Integrated Electronic health records (Key Terms) Chapter 1-2

Software that has a special purpose, such as word processing, spreadsheet, or for a particular industry such as practice management or electronic health record software.

Term used to refer to physicians, physicians' assistants, dentists, psychologists, nurse practitioner, or midwife.

A service that processes data into a standardized billing format and checks for inconsistencies or other errors in the data.

Coding system used to convert narrative procedures and services into numeric form. CPT is used to code procedures and services in a physician's office; in a hospital setting, it is used for outpatient coding (emergency room, outpatient diagnostic testing, or ambulatory surgery, for example). Save Changes

Administrative data that identifies the patient. Consists of name, date of birth, sex, and social security number (may vary by facility policy).

Submitting insurance claims via wire to a clearinghouse or directly to the insurance carrier.

Comprehensive record of all health records for a patient, which is able to be shared electronically with other health providers as necessary.

The legal patient record that is created within any healthcare facility (hospital, nursing home, ambulatory surgery facility, physician's office, etc.). The EMR is the data source for the electronic health record (EHR).

A document (paper or electronic) that is used in medical offices to capture the diagnoses and services or procedures performed and from which the CMS-1500 billing form is completed.

The classification system used to convert narrative diagnoses and procedures into numeric codes. Effective October 1, 2015, replaces ICD-9-CM.

The classification system used to convert narrative diagnoses and procedures into numeric codes. Effective October 1, 2015, replaces ICD-9-CM.

Many different functions can take place and information can be shared between computer systems, or within applications of the same computer system, which is not possible with a manual or paper record system.

A permanent listing of all patients who have received care in a hospital (inpatient or outpatient). In physicians' offices, more often referred to as Master Patient List or Patient List.

Documentation, dictation, ordering of tests and procedures that occur at the same time the patient is being seen.

Software used in physicians' offices to gather data on every patient and perform administrative functions from the time an appointment is made through the time the bill for each visit is paid.

Software that recognizes the words being said by the person dictating, and converts the speech to text.

PrimeSUITE is both a PM and EHR solution using a single database.

This is done by compiling the patient's identifying information, insurance information, and the ICD-10-CM/PCS and CPT codes into a form called the CMS-1500, which is used by physicians' offices, or the UB-04, which is used to bill hospital claims.

ear, nose, and throat specialist

PrimeSUITE help text can be accessed through any screen. By clicking on Help, you will gain access to the entire user's guide (Figure 1.9). How many ways are there to locate information?

Three ways. How many ways are there to locate information?

a form of speech recognition technology.

Exchange of clinical information between medical providers or other entities

Exchange of clinical information between medical providers or other entities with a need to know, through the PrimeEXCHANGE solution.

Prescribing medications electronically to the patient's pharmacy of choice through use of the ePrescribing solution.

The ability to access clinical trials, evidence-based medicine, and pharmaceutical research to improve patient care, and access to clinical and financial benchmarking services to enhance financial management by using the PrimeRESEARCH solution

Mobile EHR applications available on personal digital assistants (PDAs) or smartphones to allow providers instant access anytime and anywhere through PrimeMOBILE.

1:Appointment scheduling 2: Front desk check-in 3: Nursing/clinical support 4: Care provider 5: Check-out desk 6:Business office/billing 7: Clinical staff/care provider

In cases where the care provider ordered diagnostic procedures such as x-rays or laboratory tests, then the clinical documentation steps would be repeated

What is Practice Management?/Practice Management applications -Master Patient Index/Patient List -Scheduling appointments -Assign ICD-10-CM/PCS and CPT codes -Complete billing claim form -Send insurance claims to carriers

Disadvantages -Increased security functions -High cost of implementation -training requirements Advantages -Possibly more secure than paper records -Return on investment is high -All information in one place -Interoperability -Assures regulatory compliance -Exchange of information with those who have a need to know

-Clinical documentation -Electronic prescribing -Exchange of clinical information -Research evidence-based medicine, pharmaceutical research, clinical and financial benchmarking studies -Speech recognition

-Appointment scheduling -Front desk check-in *Verify demographic information *Sign authorization/administrative forms, if necessary -Patient taken to examining room *Height, weight, vital signs are taken *Patient states the reason for today's visit (chief complaint) -Care provider meets with the patient *Provider verifies reason for visit; updates history *Provider examines patient *provider makes referrals, if necessary *Prescriptions are electronically sent to pharmacy, if necessary *Provider completes the chart, which then starts the coding and claims process *Provider completes the visit and provides patient with a Superbill or encounter form -Patient stops at the check-out desk *Superbill is given to staff member at the check-out desk *Patient pays co-pay, if not paid during check-in process *Patient leaves the office -Business office/billing *Insurance claim form is completed electronically *Insurance claim is submitted electronically *Insurance payment (or notice of denial) is received *Payment is entered in the system *Patient's account is updated *Statement is sent, if necessary -Follow-up *Results of diagnostic tests received, if applicable *Record is updated with results *Provider reviews results *Patient is contacted, if necessary

Use of Help from menu bar Other means of accessing help feature User's Guide

Signed into law by President Obama on February 17, 2009; this economic "stimulus plan" includes provisions for the Health Information Technology for Economic and Clinical Health (HITECH) Act.

Allows access to current treatment options for a disease, through electronic or remote methods. Alerts the care provider to possible medication interactions, gives treatment options based on results of clinical trials or research, alerts provider that a patient may have a particular diagnosis based on the data found in the patient's electronic record.

A nonprofit, nongovernmental agency whose purpose is to certify electronic health records for functionality, interoperability, and security.

A single, raw fact such as a patient's name, height, or weight. Often used interchangeably with information, though they are not synonymous terms.

A leadership position within a healthcare facility, including chief executive officer, chief operating officer, chief financial officer, chief information officer, or other higher level management positions. May also be referred to as healthcare manager or health systems manager.

The movement or sharing of information between healthcare entities in a secure manner, and in keeping with nationally recognized standards.

A leadership position specifically responsible for the information technology (IT) functions within an organization or facility.

Passed in 1996, this act includes regulations that afford people who leave their employment the ability to keep their insurance or obtain new health insurance even if they have a pre-existing medical condition. Also sets standards for storing, maintaining, and sharing electronic health information while ensuring its privacy and security.

A portion of the American Recovery and Reinvestment Act (ARRA) that is meant to increase the use of an electronic health record by hospitals and physicians through a monetary incentive program.

Raw facts that, when viewed as a whole, have meaning. Example: a report of all patients treated at Memorial Medical Center with a primary diagnosis of streptococcal pharyngitis (strep throat), sorted by patients' age.

An independent, nonprofit, nongovernmental organization that works to provide unbiased and authoritative advice to decision makers and the public.

Part of the requirements of the Health Information Technology for Economic and Clinical Health (HITECH) Act which is meant to increase the use of an electronic health record through monetary incentives provided the EHR is used in a meaningful way to improve patient care.

A set of standards, services, and policies that enable the secure exchange of health information over the Internet.

A unique identifier that must be used on insurance claims to identify the care provider and/or group practice that rendered care to the patient.

The principal federal entity charged with coordination, implementation, and use of health information technology and the electronic exchange of health information.

A record, kept by the patient, that contains a person's health history, immunization status, current and past medications, allergies, and instructions given by a care provider; it often includes patient education materials as well.

Computerized system for enhanced viewing and sharing of images such as x-rays, scans, ultrasounds, and mammograms.

Any piece of information that identifies a patient, including a patient's name, date of birth, address, email, telephone number, employer, relatives' names, social security number, medical record number, account numbers tied to the patient, fingerprints, photographs, and characteristics about the patient that would automatically disclose his or her identity. PHI also includes any clinical information about an identified patient.

An organization that assists healthcare providers with the selection and implementation of electronic health record systems.

Healthcare organizations in a geographic area that exchange health information with the goal of improving patient care, reducing duplication, and reducing unnecessary costs.

Data that fits a particular model or format, which can be tracked and may be part of a database. Examples include ICD-10-CM/PCS codes, CPT codes, a patient's temperature, or a patient's age.

Data in the form of words or audio files that cannot be tracked. Examples include emails, written narratives, and audio files from speech recognition technology.

chief executive officer (CEO), chief operating officer (COO), chief financial officer (CFO), or chief information officer (CIO).

(manager)

American Health Information Management Association

American Association of Medical Assistants

the American Medical Technologists,

Healthcare Information and Management and Systems Society

the Physician Office Management Association of America

may be a chief executive officer (CEO), chief operating officer (COO), chief financial officer (CFO), or chief information officer (CIO). These individuals typically have a bachelor's or master's degree (preferred) in healthcare administration and are responsible for overseeing several departments (or the entire organization).

Medical assistant is required to enter and retrieve data quickly yet accurately whereas an office administrator (manager) will be gathering information from the practice management and EHR systems to ensure claims are filed and paid accurately and in a timely manner, to ensure requirements of managed care organizations are met, and to ensure compliance with Meaningful Use (MU) requirements.

A single raw fact such as a persons name, height or weight.

unstructured data are a dictated report, a written progress note, voice files, or scanned images of original documents. difficult to track or share. Structured data allow computers to process the data into usable information.

a person's health history, immunization status, current and past medications, allergies, and instructions given by a care provider; it often includes patient education materials as well.

health information exchange.

customized.

Institute of Medicine

establish standards for keeping of health information

Health Insurance Portability and Accountability Act

In a physician's office, patient data collection begins when:

view videos

data.

are discharged.

engaging in mean

interface

CMS-1500

Library

Data dictionary

administrative

Health Level Seven (HL7)

Continuity of Care Documents (CCD)

provider

assignment of benefits authorization

the place of service code

race

unique identifier

ICD-10-CM

Greenway Medical Center has partnered with five area physician's offices as well as a rehabilitation facility nearby for the purpose of offering high quality, coordinated care to patients in that geographic area. This partnership is known as a/an _________________.

data

the patients' health records

An index of all patients ever treated in a hospital

medical (health) record number

one

five

Patient list

once

Permanently

patients are registered in all of these settings

Centralized registration

reason for the visit

Scheduling

edit

Default

patient stops at the cashier or check-out desk

insurance card

field.

logical.

Which of the following is NOT a required patient history? Family

Care providers Patients Receptionists All of these

family

Facesheet

Interview

Allergies

Name DOB Medical record number All of these

approximate date of the procedure.

adjacent

body mass index

Social history

documented.

Duration

Annual exam

plan

medical history form.

generate

speed of turn-around time

objective

more it learns voice inflections.

care provider request

transcriptionist.

Only those that apply to the patient's chief complaint

Patient's chief complaint

problem list

HITECH

claim

necessary

Clinical modification

insurance plan.

MA or care provider interacts with patient

provider; patient

an invalid code assignment.

followed

office manager

Care provider

Accounts receivable

It is an incentive model.

written off as paid in full or sent to collections.

makes an appointment.

Providers Office staff The facility

Healthcare provider

Job description

offsite

all

CPT codes ICD-10 codes HCPCS codes

certified

breach of confidentiality

hidden.

accessible

secure

might be

encrypted.

increase the implementation of EHR systems.

Coding and billing that is inconsistent with typical coding and billing practices.

A reimbursement model where hospitals, physicians, other healthcare providers form partnerships whereby all are accountable for the quality of care, efficiency of medical services (to contain costs), and patient satisfaction. A pay for performance model of healthcare reimbursement.

Monies being paid from the medical practice, for instance to pay for supplies, rent, utilities, payroll,

Monies coming into a medical practice, for instance insurance payments or payments made by patients.

Signed into law in 2010, the ACA resulted in improved access to affordable healthcare coverage and protection from abusive practices by healthcare insurance companies. Gives consumers more control over their healthcare coverage and ties reimbursement to quality, patient satisfaction, and

The amount due from the patient at the time of the office visit; typically a requirement of managed care plans.

A formal, written document that describes how the hospital or physician's practice ensures rules, regulations, and standards are being adhered to.

The out-of-pocket payment amount that a policyholder must meet before insurance covers the service(s).

The CPT codes used to capture the face-to-face time between a patient and the care provider; takes into consideration the extent of the history, extent of the physical exam, and the level of medical

An explanation of the charges for services, the amount paid by the insurance company, and the amount due by the subscriber, which is sent to the subscriber (and also to the provider, in some instances).

The amount charged for services rendered in a physician's office by Current Procedural Terminology (CPT) code.

Intentional deception, which in healthcare takes advantage of a patient, an insurance company, Medicare, or Medicaid.

Coding system required by Medicare and Medicaid to document services and procedures (Level 1, Current Procedural Terminology, CPT) and equipment, supplies, and transport (HCPCS Level 2).

The medical insurance contract under which a patient is covered; the extent to which services are covered. Also referred to as "the plan."

The process of contacting the insurance carrier and receiving validation of coverage for that patient, deductible status, and co-pay amount.

Insurance plans that promote quality, cost-effective healthcare through monitoring of patients, preventive care, and performance.

The fact that there is a medical reason to perform a procedure or service. Documentation exists in the patient's record to show there are sufficient signs, symptoms, or history to warrant the

A detailed accounting of the claims for which payment is being made by an insurance company. The remittance advice accompanies the payment from the insurance company.

The primary person covered by an insurance plan.

Posting of charges and the payment of claims in the Practice Management system to update patients' accounts.

patient does not pay

A method of accessing portions of one's own health information from the care provider's or hospital's electronic health record.

The housing of data in a clout environment, which is a commercially main-tained site on the Internet