PD 4 - Exam 1 Flashcards
What is health IT? What are the 2 different forms?
Allows healthcare providers to collect, store, retrieve, and transfer information electronically
Passive - information storage
Active - patient reminders, prescribing alerts, etc.
What are the 3 categories of health IT?
Administrative and Financial: Payroll, patient registration, patient accounts, scheduling, supply management
Clinical Systems: Electronic Health Records (EHR), provider orders, remote patient monitoring, e-prescribing, drug interaction checks, e-mail, patient portals
Infrastructure: computers, servers, internet service, handheld devices, barcoding information
What is interoperability?
Extent to which systems and devices can EXCHANGE data and INTERPRET shared data
What are the 3 levels of interoperability?
foundational: think faxing
structural: think sending across a hospital system
semantic: all information is already seen and interpreted
What are the 3 different kinds of EHR templates?
templates - pre-structured portions of software for common or basic data
structured - give framework for data entry
unstructured - free-form data entry
**What is the electronic medical record for clinicians composed of?
Digital version of paper chart in a clinician’s office
Info collected by and for the clinicians in that facility
Primarily used for dx, tx, and preventative care
May NOT have all records from all providers
Clinical-related functions
Confidential notes/reminders
How can patient accesses their patient health records?
To be accessed and managed by pts
May be presented as a patient portal
What is the electronic health record?
all components of EMR and overall health information for a given patient
and gives a broader view of the patient’s care and is meant to follow the patient from practice to practice
What is the purpose of CPOE? Computerized Provider Order Entry
Designed to replace facility paper-based ordering systems and can electronically write a full range of orders
includes electronic medication administration record and helps providers follow less expensive alternatives or hospital protocol
Why was CPOE created?
Created in response to significant rates of hospital errors in medication administration and procedures and has NOT shown to dramatically increase patient care
HAS increased time overall to enter orders
What is a clinical decision support system?
Provides knowledge-specific and person-specific information to enhance clinical decision making and provision of healthcare
example was primary care practice that sees lots of DM and helps them not to forget any test
What is PACS?
Picture Archiving/Communication System
radiologic film with digital image storage and transmission
What are the advantages of PACS?
improved organization of images
improved accessibility
improved viewing: can compare images easily
What are the disadvantages of PACS?
significant cost for implementation and maintenance
PACS system-wide failure could be very detrimental or even catastrophic to provision of care
Files can still become corrupted or lost
Training and understanding use
T/F: Bar coding has stopped healthcare workers from ordering incorrect interventions, performing incorrect tests, or administering incorrect treatments
FALSE
does NOT stop
these things still happen today
What is RFID? What is the basic application?
Tags attached to people or objects
Basic application - track patients for anti-elopement and anti-abduction programs
can also be used to inventory control and equipment tracking
What is the potential concern for RFID?
Potential for interference with pacemakers, ICDs
What are some advantages of automated medication dispensing machines?
increased security
increased patient safety
increased access to medications
What are some disadvantages of automated medication dispensing machines?
errors are still possible
cost of implementation, maintenance and training
What is electronic materials management?
Electronic monitoring and management of materials used in the healthcare setting
Includes monitoring how much of each material is used and when it is used the most
to help with billing and ordering of materials based on usage
**What is the distant/hub site mean in telemedicine?
where the provider is located
**What is the ongoing/spoke site mean in telemedicine?
where the pt is located
What is asynchronous telemedicine?
data is recorded and stored, then sent to another site for consultation
What are 4 common types of telemedicine?
primary care/specialist appt
remote pt monitoring: think vital signs, EKG, glucose
consumer information: Internet and wireless devices to obtain specialized health information or online discussion groups for support
medical education: CME for health professionals
What is teleradiology?
Radiologic images are sent from one location to another
Radiologist in remote location reads imaging report and sends interpretation to site
Where can the teleradiologist be physically located?
For reimbursement reasons - must use teleradiologist on US soil
What are some advantages of telepharm?
Drug therapy monitoring, patient counseling, prior authorization and refill authorization, monitoring of formulary compliance
pharm care provided to pts who may not be able to directly contact a pharmacist
What are the benefits of telemedicine?
Improved access to providers
Cost efficiencies - better management of chronic disease, shared staffing, reduced travel times
Equal or improved quality
Patient demand - patients like ease and convenience
What are the risks of telemedicine?
Increased risk of error
Decreased human interaction
Increased risk of health information exposure
What is the purpose of ICD-10? Who publishes the codes? When are they used?
Allows for standardization of assessments/diagnoses of patients
World Health Organization (WHO)
inpatient procedures
What is CPT code based on? Who publishes the codes? When are they used?
Types and number of diagnoses discussed/addressed
Extensiveness of history and physical exam
Extensiveness and complexity of decision-making process/care plan
American Medical Association
outpt procedures
** How should you list your codes?
** order of importance
T/F: Medical auditing is only to make sure the facility is not overcharging for services
FALSE!! To avoid undercharging or overcharging for services rendered
and to ensure adequate documentation of encounters
imaging, UA, EKG, wet mount/slide, spirometry are examples of ______
Diagnostic procedures and need to get coded as such
nebulizer treatment, injection, wound care are all examples of ______ and need to get coded as such
therapeutic procedures
_____ is always required! What are the 2 options for HPI?
chief complaint
brief or extended
**What are the requirements for a brief HPI?
Brief HPI - documentation of 1-3 HPI elements
** What are the requirements for an extended HPI?
Extended HPI - documentation of 4+ HPI elements or status of 3+ chronic conditions
What are the 3 options for ROS?
problem pertinent, extended, complete
Type of ROS: ______ only the system directly related to problem in HPI
problem pertinent
Type of ROS: ______ system directly related to CC plus 2-9 additional
Extended ROS
Type of ROS: ______ system directly related to CC plus 10+ additional
complete ROS
What are the 2 different options for past, family and/or social history?
pertinent or complete
_____ reviews at least one item from any of the 3 areas pertinent to the HPI in PFSH
pertinent
_____ review of two or all three areas in PFSH
complete
What is considered a problem focused PE?
1+ organ system with 1-5 elements
What is an expanded problem focused PE?
1+ organ system with 6+ elements
What is a detailed PE?
6+ organ systems with 2+ elements (comments)
What is a comprehensive PE?
9+ organ systems with 2+ elements (comments about each)
What are the requirements for a single system exam?
** Draw the chart that shows the elements required for each type of decision making
*probably need to know this chart
What are the different levels of medical risk?
minimal -> rest, gargles, bandages etc
low -> OTC drugs, PT, OT, IV fluids w/o additives, minor sx with no risk factors
moderate -> minor sx with risk factors, elective major sx, prescription drug management, IV fluids with additives
high -> major sx with risk factors, emergency major sx, IV controlled substances, drug therapy requiring extensive drug monitoring
What is the patients over paperwork initiative?
Attempt to reduce administrative burden and stop providers from trying to document “to code” rather than to the needs of the pt/visit
What is the major highlighted change that occurred with the 2021 and 2023 medicare coding changes?
Primary emphasis on either time spent caring for encounter or level of medical decision-making, not H&P requirements
**What is a new noteworthy change about the 2023 medicare coding changes?
Eliminating Codes -> Merged some codes for services like observation into existing hospital care codes
**What is the highlighted 2024 medicare coding change?
Caregiver Training Services CPT Codes Added
the patient does not need to be present during the training; focuses on strategies and techniques; facilitates functional performance
Why did people stop using ICD-9 codes?
Outdated (had not been updated for 36 years)
Nonspecific codes; Limited data collection
Insufficient to adequately describe pt’s conditions and diagnoses
What are the major changes in ICD-10?
Increased number of codes (from 13,000 to over 68,000); Increased specificity
Allows for clarification (laterality, initial/subsequent encounter, sequelae, severity, etc.)
Expandability (room to add new diagnoses); Combination codes (multiple dx in one code)
Why should people stop using ICD-10?
Already outdated (released 7 years ago) with list of dx with limited options because you must use the same terms and spellings on the list
Areas of non-congruence with current medical science advances
New diagnostic categories and reported greater ease of use (searchable)
What are the benefits of using ICD-11?
web-based search engine that recongnizes synonyms and with relatively flexible spelling
kept updated
knows common abbreviations
_______ Any infection acquired by a patient while receiving treatment for a medical or surgical condition
Healthcare Associated
Infection (HAI)
What are the 3 MC types of healthcare associated infections?
PNA
surgical site infections
GI infections
What happened to HAI when COVID hit?
dramatic increase in ventilator associated events and decreased in C. diff infections
What are 5 risk factors for HAIs?
Indwelling medical devices
skin breaks
Contamination of healthcare environment
Transmission between patients and providers/staff
Overuse or improper use of antibiotics
What are the 8 hospital “never events?”
What are the 3 methods of transmission for an infectious agent?
contact
droplet
airborne
______ are the minimum infection protection standards for all patient care
standard precautions
What are the 5 standard precautions?
Hand hygiene
Use of personal protective equipment (PPE)
Safe injection practices
Safe handling of potentially contaminated
equipment or surfaces
Respiratory hygiene/cough etiquette
What are universal precautions?
similar, but older term - specific avoidance of body fluids due to infection risk
**If the patient has an infectious diarrhea, what is the hand hygiene protocol?
the provider/staff MUST wash hands with soap and water NOT santizer
What are the 6 key situations in which you should preform hand hygiene?
Before touching a pt (even if gloves will be worn)
Before exiting pt care area after touching pt or the pt’s immediate environment
After contact with blood, body fluids/excretions, or wound dressings
Prior to performing an aseptic task (e.g., placing an IV, preparing an injection)
If hands will be moving from a contaminated-body site to a clean-body site during patient care
After glove removal
**Visibly soiled hands or after caring for pts with known or suspected infectious diarrhea, what should you do?
Wash hands with soap and water!!
What finger is frequently missed when doing hand hygeine?
THUMB!! is frequently missed
**______ is always the _____ after removing and disposing of PPE
Hand hygiene
final step
**What is the correct order with donning PPE?
**What is the correct order for doffing PPE?
_______ medical equipment is ones that enter mucous membranes or non-intact skin
Semi-critical items (colonscopy or EGD scopes)
High-level disinfection prior to reuse
_______ medical equipment is ones that enter sterile tissue or vascular system
critical items
MUST BE STERILE
_______ medical equipment is ones that touch intact skin only; no mucous membranes
Noncritical items -> BP cuff
low- or intermediate-level disinfection
______ are part that generally do not contact pt
Environmental surfaces (floor, walls)
routine cleaning with low level disinfection
_____ are used pts have an infection that can be spread by contact with another human or equipment, or environmental surfaces
contact precautions
in a pt’s room with contact precautions, what additional things do you have to have before entering?
Gown and gloves upon room entry
Use disposable single-use or pt-dedicated equipment
_____ is used for pts with infection that can spread through close respiratory or mucous membrane contact with respiratory secretions. What kind of room is preferred?
droplet precautions
SINGLE room
in droplet precautions, what additional thing but you do before entering the room?
Wear a mask upon room entry of a pt on droplet precautions
**If single room is not an option for a pt with droplet precautions, what is the second best?
separation of 3+ feet and curtain between beds
and the pt needs to wear a mask if transported out of the room
______ is used for pts with infection that can spread over long distances when suspended in air
airborne precautions
In addition to standard precautions, what additional things should you do in airborne precautions?
Wear a mask or respirator prior to room entry, depending on disease-specific recommendations
What type of room is preferred for a pt under airborne precautions? Secondary option?
Pt should be in airborne infection isolation room – single-person equipped with special air handling and ventilation
If no such room - private room with door closed until pt can be transferred
What type of healthcare worker should NOT provide care to someone under airborne precautions?
Non-immune workers should not care for pt with vaccine preventable airborne diseases
What is the national certifying body for PAs?
National Commission on
Certification of Physician
Assistants
NCCPA
What are the requirements to re-certify?
Must log 100 hrs of CME
every 2 years
Must pay $150 maintenance
fee every 2 years
Must pass a recertification
exam every 10 years
When is the earliest you can take the PANCE?
until at least 7 days after completing program requirements
What are the PANRE exam requirements?
Cannot apply to take PANRE until the 9th or 10th year of your recertification cycle
$350 registration fee
180 day timeframe to schedule exam
Can only take once in a 90 day time period
4 hour, 240 MC questions with the option to choose practice focused content
What are the PANRE- LA alternative requirements?
Cannot apply until the 6th year of your recertification cycle
Exam process is completed in years 7-9
$350 registration fee
Quarterly (q 3 mo) blocks of 25 multiple choice questions with 5 minutes per question
must complete 8 quarters of blocks
How many 50 hours do you need of each type of CME? What are the requirements?
50 hours - Category 1 CME
-Formally planned activities - follow ACCME Standards certified for credit by an ACCME accredited CME provider
50 hours - Category 2 CME
- informally planned self-initiated activities
What is a performance improvement CME?
What is a self assessment CME?
What is scope of practice?
List of activities, responsibilities, procedures and processes that a provider can perform
Differs depending on state, type of practice and provider who you are practicing under
Supervising physician will complete a form stating what responsibilities and procedures you are allowed to perform
What are the 4 parameters that define scope of practice?
- PA’s education and experience
- State laws
- Facility policy
- Needs of the practice and its patients
What are the 3 requirements an item must meet in order to be in your scope of practice?
Provider must have been educated academically or on-the-job to perform this task and have documentation proving their education
Task must be allowed (or not explicitly banned) by local, state and federal laws for a member of your profession
Facility and supervising physician must allow you to perform this task
What are the 4 functions of HIPAA?
What 4 entities are covered by HIPAA?
Health plans
Health care providers
Health care clearinghouses (billing)
Business associates
What is the key phrase for information that is protected by HIPAA?
ALL “individually identifiable health information”
What info is NOT protected under HIPAA?
“De-identified health information”
neither identifies nor provides a reasonable basis to identify an individual
What are the 2 situations that we HAVE to release information?
To individuals or their designated representatives when they request access to it
To Health and Human Services when they are undertaking a HIPAA compliance investigation
How much information should be disclose under HIPAA?
Minimum amount of information needed to accomplish the intended purpose of the disclosure
What type of disclosure notice do we have to provide?
Must provide notice of privacy practices
Notice must describe ways in which the we use patient information
Must be provided to patients as soon as care starts
T/F: Patients can make an amendment request if they feel there is incorrect data in their file
TRUE!!
T/F: If the amendment request is denied, the information in the chart stands without any additional action
FALSE, Patients can have a statement of disagreement in their file if their amendment request is denied
Patients can receive an ______ of their health information up to 6 years prior to the request
accounting of disclosures
What is the exception with regards to HIPAA protection of a minor?
Parents are considered personal representatives for minors in most circumstances
exception: if there is a reasonable belief that the personal representative is abusing or neglecting the individual
What are the 2 consequences of NOT following HIPAA?
Civil Money Penalty for those who accidentally broke HIPAA without malicious intent
Criminal Violation for those who had malintention
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
