The number-one reason for maintaining patient records is:
Legal documentation
Communication
Patient Care
Billing and reimbursement
Patient Care
See PG 9
Which is generally not considered part of a patient's medical record:
Problem list
Medication Record
Progress Notes
Digital images or films
Digital images or films
Medical records that are created and organized around the patient's problems are known as:
Chronological organized medical records
"Source - oriented" medical records
Content Based Medical Records
Patient Oriented Medical Records
Patient Oriented Medical Records
A method for measuring performance that allows for the design of measurement systems that align with the organization's strategy goals and examines multiple measures along several dimensions is known as:
Benchmarking
Outcome measures
Balanced scorecard
Cl
Balanced Scorecard
The category of statistics that are routinely gathered for health care executives are:
Census statistics
Discharge statistics
Mortality Statistics
Both a and b
A and B
Which standard billing form is submitted for health care provider services such as those provided by a physician's office to third party payers:
UB-04
CMS-1450
CMS-1500
UB-82
CMS-1500
What is a federally mandated standard assessment tool used to collect demographic and clinical information specifically about long-term care facility residents:
MDS
ACDS
UHDDS
HEDIS
MDS
The main source(s) of data that go into hundreds of aggregate reports or queries that are often developed and used by providers and executives in health care organizations are:
Patient records
Uniform billing information
Discharge data sets
All of the abo
ALL
HEDIS measures are specifically used to measure and compare the performance of:
Hospitals
Skilled nursing facilities
Physician practices
Health plans
Health Plans
Which organization is responsible for investigating fraud involving government health insurance programs?
OIG
CMS
AMA
WHO
OIG
As part of the patient's medical record, the identification form or face sheet is considered both a clinical and administrative document
True
False
T
CPT codes are published by the American Hospital Association (AHA) and updated each year
True
False
F
DRGs are used as the basis for determining appropriate inpatient reimbursement for Medicare, Medicaid, and other health care insurance beneficiaries
True
False
T
Medicare cost reports are filed annually by all hospitals, physician offices, home health agencies, skilled nursing facilities, and hospices that accept Medicare or Medicaid.
True
False
F
Health care information systems and health care processes are unrelated and should be considered independently
True
False
F
Centers for Medicare and Medicaid Services (CMS) currently requires health providers to submit claims electronically unless the provider qualifies for a waiver
True
False
T
CMS requires that all UB-04 claims include a valid 10 position unique National Provider Identifier (NPI) for each HIPAA-covered health care provider
True
False
T
An electronic health record (EHR) is an electronic record of health-related information on an individual that can be managed, shared, and controlled by that individual
True
False
F
Medicare and Medicaid do not have the authority to access a patient's medical record to confirm the accuracy of a filed claim by checking for documentation
True
False
F
ACDS is a uniform data adopted by the federal government and used as the standard for Medicare and Medicaid programs specifically in an ambulatory and outpatient care settings
True
False
T
Raw unprocessed healthcare facts generally stored as characters, words, or symbols is known as:
Health care data
Health care information
Health care text
Health care knowledge
Health Care Data
Health care data is most useful and can be best used for decision making when processed into:
Health care information
Health care knowledge
Health care statistics
Health care trends
Knowledge
The majority of problems with health care data content can generally be traced to:
Clinical processes
Documentation practices
Employee incompetence
Patients withholding information
Documentation Practices
According to the Medical Records Institute (MRI), which is NOT listed as one of the five major functions that are negatively impacted by poor-quality documentation:
Patient safety
Continuity of patient care
Employee Satisfaction
Public safety
Employee Satisfaction
Errors that can be attributed to a flaw or discrepancy in adherence to standard operating procedures or systems are known as:
Systematic errors
Random Errors
Methodical errors
Programming errors
Systematic Errors
Illegible handwriting is an example of a:
Systematic error
Random error
Methodical error
Programming error
Random
Using an abbreviation that has two different meanings is an example of a lack of:
Data currency
Data consistency
Data precision
Data granularity
Data Consistency
Handwriting, speaking, typing, touching a screen or pointing and clicking on words or phrases are all examples of:
Data processing
Information Capture
Report generation
Data recording
Information Capture
What professional organization has developed and published a data quality management tool that defines a specific set of characteristics of health care data that should always be present?
AHIMA
MIO
GAO
CMS
AHIMA
What is an example of a way system design can help reduce errors during data collection and processing?
Standardize data entry fields
Build human capacity
Institute real-time quality checking
All of the above
ALL
Data currency refers to the availability of medical information such as critical lab values to in a timely manner.
True
False
F
Content and form are two essential components that are needed to insure data quality:
True
False
T
Increased reliance on networked health care data has reduced the challenges associated with insuring and maintaining high quality data:
True
False
F
A set of universally recognized set of health care data quality standards exists today.
True
False
F
The Markle Foundation identifies the development of a "data quality culture" within health care organizations as a way to improve data quality:
True
False
T
Documenting health care information in an EHR through narrative form or unstructured fields allows for the full potential of the electronic record to be realized as a quality tool in insuring data consistency and comprehensiveness.
True
False
F
Data granularity refers to the fact that certain individual data elements such as a patient's birth date or name cannot be further subdivided into individual elements and still remain useful.
True
False
T
Either information capture or report generation must occur in order to have quality documentation.
True
False
F
Sophisticated information systems can be used to overcome inherent problems associated with poor quality data sources and data collection errors.
True
False
f
IT systems alone have been shown to improve data accessibility and legibility:
True
False
t
The process that gives health care organizations the authority to participate in the federal Medicare and Medicaid programs is known as:
Licensure
Certification
Accreditation
Recognition
CERTIFICATION
The best-known health care accrediting agency in the United States is:
NCQA
CMS
The Joint Commission
CARF
THE JOINT COMMISSION
Although state regulations may vary, the AHIMA currently recommends that patient health records for adults should be retained for how many years after the most recent encounter?
5 year
10 years
15 years
25 years
10
What quality organization is the developer and overseer of HEDIS measures and is known for their work in providing quality measures for health plans?
NCQA
CMS
The Joint Commission
CARF
ncqa
What was the first comprehensive federal regulation that offers specific protection to private health care information?
The Privacy Act of 1974
The Freedom of Information Act (FOIA)
The HIPAA Privacy Rule
The Patient Safety Act
HIPAA
The expectation that information shared with a health care provider during the course of treatment will be used only for its intended purpose and not disclosed otherwise is know as:
Privacy
Conditions of Participation
Boundaries
Confidentiality
CONFIDENTIALITY
How often must a health care organization undergo an on-site survey review by The Joint Commission?
2 year
3 years
5 years
10 year
3
The component of the HIPAA Privacy Rule that specifies that entities that improperly handle PHI can be charged under criminal law and punished and are subject to civil recourse is known as:
Boundaries
Security
Public Responsibility
Accountability
ACCOUNTABILITY
Organizations that can work with clinicians and health care organizations to identify, analyze, and reduce the risks and hazards associated with patient care are known as:
PSOs
PPOs
PSWP
PPRS
PSO
Which process tends to emphasize factors such as physical plant standards fire safety, and sanitation when assessing a health care organization?
Licensure
Certification
Accreditation
Recognition
LICENSURE
As a rule, the federal government oversees the licensure of healthcare facilities.
True
False
F
The Joint Commission's IM standards apply to both non-computerized systems and systems employing the latest technology.
True
False
T
The documents and data considered part of a patient's Legal Health Record (LHR) cannot exist physically separate from the actual paper or electronic medical record.
True
False
F
Accreditation is a mandatory process that gives health care organizations legal approval to operate
True
False
F
Electronic signatures are now accepted by both the Joint Commission and CMS as legitimate forms of provider authentication
True
False
T
Health care providers and others must obtain written authorization from a patient prior to disclosure of health information for routine uses of treatment, payment, and health care operations.
True
False
F
The Privacy Act of 1974 was written to protect patient confidentiality in all health care facilities.
True
False
F
The HIPAA Privacy Rule defines covered entities as those individuals whose health information must be protected by health plans, health providers, and other health care organizations.
True
False
F
In some instances patient-specific health care information can be released without the patient's authorization.
True
False
T
Administrative records are generally not included in a patient's Legal Health Record (LHR).
True
False
T
The type of information system that can be used to manage personnel, finances, materials supplies, or equipment is specifically known as a:
Health care information system
Administrative information system
Clinical information system
Ancillary information
ADMINISTRATIVE INFO SYSTEM
Data could be entered into a mainframe computer and viewed by an end user through a:
Shared system
Microcomputer
Minicomputer
Dummy terminal
DUMMY
The Medicare Modernization Act passed in 2003 mandated that health plans providing certain types of coverage to Medicare beneficiaries use:
CPOE
E-prescribing
Electronic Health Records
Telemedicine
E-PRESCRIBING
HIPAA was signed into law in 1996 and was intended to:
Make health insurance more affordable and accessible
Simplify administrative processes
Protect the confidentiality of personal health information
All of the above
ALL
The type of reimbursement methodology primarily used in hospitals in the 60s and 70s to compensate hospitals for services provided was:
Cost-based reimbursement
Prospective payment system
Per diem reimbursement
Capitation-based reimbursement
COST-BASED
What decade did the IOM publish its landmark report, publish a report that called for the adoption of the computer-based patient record (CPR):
1980s
1990s
2000s
2010s
1990S
The resource-based relative value scale (RBRVS) that was introduced in the early 90s was initially designed to redistribute funds from:
Specialty providers to primary care providers
Primary care providers to specialty providers
Hospitals to physician prac
SPECIALITY CARE PROVIDERS TO PRIMARY
What initiative began in the early 2000s that was specifically intended to bring multiple stakeholders into formal partnerships to exchange health data electronically?
HIEs
ACOs
PCMHs
CPOE
HIES
What term is often used to describe hosted services that are delivered over the internet?
Local Area Network (LAN)
Telemedicine
Cloud Computing
HIE
CLOUD
Value-based purchasing reimburses providers based on:
Cost of care
Number of services provided
Patient volume
Quality Metrics
QUALITY
An increased emphasis on preventative medicine and chronic disease management began in the 1990s.
True
False
T
Most of the early information systems in healthcare in the 60s were administrative applications.
True
False
T
Turnkey systems were software systems that could be easily modified to meet a hospital's unique information needs.
True
False
F
To Err is Human: Building a Safer Health Care System that was published by the IOM focused on medical errors that occur across all health care settings
True
False
F
By the end of 2010, it was more likely for a physician practice to have implemented a "basic" EHR system than a hospital
True
False
T
The HITECH Act was the first piece of legislation that authorized Medicare to reimburse for telemedicine services.
True
False
F
In current management literature, the terms information system (IS) and information technology (IT) are often used interchangeably.
True
False
T
In current management literature, the terms information system (IS) and information technology (IT) are often used interchangeably.
True
False
T
Most states have a single, central organization responsible for telemedicine issues or a complete data repository containing all relevant rules, regulations, and policies for payers and programs.
True
False
F
Electronic health records (EHRs) are considered a clinical application or clinical information system
True
False
T
The best-of-breed approach became prevalent in the 1980s and allowed organizations to easily interface different systems.
True
False
F
Electronic health records (EHRs) are considered a clinical application or clinical information system
True
False
T
Most states have a single, central organization responsible for telemedicine issues or a complete data repository containing all relevant rules, regulations, and policies for payers and programs.
True
False
F
The best-of-breed approach became prevalent in the 1980s and allowed organizations to easily interface different systems.
True
False
F
Studies have shown that about half of medication errors occur during:
Ordering
Dispensing
Administering
Monitoring
ORDERING
Monitoring patient blood sugar levels at home through a glucometer attached to a cell phone is an example of:
Telemedicine
Telehealth
Home Health
Electronic consultation
TELEHEALTH
What is NOT considered a function of a "basic" EHR system?
Clinical documentation
Diagnostic test results
Electronic ordering of medications
Computerized provider order entry (CPOE)
CPOE
What organization is responsible for testing and certifying EHR technology that can be used by a provider to qualify for EHR incentive payments through the Medicare and Medicaid programs?
ONC
CMS
OIG
HIMSS
ONC
Bar coding technology is a clinical application used to promote patient safety by improving the process of:
Medication ordering
Certified provider order entry (CPOE)
Chronic disease management
Medication administration
MEDICATION ADMINISTRATION
Approximately how much money did the federal government provide in total Medicare and Medicaid incentive dollars to encourage health care professionals and hospitals to become meaningful users of EHRs?
15 billion
30 billion
40 billion
50 billion
30N
As part of telemedicine, Store and forward technology is used primarily to:
Allow face-to-face consultation
Capture and monitor data from patients at home
Transfer digital images
Perform surgery robotically
TRANSFER DIGITAL IMAGES
What is NOT considered a major effect of clinical information systems on patient quality?
Increased provider productivity
Increased adherence to guideline-based care
Enhanced surveillance and monitoring
Decreased medication errors
INCREASE PROVIDER PRODUCTIVITY
Health care information standards and implementation specifications are examples of what type of barriers to adoption:
Financial barriers
Organizational and behavioral barriers
Technical barriers
Privacy and security barriers
TECHNICAL BARROERS
What is NOT necessarily considered a workflow advantage of CPOE?
Legibility of orders
Remote access
Turnaround time
Provider alerts
PROVIDER ALERTS
An adverse drug event (ADE) may or may not have involved a medication error.
True
False
T
Home health and hospice agencies have experienced wide spread adoption of EHRs
True
False
F
Studies consistently show that utilizing EHRs help physicians realize time savings.
True
False
F
Medline is an example of an application known as a knowledge-based reference system that allows a clinician to access the latest research findings or practice guidelines.
True
False
T
CPOE systems are easily implemented and operate in isolation.
True
False
F
It is estimated that close to 25 percent of hospitals have fully implemented CPOE systems
True
False
F
A personal health records (PHR) is managed by a consumer and may contain both health and wellness information, such as an individual's wellness plan.
True
False
T
It is estimated that close to 25 percent of hospitals have fully implemented CPOE systems
True
False
F
The majority of studies have shown that EHRs have had no negative impact on the physician-patient relationship.
True
False
T
Telehealth always involves the provision of clinical services.
True
False
F
EHR systems can help healthcare organizations realize higher reimbursements due to higher-quality documentation and improved coding practices.
True
False
T
ACOs incentivize physicians and other providers to work together to improve the quality of health care services and reduce costs for a defined population through what kind of payment model?
Shared savings
Bundled payments
Pay for performance
Episode of ca
SHARED SAVINGS
HITECH provided funding for the development of organizations to support providers in adopting and becoming meaningful users of EHRs known as:
Beacon Communities
Health Information Exchanges (HIEs)Strategic Health IT Advanced Research Projects (SHARPs)
Reg
Regional Extension Centers (RECs)
A Patient Centered Medical Home (PCMH) is an approach to providing patient care that is facilitated through what type of health care organization?
Hospitals
Primary care practices
Specialty practices
Skilled nursing facilities
PRIMARY CARE
Disclosure of an individual's protected health information (PHI) due to a security breach must be reported to Health and Human Services Office of Civil Rights and the media if it is believed to involve more than how many individuals?
100
250
500
1000
500
The most common type of HIE architecture is:
Hybrid
Centralized
Federated
Cloud based
HYBRID
The initiative that identifies leading organizations that are demonstrating how health information technology can be used in innovation ways to target specific health problems within communities is known as:
Regional Extension Center (RECs)
Strategic Heal
BEACON
What is NOT one of the three main components of Meaningful Use explicitly specified in the HITECH Act?
The use of a certified EHR in a meaningful manner
The use of certified EHR technology for electronic exchange of health information
The use of certified
The use of certified EHR to reduce costs and improve provider productivity
Referral management systems and patient navigation systems are both examples of:
Care coordination systems
Patient engagement systems
Disease registries
Master patient indices
Care coordination systems
The maximum amount an eligible professional can receive through the Medicaid EHR incentive program is:
$44,000
$63,500
$100,000
$2,000,000
63,500
The Direct Project and CONNECT Open Source Solution are two major initiatives affiliated with what efforts to facilitate health information exchange over the internet?
NwHIN
NeHC
SHARP
Innovation Center
NWHIN
Health care organizations that do not demonstrate Meaningful Use within a designated time frame will experience penalties in the form of Medicare and Medicaid payment reductions.
True
False
F
Capitation or global payment places full risk with the provider organization.
True
False
T
Capitation or global payment places full risk with the provider organization.
True
False
F
CMS is moving towards a bundled payment system where a single payment will be made to hospitals and physicians jointly for a given condition, episode of care, or procedure.
True
False
T
Eligible professionals qualifying for the Medicare EHR incentive program must have at least 30 percent Medicaid population to participate.
True
False
F
The criteria for Meaningful Use are to be implemented in 5 stages over a specified number of years.
True
False
F
Eligible hospitals can earn over $2 million through the Medicare EHR incentive program
True
False
T
CMS established an Innovation Center to test, evaluate, and expand different care models.
True
False
F
Hospitals and eligible providers do not have to demonstrate meaningful use in the first year to qualify for Medicaid EHR incentive payments but can simply adopt, implement or upgrade an EHR.
True
False
T
CMS specifies the standards, implementation specifications, and other criteria for EHR systems to be certified under HITECH.
True
False
F