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139 Cards in this Set
- Front
- Back
continuum of care, documentation, clinical decision making, knowledge building.
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The EHR affords access to longitudinal health information about an individual across the _____, assist in _____, support ____, and provide for _____.
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multiple sources, point of care, decision making process
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The EHR integrates data from ______, compares data at the _____, assists providers in ______.
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source systems
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Information systems that populate the EHR.
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clinical, administrative, financial
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Source systems are ____, ____, and ____.
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continuity of care record
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A snapshot of data from the EHR and includes basic information such as diagnoses, allergies, medications, and future treatment.
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CCR
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A subset of the EHR that is used for subsequent patient care is a
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patient care
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Implementing an EHR can improve ____
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rules engine
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The infrastructure required for the EHR includes which component not found in most information systems?
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rules engine
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This controls alerts, reminders, order sets, and protocols.
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PHR
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System that includes patient information from both the patient and the provider.
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longitudinal record
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The phrase womb to tomb refers to ____.
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stark law
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This prevents physicians from receiving a fee for referring patients for any healthcare services whose care is paid for by a federally funded program.
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stark law
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This prohibits physicians or their family members from owning businesses to whom the physician refers patients for health services.
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CPOE
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This contains preprogrammed clinical decision support designed to assist the user through making an entry appropriately.
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order communication system
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This part of the EHR notifies clinical departments of orders made by the physician.
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electronic document management system
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This part of the EHR utilizes scanning to capture patient information from the paper record.
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clinical messaging
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This part of the EHR connects the medical staff and hospital by providing access to systems.
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clinical messaging
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This is the secure transmission of clinical information from one entity to another, including providers to providers, patients to providers, etc.
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structured, unstructured
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Patient care charting generally allow ____ and ____ data.
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structured
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This type of data is generally found in checkboxes, drop down boxes, and other means where the user chooses from options built into the system.
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unstructured
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This type of data can be entered in free text format by the user.
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patient safety, reminders, alerts
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The use of the CPOE can lead to significant improvements in _____ because _____ and ____ are built into the system.
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electronic medication administration record
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This part of the EHR automates many of the medication administration process in a facility.
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electronic medication administration record
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This part of the EHR can provide alerts to assist in medication timing and provide the nurse with reference material on the medication.
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clinical decision support system
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This part of the EHR provides help in association with data entry into an EHR system performed directly by the caregiver at the point of care.
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clinical decision support system
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This part of the EHR may notify the care provider of patient allergies or contraindications for medication or other treatment.
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patient provider portal
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This part of the EHR is a secure method of communication between the health care provider and the patient, just the providers or the provider and payer.
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patient provider portal
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This part of the EHR may include secure email or remote access to test results and provide patient monitoring - or access to patient education materials.
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population health
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This part of the EHR is the capture and reporting of healthcare data used for public health purposes.
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population health
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This part of the EHR allows healthcare providers to report infectious diseases, immunizations, cancer, and other reportable conditions to public health officials.
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exception to the Stark Law
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The ability of a healthcare facility to provide EHR software to physician is allowed through _____.
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certification
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CCHITs role in the EHR is
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larger facilities, physician practices
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Most EHRs are found in _____ and _____.
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cost savings, cost avoidance, productivity improvement
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Economic benefits of the EHR are ______, _____, and _____.
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easier access, faster diagnosis and treatment, quality of care, mistakes, documentation
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Clinical benefits of the EHR include _____, ______, improvement to ______, reduction in ______, and enhanced ______.
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providers, patients
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The EHR can improve communication between ______ and allow physicians to spend more time with ______.
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cost, uniform standards, training, fear
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Barriers to implementing the EHR include ____, lack of ______, ______, and ____.
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interoperability
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The lack of consistent standards in the EHR prevents _______.
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infrastructure
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This is made up of hardware, network, database, server, personnel.
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storing patient information
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The core function of the EHR is ______.
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medical devices
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The EHR can link with _______ allowing the capture of monitoring and testing.
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practice management system, billing, scheduling
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The ambulatory EHR frequently is combined with the ________ to perform ____ and _______.
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digitized
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Scanned image of an individual's actual signature.
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electronic
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Type of signature that requires a password or two-tiered authentication.
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digital
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Type of signature that used encryption and nonrepudiation to prove authenticator's identity.
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classification systems
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These are used for secondary data and group similar items together.
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reimbursement, quality of care, planning, statistics, public health reporting
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Classifications are used for which five tasks?
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interoperability
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Standards are important for ______.
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health information technology standards panel
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This organization works collaboratively with public and private sectors to achieve widespread interoperability among healthcare software applications.
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standards development organizations
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Organizations that create standards.
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american national standards institute
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This organization is responsible for accrediting standards development organizations.
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health information technology standards panel, standards development organizations, american national standards institute
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HITSP, SDO, ANSI
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vocabulary, messaging, data content
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For a system to be interoperable, it needs to follow the specific standards in which three categories:
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SNOMED
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The most widely recognized nomenclature in healthcare is
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systematized nomenclature of medicine, logical observation identifiers names and codes, unified medical language system, national drug codes
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SNOMED, LOINC, UMLS, NDC
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SNOMED
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This nomenclature system includes diagnoses, procedures, signs, symptoms, and cause of injury.
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LOINC
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This is a laboratory vocabulary used to order and report laboratory tests and record clinical observations.
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RxNorm
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This is a vocabulary for medications and provides standards for drug ingredients and strength as well as dose formats and relationships to other drugs.
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UMLS
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A database that catalogues bibliographic citations for biomedics and was developed to improve search capabilities.
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NDC
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These were developed by the FDA to act as a universal unique identifier for human drugs.
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MEDCIN
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This nomenclature and knowledge based system is designed to provide intelligent clinical database for documentation by the clinician at the time of care.
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mapping
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This is a crosswalk between the various terminologies; links between terminologies.
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use cases
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These are frequently used to create maps and describes how the user will interact with the system and what the system will do.
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digital
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The most secure type of signature used in the EHR is
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classification system
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ICD 9 is an example of a
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SNOMED
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The nomenclature used in the EHR to capture detailed clinical information is called
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SDO
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HITSP is considered a
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messaging standards
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Also called interoperability or data exchange standards.
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messaging
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With these standards, proprietary systems are able to talk to one another and allow the exchange of data.
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HL7
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This SDO provides standards for interoperabiltiy that improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer for all stakeholders.
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DICOM
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The use of this standard allows images to be transferred between systems from different vendors and allowing imaging to share information with clinical systems and EHR.
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Digital imaging and communications in medicine, national council for prescription drug programs
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DICOM, NCPDP
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NCPDP
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These standards are used by pharmacies and payer and control data to be shared for new prescriptions, refills, and other communications.
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data structures
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Refers to data stored in EHR and the way it is managed.
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data set
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Group of data elements that are the minimum accepted level of information to be collected for a specific purpose along with uniform definitions.
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data sets
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UHDDS, UACDS, MDS, DEEDS are all _____.
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Uniform hospital discharge data set, uniform ambulatory care data set, minimum data set, data elements for emergency department systems
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UHDDS, UACDS, MDS, DEEDS
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Joint Commission
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ORYX is a data set developed by the ______ to study outcomes and healthcare performance.
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database
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Collection of data carefully organized to be of value to the user.
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databases
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The EHR is a collection of ______.
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data repository
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Database that is developed in an open format allowing the facility to use it for multiple systems from one source - updated in real time.
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data warehouse
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Database containing data from other source systems in the healthcare facility - not updated in real time but is better suited for allowing querying and data analysis.
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presentation layer
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This controls the screen layout, data entry, and data retrieval.
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unstructured
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Also called narrative or free text data, this is usually entered using a keyboard, dictation, or voice recognition.
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unstructured
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This type of data allows data entered to be mores specific and detailed.
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reporting
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Unstructured data is not beneficial for _____ purposes.
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structured
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Drop down lists, check boxes, radio buttons, and other forms of controlled data entry are used in ______ data entry.
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template based entry
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This is a cross between free text and structured data entry where the user is able to pick and choose data that are entered frequently.
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interoperability
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The ability of one computer system to exchange data with another computer system.
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basic, functional, semantic
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Interoperability is divided into which three levels?
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basic
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Type of operability where the computer can send data to another computer but the receiving computer is unable to interpret the data.
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functional
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Type of operability that defines the structure of the messages so that the receiving computer can interpret the data.
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semantic
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Type of operability that allows the information to be used in a meaningful way.
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hybrid record.
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System with functional components that include both paper and electronic documents and use both manual and electronic processes.
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HL7
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____ is the messaging standard used in most information systems.
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messaging standard
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DICOM is an example of a ____
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real time
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A data warehouse is not updated in ____.
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structured data
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Check boxes are a form of ____.
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reminder
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I am entering orders on patient in my office. The computer tells me that I should order a mammogram. This is a ____.
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EMAR
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This component of the EHR uses bar codes to identify patients.
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provider portal
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The provider would use the _____ to check test results of a patient.
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healthcare providers
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The EHR improves communication between ____.
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practice management
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The ______ function is seen in the ambulatory EHR but not inpatient.
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data content
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Standard that controls content of data elements.
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SNOMED CT
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Terminology used to capture detailed clinical information.
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national drug codes
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This system is used to provide an universal unique identifier for human drugs.
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mapping
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A way to link ICD 9 and ICD 10 is through ____.
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more specific
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An advantage of unstructured data is that it can be ____.
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graphical user interface
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This provided tool such as icons, colors, buttons, and menus to help users navigate through an information system.
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NCPDP
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This is a messaging standard that is used by pharmacies and payers.
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HL7
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This messaging standard is used for clinical and administrative data.
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use cases
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Tools that provide very detailed information for programmers to use when developing they system.
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clinical data repository
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The infrastructure of the EHR should include a _____.
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subpoena audit trails
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A legal concern regarding the EHR is the ability to _____.
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False
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True or false. The US leads the way in EHR adoption by physicians.
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False
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True or false The EHR is not used for public health purposes.
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multiple ways
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In the EHR, data can be viewed in ____.
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printing, access
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In the hybrid environment, we must address issues such as ____ and ____.
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False
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True or false. The order entry/results reporting system is always utilized by the physician.
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A reason to implement an EHR is to
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improve patient care
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reminders
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notify physicians of screenings that should be performed on all 65 year old males with a past history of elevated PSA
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CCR
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A subset of the EHR that is used for subsequent patient care
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PHR
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The system that includes information from both the patient and the provider
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population health
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The component of the EHR that reports infectious diseases
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CCHITs role in the EHR
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certification
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Clinical decision support to enhance physician orders is found in which component of the EHR?
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CPOE
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Jason is on Zoloft 100 mg QD for his hospital stay on trial basis. Where would I find when this medication was given?
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EMAR
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The time it takes to enter data into the EHR is considered to be a
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barrier
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Which of the following is a benefit of the EHR?
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improved efficiency
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What function is typically found in the ambulatory EHR but not in the inpatient?
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practice management
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What is the CORE function of the EHR?
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storing patient infomation
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Which of the following is a primary barrier to EHR implementation?
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cost
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The most secure type of signature in the EHR is
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digital signature
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The concept of the crosswalk between two terminologies is called
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mapping
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Which of the following organizations is an SDO?
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ANSI
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ICD-9-CM is an example of a
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classification system
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The nomenclature used in the EHR to capture detailed clinical information is called
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SNOMED CT
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Which of the following databases is not updated in real time?
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data warehouse
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Checkboxes is a method of data entry used in
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structured data entry
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