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LCHI 303 Exam 1
Chapter 1-2
| Question | Answer |
|---|---|
| Information System | Automated system that uses computer hardware and software to record, manipulate, store, recover, and disseminate data |
| AHIMA data quality management model | displays the components of data quality management and the characteristics of data quality |
| Authorship | is the origination or creation of recorded information attributed to a specific individual or entity acting at a particular time |
| Back-end speech recognition (BESR) | use of speech recognition technology in which the physician dictates traditional manner and an editor listens to the audio and reviews the document created to ensure it was created correctly. |
| Checkbox | data field that a comprehensive list of approved answers for the data element (Ex: zero, one, or many of the options) ( click on box to place an x or checkmark) |
| Data accessibility | means that data items are easily obtainable by authorized users - accurate and relevant. In EHR, health records are immediately accessible to multiple users at the same time unless the IS is down. In case of IS downtime, data must still be accessible; a business continuity plan much be in place to address what happens during downtime |
| Data accuracy | Means that data are free of identifiable errors. Healthcare practitioners who input data into the health record are responsible for the quality of data they enter into the EHR or other IS. Poor data captures results in poor quality of care and poor business decisions.(Ex. weight wrong - weight base medication dose will be wrong) |
| Data capture | is the process of recording healthcare-related data in electronic health record system or clinical database |
| Data cleansing | is the process of checking internal consistency and duplication as well as identifying outliers (outside of normal range) and missing data, and correcting any issues - in other words, data cleansing means looking for errors or problems with the data, such as duplicate patients and addressing the discrepancy so that the error can be corrected - outlier is not necessarily an error, but it should be evaluated for accuracy because of the impact that it has on the mean and other statistical analysis of the data |
| Data comprehensiveness | means that the patient's health record must be complete, meaning that all required data are included - many governmental agencies, accreditation organizations and medical staffs have standards that mandate what data must be collected to be considered a complete health record |
| Data consistency | ensures that like data are the same on each document or computer screen |
| Data currency | ensures that data are up to date - data value is up to date if it is current for a specific point in time, and it is outdated if it was current at a preceding time but incorrect at a later time. |
| Data definition | is the specific meaning of a healthcare-related data element - defining each data element provides the foundation that allows everyone to interpret and collect the data in the same way |
| Data granularity | describes the level of detail at which the attributes and values of healthcare data are defined - required level of detail depends on the circumstances of the patient's care. |
| Data integrity | is the extent to which healthcare data are complete, accurate, consistent, and timely - goes beyond data quality as it includes the validity of the data throughout its lifecycle which makes it usable for reports, decisions, patient care, and so forth...this is critical with HC providers trusting data they are using to make decisions on patient care |
| Data mapping | allows for connection between two systems |
| Data precision | There are methods used to "prevent garbage": direct data entry, template-based entry, speech recognition, and natural language processing |
| Data quality | is the reliability and effectiveness of data for its intended uses in operations, decision making, and planning - focuses on the usability of data, whereas data integrity is about its trustworthiness - for data quality: required fields, edit checks, user-friendly data field, and field type (GIGO) - adage garbage in, garbage out - is applicable to the documentation of healthcare data. |
| Data quality management | is defined as "the business processes that ensure the integrity of an organization's data during collection, application (including aggregation), warehousing, and analysis" Collection in data quality management refers to the way that data elements are gathered |
| Data quality measure | is a mechanism to assign a quantitative figure to quality of care by comparison to a criterion. Quality measurements typically focus on structures or processes of care that have a demonstrated relationship to positive health outcomes |
| Data relevancy | is the extent to which healthcare-relate data are useful for the purposes for which they were collected - only the data that are needed or are expected to be needed in the future are collected (such as clinical data) |
| Data timeliness | means that data should be recorded in an appropriate period of time after the event and should be available to the user when needed |
| Data field | a number of data fields are available to use in IS - some of these field types can contribute to data quality by limiting the number of choices, by limiting the appropriate entries - further specifying the data required |
| Direct data entry | includes a number of manual data entry methods such as a keyboard, mouse, or other devices for entering into the IS |
| Drop down box | click on arrow to the right (or left) of a data field and a drop-down menu appears with several choices - choices controlled by HC organization based on its needs. (Ex. State) |
| Edit check | functionality within the software to minimize errors and aid in data accuracy - a standard feature in many applications' data entry and data collection software packages - preprogrammed definitions of each data field set up within the application (Flag to signal that user needs to verify data being entered to ensure that the criteria of the field are met |
| Front-end speech recognition (FESR) | when the physician or the dictator is the editor of the document that is dictated - the advantage is that the authenticated document is available in the EHR quickly |
| Hot spot | known as "pop-up" text - type of help message that is triggered when the cursor is placed on top of a data field - may indicate the next level of choices, the purpose of an icon, or an explanation of that field including valid) entries (valid entries, number of characters |
| Interface | is the zone between different computer systems across which users want to pass information - it takes data from one IS and shares it with another |
| Natural language processing (NLP) | is the technology that converts human language (structured or unstructured) into data that can be translated then manipulated by IS - sophisticated enough to be able to identify key words needed to perform specific tasks such as computer-assisted coding. This technology basically teaches the meaning of a word or phrase to a software application after several uses |
| Numeric field | allows for entry of numbers (may not allow decimals, commas, etc.) (Numeric field could also be "auto-numbering" - to prevents 2 patients being assigned the same health record numbering |
| Peer Review | a review by like professional,or peers, established according to a healthcare organizations medical staff bylaws, organizational policy and procedure, or the requirements of state law - allow medical professionals to candidly critique and criticize the work of the colleagues without fear of reprisal |
| Physician Advisor (PA) | HIM tech submits health record (missing documents or missing data, or even missing entries or signatures) for review to Physician Advisor (PA) - hired HC organization as well as all data in the health record, practitioners cannot accurately treat the patient |
| Primary data source | come directly from the original source - symptoms or the reason for coming to the healthcare organization (healthcare record) |
| Qualitative analysis | to ensure that standards are met and to determine the adequacy of entries documenting the quality of care - the reviewer considers whether the health record appropriately documents the care provided - the nurse should review the quality of nursing documentation, a physician, the physician documentation, and so forth - to ensure that all require components are in the discharge summary or other document |
| Quantitative analysis | review of the health record to determine its completeness and accuracy - used by HIM professionals as a method to detect whether elements of the patient's health record are missing - in this analysis determines whether or not the reports are present or absent from the health record. If during qualitative review of record there appears to be documentation that does not reflect best practice, if the notes appear to have a lapse in time covered, or if something does not look right, HIM tech will submit to PA. |
| Radio buttons | type of data field that also identifies a comprehensive list of choices, much like the check box |
| Secondary data source | includes indices, registries, and other databases - collection of care information related to specific disease, condition, or procedure that makes health record information available for analysis and comparison - used to conduct research, address population health issues, and for administrative purposes such as monitoring fraud. |
| Speech recognition | may be known as voice recognition, is technology that translate speech to text (FESR) and (BESR) |
| Structured data fields | guides the user during the data entry process, limiting what a user can enter into the field (Ex: SSI number, telephone number) |
| Template-based data entry | is a cross between unstructured and structured data entry - template helps ensure that field is not left "blank" |
| Time field | allows for entry of time |
| Unstructured data fields | data elements that allow for free text entry |
| Version control | the process whereby a healthcare |
| Certified health data analyst (CHDA) | AHIMA (The American Health Information Management Association) sponsors the (CHDA) certification - advanced certification covers business needs assessment, data acquisition and management, data analysis, data interpretation and reporting, and data governance (CCHIIM 2019) |
| Clinical pathways | the finding of EBM of treatment(s) determined to work best from findings from the EHR and other ISs are used to develop these pathways. Clinical pathways are tools designed to coordinate multidisciplinary care planning for specific diagnoses and treatment(s). Clinical Pathway define the best practices for treatment. |
| Clinical practice guidelines | Along with "clinical pathways" which defines the best "practice" for treatment(s). Clinical Guidelines provide "step-by-step" guide used by the HC practitioners to make knowledge-based decisions related to patient care and issued by an authoritative organization such as a "medical society" |
| Cloud computing | used to store data and run applications by many HC organizations - is the delivery of computational services (analytics, storage, and application sharing) by vendor over the INTERNET. Cloud computing where the HC organization uploads or enters data remotely into the "vendor-owned information system" --> the storage of data at a "remote" location is often referred to storing data "in the cloud". Data stored at a remote location can be assessed by all authorized users. Increase volume - vendor adds storage. |
| Computer on wheels (COW) *(WOW) - workstation on wheels | wireless computer mounted to a mobile care that can be moved from patient to patient (@ bedside) - POC improves documentation because the documentation is completed as soon as care is administered "real time" |
| Dashboards | (Key measures, graphics) summarized or aggregated reports of process measures to help leaders follow progress to assist. with strategic planning - provides the status on key measures. contains A/R, account payment, census of patients |
| Data | raw facts and figures - (Not interchangeable with Information) |
| Data analytics | HIM professionals turning data into information. Data analytics is the science of examining "raw data" with the purpose of drawing conclusion about that information. This information could be used to make business decisions concerning which services to provide and how to improve patient care. Tools used in data analytics: data mining, machine learning, statistics, dashboard, and predictive modeling (Categories: Descriptive, Diagnostic, Predictive, Prescriptive) |
| Data mining | process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors |
| Descriptive analytics | helps organization learn from the past - uses statistics such as mean, frequencies, variance, etc. - trends identified to plan for the future |
| Descriptive statistics | is a set of statistical techniques used to describe data, such as means, frequency distributions and standard deviations; statistical information describes the characteristics of a specific group or a population (Ex. mean costs for patients who had an appendectomy) (CENSUS DATA would be displayed as descriptive statistics) |
| Diagnostic analytics | helps organization to learn why something happened - patient census down due to physician leaving practice- not admitting patients (liaison not meeting quota) |
| Dumb terminals | all or most of the processing is performed at the server or mainframe, whereas some processing is performed on the (PC) |
| Electronic health record (EHR) | an electronic record of health-related info or an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more that one HC organization. EHR: past medical history, test results, allergies...reminds physician of tests that should be considered and helps with quality of documentation. help to reduce errors, increase efficiency, improve collaboration and reduce duplicates |
| Evidence-based medicine | Research concerning drugs and other medical treatments is critical to patient care. (to show drugs and medication is effective) EBM decribes HC services bases on clinical methods that have been thoroughly tested through controlled, peer-reviewed biomedical studies - uses data analysis from the EHR and other ISs to determine which treatment(s) worked best |
| Extranet | connections of private internet networks outside and organizations firewall and uses internet technology to enable collaborative applications to allow external users to access limited portions of the IS. Ex. patient portal - access health information and schedule appointments. suppliers may use extranet to monitor hospitals supply levels and make shipments without the HC organization having to place an order |
| Financial applications | software applications that handle patient accounts, budgets, and other financial activities of the HC organization |
| Health Informatics | is a "science that defines how health information is technically captured, transmitted, and utilized" (AHIMA 2009). Field of study uses ISs to manipulate and use information to improve healthcare. (Data are stored in the ISs) |
| Health Information exchange (HIE) | the exchange of health information electronically between providers and others with the same level of interoperability |
| Inferential statistics | is a set of statistical techniques that allows researchers to make generalizations about a populations characteristics on the basis of a sample's characteristics, such as HIM professionals' continuing education efforts |
| Information | is data that have been manipulated into something meaningful. (Not interchangeable with Data) |
| Information system (IS) | is an automated system that uses computer hardware and software to record, manipulate, store, recover, and disseminate (spread (data) widely) data |
| Internet | Allows thousands of networks with millions of computers to link together to share data and information. Internet enables healthcare providers to remotely access patient and other info for patient care, billing, quality improvement, etc. Allows patient info as well as administrative info to be shared outside the HC organizations with insurers, healthcare providers, health departments, etc. |
| Intranet | Private information network similar to Internet; used by an organizations own employees and authorized users. Servers are located inside a firewall or security barrier so the general public cannot gain access to info in private network - may give updates on events, bylaws, rules, policies, procedures, forms, employee directory, maps, links to payroll, time sheet etc. |
| Local area network (LAN) | ability to wire HC organizations to share data more quickly using networks - connect devices in close, physical proximity know as local area network (LAN). "Network" make departments more efficient |
| Mainframe computers | large computers that are used by the government and other organizations that require speed and the ability to process large amounts of data |
| Personal computer (PC) | some or all processing is performed on personal computer (PC), where as most or all processing is done at the server or mainframe (dumb terminals). PC has a central processing unit (CPU), the computer memory, and data storage devices designed to support a single user (individual) |
| Protocol | Set of communication rules |
| Point of Care (POC) | small mobile devices and wireless computers are often seen at the (POC) - the place or location where the physician administers services to the patient (@bedside) (POC) is used to document the care provided when it is provided. |
| Predictive Analytics | analyzing historical data to predict future happenings/results - able to predict possible admission numbers |
| Predictive modeling | is a process used to identify patterns that can be used to predict the odds of a particular outcome based on the observed data - use historical data in order to predict what is likely to happen in the future - uses algorithms through machine learning. |
| Prescriptive analytics | builds upon predictive analysis by suggesting possible course of action the HC organization may take and what the implications may be for each. Ex. rise in volume of patients: increase staff for increased nurse patient/ratio |
| Wireless on wheels (WOW) | wireless computer mounted to a mobile care that can be moved from patient to patient (@ bedside) - POC improves documentation because the documentation is completed as soon as care is administered "real time" |
| Input | the data that is entered into the information |
| Output | the data displays, reports, and other means of pulling data from the information system |
| Role of HIM professional | to collect, analyze, use, and maintain data at all levels of ISs and networks in hospitals and other healthcare organizations. As technology changes; is challenging, requiring constant updating of skills and knowledge. Adoption and implementation of technology in HC moves at a slower rate; turning over to electronic records. Technology on the rise... |
| MPI | master patient index (MPI) - computers used to help personnel with MPI functions and abstracting |
| CPU | is another name for a microprocessor, which is a microchip that processes the information and the code (instructions) used by a computer...AKA "brains of the computer" |
| Code | instructions |
| Abstracting data | capturing various patient or clinical data for reporting purposes. The ability to abstract data once into an information system and being able to send to several agencies, used to general several reports saved time Beats using old paper abstracts. Also new ISs decreased error made when transcribing by hand notes from primary to secondary sources |
| Data entry | by means of barcoding, speech recognition, touch screens, light pens, and microphones. Data entry departments: Admissions, business offices, quality improvement, utilization management - all work closely with HIM department to share data in less time - minimizing time that was once spent re keying in data. |
| Wi-fi | is wireless connectivity protocol (communication rules) that uses radio waves to connect computers and other devices to a (LAN) and the internet |
| Downside of wireless computers | they are easy targets for both physical (the device itself) and virtual theft (data). Portable devices can be easily lost or stolen (risk) |
| American Recovery and Reinvestment Act (AREA) of 2009 | law enacted an incentive program known at the time as "meaningful use" - gave HC providers who met the requirements financial incentives for implementing EHR and "using it in a meaningful way such as improving the quality of care provided to the patients" |
| Meaningful use | using EHR in a meaningful way such as improving quality of care provided to patient - use to help monitor the medications ordered for the patient to ensure that the combination of drugs is safe and no negative drug interactions |
| Upside of using computers | helps to increase employee productivity (better performing HIM roles) within HC organization |
| Benefit of "Cloud computing". | the facilitation of information sharing - allows a HC organization with multiple hospitals to share data among the hospitals. |
| Firewall | built around intranet will prevent unauthorized access to it or restricted parts of the website. |
| A patient can access his test results by using | Extranet |
| Cloud computing refers to | computational services provided by a vendor over the internet |
| Documentation at the bedside is known as | Point of care |
| The early information systems used in health care included | Financial applications |
| Where can an employee go to locate a form within an organization? | use the Intranet within the organizations network |
| Ways technology is used healthcare | enhance patient care, research, business practices, education, and public health |
| Way technology enhances/improves patient care | identifying effective medications or treatments, monitoring for epidemics, improve decision making, sharing information between HC providers at other HC organizations |
| Significant changes in HC utilizing technology | patient safety, quality of patient care, and access to information |
| Way ISs impact patient care | actual care provided to patient, patient engagement in healthcare, creation of evidence-bases medicine, creation of practice guidelines, patient safety. Information systems/technology can improve patient outcomes and give patient confidence in the HC system |
| Interoperability | is the ability of different information technology systems and software applications to communicate; to exchange data accurately, effectively, consistently - and to use the info that has been changed |
| Patient Safety | (1999) "To Err is Human: Building a Safer Health System" by the Institute of Medicine (now known as National Academies of Medicine). This report prompted the healthcare industry to take steps to improve patient safety (see Efforts of Patient safety through technology) |
| Efforts of Patient safety through technology | use of barcodes to verify patient info for medication administration, checking meds ordered against allergies and other medications, improved data quality through edits and standardization, clinical provider order entry |
| Benefits of technologies: databases in EHR | research and data analysis can be performed using existing databases - (data mining) - offers HC providers valuable knowledge such as drugs with serious complications, best treatment for condition or disease, etc. |
| Clinical provider entry (CPOE) | EHR eliminated illegibility issues that were found in the handwritten patient health record which could lead to errors in medication dosage and other patient safety issues, reduce or even eliminate incomplete information. CPOE - the physician orders tests, medications, procedures, etc, (physician required to provide all required information) |
| Improvement in Healthcare can be defined as | Improvement in: standards development, clinical pathway development, clinical practice guidelines development, etc. |
| Healthcare Standards | scientifically based statement of expected behavior against which structures, processes, and outcomes can be measured. In order to get "quality" information, quality data is needed. |
| Specializations in Health Informatics | clinical health informatics, nursing informatics, and public informatics. Not only using data IS to improve patient care, but also facilitates the sharing of data, saving money through improved communication and elimination of duplicate testing, monitoring for communicable diseases, involving patients in their care, and improving efficiency |
| Four Categories of Data Analytics | *Descriptive analystics looks at the past to determine what has already occured - helps the organization learn from the past *Diagnostic analytics - helps organization to determine "why" something happened *Predictive analysis - analyzing historical data to be able to make predictions *Prescriptive analytics - based on predictive analysis, suggest course of action to take |
| Machine learning | is an area of computer science that studies algorithms and computer programs that improve employee performance on some task by exposure to a training or leaning experience. (Ex: predict number of inpatient beds needed at the HC organization) |
| HIM Department use Technology to process what tasks? | Assigning diagnosis and procedure codes, managing the MPI, Managing registries, transcribing documents such as the discharge summary, analyzing the health record, documentation of health information activities, computer-assisted coding |
| HIM skills necessary | system implementation, databases, data governance, legal health record, data analysis, data mining, healthcare informatics, etc. HIM profession has changed from only processing health records to one that is focused on data and information that can be used to monitor quality of patient care, patient outcomes, reduce costs, etc. |
| What is AHIMA's certification that addresses data acquisition and management? | CCS |
| What is used to assess the status of key indicators? | Dashboard |
| What is Prescriptive analytics used for? | provide possible course of action |
| What is a trend seen in HIM? | The ability for staff to be able to work remotely |
| What is the tool that outlines the best practice to treat a patient? | Clinical pathway |
| To make conclusions about a population | *Inferential statistics |
| The field used to draw conclusions | Health Informatics |
| The first ISs used in healthcare | Financial applications |
| Explain Intranet. | It is used to access employee resources |
| What is the impact of ISs on HIM professionals | *Skills required |
| What is the technology where the user enters data to a remote system over the internet? | Cloud computing |
| What is used to identify hidden relationships? | Data mining |
| What is the tool used to identify why something happened? | Diagnostic analytics |
| Registry | is a collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison. |
| Data quality tools | Data dictionary, Metadata, required fields, and edit checks |
| Metadata | is defined as descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information - metadata tags are used to describe the data - provides information such as the creator of the data, the date of creation keywords, and more. |
| 3 Types of Metadata | Descriptive Metadata, Structural Metadata, and Administrative Metadata |
| Identify a data integrity tool | includes edit checks and required fields |
| What is a data integrity tool used to assist the user in data entry? | Hot Spots provide additional information about the data element |
| What type of field that is BEST for entering gender? | Radio buttons are good for a small number of entry choices such as with gender |
| What is a primary data source? | Health records are a primary data source |
| What is the BEST field type for service? | Drop down boxes are good to limit entries but allows a number of options from which to choose |
| Application | is the reason for collecting data |
| Warehousing | involves the methods used to stare the data (processes and systems used to archive data) |
| Analysis | entails converting data into information (process of translating data into meaningful information) |
| Collection | processes by which data elements are accumulated |
| 2 Methods used to help prevent inaccurate data from occurring within health record | *Qualitative analysis *Qualitative analysis |
| What is the identification of the individual who recorded a progress note in the health record? | Authorship is identifying who created an entry |
| What is addressing missing information and outliers called? | Data cleansing is looking for an addressing duplication of data, missing data, and outliers |
| What issue is an example of documentation integrity? | *Documentation integrity issues include copy and paste, authorship, amendments, and more |
| What is the characteristic of data quality that addresses the usefulness of the data collected? | Data relevance is the extent to which healthcare-related are useful for the purposes for which they were collected |
| What is an attribute of data quality that addresses data being displayed in the same format on different screens in the EHR? | Data consistency ensures that like data are the same on each document or computer screen |
| What is the type of data field that is the most appropriate for the health record number? | Auto numbering |
| What do you call the linking of the 2 systems? | Data mapping |
| What does qualitative analysis review the quality of? | determine completeness and accuracy |
| What does edit checks ensure? | to minimize errors and aid in data accuracy |
| What character of data quality addresses the level of detail of the data collected? | Data granularity |
| Which attribute of data quality addresses availability of the data collected? | Data accessibility |
| What is the benefit of front-end speech recognition? | It speeds availability of the document |
| A missing document would fall under what type of data quality characteristic? | Comprehensiveness |
| What data quality characteristic ensures that data support the reason for the collection of the data? | Precision |
| Identify the statement that is true about amending a health record | Any documentation deleted should be retrievable if needed |
| Ensuring that only the most recent report is available for viewing is know as | Version control |
| Difference between data and information? | Data is an individual unit that contains raw materials - no specific meaning. Information is a group of data that collectively carries a logical meaning. Data doesn't depend on information. |
| Understand what makes data meaningful? | When it can be interpreted, analyzed, and used to draw conclusion, make predictions, or support decision-making. (data is accurate, relevant, and sufficient in quantity to support its intended use) |
| Which type of applications were the first installed in the 1960's? | Financial applications |
| What is an EHR and what is the ultimate goal for healthcare by using it? | Electronic Health Record - digital version of patient's medical history and information - for HCPs - includes demographic info, med history, test results, diagnosis, treatment plan, and other relevant clinical information Goal is to improve patient outcomes by providing clinicians with comprehensive, accurate, and up-to date information about patient's health history - can be used to support clinical decision-making, improve coordination of care, and enhance the quality and safety of patient care. |
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