Health Informatics an Interprofessional Approach 1st Edition By Nelson Staggers

Health Informatics an Interprofessional Approach 1st Edition By Nelson Staggers

Chapter 6:

Electronic Health Records and Applications for Managing Patient Care Test Bank

MULTIPLE CHOICE

1. Which description best defines the electronic health record (EHR)? a. An electronic version of the traditional paper record created and used by the healthcare provider b. An electronic stand-alone database implemented and used in hospitals c. An electronic version of a patient’s medical record used in the clinical setting d. An electronic record of patient health information created by encounters across multiple settings ANS: D The Healthcare Information Management Systems Society (HIMSS) provides a definition of the EHR as a longitudinal electronic record of patient health information produced by encounters in one or more care settings. Every person will have a birth to death (and even postmortem) record of health-related information in electronic form from multiple sources, such as physician office visits, inpatient and outpatient hospital encounters, medications, allergies, and multiple other medical services to support care. All other answers refer to a single facility use, which is not the EHR but a potential component of the EHR. DIF: Cognitive Level: Remember REF: pp. 88-89 2. The Health Information Management Systems Society (HIMSS) developed an EMR adoption model that includes eight stages toward creating a paperless patient record environment. All application capabilities within each stage must be operational before the next stage can be achieved. Your organization has implemented systems for Stages 1 and 2. Which system should your organization consider as Stage 3 adoption? a. Computerized provider order entry (CPOE) and clinical decision support b. Nursing/clinical documentation (flow sheets) and clinical decision support c. Closed loop medication administration d. Physician-structured documentation and clinical decision support ANS: B Stage 1 includes the installation of ancillaries (lab, radiology, pharmacy). Stage 2 includes clinical data repository (CDR), controlled medical vocabulary, and clinical decision support system (CDSS) and may also include document imaging and health information exchange. Stage 3 would require clinical documentation (flow sheets), CDSS (error checking), and a picture archiving system (PACS) available outside radiology. DIF: Cognitive Level: Apply REF: p. 92 3. Which system is recommended as a method to address patient safety and reduce errors that occur during the actual administration of medicines? a. Computerized provider order entry (CPOE) b. Bar code medication administration (BCMA) c. Electronic medication administration record (eMAR) d. Electronic prescribing (eprescribing) ANS: B Bar code medication administration (BCMA) is a method used to address patient safety and reduce errors that occur during the actual administration of medicines. CPOE is used to decrease transcription errors during the ordering process. ePrescribing is also used by the physician to order the medication (not administer). The eMAR is used to document the medications that are given. DIF: Cognitive Level: Apply REF: pp. 93-94 4. Which would be considered a niche application? a. Computerized provider order entry (CPOE) b. Laboratory information system (LIS) c. Clinical decision support system (CDSS) d. Surgical information system (SIS) ANS: D Some examples of specialty department niche systems include perioperative or surgical services, maternity care, neonatal intensive care, and the emergency department. The LIS is an ancillary system. CPOE and CDSS are basic components of the EHR. DIF: Cognitive Level: Apply REF: p. 95 5. A university hospital wants to implement a “closed-loop” medication management system. Current systems include registration, computerized provider order entry, electronic medication administration record, laboratory, radiology, and pharmacy. Which system is needed to complete the loop? a. Clinical documentation b. Clinical decision support system c. Bar-coding system d. Electronic prescribing ANS: C A closed-loop medication management system would connect the pharmacy system to the CPOE, eMAR, and bar-coding systems. DIF: Cognitive Level: Apply REF: p. 96 6. As the U.S. moves toward the implementation of an interoperable EHR, which statement about the future “ownership” of the patient record is appropriate? a. The electronic medical record will be the property of the service institution. b. Provider access to the electronic record would not require consumer consent. c. Ownership may be driven by who has control and access to the data. d. Consumers will control and own the record. ANS: C Traditional medical records have always been the property of the service institution, but this may not be true in the future. Consumer consent is required for health professionals to retrieve or share patient records to ensure personal information is not accessed inappropriately. Ultimately, ownership may be driven by who has control and access to the data. DIF: Cognitive Level: Analyze REF: p. 99 7. As EHR adoption expands to include data from multiple healthcare entities, more opportunities for error exist. Which process can affect data integrity? a. System failure b. Data analysis c. Data downloading d. Data mining ANS: A Data integrity refers to the accuracy and consistency of stored and transmitted data that can be compromised when information is entered incorrectly, deliberately altered, or the system protections are not working correctly or suddenly fail. DIF: Cognitive Level: Analyze REF: pp. 99-100 MULTIPLE RESPONSE 8. Which issues are considered impediments to a fully functional electronic health record (EHR) system? (Select all that apply.) a. Cost b. Standardization c. Care coordination d. Organizational culture e. Privacy and confidentiality f. Education ANS: A, B, D, E Despite the many advances in technology, there are still many issues to resolve associated with implementation costs, ownership, data integrity, privacy and confidentiality, organizational culture, human factors, and development of an infrastructure to support a nationwide EHR. Care coordination is considered an advantage, and education is not a major issue. DIF: Cognitive Level: Understand REF: p. 99 9. The core set of Stage 1 Meaningful Use objectives requires hospitals and providers to take which actions? (Select all that apply.) a. Use computerized provider order entry for medication orders b. Transmit prescriptions electronically c. Provide patients with discharge instructions or summary of office visit d. Record and chart changes in vital signs as structured data e. Maintain current problem and diagnoses list ANS: A, B, C, E Use computerized provider order entry for medication orders, transmit prescriptions electronically, provide patients with discharge instructions or summary of office visit, and maintain current problem and diagnoses list are all Stage 1 Meaningful Use objectives. Recording and charting changes in vital signs as structured data is a Stage 2 objective because the use of structured data will not be enforced until this later stage. DIF: Cognitive Level: Remember REF: pp. 89-91 10. The university hospital is getting ready to implement computerized provider order entry and some decision support capabilities to include drug-drug and drug-allergy alerts. Which actions should the implementation team take to increase user acceptance of the system? (Select all that apply.) a. Involve users early in the design, testing, and implementation of the system b. Conduct a quantitative research study to provide deeper insight into CPOE issues c. Design the new system to support communication and work flow d. Educate clinicians on how to use the system features e. Plan for continuous safety monitoring ANS: A, C, D, E Qualitative measures such as early involvement, ensuring design supports communication and workflow, clinician education and continuous safety monitoring provide deeper insight into the benefits and issues surrounding computerized provider order entry and some decision support capabilities. Quantitative research is helpful but would not provide the deeper content of the issues. DIF: Cognitive Level: Apply REF: p. 93 11. The general attitude of consumers toward health information technology is positive. Which items are perceived EHR benefits for the consumer? (Select all that apply.) a. Collaborative interaction between patients and providers b. Security and privacy of personal information c. Timely access to personal health information d. Online access to educational materials e. Customize care through reminders ANS: A, C, D, E From a consumer perspective, an EHR system should provide the ability to customize care through appointment reminders, health risk assessments, and timely access to personal health information. The availability of online educational resources will improve understanding of treatment choices and offer more control over personal health outcomes. Consumers also benefit from EHR technology when there is collaborative interaction between patients and physicians. Although the EHR has the potential to address these items, security and privacy of personal information are perceived as major concerns and, therefore, are not a benefit to the consumer. DIF: Cognitive Level: Apply REF: p. 97