Registered Health Information Administrator / Technician (RHIA / RHIT) Health Information Systems and Technology Syllabus

Health Information Systems and Technology syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Health Information Systems and Technology in Registered Health Information Administrator / Technician (RHIA / RHIT), not a summary of it.

1. 1

   Electronic Health Record Systems

   3 topics

   • EHR Components and Functions
     • CPOE, CDS, and results reporting
     • Patient portals and personal health records
   • EHR Adoption and Meaningful Use
     • Promoting Interoperability program
     • Certification criteria (ONC)
   • System Selection and Implementation
     • Needs assessment and RFP process
     • Implementation, training, and go-live
2. 2

   Database and Information Architecture

   3 topics

   • Database Concepts
     • Relational database fundamentals
     • Tables, keys, and normalization
     • SQL query basics
   • Data Warehousing and Repositories
     • Clinical data repositories
     • Data marts and ETL processes
   • System Integration
     • Interface engines and integration
     • Health information exchange (HIE)
3. 3

   Data Security and Information Governance Technology

   3 topics

   • Technical Security Controls
     • Authentication and authorization mechanisms
     • Firewalls, intrusion detection, and malware defense
   • System Auditing and Monitoring
     • Audit trails and access logs
     • Intrusion and anomaly detection
   • Emerging Technologies
     • Cloud computing and mobile health
     • Artificial intelligence and machine learning in HIM
4. 4

   Information Governance and Data Stewardship

   3 topics

   • Information Governance Frameworks
     • AHIMA IGAM model
     • Enterprise information management
   • Data Governance Roles
     • Data stewardship responsibilities
     • Metadata management
   • Records and Content Management
     • Document imaging and ECM
     • Retention scheduling and lifecycle management

Health Information Systems and Technology flashcards for Registered Health Information Administrator / Technician (RHIA / RHIT)

22 of 51 cards from the Health Information Systems and Technology deck — real questions with worked answers.

1. What are the core clinical components of an Electronic Health Record (EHR)?

   Clinical Data Repository (CDR), Clinical Decision Support (CDS), Computerized Provider Order Entry (CPOE), and electronic results/document management. These support point-of-care documentation, ordering, and data retrieval.

2. What is the difference between an EHR and an EMR?

   An EMR (Electronic Medical Record) is a digital chart within a single organization. An EHR (Electronic Health Record) is interoperable and follows the patient across multiple organizations and care settings.

3. What is Computerized Provider Order Entry (CPOE) and its main benefit?

   CPOE lets clinicians enter orders (meds, labs, imaging) electronically. It reduces medication and transcription errors, standardizes orders, and integrates with clinical decision support.

4. What is Clinical Decision Support (CDS) in an EHR?

   CDS provides clinicians with knowledge and patient-specific information (alerts, reminders, order sets, drug-interaction checks, guidelines) at the point of care to improve decision-making.

5. What is a Clinical Data Repository (CDR)?

   A real-time database that consolidates data from multiple clinical source systems to provide a unified, current view of a patient for direct patient care.

6. What is a Personal Health Record (PHR) and who controls it?

   A PHR is a health record maintained and controlled by the patient (the individual), who decides what is entered and who may access it; it may be tethered to a provider's EHR or standalone.

7. What are the three stages of the CMS EHR Incentive Program (Meaningful Use)?

   Stage 1: data capture and sharing; Stage 2: advanced clinical processes (information exchange); Stage 3: improved outcomes. Meaningful Use later evolved into the Promoting Interoperability program.

8. What legislation established the Meaningful Use EHR incentive programs?

   The HITECH Act (Health Information Technology for Economic and Clinical Health Act), part of the ARRA of 2009.

9. What does ONC stand for and what is its role in EHRs?

   The Office of the National Coordinator for Health Information Technology. It coordinates national HIT efforts and oversees EHR certification criteria and interoperability standards.

10. What is 'certified EHR technology' (CEHRT)?

    EHR technology that meets ONC certification criteria, required for providers to participate in Meaningful Use / Promoting Interoperability incentive programs.

11. What program replaced Meaningful Use for Medicare in the value-based payment era?

    The Merit-based Incentive Payment System (MIPS) under MACRA; the EHR component is the Promoting Interoperability performance category.

12. What is a Request for Proposal (RFP) in EHR/system selection?

    A formal document sent to vendors that describes the organization's requirements and asks vendors to propose solutions, pricing, and capabilities so they can be compared.

13. In system selection, what is the difference between an RFI and an RFP?

    An RFI (Request for Information) gathers general information to narrow the vendor field; an RFP (Request for Proposal) is a detailed solicitation for specific solutions and bids used for final selection.

14. What is the purpose of a needs assessment in system implementation?

    To analyze current workflows and identify functional requirements and gaps so the selected system meets organizational goals before purchase and implementation.

15. What are the main go-live conversion strategies for a new system?

    Big bang (all at once), phased rollout (module/department by department), pilot (one site/unit first), and parallel (old and new run simultaneously).

16. What is a gap analysis in system implementation?

    A comparison of current-state capabilities against desired/required functionality to identify gaps that the new system or process changes must address.

17. What is data conversion (migration) during system implementation?

    The process of transferring and mapping data from a legacy system into the new system, including cleansing, validation, and verifying integrity.

18. What is a primary key in a relational database?

    A field (or combination of fields) that uniquely identifies each record (row) in a table; it cannot be null and must be unique.

19. What is a foreign key in a relational database?

    A field in one table that refers to the primary key of another table, establishing a relationship and enforcing referential integrity between the tables.

20. What is database normalization?

    The process of organizing data into tables to reduce redundancy and improve data integrity by eliminating duplicate data and dependency anomalies.

21. What is an entity-relationship diagram (ERD)?

    A data modeling diagram that depicts entities (tables), their attributes, and the relationships among them, used to design a database structure.

22. What is SQL?

    Structured Query Language, the standard language used to create, query, update, and manage data in a relational database (e.g., SELECT, INSERT, UPDATE, DELETE).

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