing- Breaking a medical record number into segments of single or multiple digits, with filing based on the last segment as the primary file placement, followed by the middle segment, and then first segment

Question 5

Identify centralized and decentralized registration processes

Answer 5

Centralized registration Process- type of hospital registration in which all patients presenting for any type of care are registered through one central area, regardless of the type of care being sought

Decentralized registration process- type of hospital registration in which there are multiple points of patient access, depending on the type of care being sought-inpatient admission, emergency department, outpatient diagnostics, ambulatory surgery, and so on

Question 6

Know the different methods of how medical record numbers are assigned

Answer 6

Medical Record Number- a unique numeric identifier for each patient seen in a health facility’ sometimes referred to as a health record number// is assigned medical record numbers are assigned sequentially by the computer system or manually during the registration process

Master Patient (Person) Index (MPI)- a permanent listing of all patients who have been admitted to or received care in a healthcare facility; it is the key to locating patient records in a facility and is maintained permanently

Back in the day the medical record numbers given to patients were their social security number

Question 7

Know the role of the HIM manager

Answer 7

Health Information Management (HIM)- is the practice of acquiring, analyzing, and protecting medical information to provide quality patient care, and until recent years, in a hard copy format

Role of a HIM- Health information managers are responsible for information governance, or ensuring enterprise-wide health data integrity, privacy, and security. Some of their main responsibilities may include: Implement processes and systems to support accurate and complete medical record documentation.

Question 8

Understand the patient perspective of how integrated delivery networks impact the patient

Answer 8

Integrated delivery network- a network of hospitals and physicians organized under a single parent company for the purpose of providing care across the full continuum of a patient population’s needs

Integrated delivery networks-

To capture efficiencies and saving from economies of scale by spreading costs over a larger base of operations
To efficiently integrate HIT and health information exchange into facilities
To better provide continuity of care to patients
To be better positioned for future changes to healthcare reimbursement
To better compete on quality and costs
To provide better care to patients by providing a full range of services on a timely and convenient basis

Provide one stop shopping offering all services that patients need, including primary care, specialists, and acute and long-term care, along with all support services

Question 9

Be able to put chart numbers in terminal number sequence (Page 107)

Answer 9

Terminal Digit filing- Breaking a medical record number into segments of single or multiple digits, with filing based on the last segment as the primary file placement, followed by the middle segment, and then first segment

Question 10

Define concurrent documentation

Answer 10

Concurrent means “happening simultaneously.” The concurrent health record is the developing health record that is compiled while the patient is hospitalized or being seen in an ambulatory setting.

Question 11

CAHIM health informatics- what is included

Answer 11

Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)- an independent accrediting organization whose mission is to serve the public interest by establishing and enforcing quality Accreditation Standards for Health informatics and Health Information Management (HIM,2014) educational programs (CAHIIM,2014)

Endorsed a health informatics curriculum at the graduate level, consisting of three parts:

1. Information systems
2. Informatic principles
3. Information technology

HIM is an underlying element that shapes all parts of health informatics allowing information to be used properly and effectively. Health informatics is built on top of this governed information and is focused on the resources, devices, and methods required for optimizing the-

acquisition
storage
retrieval
use of clinical and related patient data

Tools include not only computers but also-

clinical guidelines
formal medical terminologies
information & communication systems

Question 12

EHR

Answer 12

• EHR captures more information than an EMR and its designed to be exchanged and used at any point of care, following the patient, EHRS need to meet Meaningful use standards

Question 13

Portal

Answer 13

a secure website where a patient can access information from a provider’s EHR, such as diagnoses, lab results, discharge summaries, immunizations, and imaging study reports. a portal typically contains other information and functionality, such as the ability to schedule appointments, refill prescriptions, email clinicians, check insurance claims data, make payments and gain access to online forms

Question 14

MPI-Master Patient (Person) Index

Answer 14

• a permanent listing of all patients who have been admitted to or received care in a healthcare facility; it is the key to locating patient records in a facility and is maintained permanently

Question 15

HITECH

Answer 15

legislation resulting from the ARRA that provides incentives to providers and hospitals that adopt or upgrade existing electronic health record EHR systems and associated technologies and use them in specified ways.

• allocated $32 billion to revolutionize healthcare//consisting of $30 billion to Medicare and Medicaid incentive payments to physicians and hospitals to adopt and use health information technology (HIT) and EHRs in ways defined as “meaningful”
• anticipated the passage of the Affordable Care Act (ACA) as well as the acts specific goals of cost reduction through the introduction of new models of payment, improvement of care delivery and administrative processes, and improvement of quality through measurement and reporting.

Principle goals

		- increase the use of EHRs
		- establishment of a nationwide healthcare information system, and data analysis as well as reporting among hospitals, physicians, labs, pharmacies, clinics, public health         organizations, payers, and patients, 
		- make the fundamental changes that are required by ACA possible

Question 16

Meaningful use

Answer 16

The Section of HITECH meant to increase the effective use of electronic health records through monetary incentives to adopt and use certified technology.

Meaningful Use requirements ensure that EHRs are used to achieve benchmarks in improving patient care in a way that can support payment reform and reporting requirements in the future

Question 17

IDN

Answer 17

Integrated delivery network- a network of hospitals and physicians organized under a single parent company for the purpose of providing care across the full continuum of a patient population’s needs

Question 18

Administrative data

Answer 18

nonmedical data, such as a patient’s identifiers, insurance-related data, authorizations, and business correspondence

Question 19

CDI (Page 112)- (Clinical Documentation Improvement)

Answer 19

the review of health records, usually concurrently, to ensure that the documentation in the health record is at the level of specificity that allows for code assignment that accurately depicts the patient’s diagnoses and procedures performed

Question 20

mHealth (Page 83)

Answer 20

mobile-based or mobile-enhanced solutions that deliver healthcare

Question 21

Legacy systems (Page 74)

Answer 21

prior computer or business systems used to accomplish the tasks now accomplished by a new system’ often, legacy systems continue to be partially used during system upgrade cycles

Question 22

Change management (Page 71)

Answer 22

a structured approach for ensuring that changes in an organization are thoroughly and smoothly implemented and that the benefits of change are achieved

Question 23

Workflow (Page 71)

Answer 23

a well-defined sequence of activities undertaken in order to achieve a work outcome

Question 24

Personal health record (Page 82)

Answer 24

a paper record, a website, or software that contains information similar to that in an EHR such as diagnoses, medications, and medical history. the patients can also add information themselves, such as notes from other clinicians (ex-specialists) their personal notes and observations, and data from home monitoring devices or other sources. the patient or the patient’s caregiver determines who has access to a PHR

Question 25

WORM technology (Page 110)

Answer 25

WORM is an acronym for “write once, read many” meaning that records may be read numerous times, but nothing on the disk can be altered in anyway
Scanned records added to the EHR from optical disks cannot be altered, added to, or deleted.

Question 26

Jukebox (Page 114)

Answer 26

a means of storing multiple optical discs using a robotic arm that loads and unloads optical disks for delivery of requested health records

Question 27

Enterprise - health system

Answer 27

a great number of hospitals are apart of a health system

-health information is shared by each facility in the enterprise. Thus, an accurate complete master patient index is crucial

Question 28

Demographic data (Page 91)

Answer 28

administrative data that identify the patient- name, date of birth, address, and gender

Question 29

Project Management (Page 72-73)

Answer 29

the application of knowledge, skills and techniques to execute projects efficiently and effectively

Question 30

eSignature (Page 101)

Answer 30

a digitized signature placed on a chart entry through the use of a personal identification number (PIN)

Question 31

hybrid record (Page 96)

Answer 31

health record maintained in paper, electronic format, and or in the form of recordings or tracing derived from diagnostic tests

Question 32

record retention plan

Answer 32

a written policy that documents the length of time a health care facility retains its health records, the form (medium) in which the records will be kept, and the location(s) of the records

Question 33

regional extension center (Page 69)

Answer 33

an organization funded by the HITECH act to assist providers by extending EHR adoption training and support services, offering guidance in EHR implementation, troubleshooting related technical issues, and meeting Meaningful use

Question 34

Fax

Answer 34

Can easily fall into the wrong hands, which would be a violation of privacy

If you do fax patient information, make sure you are faxing it to a dedicated fax machine in a secure location and make certain

Yes. The Privacy Rule allows covered health care providers to share protected health information for treatment purposes without patient authorization, as long as they use reasonable safeguards when doing so. These treatment communications may occur orally or in writing, by phone, fax, e-mail, or otherwise.

Question 35

Be able to flow chart a patient from registration through the process of permanently filing the medical record (Page 98)

Answer 35

• patient is registered
• previous records are delivered to care unit if applicable
• documentation is written by physicians, nurses, therapists, and other healthcare professionals, and results of tests are filed in the record
• patient is discharged
• health record is assembled
• health record is analyzed for missing documentation
• physician(s) and other healthcare professionals complete missing documentation or signatures
• health record is reviewed again until it is complete
• record is permanently filed (until needed again)

Question 36

Concurrent Analysis is the same as?

Answer 36

Quantative Analysis

Question 37

On-site client/ Server solutions

A form of filing medical records

Answer 37

the use of computers in a network where functions are split between server talks and client tasks; the client computer makes requests of the more powerful server computer in order undertake local processes

the client computer runs the EHR software in a clinic, and the patient data and additional software supporting the EHR are stored on the server. In this case, Patient records are stored on a server in a secured area at the hospital or doctor’s office. Hospitals and most clinics use this model.

Question 38

Cloud- Based Solutions

A form of filing medical records

Answer 38

service in which software and data are stored on remote computers and accessed by a local computer through the internet, typically using a browser

Most EHR Vendors offer a hosted version of their EHR. Under this model, the client software is more or less the same, but the health data and application software is “In the cloud” being hosted on remote servers by the vendor and accessed via a secured internet connection. The provider does not have to maintain, secure, and back up a local server but does have to pay monthly fees to the vendor.

The second type of cloud solution is an EHR that is available only over the Web. This is a “pure” cloud-based solution and is accessed through a browser. Very little customization can be done with this type of EHR, and it is simpler than the cloud solutions offered by traditional client/server vendors. This pure cloud EHR is a cost-effective solution for smaller practices that cannot afford the EHR, server maintenance and customization expenses of the other solutions.