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NR599: Nursing Informatics Final Exam
Study Guide
● Ethical decision making ■ ANA (2015) provides specific guidance for ethical decision making via its Code of Ethics for Nurses with Interpretive Statements ● Respect for human dignity ● Respect for the individual right to self-determinism ● Primary commitment to the patient (defined as individual, family, group, or community) ● Advocacy for the patient ● Participation in the creation, maintenance, and improvement of healthcare environments ● Advancing the profession ● Collaboration with others to meet health needs ● Shaping social policy ○ Ethical Issues with HIT and Nursing Informatics ■ As with everything, a new way of viewing the world = enduring values of the previous worldview ■ As healthcare transforms digitally (communications, telehealth, and wearable technologies) it brings some familiar tools and skills recognized in the form of values, such as privacy, confidentiality, autonomy, and nonmaleficence. ● Although those basic values should remain unchanged, the standards for living out these values will take on new meaning as health professionals confront new and different moral dilemmas brought on by the adoption of technological tools for: ○ information management ○ knowledge development ○ and evidence-based changes in patient care ■ The ethical-decision frameworks should not change but only become more complex. ■ Examples of issues having an ethical component include the following: ● Failure to adapt technology or use it adaptly ● Lack of regard to data integrity such as discrepancies in record information that are noted but no corrective action is taken ● Failure to address threats to privacy and
personal health information ● Inappropriate access to PHI without a need to know
■ Emerging technology will introduce new issues and dilemmas.
■ In addition to the use of EHRs, there is a growing use of social media to market provider services and provide support. ● Many organizations struggle with questions surrounding the proper use of social media. ● Genomics, or personalized medicine targeted to one's specific genetic make-up, is an area within our grasp but still not widely known. ● And, technological advancements and miniaturization are quickly making nanotechnology an area that we will need to address. ● Nanotechnology is science, engineering, and technology that is conducted at the level of the nanoscale (nano.gov, n.d.). For reference purposes, a nanometer is equal to one billionth of a meter. ● Bioethical standards ○ The study of healthcare ethics ○ Study and formulation of healthcare ethics. ○ Bioethics takes on relevant ethical problems experienced by healthcare providers in the provision of care to individuals and groups. ● Telehealth and Point-of-Care (POC) Technologies ○ Many mHealth technologies are being used to broaden access to care, either by extending the reach of providers through remote monitoring of patients or by giving advice when users otherwise would not visit a medical professional. ○ Apps like Pocket Doctor and iTriage, which suggest possible diagnoses on the basis of inputs from patients, are proliferating. ○ Making medical advice available beyond traditional settings could broaden access to care for the uninsured, those living in rural areas, immigrants, and perhaps even elderly patients. Tremendous strides have been made in deploying mHealth technologies to expand access to care in less developed countries. ○ Telehealth is still an evolving technology; while the offsite interventions or contacts often lead to less time being wasted on non-care-oriented tasks because of the efficiencies offered by the technology applications, its use must never be associated with less care. It is also important to note that nursing activity in telehealth still follows the same best-practice standards as those espoused in conventional care. ○ Clinical Uses for Telehealth ■ Transmitting images for assessment or diagnosis ● Wounds for assessments and treatment consults
○ Mobile health is also known as mHealth, is defined as the use of wireless communication to support efficiency in public health and clinical practice (Yetisen et al., 2014). ○ Facilitation of mHealth = mobile apps which can be executed either on a mobile platform or a web-based software application that is tailored to a mobile platform but is executed on a server. ■ Mobile medical apps = accessory → smartphones, tablets, smartwatches, and POC devices ○ Major areas for mHealth growth are: ■ Preventive medicine and health promotion can be leveraged through education and awareness applications; ■ Portable diagnostic devices that allow monitoring of human conditions in clinical settings or offsite locations; ■ Applications for data management, training medical personnel, and mobile payments. ● Medical Devices ○ Any device intended to be used for medical purposes ● FDA Oversight for Medical Devices ○ The United States Food and Drug Administration (FDA) oversees medical applications and assesses their potential misuse or malfunction in order to reduce these risks to the public. ■ 2013 the FDA released its final guidance entitled “Mobile Medical Applications Guidance for Industry and Food and Drug Administration Staff” → which offers a clear distinction between an unregulated mobile application and a mobile medical application that are subject to overt FDA regulation. ■ This guidance focuses on apps that possess a greater risk to patients if they don’t function as they intended. ● Medical Device vs. Mobile Application? ■ The Food and Drug Administration (FDA) (2013) recognizes the extensive variety of actual and potential functions of mobile apps, the rapid pace of innovation in mobile apps, and the potential benefits and risks to public health represented by these apps. ■ The FDA intends to apply its regulatory authorities to select software applications intended for use on mobile platforms. ■ Given the rapid expansion and broad applicability of mobile apps, the FDA is issuing this guidance document
to clarify the subset of mobile apps to which the FDA intends to apply its authority. ■ Many mobile apps are not medical devices, meaning such mobile apps do not meet the definition of a device by the Federal Food,
○ 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 the safety and effectiveness of new devices and software. ■ Considerations of cybersecurity must be included in any evaluation process. ● Computer-aided translators ○ A form of language translation in which a human translator uses computer hardware to support and facilitate the translation process ● HIPPA: enacted in 1996 ○ “Key persons and organizations that handle health information to have policies and security safeguards in place to protect your PHI whether it is stored on paper or electronically.” ■ Protect personal health information (PHI) ■ Ensures portability of insurance for individuals moving from one job to another ■ Legal protection for PGI ■ Mandates standards for the electronic data interchange of healthcare data for encounter and claims information ■ 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 ● 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 ○ How does this apply to APNs? ■ As nurse leaders, the APN is often in an authoritative position or perceived as a role model. ● For these reasons, he or she needs to determine if appropriate safeguards to protect PHI are in place and if HIPAA requirements and other legal
mandates are met.
● Diagnosis does explain the need = $ ● Medical Billing: the process of submitting claims to receive payment
● Evaluation and Management Coding ○ Administrative data → billing information derived from insurance claims, inpatient discharges (or hospital bills), and outpatient visits (the bill from the emergency room visits that do not result in being admitted to the hospital or services delivered in a hospital but not part of an overnight admission). ○ Administrative data include documentation of clinical diagnoses and use of health services as recorded through predefined coding systems such as the International Classification of Diseases, ninth revision, Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPTs), or Healthcare Common Procedure Coding System (HCPCS). ● Reimbursement Coding ○ Reimbursement codes are assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. ○ This is a critically important intersection between the clinical and 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 that are appropriate for each patient visit. ■ Therefore, it is imperative for APNs to have knowledge of the link between billing, coding, and the EHR. Success application of ICD-10 codes is not intuitive and requires training beyond the scope of this course. ● Documentation in Coding : translated into alphanumeric codes and transferred to the payer ○ The written H&P has several purposes: ■ Document that gives concise information about the patient ■ Outlines plan for addressing reasons for visit ■ Means of communicating information to other providers ■ Medical-legal document ■ Essential to accurately code and bill for services ● Fee for Service: ○ The US healthcare system uses fee for service model ■ Paid based on the complexity of work performed ○ Medicare Physician and Non-physician practitioner fee → value is assigned to each CPT code adjusted for geographic location
■ You would NOT be reimbursed the same amount for both patients. ● Diagnosis-related groups (DRGs) vs. Major diagnostic categories (MDCs) ○ Systemically group these more specific codes into meaningful broader categories ■ The purpose of the DRG group is to facilitate payment through the prospective payment system ■ While MDCs organize diagnoses and utilization → primary purpose is for billing. ● *More expensive services are likely to be identified first in the administrative record, not necessarily as events or procedures that occurred chronologically or even simultaneously. ● Clinical Support Tools ○ 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 EHRs ■ Examples: 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 scientific evidence to help guide appropriate decision- making. CDS tools include but are not limited to: ■ Computerized alerts and reminders for providers and patients ■ Drug-drug interaction alerts ■ Underdose or overdose alerts based on renal or liver function or age or drug levels ■ Actionable clinical guidelines ■ Condition-specific order sets ■ Focused patients data reports and summaries ■ Diagnostic support ■ Contextually relevant reference information ○ CDSSs are quickly becoming essential tools for providers as the volume of available data increases alongside their responsibility to deliver value-based care. ■ Reducing clinical variation and duplicative testing, ensuring patient safety, and avoiding complications that
may result in expensive
response by drug and provider specialty, and offer a range of interruptive and non-interruptive support mechanisms. ■ Finances are another issue:
● The most complex decision support systems attempt to aid clinical decisions = costly to maintain ● The application of artificial intelligence to medicine has a long history; however, most diagnostic expert systems have been stand-alone, requiring effort by the clinician outside of their normal workflow and have thus seen limited clinical implementation. ○ The primary goal of a CDSS is to leverage data and scientific evidence to help guide appropriate decision-making. ■ The CDSS team needs to approach the project in a data-driven manner supported by the evidence. ● This requires an in-depth analysis of the scientific evidence coupled with data-analysis methods to identify gaps in practice within the organization. ● It is equally important to identify where there are gaps in the ability to report how an organization is doing with respect to patient care and if recommended practice guidelines are being followed. This constitutes the absence of data captured to track that information. ● The gaps will tell an organization where to focus with respect to adding where a CDSS tool should be. ■ It is the role of the CDSS teams to identify the elements of a process and use data to identify areas where processes might be enhanced with the use of CDSS tools to provide users with the best evidence and to support appropriate decision-making and treatment decisions. ● Workflow analysis ○ Workflow is a term used to describe the action or execution of a series of tasks in a prescribed sequence. ■ Another definition 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. ● Workflows: ○ Sequential: each step depends in the occurrence of the previous step ○ Parallel: two or more steps can occur concurrently ○ Workflow is sometimes interchangeable with process or process flows, particularly in context of implementations.
