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Informatics > Electronic Health Records > Flashcards

Electronic Health Records Flashcards

1
Q

Electronic Health Record (EHR)

A

Electronic record of health-related information on an individual
Conforms to nationally recognized interoperability standards
Can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.

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2
Q

Qualified EHR

A

Includes patient demographic and clinical health information
AND
has the capacity to:
provide clinical decision support
support physician order entry
capture and query information relevant to health care quality
able to exchange electroni health information with and integrate such information from other sources

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3
Q

Functions of EMR

A
  1. Captures and enables use of data at POC
  2. Health Information Exchange
  3. Quality measurement, reporting, and improvement
  4. Supports clinical decision makeing
  5. Collects and integrates source data
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4
Q

3 Components of MU incentive program

A
  1. Certification Program whereby EHR technology is tested and certified as meeting standards and criteria.
  2. Standards and Criteria that certified EHR technology must meet
  3. Objectives and measures for earning incentives
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5
Q

Certification of EHRs

A

Oversight by ONC (Office of the National Coordinator for Health Information Technology)
Testing Laboratories are accredited by
*Americant National Standards Institute (ANSI)
*National Voluntary Laboratory Accrediaton program (NVLAP)

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6
Q

Standards that EHRs must meet

A

Address specifications for exchanging health information content,
vocabularies for representing health informaiont,
protection of health information created, maintained, and exchanged by EHR technology

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7
Q

Objectives and meausre for earning incentives

A

Defined by Centers for Medicare and Medicaid Services (CMS)

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8
Q

Stages of MU implementation

A

2011: Data capture and sharing
2013: Advanced clinical processes
2015: Improved outcomes

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9
Q

Priorities for adoption of EHR Technology

A
  1. Improve quality, safety, efficiency, and resude health disparities
  2. Engage patiens and their families in their healthcare
  3. Improve care coordination
  4. Improve population and phblic health
  5. Ensure adequate privacy and security protections for personal health information
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10
Q

Specific outcomes for EHR

A
  • Improve quality of healthcare
  • Enhance patient safety
  • Support health maintenance
  • Increase productivity
  • Reduce hassle factors
  • Support revenue enhancement
  • Support predicitive modeling
  • Maintain patient confidentiality
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11
Q

Improving quality of Health care with EHR

A

Data availability

Links to knowledge sources

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12
Q

Enhancing paitient safety with EHRs

A 
Context-sensitive reminders and alerts
clinical decision support
automated surveillance
Chronic disease managment
Drug/device recall capability
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13
Q

Support of health maintenance by EHRs

A 
Preventive care and wellness with reminders
Health summaries
Tailored instructions
Educational materials
home monitoring/tracking
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14
Q

Increased productivity with EHRs

A

Data capture and reporting formats tailored to users
streamlined workflow supprot
patient-specific care plans, guidelines, and protocols

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15
Q

Reduction of hassle factors with EHRs

A

Improve satisfaction for clinicians, consumers, and caregivers by managing:

  • scheduling
  • registration
  • referrals
  • medication refills
  • work queues
  • auto generation of administrative data
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16
Q

Support of revenue enhancement by EHRs

A 
Eligibility and benefit information
Cost-efficiency analysis
Clinical trial recruitment
Rules-driven coding assistance
External accountability reporting/outcome mx
Contract managment
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17
Q

EHR System components

A 
Hardware
Software
People
Policy
Process
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18
Q

4 main categories of information systems that comprise the EHR

A
  1. Sources systems that collect data, including administrative, financial, and clinical
  2. Core clinical systems that enable use of data at the point of care
  3. Supporting infrastructure that integrates data from applications internalk to a given care delivery organization
  4. Connectivity systems that support the integration of data across different organiatons and with patients or their caregivers
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19
Q

MPI

A

Master patient index

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20
Q

R-ADT

A

Registration - Admission, Discharge, Transfer

21
Q

PMS

A

Practice Management System (ambulatory)

22
Q

PFS

A

Patient Financial Services

23
Q

HIM

A

Health Information Management

24
Q

EDMS

A

Electronic Document Management Systems

25
Q

DIMS

A

Document Imaging systems

26
Q

ED/CM

A

Electronic Document content management

27
Q

OC/RR

A

Order Communication/Results Retrieval Systems

28
Q

LIS

A

laboratory information system

29
Q

RIS

A

Radiology Information System

30
Q

PIS

A

Pharmacy Information System

31
Q

PACS

A

picture archiving and communications systems

32
Q

POC charting systems and types of data

A

Clinical documentation systems

Structured data = discrete data : data tht have been predefined in a table or checklist or uses drop down menus

Unstructure data = narrative data

33
Q

POC charting systems

A 
Smart phones
Tablets
wireless on wheels /workstations on wheels
laptops
PDAs
34
Q

CPOE

A

computerized provider order entry

35
Q

CCR

A

Continuity of Care Record

36
Q

CCD

A

Continuity of care document rendered in xml or pdf using HL7 Clinical docuemtn Architecture

37
Q

CDR

A

Clinical Data Repository
Relational database intended to support direct care delivery functions
Can process many kinds of transactions

38
Q

CDS

A

Clinical Decision Support
Software that porocesses infoirmation to provide assistance with making a clinical decision
Embedded in EHR

39
Q

CPT

A

Current Procedural Terminology

40
Q

Executive decision support

A 
Standalone system that analyzes a large volume of aggregated data and provides trending information
Typically retrospective
Quality miprovement
Procutivity
Staffing
41
Q

CDW

A 
Clinical Data Warehouse
Advanced component of EHR
Database that has been optimized for analysis
Used for data mining
Used for predictive modeling
42
Q

PHR

A

Personal Health Record
Systems designed to suppport patient-entered data.
May be standalone or linked to provider

43
Q

Telemedicine

A

Use of medical informtion exchanged from one site to another via electronic communications to improve,l maintain, or assist patients health status.
Closely associated with telehealth
May include home monitoring

44
Q

HIE

A

Health Information Exchange
Seamless exchange of health informaton across disparate organizatons.
May be part of a format HIO - Health Information Organization
Maybe local, regional, or state
Supports the development of the nationwide health infomation network (NWHIN)

45
Q

AHIMA

A

American Health Information Management Association

46
Q

Integration

A

The task of linking inforamtion system comp0onents together to that they communicate and act as a uniform entity.
Information systems built on same platform are built to be integrated
Other wise systems integrators use various programming and process techniquest to integrate disparate systems.

47
Q

Interoperability

A

The ability of differen information systems and softare applications to communicate and exchange data

48
Q

Electronic Medical Record (EMR)

A

Electronic record of health related information on an individual
Created, gathered, managed, and consulted by authorized clinicians and staff withon one healthcare organization

Informatics (2 decks)

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