NR599: Final Exam Study Guide, Study Guides, Projects, Research of Medical Records

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NR599: Final Exam Study Guide

1. Nursing informatics: specialty that integrates nursing science, computer sci- ence, and

information science to manage and communicate data, information, and knowledge in nursing practice

2. Levels of Nursing Informatics Practice: Generalist and Informatics Nurse Spe- cialist

3. Informatics Nurse Specialist: Completed graduate level education in informat- ics or related

field

4. Knowledge: The awareness and understanding of a set of information and the ways that

information can be made useful to support a specific task or reach a decision.

5. Knowledge Workers: Those who work with information and generate knowledge as a product.

Nurses are an example of such.

6. Wisdom: the ability to apply valuable and viable knowledge, experience, under- standing and

insight while being prudent and sensible. Sometimes considered the highest form of "Common Sense"

7. Scientific Underpinning: Provide the basis of knowledge to advance nursing practice;

include sciences such as biology, physiology, psychology, ethics, and nursing. -DIKW Paradigm (Data, Information, Knowledge, Wisdom)

8. Foundation of Knowledge model: Model that proposes that humans are organic information

systems constantly acquiring, processing, and generating information or knowledge in both their professional and personal lives.

9. Computer Science: Study of storage, conversion and transformation, transfer or transmission

of information in computers through algorithms and practical imple- mentation problems.

10. Cognitive Science: Studies how the mind works from an information processing perspective.

11. Information Science: The study of the retrieval, application, use and manage- ment of

information as well as the human-computer interaction.

12. Standard Terminologies: Structured, controlled languages developed to repre- sent concepts

in a given domain in a clear, unambiguous fashion that conveys the exact same meaning for data, information, and knowledge across settings, regions, and even different countries.

13. Nomenclature: Refers to a system of rules and procedures for adding names used in an art

or science, such as nursing.

14. Classification: Systems that capture categories, which are then used to de- termine costs

or outcomes but are insufficient in detail for clinical documentation purposes

15. Taxonomy: Uses classification according to a predetermined system, with the resulting

catalog used to provide a conceptual framework for discussion, analysis, or information retrieval.

16. Data Set: Refers to a named collection of data consisting of individual informa- tion

organized in a prescribed fashion

17. Analytics: A term describing the extensive use of data, statistical and quantita- tive

analysis, explanatory and predictive models, and fact-based management to drive decisions and actions. Can improve marketing or in healthcare, services for the demographics served.

18. Nursing Informatics Competencies: The integration of knowledge, skills, and attitudes in the

performance of various nursing informatics activities within pre- scribed levels of nursing practice

19. ICD: International Statistical Classification of Diseases and Related Health Prob- lems;

Maintained by the WHO and provides a description and classification of known diseases and injuries.

20. CPT: Current Procedural Terminology; Unique billing codes for services ren- dered;

Maintained by the American Medical Association.

21. Nursing Informatics Roles: Project Manager, Consultant, Educator, Re- searcher, Product

Developer, Decision Support/Outcomes Manager, Advocate/Pol- icy Developer, Clinical Analyst/System Specialist, Entrepreneur

22. TIGER Initiative: -The work of the Technology Informatics Guiding Education Reform Team.

This team of nursing leaders developed a vision for utilizing informa- tion technology to transform nursing practice. -Key purpose was to create a vision of nursing that bridges the quality chasm w/ information technology, enabling nurses to use informatics in practice and education to provide safer, higher quality of care.

23. TIGER Based Nursing Informatics Competency Model: Includes (3) pillars: Information

Literacy, Computer Literacy, Clinical Information Management

24. (3) Pillars of TIGER Based Nursing Informatics Competency Model: Infor- mation Literacy,

Computer Literacy, Clinical Information Management

25. Information literacy: Ability to identify when information is needed as well as the skills to

find, evaluate, and effectively use the same

26. Computer Literacy: Basic familiarity with computer uses and common applica- tions, ability

to navigate hyperlinks, able to set up and use a database to collect and retrieve information

27. Clinical Information Management: -Uses clinical decision making (CDS) and system

safeguards to protect patients and protected health information (PHI) -Able to request and evaluate reports for the purpose of informed decision making -Participate in the selection, design, and evaluation of clinical information systems and patient- care technologies -Uses available technologies to appropriately and effectively communicate

28. Health Literacy: a person's capacity to obtain, process and understand basic health

information and services, and to use these resources to promote one's health and wellness

29. Clinical Decision Support System (CDSS): provides timely information, usu- ally at the point

of care, to help inform decisions about a patient's care.

30. Meaningful Use (MU): The set of standards defined by the Centers for Medicare & Medicaid

Services (CMS) Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.

31. HITECH Act: -Health Information Technology for Economic and Clinical Health Act was

enacted to promote the adoption and meaningful use of health information technology. -Monetarily Incentivize health organizations and providers to become meaningful users of EHR. -Introduced in 2009 as part of the American Recovery and Reinvestment Act (ARRA)

32. Digital Natives: a generation of people born after 1980 who have been raised in a digital

age

33. Human Technology Interface (HTI): The portion of the assistive technology system with which

the user interacts; The hardware and software through which the user interacts with any technology.

34. Patient Centered Information System: -Systems focused on augmenting tra- ditional

approaches to health information management

-Designed to support patient participation in health care decision making and treatment activities.

35. Electronic Medical Record (EMR): Patient medical record from a single med- ical practice,

hospital, or pharmacy

36. Information Literacy Competency Standards for Nurses: -Determine the extent of

information needed -Access the needed information effectively and efficiently -Critically evaluate the information and sources

-Utilize information effectively to accomplish a specific purpose -Understand implications from the economic, legal, and social perspectives sur- rounding the access and use of information

37. Ethical Decision Making: -Process that requires striking a balance between science and

morality. -Making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong.

38. American Nurses Association- Code of Ethics for Nurses with Interpretive Statements.: provides

specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT

39. Bioethical Standards: Autonomy, freedom, veracity, privacy, beneficence, and fidelity are

maximally appropriate to the health care setting.

40. Autonomy: The right to choose for himself or herself; respecting the clients opinions,

perspectives, values and beliefs.

41. Freedom: The ability of an individual to act independently, without coercion or constraint in

ones choice and action

42. Veracity: Being completely truthful with patients; a patients right to truth.

43. Privacy: The right to be left alone when you want to be, to have control over your own

personal possessions, and not to be observed without your consent.

44. Beneficence: Actions performed that contribute to the welfare of others; Action of doing

good or right by and for the patient.

45. Fidelity: Right to what has been promised; keeping to one's promise.

46. Telehealth: Use of electronic information and telecommunications technologies to support

long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videocon- ferencing, the internet, store- and-forward imaging, streaming media, and terrestrial and wireless communications.

47. Telemedicine: Remote clinical health services

48. mHealth (Mobile Health): -The practice of medicine and public health support- ed by mobile

devices such as mobile phones, tablets, personal digital assistants and the wireless

infrastructure. -The use of wireless communication to support efficiency in public health and clinical practice.

49. Mobile Medical Applications (Apps): -Accessories to a regulated medical device or are a

software that transforms a mobile platform into a regulated medical device. -Facilitates mHealth

50. Medical Devices: Any equipment, instrument, implant, material, or apparatus used for the

diagnosis, treatment, or monitoring of patients.

51. Non-Medical Devices: -Applications within a device not intended for use in the diagnosis of

disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. -Does not require FDA oversight

52. Food and Drug Administration (FDA): -Regulatory body that oversees mobile apps that are

medical devices and whose functionality could pose a risk to a patient's safety if the mobile app were to not function as intended. -Also oversee the cybersecurity management of these devices as well as the hospital network security.

53. (POC) Point of Care: Testing and diagnosis at the patient's side and can be conducted

anywhere the patient is, such as the home, physician office, ambulance, or hospital bedside

54. Confidentiality: The act of holding information in confidence, not to be released to

unauthorized individuals.

55. Cybersecurity: -Measures taken to protect a computer or computer system against

unauthorized access or attack. -FDA is main regulatory agency

56. Computer-aided Translators: A person who uses computer software to convert source code to

target text; A conversion of computer language from one to another

57. HIPPA (Health Insurance Portability and Accountability Act): Enacted in 1996; federal law that

required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

58. ICD-10 Codes: -Alphanumeric codes used by doctors, health insurance compa- nies, and

public health agencies across the world to represent diagnoses.

-Shorthand for the patient's diagnosis , which are used to provide the payer infor- mation on the necessity of the visit or procedure performed

59. Evaluation and Management Coding: process by which physician-patient en- counters are

translated into five digit CPT codes to facilitate billing.

60. Necessity prior to establishing Evaluation and Management Codes: Place of Service; Type of

Service; Patient Status

61. Components of Risk Based E/M Coding: History; Physical; Medical Decision Making

62. Medical Decision Making (MDM): 1 of 3 components to establishing E/M codes; way of

quantifying the complexity of thinking that is required for the visit.

63. 3 key elements to medical decision making: risk, data, and diagnosis

64. Reimbursement Coding: -Codes assigned contingent upon data input from clinical team

members based on a summative review of the clinical record by trained coders. -Reimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes.

65. Diagnosis-related groups (DRGs): System that categorizes into payment groups patients

who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

66. Major Diagnostic Categories (MDCs): organized diagnoses that affect similar physiological

systems used in reimbursement billing and coding.

67. Clinical Support Tools: -Found in EHR software that when applied effectively, can enhance

patient care quality and outcomes, improve efficiency, and help to ensure regulatory compliance. -Process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assess- ments, recommendations, or other forms of guidance for clinicians, patients, and others involved in care delivery.

68. Alert Fatigue: Main challenge to effective implementation of CDS Tools

69. Primary Goal of CDS Tools: leverage data and the scientific evidence to help guide

appropriate decision making.

70. Workflow: -Term used to describe the action or execution of a series of tasks in a prescribed

sequence. -The 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. -Used interchangeably w/ process or process flows;

71. Workflow Analysis: -Study of the way work (inputs, activities, and outputs) moves

through an organization. -Observation and documentation of workflow to better understand what is happening in the current environment and how it can be altered

72. Sequential Workflow: each step depends on the occurrence of the previous step

73. Parallel workflow: two or more steps in a process can occur concurrently.

74. Workflow design: A critical aspect of the informatics nurse in a workflow analy- sis

75. American Recovery and Reinvestment Act of 2009 (ARRA): -Provided funds to government

agencies for improving information-technology systems; -provisions include the right for every person to receive an electronic copy of their EHR and to have a copy of their EHR transmitted to a party that they designate -Legislation included the HITECH Act

76. Patient Protection and Affordable Care Act (ACA): Guarantees healthcare for all Americans,

expands Medicaid, provides incentives intended to improve care coordination and quality, restructures healthcare payment, and provides additional information to patients so that they can make value-based decisions.

77. Administrative Data: Include billing information derived from insurance claims, inpatient

discharges (or hospital bills), and outpatient visits.

78. National Prevention Strategy: America's Plan for Better Health and Well- ness: comprehensive

plan that sets forth evidence-based and achievable means for improving health for all Americans at every stage of life. These efforts are designed to stop disease before it starts and to create strategies for a healthy and fit nation, recognizing that prevention must be part of daily life.

79. Fee-for-Service Model: -a provider is given a set amount of monetary reim- bursement for a

specific visit or procedure performed that is adjusted for geograph- ical location -gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care.

80. Medical Coding: Assignment of codes to communicate to payers (insurance companies) in

relation to services performed by a healthcare provider and for what reason they were performed;

81. Medical Billing: Process of submitting and following up on claims made to a payer in order

to receive payment for medical services rendered by a healthcare provider