This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
The CAHIMS Exam Preparation Course
and the CAHIMS exam are the result of
collaboration between the Life Science
Informatics Center at Bellevue College
and the Healthcare Information and
Management Systems Society (HIMSS).
Significant content found in the CAHIMS
Exam Preparation Course stems from the
Office of the National Coordinator for
Health Information Technology. Creation
of the CAHIMS Exam Preparation Course
and the CAHIMS exam was made
possible through support from the National
Science Foundation (NSF).
Curriculum Team:
Margaret Schulte, DBA
Michèle Royer, PhD
Nathan Savage, MLIS
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Section 3 - HIMS Analysis and Design
Lesson 3.2 - Clinical Process and Workflow Analysis
Assessment Questions Answer Key
Lectures 1 & 2
1. Which of the following best describes a process? Choose the best answer:
a. A small batch of work
*b. A series of activities that produce work
c. A group of people that undertake work
d. An organization that performs work
Answer: b. Merriam-Webster (2011) defines process as a series of actions or
operations conducing to an end. Similarly, the American Society for Quality
(ASQ) (2011) defines Process as “a set of interrelated work activities
characterized by a set of specific inputs and value added tasks that make up a
procedure for a set of specific outputs.”
Lecture/Slide: 1/5
2. Process analysis includes which of the following? Choose the best answer:
a. Knowledge of process components and relationships between them
b. Identification of opportunities for improvement
*c. Both
d. Neither
Answer: c. Because the goal of our “analysis” is to ultimately improve a process,
we also look for things like gaps, lack of conformity with best practice such as
meaningful use of health IT and health care quality improvement, delays,
redundancy, rework, and lack of efficiency. For us, the combination of 1)
understanding process elements and the relationships between them and 2)
identification of opportunities for improvement comprise Process Analysis.
Lecture/Slide: 1/6
3. Process redesign includes which of the following? Choose the best answer:
a. A change in a process
b. Anticipation of a good outcome
*c. Both
d. Neither
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Page 1
Answer: c. Process Redesign, then, is the revision in appearance, function, or
content of a process. The reason why we analyze a process is to improve it. The
improvement is achieved through Process Redesign.
Lecture/Slide: 1/7
4. A workflow is a Process. True or False?
*a. True
b. False
Answer: a. In everyday use, the terms workflow and process are used
interchangeably. Workflow is often more specifically thought of as the flow or
path of the work steps, i.e., the way in which work progresses, including things
like order of steps and selection between alternative steps. Like a process, a
workflow has inputs and outputs, i.e., resources (mass, energy, information) and
the people or things that perform the steps or activity that comprise the work are
considered.
Lecture/Slide: 1/8
5. Workflow analysis includes which of the following? Choose the best answer:
a. Knowledge of process components and relationships between them
b. Identification of opportunities for improvement
*c. Both
d. Neither
Answer: c. In this component, the words workflow and process will be used
interchangeably; therefore, workflow analysis is process analysis are the same.
Lecture/Slides: 1/6, 8
6. Which of the following is NOT one of the IOM characteristics of quality health
care? Choose the best answer:
a. Efficient
b. Timely
*c. Provider centered
d. Equitable
Answer: c. The system of care should revolve around the patient, respect patient
preferences, and put the patient in control; therefore, is not Provider Centered,
but Patient Centered.
Lecture/Slide: 1/19
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Advanced Technological Education Grant 1003223
Page 2
7. Which of the following is NOT a characteristic of Meaningful Use of Health IT?
Choose the best answer:
a. Refers to the use of Health IT to improve patient care
b. Includes ePrescribing and provider order entry
*c. Has been in legislation for over 20 years
d. Includes incentives for meeting requirements for care and Health IT
Answer: c. “Meaningful Use” of EHRs is used to collectively describe those
criteria established by the (American Recovery and Reinvestment Act) ARRA to
qualify health care providers for the electronic health record incentives to be
provided. This term was coined by the framers of the Act in 2009.
Lecture/Slides: 1/20-26
Read the scenario and answer the following questions.
Scenario: Every morning in Doctor Jones’ practice, Medical Assistant Grant logs onto
their account with the local lab and prints lab result sheets. Basic demographic
information (from the sample requisition form) for each patient is included on the lab
sheet, along with the provider’s name. Mr. Smith’s lab results are in those available first
thing in the morning. Medical Assistant Grant gives Nurse Adams the printed lab results
for Mr. Smith. Nurse Adams glances through the results and sees that all of the test are
within normal clinical limits. Nurse Adams asks Medical Assistant Grant to phone Mr.
Smith and let him know that the lab results are normal, and to let him know that the
office will phone in a prescription for the oral antifungal to his pharmacy on record,
which of course, Medical Assistant Grant will confirm while on the phone with Mr. Smith.
Following the request the day before from Dr. Jones, Nurse Adams also asks Medical
Assistant Grant to schedule Mr. Smith for a Follow-up appointment and blood draw in
two weeks.
8. Which of the following are activities stated in the scenario?
a. Receive lab print-out in the mail
b. Email lab results to patient
*c. Identify out-of-range results
d. Call lab to obtain results
Answer: c. A patient visit to a provider’s office can be broken down into their
component processes; these processes are composed of more detailed
activities. Examples of these activities in clinical care, listed here, include
interaction with patients, physical assessment, ordering tests, making a
diagnosis, developing a treatment plan, following-up on test results, etc.
Lecture/Slide: 2/7
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Advanced Technological Education Grant 1003223
Page 3
9. Which of the following roles DOES NOT participate in the scenario?
a. Lab technician
b. Receptionist
*c. Patient
d. Physician assistant
Answer: c. There are several roles that are common to many health care
practices.
Lecture/Slides: 2/10, 25
10. Which of the decisions are made in the scenario?
a. Which lab to contact for the results
b. Whether or not the lab results are correct
*c. Whether or not the results are out-of-range
d. Whether or not to call the patients with the results
Answer: c. Conducting workflow analysis and process redesign in health care is
different than working in other settings because of the unique aspects of health
care. Decisions sometimes make the difference between “life or death”, or have
the potential to seriously impact a person’s health.
Lecture/Slides: 2/13, 26
11. At which point in the scenario could more than one path be taken?
a. When the medical assistant logs into the lab website
b. When the lab results are printed
*c. When the lab results are reviewed
d. When the patient is contacted
Answer: c. Other unique aspects of health care and clinical workflows that make
workflow analysis and process redesign complex include the fact that clinical
workflows:
 Vary from practice to practice,
 Involve multiple people and organizations, thus there are many opportunities
for delays and variability,
 Must take patient preference into account,
 Have many interruptions,
 Have many options and exceptions,
 Have overlapping roles and responsibilities, and
 Involves humans, organizations, information, and technology.
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Page 4

Because of the need to contain costs, health care today is subject to
considerable time and resource pressure.
Lecture/Slide: 2/14
Lectures 3 & 4
12. Mark the symbol(s) that are common flowchart symbols:
a. Pentagon
*b. Arrow
c. Triangle
d. Dodecahedron
Answer: b. The flow line represents a process path which connects process
elements. The arrowhead indicates the direction of the flow.
Lecture(s)/Slide(s): 3/20
13. What symbol should be used to diagram the following process step: “If the
patient is a new patient …” then
a. Pentagon
*b. Diamond
c. Oval
d. Rectangle
Answer: b. The decision symbol is a diamond which designates a decision point
from which the process branches into two or more paths. The path taken
depends on the answer to the question which appears within the diamond. Each
path is labeled to correspond to an answer to the question.
Lecture(s)/Slide(s): 3/20
14. Which of the following is used to indicate that a flowchart continues on
another page?
*a. Circle connector
b. Process box
c. Dotted line
d. Curved arrow
Answer: a. The connector is a circle which is used to indicate a continuation of
the flow diagram to another diagram, perhaps on a different page.
Lecture(s)/Slide(s): 3/20-21, 3/25-26
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 5
15. Which of the following should be used to diagram the following text: “…the
new patient intake form is received, the information is confirmed with the patient,
then entered into the EMR.”
a. Terminal symbol, then two parallel process boxes
b. Circle, process box, then a diamond
*c. Document symbol, then two sequential process boxes
d. Document box, then a diamond followed by a terminal symbol
Answer: c. The document symbol is a human readable document pertinent to the
process, for example, input to the process, or output from it. The process symbol
is a rectangle which designates an activity. Within the rectangle is a brief
description of that activity.
Lecture(s)/Slide(s): 3/20
16. An analyst needs to show the context in which a process operates. Which of
the following methodologies is the most appropriate?
*a. Yourdon
b. Unified Modeling Language
c. Flowchart
d. Entity-relationship diagram
Answer: a. There are five notations that are commonly used to diagram
processes: ISO 5807, Yourdon, Gane-Sarson, UML, and E-R diagrams. ISO
5807 can be used to represent process steps and their sequence and control, as
well as information transformation and roles involved in the process. Yourdon
represents context, process steps, and information transformation. Gane-Sarson
represents the latter two process aspects. Unified Modeling Language,
developed a few decades after and heavily influenced by the earlier methods,
was designed to represent all but the Yourdon-style context diagram. The EntityRelationship diagram is designed to represent only information content.
Lecture(s)/Slide(s): 4/12
17. An analyst needs to show information movement and the order of the steps.
Which of the following diagram notations should be used?
a. Use case scenario
b. Stakeholder diagram
c. Context diagram
*d. Data flow diagram
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Answer: d Not all of the process aspects noted earlier are critical for process
analysis and redesign work covered here. For the health care workflow process
analysis and redesign we recommend the following: Yourdon Data Flow
Diagrams or ISO 5807/Flowcharts process steps, step sequence and other
control diagrams, as well as Roles performing the steps.
Lecture(s)/Slide(s): 4/14
18. An analyst needs to show information content. Which of the following
notations would be appropriate?
a. Flowchart
*b. E-R diagram
c. Data flow diagram
d. Workflow diagram
Answer: b. The Entity-Relationship diagram is designed to represent only
information content.
Lecture(s)/Slide(s): 4/12
19. An analyst needs to show detailed process steps. Which of the following
diagrams is the most appropriate?
a. UML diagram
*b. ISO data flow diagram
c. Context diagram
d. E-R diagram
Answer: b. ISO 5807 can be used to represent process steps and their sequence
and control, as well as information transformation and roles involved in the
process.
Lecture(s)/Slide(s): 4/12
20. Indicate which statement is true:
a. Information flow and workflow are the same thing
b. Information flow and workflow can be shown on a context diagram
c. Information flow and process flow can be shown on an E-R diagram
*d. Information flow and process flow can be shown on a flowchart
Answer: d. ISO 5807 flowcharts can be used to represent process steps and their
sequence and control, as well as information transformation and roles involved in
the process.
This work is funded by the National Science Foundation
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Lecture(s)/Slide(s): 4/12
21. Indicate which statement is true:
*a. Multiple process aspects may be represented on some diagrams
b. There is only one type of diagram for each process aspect
c. There is not any overlap in the symbols used in different notations
d. There is only one correct representation for any process
Answer: a. While on the surface, this seems simple, most processes are complex
systems. They can be examined and viewed from different perspectives,
including static and dynamic aspects, data flow versus workflow, and at different
levels of detail. Process diagramming provides the ability to smoothly progress
from abstract to more detailed. Additionally, process diagrams are
multidimensional, conveying different types of information about a process.
Different types of diagrams are used to make explicit and document the “who,
what, when, where, and how” of processes.
Lecture(s)/Slide(s): 3/6
Lectures 5 & 6
22. Which of the following are NOT steps in process analysis as described in this
unit?
a. Create process inventory
*b. Conduct process redesign
c. Report analysis findings
d. Identify EHR functionality
Answer: b. Steps in process analysis include: 1) Start with process inventory &
process diagrams (covered in units 2 and 3). These should provide a context
diagram showing clinic functions and a flowchart for each process. 2) For each
process, list the process variations applicable to the clinic as well as exceptions
that often occur. For example, for a patient visit, a common exception would be
that a patient cancels or does not show up. The last step in process analysis is
3) report findings. The findings from a process analysis would include: Major
observations, a list of EHR functionality necessary to support clinic functions, and
opportunities for improvement (technology assisted and otherwise).
Lecture(s)/Slide(s): 5/11
23. What is the correct order of steps for Process Analysis?
1-Create process inventory
2-Report analysis findings
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3-Identify variations and exceptions
4-Identify needed EHR functionality
a. 1, 2, 3, 4
b. 3, 1, 2, 4
*c. 1, 3, 4, 2
d. 4, 1, 3, 2
Answer: c. Steps in process analysis include: 1) Start with process inventory &
process diagrams (covered in units 2 and 3). These should provide a context
diagram showing clinic functions and a flowchart for each process. 2) For each
process, list the process variations applicable to the clinic as well as exceptions
that often occur. The last step in process analysis is 3) report findings. The
findings from a process analysis would include: Major observations, a list of EHR
functionality necessary to support clinic functions, and opportunities for
improvement (technology assisted and otherwise).
Lecture(s)/Slide(s): 5/11
24. Choose the answer that best describes a process inventory.
a. Counting and tracking available stock
b. Objectifying and measuring processes
c. Analyzing and improving stock processes
*d. Identifying and recording processes
Answer: d. After the processes for analysis have been identified, the analyst,
working with people from the clinic creates diagrams of the processes. These
graphical representations of the processes are used in the process analysis and
redesign. We start with a process inventory and diagrams because sometimes
they are all that is needed, and they point to areas where different types of
objective information may be needed.
Lecture(s)/Slide(s): 5/12
25. Which of the following processes does NOT occur at most clinics?
a. Billing
b. Labs
*c. Surgery
d. Prescriptions
Answer: c. Sample Practice Process List: Patient check-in, Patient visit,
Prescriptions, Assimilating received documentation, Labs, Other Diagnostic
Tests, Referral / consult, Disease Management, and Billing.
This work is funded by the National Science Foundation
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Lecture(s)/Slide(s): 5/14
26. Which of the following processes varies most by clinical specialty?
*a. Diagnostic tests
b. Billing
c. Office visits
d. Appointment scheduling
Answer: a. There are many variations for patient office visits. A few of them are
referral out needed, procedure needed, and diagnostic test needed. Depending
on the type of clinic, certain diagnostic tests may or may not be performed.
Lecture(s)/Slide(s): 5/16, 6/6
27. Which of the following would be variations of a Diagnostic test process?
a. Patient cannot tolerate the test
b. Patient is not compliant with preparatory instructions
c. Test returns a false positive
*d. Test is conducted by referral to an external facility
Answer: d. Diagnostic tests vary widely depending on the type of practice.
Common diagnostic test variations include the following: Test done in clinic, Test
done externally, Report expected, and Image or test result data expected.
Lecture(s)/Slide(s): 6/10
28. Which of the following would be variations of an appointment scheduling
process?
a. Miscommunication of the date or time of appointment
*b. Online appointment scheduling
c. Appointment scheduling session timed out
d. Appointment not found within necessary time window
Answer: b. Process variations are processes used by the clinic, i.e., the way a
particular clinic does something, the clinic’s process. They are called variations
because they vary from clinic to clinic. For example, some clinics only schedule
appointments by phone while others use online scheduling or both online and
phone.
Lecture(s)/Slide(s): 5/16
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29. Which of the following would be exceptions in a prescription process?
a. ePrescribing
*b. potential drug interaction identified by pharmacy
c. use of online medication service/pharmacy
d. prescription refill needed
Answer: b. Common exceptions or errors that can occur during a prescription
process include no insurance or a non-covered service, samples provided,
prescriptions need to be sent to multiple pharmacies, and the prescription can’t
be filled at a pharmacy. The identification of drug interactions by the pharmacy
would fit into this category.
Lecture(s)/Slide(s): 6/7
30. Which of the following would be an exception to a document receiving
process?
a. receipt of fax documents
b. receipt of electronic documents
c. receipt of documents within a week of patient visit
*d. receipt of documents with no patient identifiers
Answer: d. Common exceptions with external documents include inadequate
patient identification, inadequate source identification, and unintelligible or
ambiguous information.
Lecture(s)/Slide(s): 6/8
31. Which of the following may indicate needed EHR functionality?
a. Generic processes used by a clinic
b. Process variations used by a clinic
c. Process exceptions likely encountered by a clinic
*d. All of the above
Answer: d. The end result of a process analysis is a list of 1) clinic processes,
i.e., the process variations used by the clinic, and 2) a list of common exceptions.
For example, based on the process analysis, by-phone appointment scheduling
would be on the list for Suburban Family Clinic, as would the listed exceptions.
Lecture(s)/Slide(s): 6/20
Read the scenario below. Use it to answer the following questions.
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Scenario: Patient Patty arrives at the clinic and is signed in by Receptionist Ronald.
Receptionist Ronald locates Patient Patty’s record on the clinic’s schedule. He notices
that she is an existing patient, and marks her record as “arrived”, and confirms Patient
Patty’s contact and insurance information. Receptionist Ronald instructs Patient Patty
to have a seat in the waiting room.
Nurse Ned sees that Patient Patty has arrived and pulls her chart from the filing room.
Nurse Ned goes to the waiting room entrance and calls Patient Patty. Nurse Ned
escorts Patient Patty to the exam room, interviews her regarding symptoms and/or
complaints and records into the Nurses/Progress notes, and takes and records vital
signs in progress notes. Nurse Ned then alerts the Doctor Dan that the patient is ready
to be seen.
Within a few minutes, Doctor Dan takes the chart from the box on the exam room door
and glances through the first page. Doctor Dan then enters the exam room where he
examines Patient Patty and records findings in the progress notes section of the chart.
During the exam, Doctor Dan determines if a prescription, procedure, lab work or a
referral is required and completes the necessary paperwork if applicable. Doctor Dan
provides some additional instructions to Patient Patty and concludes the visit. Finally,
Doctor Dan provides the patient chart to the office staff to be re-filed. On the way out,
Patient Patty pays her co-pay and concludes the office visit.
32. Which of the following EHR functionality is indicated by the scenario?
a. Pulling and tracking paper charts
b. Receipt of lab results from external lab
c. Appointment scheduling
*d. Clinical documentation
Answer: d. Some of the information gained from process analysis translates
directly into EHR functionality, for example: the process variations, flow control
between variations, and handling process exceptions. This is the information that
we have covered thus far in this slide set. Often, there are opportunities to make
process changes, including leveraging technology. Such changes are decided
during process redesign and also result in identification of necessary EHR
functionality. In-turn, an analyst’s knowledge of available EHR functionality
informs process redesign, i.e., the analyst who is familiar with available functions
draws on this knowledge to suggest ways in which technology can be leveraged
to improve processes.
Lecture(s)/Slide(s): 6/19
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Page 12
33. Which of the following process variations should be further investigated, i.e.,
there is not enough information in the scenario to determine which variation(s)
may be in use?
a. Tracking and access of paper charts
b. Patient payment as part of clinic exit
*c. Billing performed in practice management system
d. Pre-exam data collection by Nurse
Answer: c. Billing is a core process of any practice. Some billing variations are
using a paper superbill, i.e., the sheet that providers use to check off tests and
write diagnoses on during the visit, as the source, electronic data recorded by
providers during the visit as the source, where the coding is done, and whether
or not billing and collections are done externally. Billing exceptions include: No
insurance or non-covered service, claim denied, coding errors, and data errors.
Lecture(s)/Slide(s): 6/14
Read the scenario and answer the following questions.
Scenario: Every morning in Doctor Jones’ practice, Big City Family Practice, Medical
Assistant Grant logs onto their account with the local lab and prints lab result sheets.
Basic demographic information (from the sample requisition form) for each patient is
included on the lab sheet, along with the provider’s name. Mr. Smith’s lab results are in
those available first thing in the morning. Medical Assistant Grant gives Nurse Adams
the printed lab results for Mr. Smith. Nurse Adams glances through the results and
sees that all of the tests are within normal clinical limits. Nurse Adams asks Medical
Assistant Grant to phone Mr. Smith and let him know that the lab results are normal,
and to let him know that the office will phone in a prescription for the oral antifungal to
his pharmacy on record, which of course, Medical Assistant Grant will confirm while on
the phone with Mr. Smith. Following the request the day before from Dr. Jones, Nurse
Adams also asks Medical Assistant Grant to schedule Mr. Smith for a Follow-up
appointment and blood draw in two weeks. After calling Mr. Smith, Medical Assistant
Grant files the lab results in his chart.
34. Which of the following would be exceptions in the lab result receipt process?
a. Lab results received
*b. Practice account is locked out
c. Abnormal lab results received
d. Receipt of lab results by mail
Answer: b The receiving and communicating lab results indicate the following
processes: Variations in lab scenarios include lab sample processing at external
lab, lab sample acquisition, receiving lab results, and communicating lab results.
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Lab process exceptions include: No results received, results not matchable to a
patient, results not matchable to a provider, results abnormal and require action,
and patient not contactable / not responsive to contact attempts. Having the
practice account locked out would be an exception to normal process.
Lecture(s)/Slide(s): 6/9, 6/24
35. Which of the following EHR functionality is indicated by the scenario?
a. Lab sample tracking
b. Lab sample acquisition
c. Referral to external lab
*d. Interface with the local lab
Answer: d. Some of the information gained from process analysis translates
directly into EHR functionality, for example: the process variations, flow control
between variations, and handling process exceptions. This is the information that
we have covered thus far in this slide set. Often, there are opportunities to make
process changes, including leveraging technology. Such changes are decided
during process redesign (covered in Unit 6) and also result in identification of
necessary EHR functionality.
Lecture(s)/Slide(s): 6/19, 24
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