SOFTWARE APPLICATIONS AND EQUIPMENT

Question 1

Mandates comprehensive health insurance reform; some of the provisions of this law include prohibiting the denial of coverage based on pre-existing conditions, preventing insurance companies from rescinding coverage when someone gets sick, eliminating lifetime limits or caps on insurance coverage, appealing insurance company decisions, providing free preventive care, getting tough on health care fraud, and extending the amount of time parents can cover their adult children on their own insurance policies; many more provisions are in place today and more will roll out through 2014

Answer 1

(ACA) AFFORDABLE CARE ACT

Question 2

consists of three major goals: create and save jobs, spur economic activity and invest in long-term growth, and support accountability and transparency in recovery spending

Answer 2

(ARRA) AMERICAN RECOVERY AND REINVESTMENT ACT OF 2009

Question 3

required for any release of patient PHI; consists of specific elements that make it legal and appropriate to release information

Answer 3

AUTHORIZATION

Question 4

an organization or individual who provides specific services to a covered entity involving the use or disclosure of PHI; for example, an off-site storage company that houses EMR data

Answer 4

BUSINESS ASSOCIATE

Question 5

Federal agency charged with administration of the Medicare and Medicaid programs, as well as the Children’s Health Insurance Programs; operating division of the Department of Health and Human Service (HHS)

Answer 5

CENTERS FOR MEDICAID AND MEDICARE SERVICES (CMS)

Question 6

established to evaluate and approve EHR and EMR systems; to participate in incentive programs for EHR adoption and use, facilities must use a certified EHR or EMR product

Answer 6

(CCHIT) CERTIFICATION COMMISSION FOR HEALTH INFORMATION TECHNOLOGY

Question 7

most often refers to a laptop computer that sits on top a cart with wheels that can be rolled from patient room to room and facilitates real time documentation or charting of patient care; often called COWs

Answer 7

(COW) COMPUTER ON WHEELS

Question 8

allows providers to order prescription medication, including IV therapies, laboratory tests, imaging studies, rehabilitation services, dietary requirements in the inpatient environment

Answer 8

(CPOE) COMPUTERIZED PROVIDER ORDER ENTRY

Question 9

specific practices that CMS mandates for facilities to follow if they treat patients covered under Medicare or Medicaid; similar in the Joint Commission’s accreditation requirements

Answer 9

(CoPs) CONDITIONS OF PARTICIPATION

Question 10

the widely-accepted and federally-mandated document for sharing patient health information acress facilities; replaced the CCR and CDA which were earlier attempts at addressing the continuity of patient care between facilities

Answer 10

(CCD) CONTINUITY OF CARE DOCUMENT

Question 11

an early form of a document developed to make communication about patients’ course of care available across facilities; CCD replaced it

Answer 11

(CCR) CONTINUITY OF CARE RECORD

Question 12

providers who transmit PHI in an electronic format, health plans and health care clearinghouses

Answer 12

COVERED ENTITIES

Question 13

process used to document a provider’s education, licensure, and qualifications in order to allow for the assignment of privileges to practice in a hospital or health care system

Answer 13

CREDENTIALING

Question 14

a nomenclature or naming system the American Medical Association (AMA) publishes and maintains; allows providers to code for services provided and submit bills for reimbursement

Answer 14

(CPT) CURRENT PROCEDURAL TERMINOLOGY

Question 15

organized collection of pieces of information or data; electronic version of file cabinets with folders and files; the term generally refers to data collected and stored in an electronic environment

Answer 15

DATABASE

Question 16

transform information from a paper-based document into an electronic format; some systems use document scanning that includes Optical Character Recognition (OCR) capabilities, which transforms a scanned document from a static image to a searchable document

Answer 16

DIGITIZE

Question 17

report written by the provider when a patient is being discharged from inpatient care; summarizes the patient’s chief complaint or why they were admitted to the hospital, diagnostic test results and other findings, treatments administered and how the patient responded to them; outlines recommendations for continued care and follow up, as well as dietary, medication and activity instructions; the provider must sign the final copy in the record before the record can be marked complete

Answer 17

DISCHARGE SUMMARY

Question 18

while this term is generic, its use denotes a system-wide record that involves inputs from many systems and is used across a diverse environment of care with multiple locations; although not strictly defined as such, EHR often refers to the electronic records in a hospital or integrated health care delivery system

Answer 18

(EHR) ELECTRONIC HEALTH RECORD

Question 19

refers to the conceptual EHR, including the basic structure functionality, and expected outcomes users expect from any system identified as being an electronic health or medical records system

Answer 19

EHR TECHNOLOGY

Question 20

another generic term for a digitized medical record; this term has evolved to most often refer to the single, standalone records systems that providers’ offices and other smaller outpatient settings use; the term EMR is most often used in reference to the electronic records used by provider in their private practice and outpatient settings; many EMRs can exchange data with larger hospital based EHR systems through the use of a Continuity of Care Document (CCD)

Answer 20

(EMR) ELECTRONIC MEDICAL RECORD

Question 21

functionality that allows providers to prescribe medications to patients and send the prescription to the patient’s pharmacy where it will process and be ready for pick up when the patient arrives; similar to CPOE from the Inpatient environment in that clinical checking and alerts provide important safety measures for protecting patients

Answer 21

ePrescribing

Question 22

functionality that has replaced paper records entirely; few hospitals or health care systems in the US have achieved this yet, but many are moving in this direction

Answer 22

FULLY-INTEGRATED EHR

Question 23

department responsible for the care and management of all patient information; as electronic records began to replace paper-based reocrds, HIM professionals became key players in the transition to the EHR or EMR system; previously known as the medical records department

Answer 23

(HIM) HEALTH INFORMATION MANAGEMENT DEPARTMENT

Question 24

general use of computers and related devices to manage the day to day functions in a health care environment

Answer 24

HEALTH INFORMATION TECHNOLOGY

Question 25

legislation that protects employees’ insurance coverage when they are between jobs; people today are more familiar with what was formerly called the TITLE II, or the Administrative Simplification provisions of HIPAA; TITLE II established national standards that apply to electronic transactions involving health care data and it is best known for addressing security and privacy protections for health care information

Answer 25

(HIPAA) HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 2009

Question 26

mandates the protection of patients’ personal health information by hospitals and health care facilities, known as covered entities; provides a number of rights to patients in regard to their health information, but acknowledges there are times when disclosure of that health information is necessary for the provision of patient care and other business-specific purposes

Answer 26

HIPAA PRIVACY RULE

Question 27

sets forth the administrative, physical, and technical safeguards for covered entities in order to protect the confidentiality, integrity and availability of PHI that is stored electronically

Answer 27

HIPAA SECURITY RULE

Question 28

providers document a patient’s history and perform a physical exam when she presents for health care services; this report is required to be filed in the inpatient record within 24 hours of admission for inpatients and cannot be more than 30 days old; this is often a dictated and transcribed report that must be signed by the physician before the record is considered complete

Answer 28

HISTORY AND PHYSICAL (H and P)

Question 29

encourages the adoption and meaningful use of health information technology; has strengthened portions of the HIPAA Privacy and Security regulations to more aggressively protect patients’ health information in the electronic environment; under this act, individuals and facilities that breach PHI are subject to harsher civil and criminal penalties

Answer 29

(HITECH) HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH

Question 30

collection of systems that collect, store and allow manipulation and management of data generated in the daily operations of a facility

Answer 30

(HIS) HOSPITAL INFORMATION SYSTEMS

Question 31

coding and classification system that groups diseases and disorders into similar categories

Answer 31

(ICD-10-CM) INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION, CLINICAL MODIFICATION

Question 32

IT department in facilities has emerged as a necessary response to the transition from a paper-based world to one that is increasingly reliant on technology for communications, data storage, management and retrieval, and delivery of patient care; those who work in the department work closely with all members of the health care delivery team to ensure patients’ needs are met on every level

Answer 32

(IT) INFORMATION TECHNOLOGY DEPARTMENT

Question 33

not-for-profit and independent (non-governmental)organization that accredits and certifies more than 19,000 health care facilities and programs in the US; accreditation from The Joint Commission is recognized nationally as the gold standard of accreditation and symbolizes the commitment to meeting high quality standards in providing patient care

Answer 33

(THE JOINT COMMISSION) JOINT COMMISSION ON THE ACCREDITATION OF HEALTH CARE ORGANIZATIONS

Question 34

department specific systems that pre-date the implementation of EHRs by several decades; sometimes referred to as legacy systems

Answer 34

LEGACY INFORMATION SYSTEM

Question 35

records of every patient who has been treated, seen evaluated in a facility; by law, this cannot be purged or destroyed after time and it must be forever maintained; also referred to as Master Patient Person Index (MPPI)

Answer 35

(MPI) MASTER PATIENT INDEX

Question 36

meaningful use is both a program and a definition; the Meaningful Use programs are the federal incentives established by CMS for facilities to use EHR technology in a meaningful way; meaningful use, the definition, refers to using EHR technology in manner that makes a meaningful impact on patient care and safety

Answer 36

MEANINGFUL USE

Question 37

a committee formed to discuss and recommend practices, policies, and other activities specific to the medical staff; this committee also oversees credentialing, or the assignment of privileges; in many hospitals this committee reports to the Medical Executive Committee, which makes final decisions regarding the medical staff and is accountable to the board of directors and CEO

Answer 37

MEDICAL STAFF COMMITTEE

Question 38

the language of medicine, which encompasses terms to describe anatomy, physiological processes, disease, treatment, and other terms related to the human body and the care provided in terms of health and disease

Answer 38

MEDICAL TERMINOLOGY

Question 39

process of gathering and documenting a complete list of a patient’s medications when he is admitted to a care environment, which includes medications he was taking when he came into the facility and medications the provider prescribed as new and sending the list to the next care provider when the patient leaves the facility; CMS and the Joint Commission require participating facilities to perform medication reconciliation

Answer 39

(Med Rec) MEDICAL RECONCILIATION

Question 40

a national database created in 1986 to collect information on licensed providers; providers are licensed by each state, and while bad behavior in one state can result in a loss of one’s license to practice medicine, before the NPDB, bad providers were able to move to another state, to seek licensure, and practice again

Answer 40

(NPDB) NATIONAL PRACTITIONER DATA BANK

Question 41

off-site refers to remote or distant from the place of business; data recovery and storage options are often off-site locations and accessed through a thin client, or a web portal; some hospitals also use off-site or remote access to EHR technology

Answer 41

OFF-SITE LOCATION

Question 42

patient interventions that are ordered by a provider for a nurse to carry out; these include guidance on how much assistance a patient needs to get out of bed; whether to document urinary output and liquid intake; medication orders that would not need approval by a provider each time, and dressing changes; also known as nursing orders

Answer 42

(PCOs) PATIENT CARE ORDERS

Question 43

traditionally this is a large, bound book that lists all prescription medications available on the market and includes prescribing information from the manufacturers; it is now available by subscription in an electronic format, accessible through EHR and EMR systems or through standalone electronic devices, such as a PDA or tablet PC

Answer 43

(PDR) PATIENT DESK REFERENCE

Question 44

information that can individually identify a person; includes demographic data or any common identifier, such as social security number, date of birth, address, or phone number

Answer 44

(PHI) PROTECTED HEALTH INFORMATION

Question 45

appropriate and legal release of patient health information that includes PHI; HIPAA outlines the requirements for proper release of information in various circumstances

Answer 45

(ROI) RELEASE OF INFORMATION

Question 46

control the ability to access certain areas of the system, based on the person’s role in the facility, which is associated with their login ID and password

Answer 46

(RBACs) ROLE-BASED ACCESS CONTROLS

Question 47

a medical reference vocabulary that serves to standardize the naming of terminology used in medicine and health care

Answer 47

(SNOMED-CT) SYSTEMATIZED NOMENCLATURE OF MEDICINE-CLINICAL TERMS

Question 48

pre-designed forms for the capture of data and information; common attributes of templates include drop-down menus, check boxes, and required fields, which will not allow the user to advance without answering the question or providing the data

Answer 48

TEMPLATES

Question 49

WOWs are the same as COWs; in some environments patients may be sensitive to the casual use of the word cow, so some facilities prefer to use the WOW acronym to avoid any patient misunderstanding

Answer 49

(WOW) WIRELESS ON WHEELS