Download NR 599 / NR599 Final Exam Study Guide (Latest 2022 / 2023) Nursing Informatics for Advance and more Study Guides, Projects, Research Nursing in PDF only on Docsity! R 599 Final Exam Study Guide. * General principles of Nursing Informatics * Scientific synthesis of information in nursing * Concepts: computer, cognitive, information * Knowledge + Wisdom + Scientific Underpinning + The Foundation of Knowledge Model + Computer science + Cognitive science + Information science + Standard Terminology + Informatics Competencies + Information literacy + Health literacy + Meaningful Use + Patient-centered Information Systems + Clinical Decision Support Systems + Electronic Medical Records + Human-Technology Interface + HealthInformation Technology + Alarm fatigue * Digital natives + — Information Literacy Competency Standards for Nursing + HITECH Act + TIGER-based Nursing Informatics Competencies Model + Workarounds are ways invented by users to bypass the system to accomplish a task; usually indicate a poorfit of the system or technology to the workflow or user; devised methods to beat a system that does not function appropriately or is not suited to the task it was developed to assist with (McGonigle & Mastrian, 2018, p. 584). Workarounds negate expected practice protocols and are rarely necessary or appropriate means to ensure patient safety. + Longevity is defined as usability beyond the immediate clinical encounter (McGonigle & Mastrian, 2018, p. 570). © HITCHACT- become meaningful users of EHR. o American Recovery and Reinvestment Act of 2009 + Communication systems improve productivity to promote interaction among healthcare providers and between providers and patients. Healthcare professionals overwhelmingly recognize the value of these systems to promote data and information processing. Examples of communication systems include call light systems, wireless telephones, pagers, email, and instant messaging, which have traditionally been forms of communication targeted at clinicians (McGonigle & Mastrian, 2018, p. 190). A major barrier to widespread adoption of educational opportunities for patients among American healthcare providers isthe fact that reimbursement mechanisms for electronic health care interventions are inadequate or nonexistent. The goal of the interactive behavior change technology is to improve communication between patients and healthcare providers and to provide educational interventionsthat promote better disease management between office visits (McGonigle & Mastrian, 2018, p. 335). Once the technology is integrated into the organization, biomedical engineers can become valuable partners in promoting patient safety through appropriate use of these technologies. For example, inone organization, the biomedical engineers helped to revamp processes associated with the newtechnologyalarm systems after they discovered several key issues: slow response times to legitimate alarms and multiple false alarms (promoting alarm fatigue) created by alarm parameters that were too sensitive. Strategies for addressing these issues included improving the nurse call system by adding Voice over Internet Protocol telephones that wirelessly receive alarms directly from technology equipment carried by all nurses, thus reducing response times to alarms; feeding alarm data into a reporting database for further analysis; and encouraging nurses to round with physicians to provide input into alarm parameters that were too sensitive and were generating multiple false alarms (McGonigle & Mastrian, 2018, p. 297). This deluge of information available via computers must be mastered and organized by the us. er if knowledge is to emerge. Discernment and the ability to critique and filter this information must also be present to facilitate the further development of wisdom (McGonigle & Mastrian, 2018, p.53). Nurses have historically gathered and recorded data, albeit in a paper record. There is no doubt that nursing experiences build knowledge and skill in nursing practice, but paper-based documentation has hindered the ability to share knowledge and to aggregate experiences to build new knowledge (McGonigle& Mastrian, 2018, p. 106). Healthcare providers need to embrace the Internet as a source of health information for patient education and health literacy. Patients are increasingly turning there for instant information about their health maladies. Health-related blogs (short for weblog, an online journal) and electronic patient and parent support groups are also proliferating at an astounding rate. Clinicians need to be prepared to arm patients with the skills required to identify credible websites. They also need to participate in the development of well-designed, easy-to-use health education tools. (McGonigle & Mastrian, 2018, p. 330). Patients are occasionally interested in interacting with others who have the same or similar conditions, and some healthcare organizations are providing the information necessary to help them connect. This so- called peer-to-peer support is especially popular with patients who have cancer diagnoses, diabetes, andother chronic and debilitating conditions (McGonigle & Mastrian, 2018, p. 328). Ethical decision making Bioethical standards Telehealth Medical Applications Medical Devices FDA Oversight for Medical Devices Privacy Confidentiality Cybersecurity Computer-aided translators HIPPA ICD-10 Coding Evaluation and Management Coding Hard to maintain due to social media and use of mobile devices such as smartphones, they are being utilized in treatment rooms around the globe, Providers need to be aware of institutional policies regarding audio/video recordings by patient and families, requires two-party consent, sometimes enthusiasm for patient care and learning can lead to ethics violations. Another federal regulatory agency with a role in the privacy and security of health care data is the Food and Drug Administration (FDA). The FDA oversees the safety of medical devices, which includes addressing the management of cybersecurity risks and hospital network security. Recent guidelines issued (FDA, 2013) recommend that medical device manufacturers and health care facilities take steps to ensure that appropriate safeguards are in place to reduce the risk of failure caused by cyberattack. This could be initiated by the introduction of malware into the medical equipment or unauthorized access to configuration settings in medical devices and hospital networks. The consequences of not adequately addressing these risks could be dire. As medical devices are increasingly integrated within health care environments, there will be a need for vigilance toward cybersecurity practices to ensure all systems are adequately protected and patients remain safe from harm. Nurse Informaticists are frequently called on to evaluate safety and effectiveness of new devices and software. Considerations of cybersecurity must be included in any evaluation process. HIPAA was enacted in 1996. While it is best known among consumers and healthcare professionals for its protection of personal health information (PHI) and the additional forms that each of us are asked to sign when we go to provider offices, HIPAA also ensures portability of insurance for individuals moving from one job to another, legal protection for PHI, and mandates standards for the electronic data interchange of healthcare data for encounter and claims information, and was intended to simplify the claims submission process by eliminating paper claims. HIPAA established legal sanctions for institutions and individuals who fail to protect PHI. As healthcare professionals, we are cognizant of HIPAA requirements before we share PHI via writing, electronic means, faxes, telephone, or in person. Specific measures to protect PHI include limiting record access to individuals with a right to know, signed disclosures to release information, encryption of e-mail and files, fax cover sheets, designated persons who may receive PHI, and the use of passwords to guarantee that PHI is only disclosed with persons designated by the consumer as having a right to know. HIPAA has also changed sign-in procedures for patients, disposal of forms containing PHI, and how we use whiteboards to show patient information. Currently, we are inthe tenth revision of the system, and, therefore, the classification system is known as ICD- 10. 1CD-10 codes are shorthand for the patient's diagnoses, which are used to provide the payer informationon the necessity of the visit or procedure performed. This means that every CPT code must have a diagnosiscode that corresponds. Before you can determine your E&M, code you must first identify the p lace of service, type of service , and the patient status. The place of service refers to where the service was rendered There are several categories to choose from, but the two most common are the inpatient and outpatient settings. This is pretty straightforward. The type of service refers to t he type of service provided . Some examples of types of services include consultation, hospital admission, office visit, and so forth. Again, pretty straightforward. As astudentin your practicum rotations, nearly all of your place s and types of service will be outpatient office visits. Finally, you need to identify the patient's status. Patient status refers to whether or not the patient is a new patient or an established patient of your practice. By definition, a new patient is one who has not received professional service from a provider from the same group practice within the past 3 years. Conversely, an established patient has received professional service froma provider of your office within the last 3 years. There are three key components that determine risk-based E&M codes. 1. History 2. Physical 3. Medical Decision Making (MDM) ivo a)risk b) data c) diagnosis Reimbursement codes are assigned and contingent upon data inpur from clinical team members based ona summative review of the clinical record by trained coders. This is critically important intersection between the clinicaland administrative teams. if the patient encounter, procedure, or diagnosis are incorrectly entered into a clinical management system, the billing and coding process will also be incorrect. Providers play an important role in ensuring the success of the business by clearly identifying the diagnosis and service codes are appropriate for each patient visit. It is imperative for APNs to have knowledge of the link between billing, coding, and the EHR. Diagnosis related groups (DRGs) or Major diagnostic categories (MDCs) systematically group these more specific codes into meaningful broader categories. DRG group is to facilitate payment through the prospective payment system, MDCs organize diagnoses that affect similar physiological systems. Primary purpose is for billing. Clinical decision support (CDS) as a process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assessments, recommendations, or other forms of guidance that are then presented to a decision-making recipient or recipients that can include clinicians, patients, and others involved in care delivery. CDS tools existed prior to development of EHRs. Historical examples include practice guidelines carried in clinicians’ pockets, patient cards used by providers to track a patient's treatments, and tables of important medical knowledge. The primary goal of implementing a CDS tool is to leverage data and the scientific evidence to help guide appropriate decision making. CDS tools include but are not limited to: Workflow is a term used to describe the action or execution of a series of tasks in a prescribed sequence. Another definition of workflow is a progression of steps (tasks, events, interactions) that constitute a work process, involve two or more persons, and create or add value to the organization's activities. In a sequential workflow, each step depends on the occurrence of the previous step; ina parallel workflow, two or more stepscan occur concurrently. The term workflow is sometimes used interchangeably with process or process flows, particularly in the context of implementations. Observation and documentation of workflow to better understand what is happening in the current environment and how it can be altered is referred to as processor workflow analysis. A critical aspect of the informatics role is workflow design. Nursing informatics is uniquely positioned to engage in the analysis and redesign of processes and tasks surrounding the use of technology. 1. Informatics nursing is distinguished from other nursing specialties by its focus on: computerized medical records. data coding and the use of abbreviations. training and education. 2. Applications that are designed to run ona common platform, operate in a common environment, and communicate through direct data transfer are known as: integrated. interfaced. normalized optimized. 3. Adult learners most effectively learn about a new clinical information system when the instructor: assumes that the learner knows nothing about the system. begins the formal training as early as possible in the implementation process. emphasizes the technical specifications of the structure of the system. 4. Knowledge that is patterned for use in reasoning is known as: artificial intelligence. knowledge query. ‘Tepresentation.neural computing. 5, What process produces a blueprint that details how hardware and software meet the needs of the organization? Benchmarking Feasibility study System analysis 6. Ease of navigation, appropriate language, efficiency of use, ease of learning, and intuitiveness are all examples of: affective skills. behavioral needs. user ergonomics. 7. The problems of an existing system have been identified, along with possible solutions. What is the next step in the systems analysis stage?