CHAPTER 14

The Electronic Health Record

and Clinical Informatics

McGonigle & Mastrian • Nursing Informatics and the Foundation of Knowledge

Comprehensive Study Notes | Key Terms | Diagrams | 50-Item Mock Exam

■ LEARNING OBJECTIVES

• Describe the common components of an electronic health record.

• Assess the benefits of implementing an electronic health record.

• Explore the ownership of an electronic health record.

• Evaluate the flexibility of the EHR in meeting the needs of clinicians and patients.

• Examine the impact on patient outcomes when social determinants of health are included in the EHR.
PART 1 — KEY TERMS GLOSSARY
Administrative Process — Electronic activities carried out by scheduling, billing, and claims management
systems, including insurance eligibility validation and drug recall support.
American Recovery and Reinvestment Act (ARRA) — 2009 U.S. legislation that included the HITECH Act and
provided financial incentives for healthcare organizations to adopt certified EHRs.
Connectivity — The ability of an EHR to link and interface with other providers, laboratories, pharmacies,
patients, and government disease registries.
Decision Support — Use of computer reminders and alerts to improve diagnosis and care — includes drug
interaction screening, vaccination reminders, and clinical guidelines.
Electronic Communication — Online communication among healthcare team members, care partners, and
patients via email, web messaging, and integrated health records across settings.
Electronic Health Record (EHR) — A digital or electronic record that can provide comprehensive health
information about patients and be shared among authorized providers and institutions.
Health Information — Patient data needed for sound clinical decisions — demographics, diagnoses,
medication lists, allergies, test results, consents, and directives.
HITECH Act — Health Information Technology for Economic and Clinical Health Act (2009); incentivized EHR
adoption and resulted in CMS penalties by January 2015 for non-adopters.
Interoperability — The ability of different EHR systems to exchange and use health information seamlessly
across settings, institutions, and organizations.
Meaningful Use — CMS program requiring healthcare organizations and providers to demonstrate beneficial
use of certified EHR technology to receive financial incentives.
Order Entry Management — Ability of a clinician to enter medication, laboratory, radiology, nursing, and
other care orders directly into a computer.
Patient Support — EHR component encompassing patient education, self-monitoring tools, home
telemonitoring, and telehealth systems.
Population Health Management — Data collection tools supporting public and private reporting, including
standardized terminology and machine-readable format reporting.
Reporting — EHR function supporting public and private data reporting requirements with standardized,
machine-readable data.
Results Management — Ability to manage all types of results electronically, including current and historical
laboratory and radiology procedure reports.
Social Determinants of Health (SDOH) — Economic and social conditions that influence individual and group
differences in health status — includes economic stability, education, healthcare access, neighborhood
environment, and social/community context.
 PART 2 — COMPREHENSIVE STUDY NOTES

1. Introduction & Significance of EHRs in Nursing

EHRs are more than automated clinical documentation — their implications touch every dimension of nursing: how care
is delivered, how nurses interact with patients, and how research informs tomorrow's practice. Basic EHR knowledge is
now considered an entry-level nursing competency.

AHIMA Health Information Management Competency Model (6 Levels)

• Personal effectiveness competencies

• Academic competencies

• Workplace competencies

• Industry-wide technical competencies

• Industry-sector technical competencies (includes EHR skills, privacy & security)

• Management competencies (shared with occupation-specific requirements)

2. Setting the Stage — Legislative History

Year / Event Key Detail

2001 — IOM Report Proposed EHRs as a solution to the dual challenge of improving care quality
while controlling costs.

2004 — President Bush Called for most Americans to have an EHR by 2014; stated health records
computerization could 'avoid dangerous medical mistakes.'

2009 — ARRA / HITECH Act Provided CMS financial incentives for EHR adoption; mandated meaningful use.
Non-adopters faced penalties by January 2015.

2015 — HIMSS Stage 3 77% of U.S. healthcare organizations at Stage 3; basic EHR components
implemented (lab, radiology, pharmacy, nursing documentation, clinical decision
support).

2020 — 21st Century Cures Act Updated ONC certification criteria; added information-blocking prevention rules;
revised privacy/security certification criteria.

Current 96% of U.S. hospitals and 78% of physicians' offices have adopted an EHR
(Office of National Coordinator for Health IT).

HIMSS EHR Adoption Stages (Key Levels)

• Stage 3 — Basic EHR components: lab, radiology, pharmacy, nursing documentation, clinical decision support.

• Stage 6 — Full physician documentation, robust clinical decision support, electronic access to medical images
(1,313 U.S. hospitals).
 • Stage 7 — HIGHEST: Data sharing and warehousing; completely interfaced with emergency and outpatient facilities;
totally paperless (200+ hospitals).

3. Eight Core EHR Components (IOM, 2003)

The Institute of Medicine (IOM) distilled EHR functions into 8 essential components that promote patient safety:

# Component Description

Health Information & Patient demographics, medical/nursing diagnoses, medication lists, allergies, test results,
1 care management data, consents, directives, nursing assessments, and problem lists.
Data

Electronic management of all current and historical laboratory and radiology procedure
2 Results Management
reports.

Clinician entry of medication and care orders (lab, microbiology, pathology, radiology,
Order Entry
3 nursing, supply orders) directly into a computer; includes nursing orders in comprehensive
Management
EHRs.

Computer reminders and alerts for drug selection/dosing, medication interactions,

4 Decision Support
vaccinations, health screening, and clinical guidelines for disease treatment.

Electronic Online communication among team members and patients via email, web messaging,
5 Communication & integrated health records, e-prescribing, and government disease registries. Reduces care
Connectivity fragmentation.

Patient education and self-monitoring tools including interactive computer-based education,

6 Patient Support
home telemonitoring, and telehealth systems.

Administrative Electronic scheduling, billing, claims management, insurance eligibility validation, drug recall
7 support, and identification of research study participants.
Processes

Reporting &
Data collection tools supporting public and private reporting; data in standardized,
8 Population Health
machine-readable format.
Management

4. EHR Certification Criteria

The ONC initially established 45 NIST certification criteria in 2010. By 2015, these were expanded to 60 criteria in 8
categories. The 21st Century Cures Act (2020) further updated these standards.

2015 ONC Eight Certification Categories

• 1. Clinical Processes

• 2. Care Coordination

• 3. Clinical Quality Measurement

• 4. Privacy and Security

• 5. Patient Engagement
 • 6. Public Health

• 7. Health IT Design and Performance

• 8. Electronic Exchange

Certifying Bodies: Drummond Group and the Certification Commission for Healthcare Information Technology (CCHIT),
authorized by the U.S. Department of Health and Human Services (HHS).
5. Advantages of EHRs
Four most-cited early benefits (Chaudhry et al., 2006; ONC, 2017):

• Increased delivery of guidelines-based care

• Enhanced capacity for disease surveillance and monitoring
• Reduction in medication errors
• Decreased use (i.e., cost) of care

ONC (2022) — EHRs promise to deliver:

• Better health care — improved safety, effectiveness, patient-centeredness, timeliness, efficiency, equity
• Better health — healthier lifestyles, better nutrition, more preventive care
• Improved efficiencies & lower costs — preventive medicine, reduced waste and redundant tests
• Better clinical decision making — integrating patient information from multiple sources

Context Specific EHR Benefit

General No longer interpret poor handwriting; legible, searchable records

Emergency Dept. Reduced turnaround time for lab results

Inpatient Nursing Decreased time to first antibiotic dose; fewer medication errors

Ambulatory / Clinics Better cardiac risk factor management in diabetic patients; medication recall
notifications

Safety Net / Research EHR + decision support identifies patients for research studies or prescription
drug benefit programs

Nursing Perceptions Better care coordination, fewer medication errors, improved communication
during patient transfers (Kutney-Lee & Kelly, 2011)

HIMSS Davies Award Winners show: fewer medication errors, decreased medical records expenses,
reduced adverse drug reactions, fewer duplicate lab orders

EHR as a Clinical Information System (CIS)

• Provides instant access to information at point of care.

• Supports clinical decision making; electronic patient record.

• Enables data mining, outcome analysis, and research.

• Improves patient safety — especially identification of adverse drug reactions and fall risk.

• CIS with standardized codes supports rigorous analysis of clinical data (length of stay, mortality, readmissions,
complications).

• Evidence-Based Practice (EBP) references available at a mouse click; prompting capabilities reinforce
evidence-seeking behavior.

6. Social Determinants of Health (SDOH) & the EHR

SDOH are economic and social conditions that influence individual and group differences in health status. They affect
life expectancy, morbidity, and mortality. Average life expectancy is reduced by 15–20 years for people in low-income
communities due to stroke, chronic disease, and other concerns.

Healthy People 2030 — Five SDOH Domains

• 1. Economic Stability

• 2. Education Access and Quality

• 3. Health Care Access and Quality

• 4. Neighborhood and Built Environment

• 5. Social and Community Context

While medical care accounts for approximately 20% of healthcare, physical environment, socioeconomic factors, and
health-related behaviors — all elements of SDOH — account for about 80% of outcomes (Rohatgi, 2022).

The CMS Accountable Health Communities model addresses SDOH needs affecting healthcare utilization and costs.
Unmet health-related social needs (food insecurity, inadequate housing) increase chronic disease risk, health care costs,
and avoidable utilization.

7. Standardized Terminology & the EHR

Standardized terminologies are essential for interoperable EHRs. They must be machine-readable to support data
mining, value-based care metrics, and research.

Terminology Purpose / Notes

ICD-10 International Classification of Diseases, Version 10 — Medical diagnosis code

set (administrative/billing)

CPT Current Procedural Terminology — Used to code procedures for billing

SNOMED CT Systematized Nomenclature of Medicine Clinical Terms — Comprehensive

clinical terminology; nursing-orders mapping ongoing

LOINC Logical Observation Identifier Names and Codes — Universal codes for
laboratory and clinical observations

RxNorm Terminology for drug names; links to drug vocabularies and interaction software

UMLS / Metathesaurus Unified Medical Language System — Supports terminology integration and
online searches (NOT a terminology itself)

NANDA North American Nursing Diagnosis Association — Interface nursing terminology

NIC Nursing Interventions Classification — Interface nursing terminology

NOC Nursing Outcomes Classification — Interface nursing terminology

ICNP International Classification for Nursing Practice — Interface nursing terminology

(mapped to SNOMED CT)

Interface terminologies (NANDA, NIC, NOC) reflect nurses' everyday language for describing patients and
documenting care. Reference terminologies (SNOMED CT, LOINC) are used in the structured elements of information
systems. Mapping interface → reference terminologies allows a standard, shared vocabulary to communicate data
across settings (ONC, 2017).
8. Ownership of Electronic Health Records
Successful EHR ownership involves selection, implementation, evaluation, and optimization — requiring all
healthcare organization members from executive leadership to bedside clinicians to feel ownership.

Step Key Activities

Step 1 — Vendor Selection Clinicians (primary end-users) drive the project; assess needs of executive
leadership, IT, project management. Evaluate HIT industry. Identify
organizational risks.

Step 2 — System Choice Evaluate vendors' products based on completed needs assessment. Establish
key evaluation criteria: clinical workflows, decision support, reporting, usability,
technical build, maintenance.

Step 3 — Implementation Planning Begins with selection; includes scope of work, sequencing of EHR components,
resources. Identify key metrics to measure EHR success (financial, quality,
clinical outcomes).

Step 4 — End-User Adoption Develop change management plan alongside implementation. Pre-live: include
end-users as subject matter experts, usability testing, shadowing, formal training.
Training = classroom + e-learning + peer-to-peer support.

Step 5 — Optimization Long-term, ongoing step — routinely overlooked. Emphasizes continued clinician
involvement; transforms care delivery rather than just automating old processes.

Common EHR Success Metrics

• Reduction in duplicate laboratory tests through duplicate-orders alerting

• Reduction in adverse drug events via barcode medication administration

• Meaningful use objectives and measures

• Financial, quality, and clinical outcomes improvements

9. Flexibility, Expandability & Interoperability

No single EHR system can fully serve all specialties (e.g., oncology needs chemotherapy ordering, cumulative dose
tracking). EHRs must evolve to support interprofessional collaboration beyond physicians and nurses (dietitians,
physical/occupational therapists).

• Continuity of Care Document (CCD) — Current interoperability standard. Includes demographics, medications,
allergies, and problems. Formatted per HL7 standards; both machine- and human-readable.
• Cloud-Based EHRs (Box 14-4) — Shift from facility-owned to vendor-owned, web browser-accessible systems.
Reduces hardware/software burden but requires relinquishing some control; security remains a challenge.
• Accountable Care Organizations (ACOs) — EHRs with data-sharing capabilities are central to ACO support. Core
IT requirements: EHRs, Health Information Exchanges (HIEs), care management systems, analytics & reporting.
• HL7 International — Not-for-profit, ANSI-accredited standards organization (founded 1987); develops
behind-the-scenes programming standards for interfaces and interoperability at the application layer of the OSI
model.
PART 3 — DIAGRAMS & VISUAL MODELS

Diagram 1: The 8 Core EHR Components (IOM Model)

Health Information & Order Entry

Results Management
Data Management

Reporting & Population EHR CORE

Decision Support
Health Mgmt COMPONENTS

Administrative Electronic Comm. &

Patient Support
Processes Connectivity

Figure 1. The eight core EHR components as defined by the IOM (2003).

Diagram 2: EHR Legislative & Adoption Timeline

YEAR EVENT SIGNIFICANCE

2001 IOM Report EHRs proposed to improve care quality & control costs

President Bush State of

2004 Goal: EHR for all Americans by 2014
Union

2009 ARRA / HITECH Act Financial incentives for EHR adoption; meaningful use requirements

2013 HIMSS Tracking 77% U.S. orgs at Stage 3; basic EHR components only

2015 ONC Certification Update 60 criteria in 8 categories; non-adopters penalized by CMS

2020 21st Century Cures Act Updated ONC criteria; information-blocking rules added

Present 96% hospitals adopted 78% of physicians' offices also using EHRs

Figure 2. Legislative and adoption timeline of EHRs in the United States.

Diagram 3: EHR Ownership Process Flow

VENDOR SYSTEM IMPLEMENTATI END-USER LONG-TERM

SELECTION ■ CHOICE ■ ON PLANNING ■ ADOPTION ■ OPTIMIZATION

Figure 3. The five-step EHR ownership process. Optimization (Step 5) is the most commonly overlooked step.
Diagram 4: SDOH Five Domains & Health Outcomes

Neighborhood & Social & Community

Economic Stability Education Access Health Care Access
Environment Context

▼ ▼ ▼ ▼ ▼

HEALTH OUTCOMES (Life expectancy · Morbidity · Mortality · Well-being)

Figure 4. Healthy People 2030 SDOH five-domain framework and their influence on health outcomes. SDOH account for ~80% of
health outcomes (Rohatgi, 2022).

Diagram 5: How EHRs Support Accountable Care (Figure 14-2 from text)

EH Accountable Care Benefit

RF
un
cti
on

1. Store data electronically for exchange & reporting

2. Put accountability into nursing care

3. Standardize care via shared protocols

4. Improve care coordination

5. Provide decision support for EBP

6. Automate clinical processes

7. Measure clinical risks

8. Provide decision support

9. Enhance evidence-based practice

10. Improve practice workflows

11. Retain complete patient data

12. Reduce errors

13. Leverage for clinical analysis

Figure 5. Functions of EHRs in supporting Accountable Care Organizations (adapted from ECG Consultants, 2015).
Quick Reference Summary Card

CONCEPT FAST FACT

IOM 8 Components Health Info & Data | Results Mgmt | Order Entry | Decision Support | Comm. & Connectivity | Patient
Support | Admin Processes | Reporting/Pop. Health Mgmt

HITECH Act 2009 law within ARRA; incentivized EHR adoption; non-adopters penalized by CMS by Jan 2015

HIMSS Stages Stage 3 = basic EHR; Stage 6 = full physician docs; Stage 7 = totally paperless, data sharing

ONC Certification Initially 45 NIST criteria (2010) → 60 criteria in 8 categories (2015) → updated by 21st Century Cures Act
(2020)

EHR Certifiers Drummond Group & Certification Commission for Healthcare IT (authorized by HHS)

Interoperability via Continuity of Care Document (CCD); HL7 standards; ARRA minimum data set requirements

SDOH % of Outcomes SDOH accounts for ~80% of outcomes; medical care only ~20%

Standardized Tx Interface: NANDA, NIC, NOC | Reference: SNOMED CT, LOINC, RxNorm | Admin: ICD-10, CPT

ANA Position (2018) Reaffirmed support for use of recognized terminologies in nursing practice and IT solutions

Key Nursing Role Nurse informaticists design user-friendly systems; nurses advocate for patients through SDOH data

EBP & CIS EBP links/reminders embedded in CIS workflow; translational research bridges research to practice
 PART 4 — 50-ITEM MULTIPLE CHOICE MOCK EXAM
Instructions: Select the BEST answer for each item. Correct answers are highlighted in green. Rationales are provided after
each question.

1. According to the IOM (2003), which of the following is NOT one of the 8 core components of an EHR?
A. Results Management
B. Decision Support
✓ C. Financial Forecasting
D. Administrative Processes
Rationale: Financial forecasting is NOT one of the IOM's 8 components. The 8 are: Health Information & Data, Results
Management, Order Entry Management, Decision Support, Electronic Communication & Connectivity, Patient Support,
Administrative Processes, and Reporting & Population Health Management.

2. Which U.S. legislation in 2009 specifically incentivized healthcare organizations to adopt EHRs?
A. HIPAA
✓ B. HITECH Act
C. ACA
D. Medicare Modernization Act
Rationale: The Health Information Technology for Economic and Clinical Health (HITECH) Act was part of the ARRA of
2009 and specifically incentivized EHR adoption through CMS reimbursement incentives. Non-adopters faced penalties by
January 2015.

3. Which HIMSS Stage represents a hospital that is totally paperless with full data sharing and
warehousing capabilities?
A. Stage 3
B. Stage 5
C. Stage 6
✓ D. Stage 7
Rationale: HIMSS Stage 7 is the highest level — hospitals are totally paperless with data sharing and warehousing
capabilities and are completely interfaced with emergency and outpatient facilities.

4. The Health Information and Data component of an EHR includes which of the following?
A. E-prescribing and telemedicine tools
✓ B. Demographics, medication lists, allergies, and test results
C. Scheduling and insurance eligibility validation
D. Public and private reporting in machine-readable format
Rationale: Health Information and Data includes patient demographics, medical and nursing diagnoses, medication lists,
allergies, test results, care management data, consents, directives, nursing assessments, and problem lists.

5. Which EHR component involves computer reminders, drug interaction alerts, and clinical guidelines?
A. Order Entry Management
B. Patient Support
✓ C. Decision Support
D. Results Management
Rationale: Decision support uses computer reminders and alerts to improve diagnosis and care, including drug interaction
screening, vaccination reminders, health screening, and clinical guidelines for disease treatment.

6. How many initial NIST EHR certification criteria were established in 2010?
 A. 30
✓ B. 45
C. 60
D. 75
Rationale: The initial NIST test procedure included 45 certification criteria in 2010, ranging from basic patient demographics
recording to complex electronic exchange of clinical information. These were later expanded to 60 criteria in 2015.

7. In 2015, ONC expanded EHR certification criteria to how many criteria in how many categories?
A. 45 criteria in 6 categories
✓ B. 60 criteria in 8 categories
C. 75 criteria in 10 categories
D. 50 criteria in 5 categories
Rationale: The 2015 update expanded certification from 45 to 60 criteria organized into 8 certification categories: Clinical
Processes, Care Coordination, Clinical Quality Measurement, Privacy and Security, Patient Engagement, Public Health,
Health IT Design and Performance, and Electronic Exchange.

8. Which two organizations were initially authorized by HHS to certify EHR vendors?
A. ANA and HIMSS
✓ B. Drummond Group and CCHIT
C. IOM and ONC
D. NIST and HL7
Rationale: The U.S. Department of HHS initially granted the Drummond Group and the Certification Commission for
Healthcare Information Technology (CCHIT) authority to accredit EHRs against standards developed by NIST and
endorsed by the ONC.

9. According to early research, the FOUR most-cited benefits of EHRs include all of the following EXCEPT:
A. Increased delivery of guidelines-based care
B. Reduction in medication errors
✓ C. Complete elimination of adverse drug events
D. Decreased use of care
Rationale: The four most-cited early benefits were: (1) increased delivery of guidelines-based care, (2) enhanced
surveillance and monitoring for disease conditions, (3) reduction in medication errors, and (4) decreased use of care.
'Complete elimination' of adverse drug events is not claimed — only reduction.

10. Social determinants of health account for approximately what percentage of health outcomes?
A. 20%
B. 50%
✓ C. 80%
D. 95%
Rationale: According to Rohatgi (2022), while medical care accounts for approximately 20% of healthcare outcomes, all
elements of SDOH (physical environment, socioeconomic factors, health-related behaviors) account for about 80% of
outcomes.

11. Which Healthy People 2030 SDOH domain addresses employment, income, and food security?
A. Education Access and Quality
B. Social and Community Context
✓ C. Economic Stability
D. Neighborhood and Built Environment
Rationale: Economic Stability is the SDOH domain that addresses employment, income, food security, and housing stability
— all economic factors that directly influence health outcomes.
12. The Continuity of Care Document (CCD) currently supports which EHR function?
A. Clinical decision support alerts
✓ B. Interoperability between different EHR systems
C. Patient portal access
D. Insurance eligibility verification
Rationale: The Continuity of Care Document (CCD) is the current standard for interoperability. It includes patient
demographics, medications, allergies, and problems, is formatted per HL7 standards, and is both machine- and
human-readable, enabling data exchange between different EHR systems.

13. Which nursing terminology is considered a reference terminology (NOT an interface terminology)?
A. NANDA
B. NIC
C. NOC
✓ D. SNOMED CT
Rationale: SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) is a reference terminology, used in the
structured elements of information systems. NANDA, NIC, and NOC are interface terminologies that reflect nurses'
everyday language for documenting patient care.

14. The HIMSS Davies Award is significant for EHRs because it:
A. Certifies EHR vendors for ONC compliance
✓ B. Recognizes organizations achieving excellence in EHR implementation and value
C. Establishes minimum EHR certification standards
D. Provides financial penalties for non-adoption
Rationale: The HIMSS Davies Award recognizes healthcare organizations that have achieved both excellence in EHR
implementation and value from health information technology. Davies Award winners demonstrate reduced medication
errors, decreased medical records expenses, and reduced adverse drug reactions.

15. In the EHR ownership process, which step is most commonly overlooked?
A. Vendor selection
B. Implementation planning
✓ C. Long-term optimization
D. End-user training
Rationale: Long-term optimization is the commonly overlooked final step in EHR ownership. Its omission often results in
benefits falling short of expectations because resources are not sustained. It is essential for transforming care delivery
rather than merely surviving the change.

16. Which EHR component encompasses electronic scheduling, billing, and insurance eligibility
validation?
A. Patient Support
✓ B. Administrative Processes
C. Reporting and Population Health Management
D. Order Entry Management
Rationale: Administrative Processes are activities carried out by electronic scheduling, billing, and claims management
systems — including electronic insurance eligibility validation, claim authorization, drug recall support, and identification of
research study participants.

17. What is the primary purpose of implementing standardized nursing terminologies in EHRs?
A. To simplify billing and insurance claims
✓ B. To enable interoperable exchange and data mining across settings
C. To eliminate the need for nurse documentation
D. To replace physician orders with nursing orders
 Rationale: Standardized terminologies must be in machine-readable format to support interoperable exchange of
information and data mining. Mapping interface terminologies (NANDA, NIC, NOC) to reference terminologies (SNOMED
CT, LOINC) allows a standard, shared vocabulary to communicate data across settings.

18. A nurse documents using NANDA diagnoses in the EHR. NANDA is classified as which type of
terminology?
A. Reference terminology
B. Administrative terminology
✓ C. Interface terminology
D. Universal terminology
Rationale: NANDA (North American Nursing Diagnosis Association) is an interface terminology — it reflects nurses'
everyday language used to describe patients and document care. Interface terminologies interface between nurses'
everyday language and the structured elements of the information systems nurses use.

19. According to the ONC (2019), EHRs have the potential to reduce fragmentation of care primarily
through:
A. Standardized billing codes
B. Eliminating the need for nursing assessments
✓ C. Enhancing care coordination via EHR interfacing
D. Providing patients with printed health records
Rationale: The ONC (2019a) believes EHR interfacing has the potential to reduce the fragmentation of care by enhancing
care coordination — connecting providers, laboratories, pharmacies, patients, and government disease registries
electronically.

20. Which act in 2020 implemented changes to EHR certification criteria that included information-blocking
prevention?
A. HITECH Act
B. ARRA
✓ C. 21st Century Cures Act
D. Affordable Care Act
Rationale: The 21st Century Cures Act resulted in changes reflected in the 2020 revised ONC certification criteria, including
conditions and maintenance of certification requirements, voluntary certification of pediatric health IT, and 'reasonable and
necessary activities that do not constitute information blocking.'

21. Which organization is designated as the central coordinating body for clinical terminologies by HHS?
A. American Nurses Association (ANA)
✓ B. National Library of Medicine
C. Centers for Medicare and Medicaid Services (CMS)
D. Joint Commission
Rationale: HHS has designated the National Library of Medicine as the central coordinating body for clinical terminologies.
It supports terminology integration efforts and online searches through the Unified Medical Language System (UMLS) and
the Metathesaurus.

22. A patient's EHR includes information about home telemonitoring and interactive computer-based
education. This represents which EHR component?
A. Electronic Communication and Connectivity
B. Administrative Processes
✓ C. Patient Support
D. Reporting and Population Health Management
Rationale: Patient Support encompasses patient education and self-monitoring tools, including interactive computer-based
patient education, home telemonitoring, and telehealth systems (IOM, 2003).
23. The ability to manage laboratory and radiology results electronically is part of which EHR component?
A. Order Entry Management
B. Decision Support
✓ C. Results Management
D. Health Information and Data
Rationale: Results Management is specifically defined as the ability to manage results of all types electronically, including
both current and historical laboratory and radiology procedure reports (IOM, 2003).

24. What percentage of U.S. hospitals had adopted an EHR as reported by the Office of the National
Coordinator?
A. 78%
B. 84%
C. 90%
✓ D. 96%
Rationale: According to the Office of the National Coordinator for Health Information Technology, 96% of U.S. hospitals
have adopted an EHR. Additionally, 78% of physicians' offices have adopted an EHR.

25. Which finding best demonstrates the advantage of EHRs from the Kutney-Lee & Kelly (2011) study?
A. Decreased patient satisfaction scores
B. Increased nursing documentation time
✓ C. Better care coordination and fewer medication errors in hospitals with EHRs
D. Higher hospital readmission rates
Rationale: Kutney-Lee & Kelly (2011) found that nurses in hospitals with a functioning EHR reported better care
coordination and fewer concerns about patient safety, including better communication among staff during patient transfers
and fewer medication errors.

26. HL7 International was founded in which year?

A. 1973
✓ B. 1987
C. 1995
D. 2001
Rationale: Health Level Seven International (HL7) was founded in 1987. It is a not-for-profit, ANSI-accredited standards
organization dedicated to developing standards for the exchange, integration, sharing, and retrieval of electronic health
information.

27. In the context of EHRs, 'meaningful use' refers to:

A. Using an EHR for more than 8 hours per shift
✓ B. Demonstrating beneficial use of certified EHR technology to receive CMS incentives
C. A system that is user-friendly for all healthcare staff
D. Using an EHR that costs less than paper records
Rationale: Meaningful Use is the CMS program requiring healthcare organizations and providers to demonstrate beneficial
use of certified EHR technology to qualify for financial incentives. It is now part of the updated ONC certification framework.

28. Which of the following is a key challenge identified by Shekelle et al. (2006) in EHR cost-benefit
research?
A. EHRs are too expensive to implement in any setting
✓ B. Most EHR data came from a few leading organizations, limiting generalizability
C. EHRs have no measurable benefits in ambulatory care
D. Nurses refuse to use standardized EHR systems
 Rationale: Shekelle et al. (2006) noted that most EHR data came from a small number of leading healthcare organizations
in the U.S. — fewer than 1% of hospitals — which significantly limits generalizability of findings to the broader healthcare
industry.

29. Which EHR component specifically supports the exchange of health information with government
disease registries?
A. Patient Support
B. Reporting and Population Health Management
✓ C. Electronic Communication and Connectivity
D. Administrative Processes
Rationale: Electronic Communication and Connectivity has been expanded to include interfaces required to exchange
health information with other providers, laboratories, pharmacies (e-prescribing), patients, AND government disease
registries (Green, 2023).

30. A nursing informatics specialist designing an EHR must ensure the system is 'highly usable.' This
primarily means:
A. The system should only be used by physicians
✓ B. The system should decrease errors and improve information entry and retrieval
C. The system must comply with insurance billing requirements only
D. The system should replace all nurse-patient interactions
Rationale: A highly usable EHR product should decrease errors and improve information entry and retrieval. Nurse
informaticists must design systems that meet the needs of the staff who will actually use them — and work continues even
after installation to improve the system.

31. The AHIMA Health Information Management Competency Model has how many levels?
A. 3
B. 4
C. 5
✓ D. 6
Rationale: The Health Information Management Competency model developed through AHIMA's collaboration is divided
into six levels: personal effectiveness, academic, workplace, industry-wide technical, industry-sector technical, and
management competencies.

32. Which act, part of ARRA, required a minimum set of EHR data to be interoperable across healthcare
settings?
A. HIPAA
B. ACA
C. HITECH
✓ D. ARRA itself
Rationale: ARRA itself set the expectation that despite the large number of settings in which a patient may receive care, a
minimum set of data from those records must flow, or 'interoperate,' among each setting and its unique EHR systems.

33. The IOM's Health Information Management Competency model includes which industry-sector
technical competency?
A. Time management skills
✓ B. Health informatics skills using the EHR
C. Financial planning for health systems
D. Medication administration rights
Rationale: The industry-sector technical competencies section of the AHIMA competency model includes health information
literacy and skills, health informatics skills using the EHR, privacy and confidentiality of health information, and health
information/data technical security.
34. In which setting was the implementation of an EHR associated with fewer hospital readmissions and
ER visits for seniors with multiple health challenges?
A. Pediatric outpatient clinic
✓ B. Integrated care system using EHR (Bayliss et al., 2015)
C. Rural health clinic without connectivity
D. Pharmacy-based walk-in clinic
Rationale: Bayliss et al. (2015) demonstrated that an integrated care system utilizing an EHR resulted in fewer hospital
readmissions and emergency room visits for over 12,000 seniors with multiple health challenges.

35. LOINC codes are primarily used in EHRs for:

A. Billing and insurance claims
B. Nursing diagnoses documentation
✓ C. Universal codes for laboratory and clinical observations
D. Drug name terminology and interaction software
Rationale: LOINC (Logical Observation Identifier Names and Codes) provides universal codes for laboratory and clinical
observations. RxNorm is used for drug names, and ICD-10/CPT are used for billing.

36. Accountable Care Organizations (ACOs) primarily use EHRs to:

A. Replace primary care physicians with nursing staff
✓ B. Support quality, coordinated care while limiting costs
C. Eliminate the need for Health Information Exchanges
D. Provide direct-to-consumer pharmaceutical advertising
Rationale: ACOs are a CMS payment incentive program for shared medical and financial responsibility designed to provide
quality, coordinated care while limiting costs. EHRs with data-sharing capabilities are central to ACO support — enabling
care management, analytics, and reporting.

37. Which pre-live EHR implementation strategy involves staff working alongside both the old system and
the new system simultaneously?
A. Go-live training
B. Formal classroom instruction
✓ C. Shadowing end users in their current daily work in parallel with the new system
D. Post-live retraining
Rationale: Successful pre-live strategies include shadowing end users in their current daily work in parallel with the new
system. This helps assess the effect of the new EHR on current workflow and processes, and it allows for more change
management if the effect is large.

38. Free-text reporting in clinical systems (as opposed to coded entry) primarily creates which problem?
A. Overuse of nursing terminologies
✓ B. Inconsistency of reporting and difficulty in data analysis
C. Increased medication error rates due to over-documentation
D. Better evidence-based practice integration
Rationale: Free-text reporting leads to inconsistencies of reporting from clinician to clinician and patient information that is
fragmented or disorganized. This limits the usefulness of patient data for quality assurance and measurement, and makes it
difficult to create analytical reports.

39. Which of the following best describes the relationship between EBP and clinical information systems?
A. CIS replaces the need for EBP in nursing practice
✓ B. EBP information is embedded in CIS workflow via links, reminders, and prompts
C. EBP only applies to physician decision-making, not nursing
D. CIS makes EBP irrelevant by automating all clinical decisions
 Rationale: To incorporate EBP into clinical nursing practice, the information needs to be embedded into the computerized
documentation system as part of the workflow — most typically through clinical practice guidelines. Links, reminders, and
prompts are used as vehicles for transmitting this EBP information.

40. The primary goal of the CMS Accountable Health Communities model is to:
A. Privatize all healthcare services
✓ B. Address SDOH needs affecting healthcare utilization and costs
C. Eliminate Medicare and Medicaid reimbursements
D. Replace EHRs with paper-based records
Rationale: The CMS (2023) Accountable Health Communities model addresses a critical gap between clinical care and
community services by identifying and attending to SDOH needs that affect healthcare utilization and costs. It is based on
evidence that tackling health-related social needs improves health outcomes and decreases costs.

41. Average life expectancy is reduced by approximately how many years for people living in low-income
communities?
A. 5–10 years
B. 10–12 years
✓ C. 15–20 years
D. 25–30 years
Rationale: Paruk (2019) shared that research demonstrates SDOH factors reduce average life expectancy by 15 to 20
years for people living in low-income communities, due to increased risk for stroke, chronic disease, and other health
concerns.

42. Which component of cloud-based EHRs presents the BIGGEST challenge for healthcare
organizations?
A. Reduced hardware and software costs
✓ B. Maintaining security while relinquishing some control to vendors
C. Inability to access records via web browsers
D. The elimination of all EHR functionality
Rationale: While cloud-based EHRs offer benefits (reducing IT burden, cost savings), healthcare providers must relinquish
control as they strive to maintain security. Vendors developing and maintaining the cloud environment also face challenges
from both legislators and healthcare providers.

43. Which of the following is the BEST question a nurse informaticist or CNO should ask when selecting
an EHR?
A. Does this EHR cost less than our current paper system?
✓ B. To what extent are nursing care contributions visible, retrievable, and accurately represented in this
EHR?
C. Can this EHR replace all nursing staff with automated documentation?
D. Does this EHR use only physician-developed terminology standards?
Rationale: The text explicitly identifies this as the critical question: 'To what extent are nursing care contributions visible,
retrievable, and accurately represented in this EHR?' This ensures nursing's work is captured, making it available for
research, reporting, and quality improvement.

44. SNOMED CT is being mapped to nursing terminologies primarily to:

A. Reduce documentation time for nurses
✓ B. Ensure nursing concepts in the EHR use SNOMED CT's comprehensive clinical vocabulary
C. Replace all nursing interface terminologies with physician terminology
D. Eliminate the need for nursing diagnoses in care planning
Rationale: Ongoing efforts are mapping nursing problem lists to SNOMED CT (Matney et al., 2012) to ensure EHRs capture
nursing content using evidence-based taxonomy mapped to SNOMED CT and LOINC — ensuring nursing care
 contributions are visible and retrievable in the EHR.

45. Which approach to training is identified as most effective for EHR end-user adoption?
A. A single comprehensive training session before go-live
✓ B. A combination of classroom, e-learning, independent exercises, and peer-to-peer support
C. Exclusively self-directed online modules
D. Vendor-only training without nurse involvement
Rationale: Training may be delivered in a variety of media, and often a combination works best: classroom time, electronic
learning, independent exercises, and peer-to-peer at-the-elbow support. Training must be workflow-based, reflect real
clinical processes, and be planned through the post-live period.

46. A 'Safety Net' hospital in the context of EHR decision-support benefits refers to:
A. A hospital specializing in fall prevention
✓ B. A hospital with a legal duty to provide care regardless of ability to pay
C. A hospital using advanced AI safety systems
D. A pediatric hospital specializing in rare diseases
Rationale: Safety net refers to U.S. medical hospitals and clinics with a mission, legal duty, or obligation to afford health
care to individuals irrespective of their ability to pay or health insurance status — making all care accessible to all U.S.
populations.

47. According to the American Nurses Association (ANA) 2018 reaffirmation, standardized terminologies
have become a significant vehicle for:
A. Reducing nursing staff in hospitals
✓ B. Facilitating interoperability between different concepts, nomenclatures, and information systems
C. Replacing physician-generated medical records
D. Eliminating the need for nursing care plans
Rationale: The ANA's 2018 position statement reaffirmed support for recognized terminologies supporting nursing practice
and stated that standardized terminologies have become a significant vehicle for facilitating interoperability between
different concepts, nomenclatures, and information systems.

48. When identifying metrics for EHR implementation success, organizations should choose metrics that:
A. Are focused exclusively on financial outcomes
B. Are so numerous that all possible benefits are captured
✓ C. Match the organization's overall strategy and goals; are practically defined and measurable before and
after
D. Are chosen solely by IT staff without clinical input
Rationale: It is important to choose metrics that match the organization's overall strategy and goals in the coming years —
including expected improvements in financial, quality, and clinical outcomes. They must be carefully and practically defined,
measured before AND after implementation, with accountability assigned.

49. EHR interoperability is MOST important for which of the following purposes in healthcare today?
A. Eliminating the need for health insurance
✓ B. Coordinating care, reducing costs, managing population health, and improving patient experience
C. Replacing physical examination with remote digital diagnosis
D. Providing nurses with administrative duties only
Rationale: Interoperable EHRs facilitate data sharing to help 'coordinate care, reduce costs, manage population health,
improve patient experience and outcomes, and address health equity challenges' (Juhn & Galvez, 2022, p. 426).

50. Which of the following BEST represents the ideal future state of clinical documentation as described in
Chapter 14?
A. All documentation should be in free text to capture clinical nuance
✓ B. All clinical documentation shared through a national database in standard language, enabling
evaluation of nursing care and improving patient outcomes
C. Documentation should only be accessible to physicians
D. Paper records should supplement all EHR documentation
Rationale: In an ideal world, all clinical documentation would be shared through a national database in a standard language
to enable evaluation of nursing care, increase the body of evidence, and improve patient outcomes. With minimal effort,
information would be translated into new research that could be analyzed and linked to new evidence intuitively applied to
the CIS.