CDIP Technology and Health Information Systems 5 — Questions and Answers
Question 1: A hospital's EHR uses a master patient index (MPI). Which scenario MOST directly threatens MPI integrity?
- A nurse documents allergies in a structured field rather than free text
- A registration clerk creates a duplicate record for a returning patient (Correct answer)
- A coder queries a physician through the EHR messaging system
- A pharmacist reconciles medications at discharge
Correct answer: A registration clerk creates a duplicate record for a returning patient
Duplicate patient records created during registration are the primary threat to MPI integrity, potentially causing care fragmentation and safety risks.
Question 2: Under the ONC's Trusted Exchange Framework and Common Agreement (TEFCA), what is the role of a Qualified Health Information Network (QHIN)?
- Certifying EHR products for Meaningful Use compliance
- Serving as a nationwide network operator enabling interoperability between networks (Correct answer)
- Auditing hospital coding accuracy for CMS
- Providing cloud storage for de-identified patient data
Correct answer: Serving as a nationwide network operator enabling interoperability between networks
QHINs are designated network operators under TEFCA that connect health information networks to enable nationwide health data exchange.
Question 3: A CDI specialist reviews a CAC system's output and finds that a post-operative wound infection present on admission (POA) is being suggested without a POA indicator. What is the MOST likely consequence if this error reaches final billing?
- The claim will be denied entirely by Medicare
- The condition may be misclassified as a hospital-acquired condition, triggering a payment penalty (Correct answer)
- The MS-DRG will be upgraded to a higher-paying category
- SNOMED CT mapping will fail during transmission
Correct answer: The condition may be misclassified as a hospital-acquired condition, triggering a payment penalty
Without the correct POA indicator, a condition present before admission can be flagged as hospital-acquired, resulting in a HAC payment reduction under Medicare.
Question 4: Which component of a data warehouse architecture is responsible for cleansing, transforming, and loading data from source EHR systems before it reaches the analytical repository?
- Online transactional processing (OLTP) layer
- Extract, Transform, Load (ETL) process (Correct answer)
- Data mart query engine
- FHIR bulk data API endpoint
Correct answer: Extract, Transform, Load (ETL) process
The ETL process extracts raw data from source systems, transforms it to a consistent format, and loads it into the data warehouse for analysis.
Question 5: A hospital uses natural language processing (NLP) to scan clinical notes for unspecified anemia in patients with documented chronic kidney disease. The CDI team uses these results to send physician queries. This workflow BEST illustrates NLP's role in:
- Automated DRG assignment without human review
- Prospective CDI opportunity identification (Correct answer)
- Retrospective denial management
- Real-time pharmacy alert generation
Correct answer: Prospective CDI opportunity identification
Using NLP to identify documentation gaps in active patient records for CDI query opportunities is a prospective CDI workflow that improves capture before discharge.
Question 6: In the 21st Century Cures Act, what specific practice is prohibited to prevent health information technology vendors and providers from restricting the flow of electronic health information?
- Charging patients for printed copies of their records
- Information blocking (Correct answer)
- Using proprietary code sets instead of SNOMED CT
- Storing PHI on servers outside HIPAA-covered entities
Correct answer: Information blocking
The 21st Century Cures Act explicitly prohibits information blocking—practices that unreasonably interfere with the access, exchange, or use of electronic health information.
Question 7: A CDI department wants to benchmark its query rate and CC/MCC capture rates against national standards. Which organization publishes benchmarking data MOST relevant to inpatient CDI program performance?
- The Joint Commission (TJC)
- Association of Clinical Documentation Integrity Specialists (ACDIS) (Correct answer)
- Centers for Medicare & Medicaid Services (CMS) Open Payments
- National Committee for Quality Assurance (NCQA)
Correct answer: Association of Clinical Documentation Integrity Specialists (ACDIS)
ACDIS publishes annual CDI benchmarking surveys and industry metrics, including query rates and CC/MCC capture rates, making it the primary benchmarking source for CDI programs.
CDIP Technology and Health Information Systems 5
A hospital's EHR uses a master patient index (MPI).
Which scenario MOST directly threatens MPI integrity?