WGU D220- Information Technology in Nursing Practice Exam 100% Complete

1. A charge nurse uses the department’s smartphone to send a text message containing the patient’s last name, room number, and most recent vital signs to the attending physician. Which federal act does this violate?

Health Insurance Portability and Accountability Act (HIPAA)

1. A clinic employee left a message at home for a patient that included details of both a medical condition and treatment plan. The patient requested any contact regarding medical conditions be done through the patient’s work phone number. What should the clinic’s next steps be?

Train employees to provide only the minimum necessary information in messages.

1. A facility has noted a decrease in revenue related to inaccuracies in coding. A nurse recommends computer-assisted coding (CAC) as a solution. What is the financial benefit of CAC?

CAC improves coding accuracy.

1. A facility recently implemented a new EHR. End nurses are now suggesting changes to improve the HR and workflow processes. Which phase in the SDLC does this describe?

Maintenance

1. After a patient leaves an appointment with a healthcare provider, a nurse notices that the patient’s printed visit information was left in a public location. Which action adheres to the ethical and legal requirements for the disposal of this material?

The nurse disposes of the printed document in the appropriate document shredder.

1. After a patient’s assessment, a nurse observes a decrease in respiration and wheezing on auscultation. Which data set in the medical record informs the decision to implement the ineffective airway clearance nursing care plan?

The radiology report impression indicates pulmonary infiltrates and the nursing assessment indicates a decrease in respirations.

1. After a patient’s initial assessment, a nurse observes an increase in edema, bilateral crackles, and persistent cough. Which data set in the medical record from the last shift informs the decision to implement the fluid volume overload care plan?

Nursing flowsheet and intake and output record

1. A healthcare organization has determined which outcomes it wants to improve over the next year and what changes will be implemented to help the organization achieve its goals. The organization builds an interactive reminder tool in the electronic health record (EHR) for staff. Data can be collected from this tool to determine if the changes are implemented. Which type of data collection is this?

Checklist

1. A heparin medication error and a subsequent failure mode effects analysis (FMEA) results in the purchase of smart pumps. How do smart pumps reduce the potential for medication errors?

Dosing limits and alerts are provided.

1. A high number of data-entry fields in the EHR can be overwhelming for staff and make it difficult to find where information should be documented. Which informatics solution could solve this problem?

Cascading documentation

1. A hospital has a surgical department that uses a different EHR from the main EHR (integrated). When a physician inputs an order in the surgical department, how would you ensure that it is in the main EHR?

Chart in one and it will go into the EHR.

1. A hospital notes a decreased use of barcoded medication administration (BCMA) along with an increase in medication errors. What should be the next course of action?

Monitor BCMA usage reports for trends.

1. A mother brings her child to the emergency department after noticing the child had trouble breathing, refused breastfeeding, and no urine in the diaper within the last eight hours. The provider suspects respiratory syncytial virus and admits the infant to the hospital. How will data in the medical record inform the decision to select appropriate infection-control precautions?

The data will identify the pathogen causing the patient’s symptoms.

1. An adult asks a nurse to look up lab results for their adult family member. How should the nurse respond to this request?

Explain to the family member that lab results are protected health information and can only be released to the patient or an authorized representative.

1. An ER doctor needs patients’ data from a different state. Does the doctor need patient permission to get it?

1. An informatics nurse is collaborating with a nursing director of a long-term care facility to address an ongoing issue with medication errors. Which solution should they consider?

Use digital platform and barcode systems.

1. An informatics nurse is working on genomics data to facilitate disease identification and develop individualized treatment plans for patients in a complex medical facility. What is considered a fundamental requirement for valid interpretation of genomics data?

High throughput computing system

1. A nurse admits an infant with a severe, hacking cough who is vomiting and who has had a fever for the past two weeks. Which data in the electronic health record (EHR) informs the decision to implement infection-control precautions?

The nasopharyngeal swab culture results indicate the patient is positive for Bordetella pertussis.

1. A nurse assists with implementing a new remote patient monitoring (RPM) system for collecting patient data, which improves patient outcomes. Which task is a high priority for an informatics clinician when implementing a new technology for patient data collection?

Identify and define the goal of the technology.

1. A nurse in a primary care provider’s office needs to review results from a patient’s cardiology consultation. Using health information exchange (HIE) technology, the nurse requests this information from the cardiologist’s office. Which type of exchange is described?

Query based.

1. A nurse is asked to be part of a study. What should the nurse do?

Provide de-identified data.

1. A nurse is documenting the electronic record of a patient while in a common area. The nurse is called away to briefly assist nearby. Which action is correct for the nurse to complete prior to assisting in the other area?

Close the record and log out of the account.

1. A nurse is planning the care for a patient admitted to the hospital with COVID. Which list of information in the EMR will help the nurse plan the care for this patient?

The patient’s laboratory results over the last 72 hours.

1. A nurse is teaching a patient-centered health education course at a hospital. As an informatics nurse leveraging technology to help improve patient understanding, which learner would be more likely to have a low health literacy and require more focus?

An elderly person

1. A nurse is working in a medical-surgical unit assigned care for five patients. The nurse has many tasks to accomplish during a shift. Which informatics solution assists in ensuring these tasks are accomplished?

Electronic checklist

1. A nurse manager is informed that bedside nurses have begun using a workaround for scanning a patient’s armband prior to medication administration. The nurse manager finds that several patients are missing armbands and that their armbands are connected to their bed frames. What is the nurse manager’s first course of action for this workaround to bedside-scanning technology?

Question nursing staff about what issues have caused this.

1. A nurse performing patient discharge from a facility provides a continuity of care document (CCD) to a patient and explains the document and contents at discharge. What is a benefit provided by the CCD?

It provides a summary of care to patients and clinicians.

1. A nurse scans the barcode of a medication prior to administering it to a patient. Which metric is reduced when a healthcare system implements a policy which promotes barcode scanning of medications?

Medication Errors

1. A nurse supporting a new employee within a patient care setting witnesses the new employee incorrectly explaining their patient’s procedure to other employees in the cafeteria. Which action should the nurse perform?

Remind the group of the privacy requirements.

1. A nurse thinks the electronic health record (EHR) has too many documentation fields, making it difficult to know where to document some items. As a result, the nurse uses the notes instead or in addition to documenting in a specific field in the health record. What is the least significant impact of this action?

Duplicate documentation appears multiple times in the chart.

1. A patient completes the course of treatment for tuberculosis and is ready to be discharged home. Which instructions should be included in the patient’s discharge education?

Importance of completing the medication prescribed.

1. A patient is admitted to the hospital with a painful rash on the left side of the face. The provider orders the patient to be placed on contact precautions. Which data in the electronic health record (EHR) informed the decision to implement contact precautions?

The skin culture results indicate the presence of the varicella-zoster virus.

1. A project team is moving a hospital from using paper charting to using an electronic health record for documentation. How should the project team roll out the software to reduce the impact on the hospital?

A large stand-alone department should go live first.

1. A provider receives a request from a third-party for details of a patients encounter. When must the provider obtain consent from the patient before releasing this information?

When it is provided to be a life insurer for coverage purposes (do not release life health records to life insurance unless allowed by patient)

1. A researcher wants patient’s data for a journal, what do you need to provide?

Patient consent and de-identified information/data

1. A rural hospital is planning to implement teleradiology in its busy ER department. What is a security consideration in teleradiology implementations?

Access to patient images

1. A team of healthcare workers were stunned when a reality show actor was brought to their emergency unit. A few of them took videos of the actor and streamed them live on social media. Which law did the healthcare workers possibly violate?

Health Insurance Portability and Accountability Act (HIPAA)

1. Benefit of MD using CPOE and DSS?

Alerts when ordering Viagra when patient is taking a cardiac medication.

1. Benefit of mHealth

Integrates with EHR

1. Busy ER, what can a nurse do to help?

Nurse can start the admission process.

1. Clinical data enters the date warehouse in a de-identified state.

Ensures data is clean and accurate.

1. Constipation treatment:

Physician orders (plan and manage) for PRN medications.

1. Currently, a facility uses phones and pagers for clinician communication. This technology is due for replacement. A nurse recommends replacing with all-in-one mobile devices. What is the benefit of all-in-one mobile technology over the current devices?

It integrates functionality within the EHR.

1. Doctors use RFID (radio frequency identification) for which purpose?

Improve documentation time and Improve access to documentation.

1. During the evening shift, a nurse notices a significant change in a patient’s blood pressure as compared to the morning shift. Which 24-hour trend information in the electronic health record (EHR) will help the nurse further evaluate and manage the patient’s blood pressure?

The intake and output record

1. During which phase of the systems development life cycle should a system be activated to effectively be used by end users

Implementation

1. Ethical/legal issue with rural hospital and tele-radiology:

State licensing issue

1. High priority task for informatics clinician when implementing a new technology for data collection is:

Identify and define goal of technology.

1. How can informatics be used to assess a person’s health literacy?

Informatics can evaluate current state and determine the resources needed to determine a patient’s level of understanding.

1. How does an informatics nurse apply expertise in workflow and technology?

By analyzing the impact of new technologies

1. Identifiable Patient information is also called:

Personal data, personal information and IPI

1. In order to institute isolation precautions, you will need:

Pathology report to confirm the pathogen.

1. In which situation should the informatics nurse recommend the use of regression testing?

When a new feature is added to the existing hospital management system

1. Looking at a survey of your facilities patients, you see that 917 patients found your company using an online search, 425 by word of mouth and 217 by seeing your ads on TV. Which graph would be best to display this data?

Bar Graph

1. Medication alert pop ups and what system is alerting?

Clinical Decision Support (CDS) System

1. Mobile health (mHealth) apps have demonstrated benefits to patients by increasing engagement and participation in care. What is a benefit for clinicians?

Integrates with electronic health records (EHRs)

1. Nurse finds 100 errors in coding:

AHIMA and report to nurse manager

1. Nurse sends message to doctor, “Mr. Smith, BP 84/74. 54”

Not enough information for the doctor to prescribe treatment.

1. OR staff are reliant on a manual whiteboard for patient tracking. Recently, surgeons have complained that the turnaround time between surgical cases has increased and blame the manual system. An informatics nurse recommends expanding the use of the existing surgical information system (SIS). Which resolution can improve this workflow issue?

Radiofrequency identification (RFID) in patient labels

1. Patient Discharge Teaching things to consider:

Teach back, 5th grade level, starts on admission, time of day (especially for diabetics), increase font size or ask the patient what works best for them.

1. Patient is being transported to another hospital. The first hospital uses one system, and the admitting hospital uses a different system. What does the nurse need to do in order to obtain the patients information from the ED visit?

Request a copy of the medical record from the transport team.

1. Patient transferring from the ED to the ICU. Information comes from:

Progress notes of the previous nurse (if in the same hospital) OR HIE (from different hospital)

1. Patient use of technology has increased dramatically. While patients are more active in their care, a nurse notes they are often misinformed or obtain information that is inaccurate. Which recommendation should the nurse give to ensure education is accurate?

List credible education resources for the patient’s research.

1. Pharmacies are required to maintain logbooks regarding pseudoephedrine purchases. A pharmacy kept their logbooks open on the counter where patients approach to pick up prescription medications. Which statement is true regarding the pharmacy’s logbook?

HIPAA was violated as the logbooks contain protected health information.

1. Pharmacy adds a field into the medication administration record to document the lot number when a chemo medication is administered but fails to communicate this to the nurse responsible for the medication administration documentation. What is a consequence of this action?

Pharmacy cannot determine if there is a problem with a medication batch.

1. Physicians rely on free text notes for a significant amount of their patient-related documentation. An organization is reviewing data to identify and progress toward set goals related to patient outcomes. What challenge does this present?

Qualitative data is manually extracted from the health record.

1. RN needs to override a medication, which one would she NOT override?

Comfort Care patient with 2 new orders

1. Staff is resistant to tele-ICU (implementing new process). What are the benefits?

Improve workflow, Resources and expertise.

1. Standardized terminology was implemented to promote interoperability across electronic health records (EHRs). Which terminology is specific to laboratory tests, orders, and results?

LOINC

1. Statewide HIE responsible for implementing interoperability standards. What is the name of the state level HIE and what is the mission off it?

Health Level 7 (HL7); To provide a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of EHI; enhance interoperability.

1. The ER is trying to improve quality of care and decrease the waste time. Nurse recognizes a problem and thinks of which solution:

Planning phase when the nurse recognizes a problem and solution.

1. The health administrator at a clinic observes an increase in the number of patients with a complaint of difficulty breathing, fatigue, and loss of appetite. Which data in the electronic health record (EHR) will provide a cross-reference to the impacted patient population?

Patient demographic records

1. The hospital announced its integration engine has stopped functioning. What does this mean for system interoperability throughout the organization?

Manually chart the VS

1. The hospital director asks the informatics nurse about an effective patient record management system. Which basic feature of a patient health record (PHR) system would the informatics nurse endorse?

Encourage the active participation of patients in the management of their condition.

1. The nurse manager of an outpatient laboratory clinic is investigating decreased patient satisfaction scores and cited delays in receiving lab results. The first step is to review testing turnaround times for the clinic. Which health information system (HIS) should the nurse manager review for this data?

Laboratory information systems (LIS)

1. The nursing unit of a major hospital is revisiting their policy on the use of mobile devices for accessing the EMR. Which guideline should take precedence?

Ensure legal and regulatory compliance.

1. To create an informatics culture, you should:

Assess current state to determine gaps.

1. To monitor a patient’s blood glucose level, you will need:

A nurse flow sheet

1. Treatment of patient related to BP measures or fluctuation blood glucose levels:

Medication administration and MAR

1. Two nurses are in the cafeteria talking about lab reports and they commit HIPAA violations. What is the action?

$100-50,000 Fines

1. We have the date on how much each of our patients paid over the last year, covering thousands of transactions. Which graph would be best to display this data?

Histogram

1. What are patient portals?

Patient portals are facility-owned and associated with an electronic health record.

1. What are the correct steps in medication administration that require scanning verification?

Scan the serial numbers on the medication label and patient’s identification bracelet.

1. What are the requirements for data collection and tracking in clinical healthcare research?

Include all data whether or not it aligns with the expected outcome.

1. What does the informatics nurse recommend to increase attendance to follow-up appointments?

Automated text or email reminders

1. What is a barrier and benefit to using biometrics?

Barrier – Financial; Benefit – Security

1. What is a Database?

File structure that supports the storage of data in an organized fashion and allows data retrieval as meaningful information

1. What is Administrative Information System (AIS)?

Systems that support patient care by managing financial and demographic information and providing reporting capabilities.

1. What is AHIMA?

American Health Information Management Association

1. What is AHRQ?

Agency of Healthcare Research and Quality

1. What is AI?

Artificial Intelligence

1. What is AIS?

Administrative Information System

1. What is alarm fatigue?

Phenomenon that occurs when the volume of alerts, alarms, or warning messages acts contrary to intention through desensitizing the clinician to the indicators and/or the purpose.

1. What is Analysis?

New technology going to roll out and staff is deciding what can make it better.

1. What is analytics?

Discovery, interpretation and communication of meaningful patterns from data to offer solutions and drive decisions

1. What is an audit trail?

Electronic tool that can tract system access by individual user, by user class or by all persons who viewed a specific client record

1. What is a patient safety benefit of a pharmacy information system (PIS)?

Alerts regarding allergies and interactions

1. What is ARRA?

American Recover and Reinvestment Act of 2009

1. What is Artificial Intelligence (AI)?

Use of algorithms and other technologies to mimic human cognition and predict outcomes.

1. What is authentication?

Action that verifies the authority of users to receive specified

1. What is BCMA?

Barcode Medication Administration

1. What is Benchmarking?

indicators against which a process is measured

1. What is Big Data?

Very large data sets that are beyond human capability to analyze or manage without the aid of information technology.

1. What is Biometrics?

A unique measurable characteristic of trait of a human being for automatically recognizing or verifying identity

1. What is CAC?

Computer Assisted Coding

1. What is CCD?

Continuity of Care Documentation

1. What is C-CDA?

Consolidated-Clinical Document Architecture

1. What is CCR?

Continuity of Care Record

1. What is CDSS?

Clinician Decision Support System

1. What is CIS?

Clinical Information System

1. What is Clinical Decision Support System (CDSS)?

supports healthcare practitioners in making patient care decisions by integrating patient data with current clinical knowledge

1. What is Clinical Information System (CIS)?

also known as patient care information system; Large computerized database management systems used to access the patient data that are needed to plan, implement, and evaluate care

1. What is CMS?

Centers of Medicare and Medicaid Services

1. What is Computerized Provider Order System (CPOS)?

An application that supports direct electronic entry of patient-care-related orders by authorized practitioners and direct transmission of those orders to designated entities.

1. What is Computer Literacy?

Familiarity with the use of computers, including software tools such as word processing, spreadsheets, databases, presentation graphics and email

1. What is Confidentiality?

Tacit understanding that private information shared in a situation in which a relationship has been established for the purpose of treatment or delivery of services will remain protected

1. What is CPOE?

Computerized provider order entry

1. What is CPOS?

Computerized provider order System

1. What is CPT?

Current Procedural Terminology

1. What is Data?

Collection of numbers, characters or facts that are gathered according to some perceived need for analysis and possibly action at a later point in time

1. What is Data Analysis?

identifies patterns in data and then uses models to recommend actions

1. What is Data Cleansing/Data Scrubbing?

Use of software to improve the quality of data to ensure that it is accurate enough to use in data mining and warehousing. Removes incorrect, incomplete, duplicate, or improperly formatted items using special software

1. What is Data Governance?

Collection of policies, standards, processes and controls applied to an organizations data to ensure that it is available to appropriate persons when, where, and in the format needed while maintaining security

1. What is Data Integrity?

Ability to collect, store, and retrieve correct, complete, and current data so that the data are available to authorized users when needed.

1. What is Data Mining?

Technique that looks for hidden patters and relationships in large groups of data using software

1. What is Data Warehouse?

Provides a powerful method of managing and analyzing data

1. What is DIKW?

Data Information Knowledge Wisdom Framework

1. What is EBP?

Evidence Based Practice

1. What is eHealth Literacy?

Ability to use electronic sources to search for, find, comprehend and evaluate information and images found online and apply acquired knowledge to address or solve a health issue

1. What is EHR?

Electronic Health Record

1. What is EHRS?

Electronic Health Record System

1. What is Electronic Health Record System (EHRS)?

Database-management software enabling the many functions needed to create and maintain an EHR

1. What is Electronic Medical Record (EMR)?

Legal record created in hospitals and ambulatory settings of a single encounter or visit that is the source of data for the EHR

1. What is EMR?

Electronic Medical Record

1. What is ePHI?

Electronic Protected Health Information

1. What is Evidence Based Practice (EBP)?

Using current best evidence for patient care decisions in order to improve patient outcomes.

1. What is Fishbone Diagram?

structured visual approach to look at cause and effect

1. What is Gantt Chart?

Graphic presentation that shows a project schedule with start and finish dates of selected component tasks and the person responsible for each task; used for at-a-glance management

1. What is Go-Live?

Data when an information system is first used, or the process of starting to use an information system

1. What is Healthcare Information Systems (HIS)?

Computer hardware and software dedicated to the collection, storage, processing, retrieval and communication of patient care information in a healthcare organization

1. What is Health Information Exchange (HIE)?

Electronic sharing of relevant patient information between providers, hospitals, specialists and ambulatory settings

1. What is Health Information Technology for Economic and Clinical Health (HITECH)?

Provision of ARRA that aimed to ensure that healthcare organizations were adopting EHRSs and validating their implementation by showing MU

1. What is Health Information Technology (HIT)?

Information systems and other information technology used to record, monitor, and deliver patient care as well as perform managerial

1. What is Health Insurance Portability and Accountability Act (HIPAA)?

Enacted in 1996, created standards to protect sensitive patient health information from being disclosed without the patients consent or knowledge.

1. What is Health Literacy?

Degree to which individuals can obtain, process, and understand the basic health information and services needed to make appropriate health decisions

1. What is HI?

Healthcare Informatics

1. What is HIE?

Health Information Exchange

1. What is HIS?

Healthcare Information Systems

1. What is HIT?

Health Information Technology

1. What is HITECH?

Health Information Technology for Economics and Clinical Health Act

1. What is HL7?

Health Level 7

1. What is ICD-10?

International Classification of Diseases – 10th Revision

1. What is Informatics?

Science and art of turning data into information

1. What is information?

Collection of data that have been interpreted and examined for patterns and structure

1. What is information blocking?

interference with the access, exchange, or use of electronic health information

1. What is Information Literacy?

Ability to recognize when information is needed as well as the skills to find, evaluate and use needed information effectively

1. What is Information System?

A computer system that uses hardware and software to process data into information in order to solve a problem

1. What is International Classification of Disease – 10th Revision (ICD-10)?

an international standard diagnostic classification for health management purposes and clinical use; it is used for reimbursement and to classify mortality and morbidity data from patient records

1. What is Interoperability?

the ability of two entities, human or machine, to exchange and predictably use data or information while retaining the original meaning of that data

1. What is IP?

Internet Protocol

1. What is Knowledge?

synthesis of information derived from several sources to produce a single concept or idea

1. What is LIS?

Laboratory Information System

1. What is Logical Security?

non-tangible protocols used for identification, authentication, authorization and accountability

1. What is LOINC?

Logical Observation Identifiers Names and Codes (used for lab)

1. What is Meaningful Use (MU)?

Use of HIT legislated by the ARRA of 2009 to collect specific data with the intent to improve care and population health, engage patients, and ensure privacy and security

1. What is Metadata?

Set of data that provides information about how, when and by whom data are collected, formatted, and stored

1. What is MIPS?

Merit-Based Incentive Payment System

1. What is Mission?

purpose or reason for an organization’s existence, representing the fundamental and unique aspirations that differentiate it from others

1. What is MU?

Meaningful Use

1. What is National Health Information Network?

The Office of the National Coordinator (ONC) for HIT initiative to provide the standards, services, and policies that enable secure HIE over the internet

1. What is Network?

Combination of hardware and software that allows the communication and electronic transfer of information between computers

1. What is Patient-Generated Health Data (PGHD)?

1. What is PGHD?

Patient-Generated Health Data

1. What is Phishing?

A ruse to get consumers to divulge personal information through social engineering and technical subterfuge via the use of electronic communications

1. What is Physical Security?

protection of physical items, objects or areas from unauthorized access and misuse

1. What is PIS?

Pharmacy Information System

1. What is PLMC?

Project Management Lifestyle Cycle

1. What is Predictive Analysis?

(predictive modeling) uses past and current data to forecast the likelihood that an event will occur

1. What is Radio-frequency identification (RFID)?

wireless technology that creates detectable electromagnetic waves

1. What is RCA?

Root Cause Analysis

1. What is regression testing?

Ensures app still functions as expected after an update or change in improvement

1. What is Remote Patient Monitoring (RPM)?

personal health and medical data collected from an individual at one site via electronic communication technologies and transmitted to a provider at a different site for use in care and related support

1. What is RFID?

Radio-Frequency Identification

1. What is RIS?

Radiology Information System

1. What is Roll-Out?

Staggered/rolling system implementation; also known as preceding marketing campaign

1. What is RPM?

Remote Patient Monitoring

1. What is RxNorm?

Medical Prescription Normalized (contains all US drug names)

1. What is Scope Creep?

unexpected and uncontrolled growth of user expectations as a project progresses

1. What is SDLC?

System Development Life Cycle

1. What is SNOMED?

Systematized Nomenclature of Medicine Clinical Terms (related to HIE)

1. What is Stakeholder?

Persons with a vested interest in a project because it will impact them in some way

1. What is Standardized Terminologies?

Structured, controlled languages developed according to terminology development guidelines and approved

1. What is Store-and-Forward Technology?

Asynchronous connected health applications that can transmit recorded health information through secure communication networks to a provider

1. What is Strategic Plan?

A process that creates an entity’s vision of the future, develops broad goals for reaching that future and specifies high level steps for achieving goals

1. What is SWOT?

Strength, Weakness, Opportunities, Threats

1. What is SWOT Analysis?

A process that examines the strengths, weaknesses, opportunities and threats of a given situation

1. What is Syndromic Surveillance?

Processes that focus on near real time use of early disease indicators to detect and characterize evens that may need health investigation

1. What is System Development Life Cycle (SDLC)?

A sequence of activities in the planning, designing, testing, implementation and evaluation of an information system

1. What is TCP?

Transmission Control Protocol

1. What is Technology Informatics Guiding Education Reform (TIGER) Initiative?

2004 initiative that called together stakeholders with the goal to develop a US Nursing workforce capable of using EHR to improve the delivery of healthcare

1. What is Teleconferencing?

use of computers, audio and video equipment, and communication links to provide interaction between 2+ persons at 2+ sites

1. What is Telehealth?

provision of information to healthcare providers and consumers and the delivery of services to clients at remote sites through the use of telecommunication and computer technology

1. What is Telemedicine?

Use of telecommunication technologies and computers to provide medical information and services to clients at another site

1. What is the 21st Century Cures Act?

Enacted in 2016, advanced interoperability and patient access to EHI

1. What is the Affordable Care Act?

US legislation intended to improve healthcare quality through using information technology ensuring affordable care and increasing the number of insured persons.

1. What is the Agency of Healthcare Research and Quality (AHRQ)?

Agency within the Department of Health and Human Services devoted to improving healthcare quality and safety

1. What is the American Recovery and Reinvestment Act (ARRA)?

legislation enacted in 2009 to revitalize the nation’s economy and create jobs. Authorized incentive payments to specific types of hospitals and healthcare professionals for adopting and using interoperable HIT and EHRS

1. What is the benefit of the internet?

Improve communication and teamwork.

1. What is the Consolidated-Clinical Document Architecture (C-CDA)?

standard that provides a framework for the encoding, formatting and semantics of electronic documents

1. What is the Continuity of Care Record (CCR)?

Technical informatics standard that provides a snapshot of a person’s current health and healthcare to a provider who does not have access to that person EHR

1. What is TIGER?

Technology Informatics Guiding Education Reform

1. What is Translational Research?

an approach to research that seeks to produce meaningful, applicable results

1. What is true about improving health literacy?

Improving health literacy leads to better patient outcomes.

1. What is Usability?

Specific issues of human performance in achieving specific goals during computer interactions within a particular context

1. What is Virus?

A malicious program that can disrupt or destroy data

1. What is Vision?

Future oriented high-level view of what an organization would like to become that provides direction for planning purposes

1. What is Wisdom?

Application of knowledge to manage and solve problems

1. Where to get information from?

Medline

1. Where to look to further evaluate and manage patients with significant BP?

intake and output

1. Which barrier to healthcare informatics use does the HITECH Act aim to reduce?

Financial

1. Which clinical note type is exempt from being shared with patients according to the United States Core Data for Interoperability (USCDI) standards?

Psychotherapy notes

1. Which data in a medical record would inform the nurse that a PRN pain medication can be administered to the patient?

The medication administration record and the nursing assessment notes from the last shift indicate the patient’s level of comfort.

1. Which data set in the electronic health record (EHR) will assist in evaluating the number of positive influenza tests at a facility within the past year?

Laboratory records

1. Which entity is required by The Health Insurance Portability and Accountability Act of 1996 (HIPAA) to remove identifying information before sharing information publicly?

Billing Company

1. Which healthcare data set would allow identification of performance gaps and establishment of realistic targets for improvement?

Healthcare Effectiveness Data and Information Set (HEDIS)

1. Which informatics solution assists in ensuring tasks are accomplished?

Electronic checklists

1. Which information in an electronic medical record (EMR) helps a nurse plan and manage a patient’s post-operative care after an open-heart surgery?

Providers Orders

1. Which information in a patient’s electronic medical record (EMR), in addition to the nursing flowsheets and provider orders, helps a nurse plan and manage fluctuations in blood glucose levels?

MAR

1. Which information in a patient’s medical record will help a nurse plan and manage the patient’s pain?

Physician orders

1. Which information should a nurse consider as protected health information (PHI) while evaluating a patient’s records?

The patient’s gender and date of birth

1. Which medical device is useful in establishing an effective monitoring system for a patient with acute brain injury?

Temperature probe

1. Which patients are ideally positioned to fully engage in their care?

Patients that are recovering well after a full night of sleep.

1. Which situation places a clinical decision support system (CDSS) at risk for corrupt datasets?

A nurse updates a patient’s medical history after learning of a medical condition via social media.

1. Which two care settings would benefit the most from employing a nurse informatics?

A correctional facility with a clinic; A healthcare organization planning a physical expansion.

1. Which two practice environments employ informatics nurses?

A medical device manufacturer and clinical system vendor

1. Which view in the electronic health record (EHR) confirms a patient’s blood pressure is stabilizing?

Graphical trending

1. While reviewing electronic nursing documentation, a nurse identifies that a patient’s vital signs have declined since the previous shift. Which health information system assisted in this identification?

Electronic health record (EHR)

1. Workflow analysis:

Also known as the process analysis, involves identifying, prioritizing and ordering tasks and information needed to achieve the intended results of a clinical or business process. Workflow analysis mitigates these rights and increases the chances for success in an IT implementation.

Mutlidisciplinary Team Terminology
(SNOMED-CT) Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms- clinical terms covering nurisng, medicine, & allied health

Standardized Terminology Supports
Data Mining

PHR – Private Health Record
Lifetime health record, supplied by ind., healthcare providers, pharmacies, therapist, lab test, – Controlled by the consumer,

E-Sign
Same legal status as a hand written signature

MIPPA – Medicare Improvement for Patients & Providers Act provides
financial incentive for e-prescribing to providers

HIPPA provides
legal protection for personal health info, set standards for elect. data interchange of claims data, named specific code sets for use in Medicare related transactions, & Privacy

ARRA provides
provide funds for adoption of technology & provides the right for every individual to receive and electronic copy of EHR

HITECH provides
strengthened HIPPA security & privacy protection, & provides financial incentive for the user of EHR

EMR -electronic medical record provides
Legal record often restricted to a Single episode of care , building block of EHR,

EHR- Electronic Health Record is
Longitudinal record that includes client data, demographics, clinician notes, medications, diagnostics.

Major driver for US Adoption are “Meaningful Use” financial incentives from HITECH part of ARRA

Affordable Care Act provides
guarantee access to healthcare, encourage PCP,

Data is
collection of #, characters, or facts (body weight- 128lb), little meaning alone

Information is
Collection of data examined for patterns or structure that can be interpreted. ex notes prior BP and informs doc

Knowledge is
Synthesis of info from several sources to produce a single concept or idea, ex read a journal about BP

Computer Technology is
collection of data for analysis, which can be used to justify the efficacy of particular interventions & improve quality of care

HIS HEalthcare Information System is
Administrative System + Clinical Information System,

Clinical Systems include: order entry, radiology, pharmacy, physician management system

Adm system : non clinical, demographics, scheduling, risk mgmt, decision support,

Administrative System includes these functions
Managing nonclinical, client-related information (demographics, codes for procedures, & Insurance

Hippa – Compliant Codes inlcude
(ICD) International Classification of Disease, Common Procedural Terms, (ABC) Alternative Billing Codes,

ANA recognizes these terminologies
(CCC) Clinical Care Classification, (ICNP) International Classification of Nursing Practice, NANDA, NIC, NOC, the Omaha System, (PNDS) Perioperative Nursing Data Set

Teleconferencing is
use of computers, audio, & video equip. and high-grade dedicated telephone line, cable/sat connections to provide interactive communication between 2+ ppl at 2+ sites

Elearning provides
electronic media to present instruction, it allows users to skip information they already know

Distance Education is
the use of print, audio, video, computer, or teleconference capability to connect faculty & students; Can take place in real time or on a delayed basis

Web Based Instruction is
the attributes & resources of the internet to deliver & support education

Telehealth is
use of telecommunication technologies & computers to provide healthcare info & services to clients at another location

consumers are chronically ill, isolated, assisted living families
decrease er visits, decrease LOS, decrease Admissions, increased productivity for clinical

Telenursing is
telecommunications & computer technology for the delivery of nursing care & services to clients at other sites

Issues with telehealth & telenursing are
lack of reimbursement, infrastructure, plug-play standard, license & liability issues, & concerns r/t to client privacy & confidentiality

EBP- Evidence Based Practice is
the use of research & evidence to inform clinical practice, an approach to provide care that integrates nursing experience & intuition with valid and current clinical research to achieve the best patient outcomes

EBP provides
standardized best practices, reduce time that the nurse spends gathering & assessing data, provide care w/ clinical research

EBP contributes
increased job satisfaction, improved quality of care

how a nurse uses data

accessing information
collecting data
Inputting Data
analyzing data

quantitative research
concerned with objectivity, tight control over situations, define relationships between variables, seek correlation between data, ex. tries to discover how an intervention has impacted subjects IN DEPTH, tangible relations between variables,

qualitative research
concerned w/ finding out more about the human experience, accomplished thru interviews & over a long period of time, ex. how an intervention could impact an entire population, content analysis, computers can code responses to questionnaires which then can be inputted in the informatics sys for analysis,

types of patient information are

standard
general
targeted
personalized
tailored

Standard patient information is
describes procedures that all patients will encounter, ex temperature or weight

General patient information is
ask consumers to follow a PREVENTIVE course of treatment that applies to everyone ex yearly physical

Targeted patient information is
geared toward ppl who are a SUBSET of the general population ex men >40 prostate exam

Personalized information is
gives info about a SPECIFIC condition the consumer has been diagnosed with ex. DMII

Tailored Information is
information that focuses Specifically on Ind Based on Specific Conditions , it is typically gleaned from EHR or EMR

Telemedicine
improve pt outcomes by permitting pts to remain at home, allows pts to communicate w/ provider about blood glucose test or video conference w/ them directly to develop pt specific education opportunities, directed by doctors

TIGER means
Technology Informatics Guiding Education Reform

ARRA means
American Recovery & Reinvestment Act

HITECH
Health Information Technology for Economic & Clinical HEalth

CPOE
Computerized Physician order entry

– needs downtime procedure or policy prior to implementation

DSS
Decision Support Software

Info Life Cycle is

Needs assessment
System selection
Implementation
Maintence

Input devices
enter info into the computer such as keyboard, touchscreen, mouse, microphone

2nd storage examples
hard disk, usb, dvd

out put devices
use to see info such as computer screen, printer, projector, speakers

Software
interprets data by binary code, tells the computer what to do at a given moment,

operating system
tells how to move, share, and treat files. It also provides a user interface that enables the user to enter info, ex windows

application
to perform a certain function; designed to document pt & provider activity ex physician orders

network
connect mult computers in different locations

LAN
connect a few computers to the server, over large area ex docs place orders remotely at home

IntrAnet and extranet
IntrAnet- private networks that can not be accessed outside the organization
Extranet- network outside the company that enables customers & suppliers access to the services

System Check
help guide thru data collection process, ex. patient allergies to prevent conflict

EDI Electronic data interchange
permits mult systems to acquire & share data

Nursing Information System
standardized nursing language (SNL), 2 main approaches,

Nurisng Process Approach & Critical Pathway- mult discp. teams thru out, physicians orders are present for the multdisc team to observe & follow, allows the the multdisc. team to update the plan of care when variances in the pts condition are noted
Protocol Approach- streamline doc of assessment, med info, discharge info, education

Firewall
between hardware & software

interfacing types

point to point – enables to sys to communicate
Interface

PACS
allows digital manipulation

Store & Forward
Part of telehealth, ex xray from clinic sent to hospital

clincal codes
designate concepts to facilitate development of EBP

clinical term
enables the capture of data for patient care documentation

Clinical Decision Support System
designed to support health care providers in making decisions about the delivery & mgmt of patient care

Consultant
expert advice, opinions, & recommendations

4 concepts of nursing informatics

data
information
knowledge
wisdom

Decision Support
recommendations for interventions based on computerized care protocols. ex additional screening, medication interactions, drug dosages

Informatics Innovator
process of making enhancements or improvements, creative,

Informatics Nurse
RN w/ an interest or experiece working in an informatics field

Novice
beginner w/ no experience with the situations in which they are expected to perform a task

taught rules to guide actions

3 sciences of informatics

nursing science
information science
computer science

Clinical Decision Support System Examples
reminders, alerts, drug checking, guidelines, protocols, image recognition, allergy to drug

CPU
consist of computer chip that processes all the computers functions & uses “brain”

Data integrity
means that whenever the data are accessed by a user, the data are as complete as when entered or created

Information Mgmt
to ensure that the right info. is available to the people at the right time; information is managed properly,

Knowledge Mgmt
system that enables organizations to learn from their staff to improve performance, help accumulate & store the collective knowledge

Experienced Nurse
expected to more fully integrate informatics throughout the course of practice, not just for basic data entry & retrieval

Informatics Nurse
advance knowledge & profienciency in the use of IT as it applies to nursing practice

Internet Security Measures

Firewall- prevent unwanted access to the sys & its information
Limit web page access
Server Security- information is stored should not be able to access other systems if attacked
4, Update Security Software

Considerations for New Informatics System

Technical Specifications – How much downtime for maintenance
Response Time- time it takes the sys to process a request
Architecture-structure of the sys, open system to communicate together
Connectivity-able to interface with the sys in mult ways
Testing- tested in different place than it is being used, no sys maintenance can be done w/ little inconvience
Compatibility- w/ other systems,

Interfacing 2 Types

Point to Point- enables 2 sys to communicate, expensive, has to have completely customized program
Interface Engine -interfacing across several different sys

Smart Technology
links, syncs, & compiles disparate bits of info from different sys into a coherent one stop, real time documentation, provides reminders,

Stages of EMR adoption
0- organization has not installed all 3 key ancillary department sys (lab, pharm, & radiology)
1- all 3 key ancillary are installed
2- CDR-clinical data repository provides physician access for reviewing orders & results, Possibly HIE capable
3- Nursing/Clinical Documentation, eMAR, first level of clinical decision support is implemented
4-CPOE implemented
5- Closed loop med administration w/ Bar codes is implemented, 5 rights of medication adm

Full Physician Documentation , Full radiology PACS
7-No more paper charts,

P4P
Pay for Performance is an outgrowth of Affordable Health Care Act, reward providers when pts have good outcomes

Single Risk Pool
prevent insurers from using insurance pools with markets to get around market reforms & charge ppl w/ greater health problems higher premiums by increasing their premiums at higher rates

Catastrophic
lower premiums, protect against high out of pocket costs, and cover recommended preventative services

Needs to be integrated
ICD-9, G-Codes, ICD-10, CPT, HCSPC

Does not need to be integrated
C-3P0, RUGs

Telehealth Options

Store & Forward- items are transferred to experts who read and interpret information and send back results
Real Time- interactive conferencing

Nursing Informatics Definition
integration of nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom into nursing practice

Computer Literacy vs Information Literacy
Computer Lit- a familiarity with the use of personal computers
Information Lit- Ability to recognize when information is needed as as the skills to find, evaluate, and use information

Computer System consist of
hardware, software, data, procedures, and users

Computer Hardware consist of
input device, the CPU, secondary storage, and output device

Network
a combination of hardware and software that allows communication and electronic transfer of information between computers

Example of Operating System
Windows Xp

Example of application System
Microsoft Word

Bit
Smallest unit of data

WWW
an information service that provides access to Internet resources by content instead of file name

Services of the internet include
file transfer, email, instant messaging

Web 2.0
online tool that permits collaboration and sharing online, such as facebook, twitter;
Provides education- wikis, web logs, virtual worlds, facebook

HIS
group of systems used within a hospital that support and enhance client care

CIS-
used to access client data that are used to plan, implement, and evaluate care

EMR
electronic version of the client data found in the traditional medical record

Basic Components of the EMR
clinical messaging & email, data repository, and clinical documentation

EHR information includes
past medical history, demographics, immunizations, and medication history

Bar Code Arm Bands provide
patient health record, medications

Registration System
HIS is used to collect and store client identification and demographics data that are verified and updated at the time of each visit

– needs downtime procedure or policy prior to implementation

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