Patient Appointment Processing and Healthcare Identifiers Guide

Someone has recently relocated from another county, and has found that their physician she used to see is part of a larger group practice; she relocates near the new practice and schedules an appointment; the last appointment she had was about 2 years ago; how should the staff process her appointment? Within three years = established patient A patient presents to the emergency department with chest pain; he was seen by his primary care physician a week before, but now the pain is stronger; how should the patient be processed? New vs established patient rule applies to ambulatory setting, not acute/hospital setting An assignment of benefits form is: (what is it used for?) A patient authorization form that allows their health insurance or third-party provider to reimburse the healthcare provider or facility directly Difference between behavioral health and rehabilitation is:

Behavioral: a facility that provides care to patients with psychiatric diagnoses Rehabilitation: a facility that offers acute care and ambulatory care, typically serving patients recovering from accidents, injuries, or surgeries Both can offer both acute and ambulatory care A patient had a non-urgent referral for a knee x- ray and went to the hospital to get it done; the patient was given a CD with the x-ray on it and advised to follow up with the referring physician; what is the proper categorization for this encounter? Outpatient or ambulatory Some of the patient identifiers of the Master Patient Index are: Patient Identification Number Last name First name Gender DOB MRN medical record number A Master Patient Index is typically used in what type of facility (acute vs ambulatory)? Acute A guarantor is:

the person or financial entity that guarantees payment on any unpaid balances on the account. The guarantor may be the patient, another person, or a financial entity; Types: Personal/family, workers compensation, third-party liability, corporate, research What is the typical length of stay in an acute care facility? (Max number of days?) Minimum 24 hours to maximum of 30 days Purpose of the Master Patient Index is to: Match the patient with their MPI record Minimize duplication Retain lifelong health records (Assign a unique medical record number to each patient served, thus allowing easy retrieval and maintenance of patient information.) All of the following documents except ____ need to be signed by the patient to be valid Must be signed: NPP Notice of Privacy Practices Assignment of Benefits form General consent for treatment Advance directive

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A 66 year old male is admitted to his local hospital; he is still working and has private health insurance in addition to his provincial health; which insurance would be used to pay for this admission? Private insurance first as he is still working; otherwise over 65 gets medicare that is primary over supplemental; can depend on rules of state insurance commissioners Why is it important for the patient to have a single unique identifying number? If a patient has multiple identifiers, then providers may not see the true picture of a patient’s health status because important healthcare information may be misplaced, lost, or duplicated. Without a universal unique identifier or a set of data items to form a unique identifier, it is challenging to link data across healthcare facilities and providers. A guarantor is always responsible for: payment on any unpaid balances on the account All of the following can be a guarantor account type with the exception of:

Can be: personal/family, worker’s compensation, third-party liability, corporate, research One of the most important features of the MPI is: Patient identification number; Medical record number Regardless of their health insurance status, the record of a patient undergoing a specialty procedure must include a: Informed consent form All of the following are examples of the UHDDS core data elements except for: Remember uHdds H is for Hospital which means acute, or else UACDS for ambulatory UHDDS UACDS Patient identifier Patient identification Date of birth Date of birth Address Address Sex Sex Ethnicity Ethnicity Healthcare setting identification Provider identification Admission date Provider address Type of admission Provider specialty Discharge date Place of encounter Attending physician identification Reason for encounter Surgeon identification Diagnostic services

Principal diagnosis Problem, diagnosis, and assessment Other diagnoses Therapeutic services Qualifier for other diagnoses Preventive services External cause of injury code Disposition Birth weight of neonate Source of payment Significant procedures and dates Total charges Disposition of patient Expected source of payment Total charges

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In which submenu of the EHR navigator would you find the medicare provider numbers and payer lists? Settings>Facility You are trying to change a bill that was found to have error; which submenu of the navigator should you use first? Billing>Claims Management How is a CPOE different from e-prescribing? CPOE component is located by clicking Charts, selecting the patient, and clicking Manage Orders . Manage Orders is a button located on the patient’s chart. Depending on their level of access, users add, view, and cancel physician orders for treatment and care (e.g., laboratory orders, dietary orders, and therapy orders) by using Manage Orders eRx) feature that enables the system to electronically submit prescriptions to pharmacies all across the United States. The use of e-prescribing helps to reduce medication errors, thus improving patient safety and increasing practice efficiency. An EHR system that integrates an e-prescribing function increases facility productivity and efficiency by allowing a healthcare provider to view the patient’s medication history in the EHR rather than pulling a chart and writing a prescription by hand

Every EHR user must create a unique username and password to avoid: Ideally an EHR system should manage most aspects of a patient encounter which include all except: A workstation is necessary for a health information professional to complete their daily tasks. It consists of (describe workstation) includes a computer and input and output devices What is the difference between input and output devices? input device such as a keyboard, mouse, scanner, microphone, camera, stylus, or touch screen—is used to enter data into an EHR system output device such as a computer monitor, digital device screen, or printer—displays the results from EHRs Which of the following is not an input device? Anything other than: keyboard, mouse, scanner, microphone, camera, stylus, or touch screen

At the end of the day, you run a report of lab tests that have been sent to your office through the EHR system; filter them to identify abnormal test results, print the report, and give it to the physician; what activities of the information processing cycle are you performing? Processing and output Which of the following is not true about the documents function?

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Document imaging is when a paper copy of medical information is converted to a digital format to attach to a patient’s EHR. As healthcare organizations transitioned to EHRs, many organizations scanned paper records into current or new patient health records. Documents such as insurance cards, Notice of Privacy Practices, financial agreements, consent forms, advance directives authorizations, and living wills are examples of documents that may be scanned and added to a patient health record. It is important to audit documents, such as the consent form, release of information, or signature on file, to ensure the healthcare organization is in compliance with privacy and security requirements. Internal audits provide an opportunity for healthcare organizations to address areas of deficiency through training on privacy and security in the EHR. The Documents feature of an EHR system offers many benefits for healthcare personnel. For providers, this feature allows them to scan or upload documents, such as test results or handwritten notes, and attach them to a patient’s chart. This feature also allows providers to sign the notes. For all healthcare staff members, the Documents feature allows them access to view the documents and helps prevent misplaced or misfiled paperwork. In short, the ability to attach documents in an EHR system increases efficiency, productivity, and quality of patient care User permissions refer to: permissions define the areas of the software in which a user may view, add, edit, or delete information. Each user’s access to information is based on the type of information they will need to view or modify. Therefore, users are assigned access according to their job functions

A patient calls the office to schedule an appointment for the first time; you answer the call, open the EHR system, ask the patient for their name address telephone number, and health insurance information, you then record that information in the system and look for the available dates and times to schedule the appointment; what part of the information processing cycle is this? input The use of mobile digital devices in healthcare has expanded in an attempt to address: Cost of workstations and lack of ready access to data entry points An EHR must follow security protocols, which means all of the following, except: The capability of the EHR system to create and manage patient EHRs and automate the workflow is called: functionality In order to find and use patient information for higher encounter, information must be:

Collected, not erased, accurate A _____ allows computers located in large geographic areas to communicate with each other and is called: LAN (local, small) vs WAN (wide, large) Which of the following are not examples of storage devices in an EHR system? Are: on site, magnetic storage, cloud based, off site, secure server, dedicated server at the healthcare facility, server provided by vendor, healthcare system’s server, previously: paper/shelves, microfilm, optical scanning Sunrise hospital has implemented a new EHR system, and can now share patient information with several family practices. The family practitioner of a recently hospitalized patient can view the details of admission, along with the list of discharge medication and doses. Based on this information, which level of interoperability has been implemented? Structural level two – data exchange, common format Healthcare delivery systems implementing an EHR need to address privacy and security concerns by ____.

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Install secure firewalls, implement privacy policies and procedures, access monitoring, and privacy breach enforcement; use HL7 FHIR Release 4.0.1 to support interoperability and privacy and security Which of the following do an EMR and an EHR have in common? What was the purpose of creating the shared nationwide interoperability roadmap SNIR? to coordinate collective efforts around HIT interoperability, and it describes the policy and technical actions needed to realize the vision of a seamless, interoperable electronic health data system. What is the difference between level 3 and level 4 interoperability?  Level 3: The semantic interoperability level is a high level of interoperability that allows the meaning of the data to be shared. The data and information may also be interpreted, allowing EHR systems to function.  Level 4: The organization interoperability level is where the policies of data sharing both within and between organizations and individuals are created and maintained.

A cancer hospital has partnered with a number of hospitals and clinics across the country who are deploying proton therapy and other new cancer treatments with the goal of improving research capability and health outcomes for cancer patients. All partner clinics and hospitals are able to share data along with their meaning and are going through the process of unifying the various policies and procedures pertaining to data sharing. Based on this information, which level of interoperability will the hospital achieve? Level 4 organizational; shared policies There are 3 stages of meaningful use. Stage one has already been implemented in many facilities and includes all except ____. stage 1 requirements focused on data capture and sharing. Stage 2 requirements focused on advancing clinical processes, such as medication reconciliation, health information exchange, and patient-specific education. Stage 3 requirements incorporated the same measures as Stages 1 and 2 and outlined advanced coordination of care through patient engagement and participation in a health information exchange and public health reporting. The patient portal was a goal of Stage 2 Meaningful Use, Patient Electronic Access. It meets four meaningful use criteria: electronic copy of health information, clinical summaries, appointment recalls, and timely access to health information Stage 3 requirements were organized into eight topic areas of objectives in measures:

 Protect electronic protected health information (ePHI)  e-Prescribing (eRx)  Clinical decision support systems (CDSS) (provide information regarding a particular diagnosis or treatment to clinicians to enhance decision-making in the clinical workflow of the patient)  Computerized provider order entry (CPOE) (orders for medications and treatment are entered directly into the EHR)  Patient electronic access  Coordination of care (the organization of a patient’s healthcare treatment to improve the quality of care and eliminate duplication of tests and procedures)  Health information exchange  Public health reporting Which of the following is NOT true about interoperability? After the implementation of the EHR, on-call doctors at Grace hospital were able to access patient information from home and provide the necessary instructions faster. This benefit illustrates:

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immediate and improved access to patient information easy access to patients’ medical records The difference between an RHIT and an RHIA is:  RHIT: registered health information technician (associate degree) RHITs perform the technical procedures related to the management of health information, frequently working in positions of medical coding, billing, and data management.  RHIA: registered health information administrator (bachelor’s degree) The RHIA works as a liaison between healthcare providers, organization staff, payers, and patients. The RHIA is an expert in managing health information and the professionals responsible for managing this information Organizational interoperability means all except: organization interoperability level is where the policies of data sharing both within and between organizations and individuals are created and maintained. A healthcare facility is in the process of implementing a new EHR system. One of the goals is to achieve exchange of clinical and administrative data with two other hospitals owned by the same organization. What standards should the EHR comply with to achieve that goal? Fast Healthcare Interoperability Resources (FHIR) Health Level 7

HL7 FHIR Release 4.0.1 The most common communication protocol used in healthcare today is: HL7 FHIR Release 4.0.1 Which of the following statements best distinguishes an EMR from an EHR? EHR multiple organizations The ARRA and HITECH act encouraged many IT vendors to start designing EHRs for various types of facilities such as hospitals, physicians offices, dentists, etc. While this was a positive trend, new issues were created relating to: security The overall purpose of EHR is to: The term Electronic Medical Record means the following: electronic version of patient files within a single organization, and it allows healthcare providers to place orders, document results, and store patient information for one facility, commonly called the healthcare delivery (HCD) system

Interoperability is ____. (definition) the ability of an EHR system to exchange data with other sources of health information, including pharmacies, laboratories, and other healthcare providers When initiating an appointment in the EHR navigator, you do this by selecting schedules. What do you choose after that (in the schedules)? Click an open time slot and add appointment details in the dialog box In the healthcare facility, it is very important to know the location of the patients at all times. For this reason, EHRs have a feature called: EPT electronic patient tracking Discharge disposition indicates the patients destination following an episode of care as an inpatient. It can include all of the following except: Can include: home, skilled nursing facility, rehabilitation hospital, long-term acute care hospital; if they died, “expired”

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Which parameter is responsible for determining the right length of an appointment? Appointment type A scheduling feature is included in the EHR in order to: helps simplify the scheduling and billing processes in a healthcare facility Setting a facility template means that ____: showing its overall schedule of operations a matrix that shows available and unavailable appointment times When following a modified wave scheduling method, how do the patients appear when you’re scheduling them? Patients arrive at planned intervals in the first half hour, then, in the second half hour, the healthcare provider catches up. This type of scheduling may be used in an internal medicine office where the provider does not have to be in the room with the patient for the entire appointment An ambulatory care facility experiencing many no-shows should ____ in order to determine the rate of no-shows.

Tracking these types of appointments will enable the healthcare facility to run reports Run no-show reports Which appointment scheduling step is key in determining the time of an appointment? Typical parameters for scheduling a patient include ____: available providers, available scheduling days and hours, and types of visits When an existing patient schedules an appointment, what prior information would not be expected to populate a record from the MPI? New Patient Established Patient Patient’s full name Patient’s full name Telephone number Date of birth Date of birth Telephone number Chief complaint or reason for appointment Chief complaint or reason for appointment Type of insurance Insurance identification number Referring physician Social Security number Sex Address Emergency contact Responsible party information Employer information

What is the main reason for offering telehealth visits? expand access to patients in rural areas and to provide healthcare services when a patient cannot or should not visit the facility in person A pediatricians office allocates two hours of the morning to schedule well baby visits and the rest of the time is left for ill child appointments. Which scheduling method is being used? Cluster Which of the following scheduling methods would be more appropriate for an urgent care clinic? Open Hours Which of the following is typically not a general scheduling method during the whole week in ambulatory care? Time specified? Open Hours?

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Since the implementation of a new EHR system, Sunrise family practice has provided its patients with a portal where they can go to schedule their own appointments. As a result the office has had more time to dedicate to other functions. However many patients who schedule their own appointments around lunchtime end up waiting a long time to be seen by their physicians. What is the best alternative to improve the situation? Adjust hours to block off the lunch hour as unavailable; book hour before lunch as modified wave to catch up before lunch The scheduling tools include all of the following except:

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Does have: schedule appointment, appointment list, hours, view only calendar Schedule appointment dialog box has: type, date & time, duration, provider, department, procedure, patient, reason for visit, preferred contact, notes, contact information To schedule an appointment in the EHR navigator, click ____. Schedules, or select appointment list and then add appointment Outpatients are different from inpatients because they ____. Outpatients treated at an acute care hospital might be treated in the emergency room and released to their home without the need to be admitted to the hospital. Patients may also be treated as outpatients when they are seen in a clinic setting or testing area. Many hospitals also have outpatient surgical centers where patients have minor surgery and are sent home without the need to spend the night.

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Patients may be treated in a variety of outpatient settings, including a physician’s office, drug or alcohol treatment center, psychologist’s office, or dialysis facility. Which of the following statements is not true in regards to NCVHS core data elements? In 1996, the National Committee on Vital and Health Statistics (NCVHS) completed a review of core health data elements and developed a list and definitions of the 42 core elements that can be used in a variety of healthcare settings Uniform Hospital Discharge Data Set (UHDDS) for inpatient care. Developed by a committee in 1969, the UHDDS outlined a set of patient-specific data elements. This protocol, revised by the National Committee on Vital and Health Statistics (NCVHS) in 1984, was adopted by federal health programs in 1986 Uniform Ambulatory Care Data Set (UACDS) for outpatient services. The primary purpose of using this data set is to ensure that all healthcare settings and providers are gathering identical types of information on each patient and that the data collected is defined consistently across all healthcare settings. The NCVHS approved this data set in 1989. The UACDS is used in surgery centers, physician’s offices, outpatient clinics, and emergency departments. The UACDS is not required but highly recommended.

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During the gallbladder removal surgery, Dr Smith removes some liver tissue and sent it to the lab for an analysis. After analyzing the tissue, Dr Brown completed a ____ report. Laboratory tests; pathology reports Which of the following is an example of administrative data? Administrative data includes demographic information about the patient, such as the patient’s name, address, date of birth, race, primary language, religion, and marital status Great strides have been made in the implementation of EHR however paper records still exist because: Dr Holtzer visits a patient shortly after the patient is admitted to the hospital. In the medical record, he records both the patient’s past and current health conditions, an assessment, and a plan for diagnostic testing. What type of document is Dr Holtzer completing? History and physical The core data set developed by AHIMA is primarily used by which type of facility.

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physician practice EHR Which of the following media has been used to store medical records over the years? : on site, magnetic storage, cloud based, off site, secure server, dedicated server at the healthcare facility, server provided by vendor, healthcare system’s server, previously: paper/shelves, microfilm, optical scanning Which of the following statements is an example of the advantages associated with EHRs? When evaluating an EHR system, which of the following is not a priority? Upon his first visit to the cardiologist, Mr Smith was given a notice of privacy authorization. Which type of data is this? Legal data Which of the following is not an example of clinical data?

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Clinical data includes the medical information taken and recorded by the healthcare provider. The clinical data should be detailed, complete, precise, timely, and accurate, because the information plays a large role in the overall health plan of the patient. The clinical data includes documentation such as the following:  Pathology and laboratory reports  History and physical assessments  Allergies  X-rays  List of medications  Surgeries  Hospital admissions  Progress notes What is the difference between administrative and clinical data? Administrative data is information that the patient provides or populates in the health record. The administrative information typically found in the health record includes the following:  Patient’s name  Address  Telephone number  Place of birth

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 Date of birth  Age  Sex  Marital status  Ethnic origin  Emergency contact information  Primary language  Religion The healthcare staff collects administrative information to verify the patient’s identity and to help create a patient’s demographic profile What is the difference between data and information? Data descriptive or numeric attributes of one or more variables Information data collected and analyzed Health records may be used as evidence in a legal proceeding provided that they are ____.  documented following normal routines.  kept in the regular course of healthcare business.  recorded during or close to the time the event happened.  recorded by a person with knowledge of the events.

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The SOAP format is often used for progress notes and ____. Chart note for ambulatory care for health record content data category A health record includes: Clinical, administrative, legal, financial data What kind of document gives the patient permission or a recommendation to be seen by another provider? referral

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6060 Midterm

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