Download D220 INFORMATICS 2026 and more Exams Nursing in PDF only on Docsity!
D220 INFORMATICS
American Recovery and Reinvestment Act (ARRA) **Authorized INCENTIVE PAYMENTS to specific types of hospitals & healthcare professionals for adopting & using interoperable Health Information Technology and EHR's. The purposes of this act include the following: (1) To preserve/create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases. AHQR (Agency for Healthcare Research and Quality) Produced evidence making healthcare safer, improve quality, accessibility and affordability Asynchoronous Applications No contact with patient for data collection. EX: Remote pt monitoring, Using health technologies to share health metrics and data w/ providers. STORE & FORWARD APPS (ex: photos) Administrative Information System can include registration and scheduling; tracking through admission, transfer and discharge; patient acuity and staff scheduling; financial or accounting systems; risk management; payroll and human resources; quality assurance; and contract management functions. Affordable Care Act law passed in 2010 to expand access to insurance, address cost reduction and affordability, improve the quality of healthcare, and introduce the Patient's Bill of Rights, increasing the number of insured persons. Alarm Fatique Becoming desensitized to patient care alarms and missing or delaying their response to the alarm. ANA (American Nurses Association) Professional organization for all RNs. Concerned with licensure, collective bargaining and education Analytics A term describing the extensive use of data, statistical and quantitative analysis, explanatory and predictive models, and fact-based management to drive decisions and actions. Audit trail a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed Authentication A method for confirming users' identities
Authorization The process of giving someone permission to do or have something Barcode Scanning Technology Scans drug and patients wristband to verify medication order, inventory control, + pt identification, correct med admin Big Data a collection of large, complex data sets, including structured and unstructured data, which cannot be analyzed without the use of information technology Bioinformatics application of mathematics and computer science to store, retrieve, and analyze biological data Biometrics the identification of a user based on a physical characteristic, such as a fingerprint, iris, face, voice, or handwriting Business Continuity Plan A plan for how an organization will recover and restore partially or completely interrupted critical function(s) within a predetermined time after a disaster or extended disruption Business Intelligence Information collected from multiple sources such as suppliers, customers, competitors, partners, and industries that analyzes patterns, trends, and relationships for strategic decision making Change Control Board (CCB) A committee that evaluates the worthiness of a proposed change and either approves or rejects the proposed change. Chief Nursing Officer (CNO) The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services Clinical Care Classification (CCC) "Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings" CPOE (Computerized Physician Order Entry) An order entry and decision support system that allows direct entry of orders and immediately shared w/ others
C
Clinical Decision Support System A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions Ex: Alerts for abnormal VS, labs results, med contraindications, screenings, standing orders, reminders in EHR ect... Clinical Information Systems Ex: May be specific to certain departments. Lab, radiology, pharm(Both), or particular pt population. Functions may include order entry, results reporting, scheduling and documentation. Lg computerized database used to access the pt data that are needed to plan, implement and evaluate care. Clinical Nurse Specialist Expert clinician in a specialized area of practice who engages in research and helps direct practice change. clinical terminology standardized terms and their synonyms used to record pt data with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement, flow sheets, vital signs, assessments and nursing notes. Computer Literacy The ability to use computers for basic tasks, such as developing documents, sending emails and searching the internet for information. Confidentiality Relationship has been established where private info shared but NOT disclosed w/out permission configurability Refers to the extent that a given software product can be adapted or changed to meet a user's preference Contextual Inquiry involves studying customers' use of a product at their place of work Focusing on users point of view. CCR (Continuity of Care Record) Snapshot/standardized summary of the most relevant and timely health information about pt and shared to a physician who does not have access to pts EHR. Continuous Quality Improvement (CQI)
Continuous monitoring of performance and supports audit capability also known as QUALITY ASSURANCE SYSTEM Critical Care Information System Integrates captured physiological data w/ practitioner documentation and clinical data management functions, as well as access and communication w/ remote experts. Data Facts, figures, and other evidence gathered through observations. Database A collection of data organized in a manner that allows access, retrieval, and use of that data Data cleansing/scrubbing A process that weeds out and fixes or discards inconsistent, incorrect, or incomplete information Data Governance refers to the overall management of the availability, usability, integrity, and security of company data Data Integrity The correctness of data after processing, storage or transmission. Ability to store, retrieve, correct and complete data are available to authorized users Data Mining the application of statistical techniques to find patterns and relationships among data for classification and prediction using software. Data Analysis processing of data that identifies trends and patterns of relationships Data Warehousing Powerful method of managing and analyzing data DICOM (Digital Imaging and Communications in Medicine) Transmits digital imaging (DICOM & HL7 support standardization in health care data DIKW theory Data, Information, Knowledge, Wisdom (data is most discrete) Data=pt monitoring, labs, diagnostic systems (CT scans) Information=Clinical Info systems, & DSS (alerts/reminders) Knowledge=Lg databases (med articles) & Artificial Intelligence
Lifelong tool for managing health info, controlled by pt - data can be provided by MD or pharmacy. (conditions, allergies, meds, surgeries) Barriers: Poor or no internet, poorly designed apps, limited clinical integration Predictors: Awareness of PHR's, ease of access, personal motivation, increased levels of education and health literacy. emerging trends
- Secondary data
- Technology-based data management
- Digital information acquisition and retrieval
- International client base
- Information management (patient safety & error reduction) EBP (evidence based practice) Using current best evidence for pt care decision in order to improve pt outcomes (found in standing orders) Ex: sepsis protocols & CDS Expert Systems Type of CDS/DDS but does NOT need human intervention (artificial intelligence) Ex: Personal Insulin Pump EMRAM (Electronic Medical Record Analytical Model) Measures clinical outcomes, pt engagement & clinical use of EMR technology to strengthen organizational performance & health outcomes across pt populations "Basically, evaluates Health Information System" feature creep occurs when developers add extra features that were not part of the initial requirements Finacial system uses pt demographic data and insurance info to charge for services & reimbursment Functional Testing Final process in Project Management Phase 2 (planning) that ensures the innovation works as designed. Fish boning Cause/effect diagram, can help in brainstorming to identify possible causes of a prob. Firewalls hardware, software, or both designed to prevent unauthorized persons from accessing electronic information, while allowing authorized communication. Gantt Chart
A time and activity bar chart that is used for planning, managing, and controlling major programs that have a distinct beginning and end.(used for a glance at management) Gap Analysis a type of analysis that compares the differences between the consumer's expectations about and experiences with a service based on dimensions of service quality (Planning) Go Live the official time and date that the facility begins using the new system (Implementation Phase) HIE (Health Information Exchange) Electronic sharing of pt info (demographic data, allergies, diagnostic tests, and other revelant data between providers, specialists, hospitals, and insurance companies. HIS Health Information System Broad term used to describe administrative and clinical systems to streamline work flow processes efficiency. Hardware/software dedicated to the collection, storage, processing, retrieval and communication of patient care info. healthcare terminology standards designed to enable and support widespread interoperability among healthcare software applications for the purpose of sharing information HIPAA (Health Insurance Portability and Accountability Act) Kennedy Kassebaum Bill, Federal legislation to protect client records & mandate that all electronic transactions included only HIPAA compliant codes. Sets nation standards of PHI, legal protection of PHI. (signing in devices requires encryption) HIT - Health Information Technology Technology that is used to record, store, and manage patient healthcare information. Ex: CDS, CPOE, EMR, EHR, PHR, Telehealth, E-scribe National & Global implications Health literacy definition a person's capacity to learn about and understand basic health information and services, and to use these resources to promote one's health and wellness HIS (Hospital Information System) What is the name of the computer system that tracks admission and discharge information, diagnostic and treatment services, pharmaceutical and equipment information, and billing information? Advantages: Better communication, decreased errors & better access to info.
Informatics Competencies the ability to perform the tasks associated w/ informatics information A continuum of progressively developing and clustered data. Collection of data that has been interpreted & examined for patterns and structures information literacy the ability to figure out the type of information you need, find that information, evaluate it, and properly use it
- Ability to read and understand works/numbers and ability to recognize when info is needed. Information System a set of hardware, software, data, people, and procedures that work together to produce information "Data Collection" Information Technology (IT) Transmit Data Ex: EHR, CDST (clinical decision support tool) information science Primarily focused on input processing output and feedback through technology intergration 5 rights of Informatics Right - Information Person Intervention Channel Time in workflow Informatics Innovator Conducts information and RESEARCH & generate THEORY & have advanced understanding in info management & computer technology ICD- 10 Used to classify mortality and morbidity data from inpatient/outpatient records, used for reimbursement Integration Process of two systems exchanging data in a way that is seamless to end user. Interoperability
Ability of 2 entities, human/machine to exchange & predictably use data/info while retaining original meaning of data Ex: Dr-Dr, Hosp-Hosp(C-CDA), escript-pharm Interface Bridge/connector to send info from 2 different systems interoperable systems Expected outcomes=error reduction, improved revenue, increased communication. Systems share limited processes and data Information Security Security Rule - Nation set of security standards health info in electronic form GOAL: Protect privacy while adopting new technologies to improve quality & efficiency of pt care "Need to KNow basis" The Joint Comission Standards Standard The hospital respects the patient's right to receive information in a manner he or she understands. Elements of Performance The hospital provides language interpreting and translation services Note: Language interpreting options may include hospital employed language interpreters, contract interpreting services, or trained bilingual staff, and may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population. --do not have family or children translate!
- don't have to have one there the whole time - but having one there for discharge would be very important Joint Commision ACCREDIATATION key standard of information management: Protect & aggregate data, uniform language, teach info management (training), disaster and preparedness knowledge Skills, experience, and expertise coupled with information and intelligence that creates a person's intellectual resources Knowledge Database A database that not only manages raw data but also integrates them with information from various reference works knowledge translation
healthcare organizations that "meaningfully used" their certified EHR technology. The requirements include implementing security measures to ensure the privacy of patients' EHRs. Meaningful Use Stages Stage 1: Data capture and sharing (between hosp/providers) Stage 2:Advance clinical processes (standardized lang/terminology, Requires patients to view, download, or transmit their health info online. Capability for secure messaging between providers/pts) Stage 3:Improved outcomes Focused of the enhanced use of EHR's to promote HIE & improve care. Ex: electronic Rx (clinical Quality Measures) MU defined by ARRA a certified EHR used in a meaningful way to use HIT to collect specific data w/ the intent to IMPROVE CARE & POPULATIONS HEALTH, ENGAGE PTS & ENSURE PRIVACY/SECURITY. *Inpatient/Outpatient. Mission Planning purpose of an organizations existence, representing the fundamental and unique aspirations that differ it from others. LONG RANGE PLAN (not short term) MIPS (Merit-Based Incentive Payment System) Program that combines other physician quality reporting system (PRRS) & Medicare EHRs based on QUALITY, resource use, clinical practice environment & meaningful use of EHR tech. "Quality" Meaningful use requirements by CMS *Basic entry of clinical information/REQUIRES STANDARDIZED TERMINOLOGY (ALLOWS FOR UNIFORMITY & EASIER RETRIEVAL OF NURSING RELATED DATA) *Use of several software apps *Entry of clinical orders w/ safety measures M-Health (mobile health) the use of wireless communication devices to support public health and clinical practice medical informatics Application of informatics to all of the healthcare disciplines as well as to the practice of medicine LOINC (Logical Observation Identifiers Names and Codes) Standard for identifying laboratory and clinical observation for exchange (LAB)
NANDA
North American Nursing Diagnosis Association, purpose is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses.
- Standardized data language for nursing diagnosis Nursing Interventions Classification (NIC) A listing of research-based nursing intervention labels that provides standardization of expected nursing interventions. National Library of Medicine (NLM) Helps to provide validity of health information MACRA Medicare Access and CHIP Reauthorization Act GOAL: drive healthcare reform towards providing improved reimbursement for care based on volume and quality rather than quantity. Omaha System A research-based taxonomy designed to generate data following routine client care. Used in homecare, hospice, public health, school health and prisons. Ontology system that organizes concepts by meaning, describing their definitional structure as well as organizing the concept for storage and retrieval of accurate data Patient Protection and Affordable Care Act (PPACA) 2010 federal legislation designed for comprehensive health reform, with an intent to expand coverage, control health care costs, and improve the health care delivery system *Guarantee's access to healthcare for ALL Americans & incentives to change clinical practice to encourage better coordination & quality care. Insures can't charge for preexisting conditions or demographic status (Except age) personal health record (PHR) An electronic record of health-related information about an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources but that is managed, shared, and controlled by the individual. Pharmacy information system (PIS) A key tool in providing optimal patient care and assisting providers in ordering, allocating, and administering medication, with a focus on patient safety issues, especially medication errors Predictive Analytics Uses past and current data to forecast the likelihood that an event will occur.
application of information and computer science and technology to public health practice, research, and learning Project Planning The SECOND phase of the project management process that focuses on defining clear, discrete activities and the work needed to complete each activity within a single project. Phishing Deceptive method to steal sensitive info via internet. (1st email, 2nd open email, 3rd Hackers have info Physical Security The protection of physical items, objects, or areas from unauthorized access and misuse. patient data personal information about a patient, as well as information about the patient's medical insurance coverage. Name, age, wt, VS PGHD (Patient-generated health data) Health related data created, recorded, or gathered by the pt/cg to help address health concerns. Logical Security uses technology to limit access to only authorized individuals to the organization's systems and information, such as password controls Quantitative Research Focus on #'s and frequencies GOAL: Finding relationships or variables specific to outcome Qualitative Research Variable (not focused on counting) Questionnaire's, survey's, interviews, lists "Data Capturing" Ex: personal digital assistants/laptops QSEN (Quality and Safety Education for Nurses) focus on competency needed to continuously improve quality of care in their work environment Patient centered Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics-Electronic charts
Quality indicators 4 Types:
- Prevention
- Inpatient
- Patient Safety
- Pediatric Real time analytics the provision of analyzed data relatively instantly to support decision making. IBM's Watson is the best example we have today RMS Risk Management System identifies and documents potential risks and develops strategies to deal w/ them Shared electronic health record a type of EHR supported by an EHR system that allows clinicians to access an individual patients EHR data located in different facilities Scope Creep The uncontrolled expansion to product or project scope without adjustments to time, cost, and resources. SNOWMED CT systematized nomenclature of medicine clinical terms enables consistent way of capturing sharing aggregating health data across specialties site of care teminology for anatomy dx med problems nursing
- Provides common language for EHR. Standardized Terminologies Structured, controlled languages developed according to terminology development guidelines and approved by an authoritative body. Strategic Planning the process of determining the major goals of the organization and the policies and strategies for obtaining and using resources to achieve those goals NOT SHORT TERM GOALS System Development Life Cycle (SDLC) Stages (1) Design (2) Plan (Where S.W.O.T. Analysis is done) (3) Implement (4) Analyze (Look at technical requirements) (5) Evaluate
the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, health-related education, public health, and health administration *Does not always involve clinical services Telemedicine Involves the use of video, audio, and computer systems to provide medical and/or health care services. Translational Bioinformatics Ex: DDS/Decision Support System Relatively new term that supports the National Institute for Health road map for medical research Ability to translate voluminous biomedical data into proactive, predictive, preventive, and participatory health Information disseminated to a variety of stakeholders, including biomedical scientists, clinicians, and patients TIGER (Technology Informatics Guiding Educational Reform) 2004, Advance RN competencies in informatics Develop US workforce capable of using EHR to improve delivery of care. Wisdom Application of knowledge to manage and solve problems User inference Allows humans and computers to cooperatively perform tasks/goals value-based model Policy Reform 2008, focused on incentives to providers on quality (value) vs Volume. Value vs volume Hope is to reduce the number of unnecessary or limit value tests and treatments. Usability The quality of the users experience when interacting w/ a product system software or application. EFFECTIVENESS, EFFICIENCY AND USER SATISFACTION DRA (Deficit Reduction Act of 2005) "Do Not Pay" CMS oversee's the Hosp Acquired Conditions present on Admit (HAC-POA) Program Ex: stage III & IV pressure ulcer, Falls, Trauma, Cath assoc infection, surgical site infections, DVT's, Vasc. Cath Assoc Infections. (ONCHIT) Office of the National Coordination for Health Information Technology
Federal government driving healthcare Info standards. 2 Federal Advisory Committees: HITPC - framework for nationwide infrastructure & HIT standards for communities HITSC - develop standards, certifications and implementations strategies. AHIMA Standards of Ethical Coding Standards developed by the Council on Coding and Classification of the American Health Information Management Association (AHIMA) to give health information coding professionals ethical guidelines for performing their coding and grouping tasks. Barcode Medication Administration (BCMA) : * Mandated by the FDA * Real-time, automated documentation of patient's medication. Needs CPOE, A pharmacy system, & an EMAR system to function. Interoperability When 2 or more systems (Human or Machine) exchange data or information while retaining the original meaning of data. A nurse informaticist can increase interoperability by promoting standardized vocabulary & coding. ** Using an interoperable system, you can expect a reduction in errors, increase in revenue, and increased communication ** Types of Interoperability Technical Interoperability-ability to exchange the data from one point to another Semantic Interoperability-exchange of data in wh/ the meaning remains the same at both ends. Process Interoperability - Coordinates systems enabling business processes at organizations & allowing systems to work together. Benchmarking The continual process of measuring services and practices against the toughest competitors in the healthcare industry Store and Forward Applications Asynchronous. Transmit recorded health information through a secure communications network to a provider (Photos). de-indentified health information/HIPAA There are no restrictions on the use or disclosure of de-identified health information.14 De-identified health information neither identifies nor provides a reasonable basis to identify an individual. There are two ways to de-identify information; either: (1) a formal determination by a qualified statistician; or (2) the removal of specified identifiers of the individual and of the individual's relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual.
