Technology and Health Information Systems Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Technology and Health Information Systems flashcards as text
Which data element within an EHR is the CDI specialist MOST likely to use as a trigger for initiating a record review?
Answer: Laboratory values indicating organ dysfunction such as elevated creatinine or lactic acid
Abnormal lab values are objective clinical indicators that may suggest an unspecified or underdocumented condition requiring CDI clarification.
What is the role of an encoder in the CDI and coding workflow?
Answer: It translates clinical diagnoses and procedures into ICD-10-CM/PCS codes and calculates DRG assignments
An encoder is a software tool that guides coders and CDI specialists through ICD-10-CM/PCS code selection and calculates the resulting DRG and relative weight.
Which health information technology standard BEST ensures that data exchanged between a hospital EHR and an external CDI analytics platform is structured and readable?
Answer: HL7 FHIR (Fast Healthcare Interoperability Resources)
HL7 FHIR is the current standard for exchanging healthcare information electronically in a structured, machine-readable format between different health IT systems.
A CDI program wants to use predictive analytics to identify patients at high risk for a secondary diagnosis. Which data source would provide the MOST actionable input?
Answer: Aggregated clinical indicators such as vital signs trends, medication orders, and lab results fed into a risk-stratification model
Predictive models trained on structured clinical data — vitals, labs, medications — can surface high-probability secondary diagnoses before discharge, guiding proactive CDI review.
How does computer-assisted coding (CAC) technology support the CDI workflow?
Answer: It suggests diagnosis and procedure codes from clinical documentation, which CDI specialists and coders validate and confirm
CAC uses NLP to propose codes from clinical text, but human review by coders and CDI specialists is always required to validate accuracy and compliance.
Which approach BEST protects the integrity of CDI query data stored within an EHR system?
Answer: Implementing role-based access controls so only authorized CDI staff and physicians can create, view, or respond to queries
Role-based access controls ensure that only authorized individuals can interact with query records, protecting data integrity, privacy, and compliance with HIPAA requirements.
When evaluating CDI software for a hospital, which capability should be weighted MOST heavily from a compliance perspective?
Answer: The system's ability to generate compliant, non-leading query templates aligned with AHIMA/ACDIS guidelines
Query compliance is the cornerstone of ethical CDI practice; software that enforces compliant template standards mitigates risk of fraudulent documentation practices.