- 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. - Which information in a patient’s medical record will help a nurse plan and manage the patient’s pain?
Physician orders - 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. - 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. - 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 - Which view in the electronic health record (EHR) confirms a patient’s blood pressure is stabilizing?
Graphical trending - 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 - 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 - Which patients are ideally positioned to fully engage in their care?
Patients that are recovering well after a full night of sleep. - 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 - What is true about improving health literacy?
Improving health literacy leads to better patient outcomes. - 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. - 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. - What does the informatics nurse recommend to increase attendance to follow-up appointments?
Automated text or email reminders - 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. - 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. - 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 - Which barrier to healthcare informatics use does the HITECH Act aim to reduce?
Financial - 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. - 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) - 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) - What is a patient safety benefit of a pharmacy information system (PIS)?
Alerts regarding allergies and interactions - Standardized terminology was implemented to promote interoperability across electronic health records (EHRs). Which terminology is specific to laboratory tests, orders, and results?
LOINC - 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. - What are patient portals?
Patient portals are facility-owned and associated with an electronic health record. - 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. - 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. - 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) - 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. - 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. - 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. - 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. - 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 - Which medical device is useful in establishing an effective monitoring system for a patient with acute brain injury?
Temperature probe - 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. - 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. - Which healthcare data set would allow identification of performance gaps and establishment of realistic targets for improvement?
Healthcare Effectiveness Data and Information Set (HEDIS) - 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. - 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) - 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. - 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. - 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 - How does an informatics nurse apply expertise in workflow and technology?
By analyzing the impact of new technologies - 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. - 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 - 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) - 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 - 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 - 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. - 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. - 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. - 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. - 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. - 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. - 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 - 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. - 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. - 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. - 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. - 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 - 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 - 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 - 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. - Which two practice environments employ informatics nurses?
A medical device manufacturer and clinical system vendor - 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 - 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 - 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. - Which clinical note type is exempt from being shared with patients according to the United States Core Data for Interoperability (USCDI) standards?
Psychotherapy notes - 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 - An ER doctor needs patients’ data from a different state. Does the doctor need patient permission to get it?
No - Two nurses are in the cafeteria talking about lab reports and they commit HIPAA violations. What is the action?
$100-50,000 Fines - Medication alert pop ups and what system is alerting?
Clinical Decision Support (CDS) System - 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. - The hospital announced its integration engine has stopped functioning. What does this mean for system interoperability throughout the organization?
Manually chart the VS - What is a barrier and benefit to using biometrics?
Barrier – Financial; Benefit – Security - During which phase of the systems development life cycle should a system be activated to effectively be used by end users
Implementation - RN needs to override a medication, which one would she NOT override?
Comfort Care patient with 2 new orders - Nurse sends message to doctor, “Mr. Smith, BP 84/74. 54”
Not enough information for the doctor to prescribe treatment. - 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. - 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. - Which informatics solution assists in ensuring tasks are accomplished?
Electronic checklists - To monitor a patient’s blood glucose level, you will need:
A nurse flow sheet - 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. - Treatment of patient related to BP measures or fluctuation blood glucose levels:
Medication administration and MAR - 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. - To create an informatics culture, you should:
Assess current state to determine gaps. - 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 - 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 - 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. - 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) - 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 - High priority task for informatics clinician when implementing a new technology for data collection is:
Identify and define goal of technology. - What is regression testing?
Ensures app still functions as expected after an update or change in improvement - Nurse finds 100 errors in coding:
AHIMA and report to nurse manager - Constipation treatment:
Physician orders (plan and manage) for PRN medications. - Where to look to further evaluate and manage patients with significant BP?
intake and output - What is the benefit of the internet?
Improve communication and teamwork. - A nurse is asked to be part of a study. What should the nurse do?
Provide de-identified data. - In order to institute isolation precautions, you will need:
Pathology report to confirm the pathogen. - A researcher wants patient’s data for a journal, what do you need to provide?
Patient consent and de-identified information/data - Identifiable Patient information is also called:
Personal data, personal information and IPI - Busy ER, what can a nurse do to help?
Nurse can start the admission process. - Staff is resistant to tele-ICU (implementing new process). What are the benefits?
Improve workflow, Resources and expertise. - Benefit of MD using CPOE and DSS?
Alerts when ordering Viagra when patient is taking a cardiac medication. - 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) - 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. - Ethical/legal issue with rural hospital and tele-radiology:
State licensing issue - Clinical data enters the date warehouse in a de-identified state.
Ensures data is clean and accurate. - Doctors use RFID (radio frequency identification) for which purpose?
Improve documentation time and Improve access to documentation. - Benefit of mHealth
Integrates with EHR - What is Analysis?
New technology going to roll out and staff is deciding what can make it better. - Where to get information from?
Medline - What is Administrative Information System (AIS)?
Systems that support patient care by managing financial and demographic information and providing reporting capabilities. - 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. - 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 - 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. - 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 - What is analytics?
Discovery, interpretation and communication of meaningful patterns from data to offer solutions and drive decisions - What is Artificial Intelligence (AI)?
Use of algorithms and other technologies to mimic human cognition and predict outcomes. - 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 - What is authentication?
Action that verifies the authority of users to receive specified - What is Benchmarking?
indicators against which a process is measured - What is Big Data?
Very large data sets that are beyond human capability to analyze or manage without the aid of information technology. - What is Biometrics?
A unique measurable characteristic of trait of a human being for automatically recognizing or verifying identity - What is Clinical Decision Support System (CDSS)?
supports healthcare practitioners in making patient care decisions by integrating patient data with current clinical knowledge - 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 - What is Computer Literacy?
Familiarity with the use of computers, including software tools such as word processing, spreadsheets, databases, presentation graphics and email - 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. - 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 - What is the Consolidated-Clinical Document Architecture (C-CDA)?
standard that provides a framework for the encoding, formatting and semantics of electronic documents - 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 - What is the 21st Century Cures Act?
Enacted in 2016, advanced interoperability and patient access to EHI - 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 - What is Data Analysis?
identifies patterns in data and then uses models to recommend actions - 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 - 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 - 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. - What is Data Mining?
Technique that looks for hidden patters and relationships in large groups of data using software - What is Data Warehouse?
Provides a powerful method of managing and analyzing data - What is a Database?
File structure that supports the storage of data in an organized fashion and allows data retrieval as meaningful information - 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 - What is Electronic Health Record System (EHRS)?
Database-management software enabling the many functions needed to create and maintain an EHR - 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 - What is Evidence Based Practice (EBP)?
Using current best evidence for patient care decisions in order to improve patient outcomes. - What is Fishbone Diagram?
structured visual approach to look at cause and effect - 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 - What is Go-Live?
Data when an information system is first used, or the process of starting to use an information system - What is Health Information Exchange (HIE)?
Electronic sharing of relevant patient information between providers, hospitals, specialists and ambulatory settings - 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 - 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 - 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. - 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 - 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 - What is Informatics?
Science and art of turning data into information - What is information?
Collection of data that have been interpreted and examined for patterns and structure - What is information blocking?
interference with the access, exchange, or use of electronic health information - What is Information Literacy?
Ability to recognize when information is needed as well as the skills to find, evaluate and use needed information effectively - What is Information System?
A computer system that uses hardware and software to process data into information in order to solve a problem - 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 - 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 - What is Knowledge?
synthesis of information derived from several sources to produce a single concept or idea - What is Logical Security?
non-tangible protocols used for identification, authentication, authorization and accountability - 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 - What is Metadata?
Set of data that provides information about how, when and by whom data are collected, formatted, and stored - What is Mission?
purpose or reason for an organization’s existence, representing the fundamental and unique aspirations that differentiate it from others - 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 - What is Network?
Combination of hardware and software that allows the communication and electronic transfer of information between computers - What is Patient-Generated Health Data (PGHD)?
health related data created, recorded, or gathered by patients (or family members/caregivers) to help address a health concern - What is Phishing?
A ruse to get consumers to divulge personal information through social engineering and technical subterfuge via the use of electronic communications - What is Physical Security?
protection of physical items, objects or areas from unauthorized access and misuse - What is Predictive Analysis?
(predictive modeling) uses past and current data to forecast the likelihood that an event will occur - 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 - What is Radio-frequency identification (RFID)?
wireless technology that creates detectable electromagnetic waves - What is Roll-Out?
Staggered/rolling system implementation; also known as preceding marketing campaign - What is Scope Creep?
unexpected and uncontrolled growth of user expectations as a project progresses - What is Stakeholder?
Persons with a vested interest in a project because it will impact them in some way - What is Standardized Terminologies?
Structured, controlled languages developed according to terminology development guidelines and approved - What is Store-and-Forward Technology?
Asynchronous connected health applications that can transmit recorded health information through secure communication networks to a provider - 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 - 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 - What is System Development Life Cycle (SDLC)?
A sequence of activities in the planning, designing, testing, implementation and evaluation of an information system - What is SWOT Analysis?
A process that examines the strengths, weaknesses, opportunities and threats of a given situation - What is Teleconferencing?
use of computers, audio and video equipment, and communication links to provide interaction between 2+ persons at 2+ sites - 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 - What is Telemedicine?
Use of telecommunication technologies and computers to provide medical information and services to clients at another site - 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 - What is Translational Research?
an approach to research that seeks to produce meaningful, applicable results - What is Usability?
Specific issues of human performance in achieving specific goals during computer interactions within a particular context - What is Vision?
Future oriented high-level view of what an organization would like to become that provides direction for planning purposes - What is Virus?
A malicious program that can disrupt or destroy data - What is Wisdom?
Application of knowledge to manage and solve problems - What is AI?
Artificial Intelligence - What is AIS?
Administrative Information System - What is AHRQ?
Agency of Healthcare Research and Quality - What is ARRA?
American Recover and Reinvestment Act of 2009 - What is AHIMA?
American Health Information Management Association - What is BCMA?
Barcode Medication Administration - What is CAC?
Computer Assisted Coding - What is CCD?
Continuity of Care Documentation - What is C-CDA?
Consolidated-Clinical Document Architecture - What is CCR?
Continuity of Care Record - What is SWOT?
Strength, Weakness, Opportunities, Threats - What is CDSS?
Clinician Decision Support System - What is CIS?
Clinical Information System - What is CMS?
Centers of Medicare and Medicaid Services - What is CPOE?
Computerized provider order entry - What is TCP?
Transmission Control Protocol - What is TIGER?
Technology Informatics Guiding Education Reform - What is RPM?
Remote Patient Monitoring - What is RxNorm?
Medical Prescription Normalized (contains all US drug names) - What is CPOS?
Computerized provider order System - What is SDLC?
System Development Life Cycle - What is CPT?
Current Procedural Terminology - What is DIKW?
Data Information Knowledge Wisdom Framework - What is EBP?
Evidence Based Practice - What is EHR?
Electronic Health Record - What is SNOMED?
Systematized Nomenclature of Medicine Clinical Terms (related to HIE) - What is PLMC?
Project Management Lifestyle Cycle - What is RCA?
Root Cause Analysis - What is RFID?
Radio-Frequency Identification - What is EHRS?
Electronic Health Record System - What is RIS?
Radiology Information System - What is EMR?
Electronic Medical Record - What is ePHI?
Electronic Protected Health Information - What is HI?
Healthcare Informatics - What is HIE?
Health Information Exchange - What is MU?
Meaningful Use - What is PIS?
Pharmacy Information System - What is PGHD?
Patient-Generated Health Data - What is IP?
Internet Protocol - What is HIS?
Healthcare Information Systems - What is HIT?
Health Information Technology - What is HITECH?
Health Information Technology for Economics and Clinical Health Act - What is HL7?
Health Level 7 - What is ICD-10?
International Classification of Diseases – 10th Revision - What is LIS?
Laboratory Information System - What is LOINC?
Logical Observation Identifiers Names and Codes (used for lab) - What is MIPS?
Merit-Based Incentive Payment System
American Recovery and Reinvestment Act (ARRA)
**Authorized INCENTIVE PAYMENTS to specific types of hospitals & healthcare professionals for adopting & using interoperable Health Information Technology and EHR’s.
The purposes of this act include the following: (1) To preserve/create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases.
AHQR (Agency for Healthcare Research and Quality)
Produced evidence making healthcare safer, improve quality, accessibility and affordability
Asynchoronous Applications
No contact with patient for data collection. EX: Remote pt monitoring, Using health technologies to share health metrics and data w/ providers. STORE & FORWARD APPS (ex: photos)
Administrative Information System
can include registration and scheduling; tracking through admission, transfer and discharge; patient acuity and staff scheduling; financial or accounting systems; risk management; payroll and human resources; quality assurance; and contract management functions.
Affordable Care Act
law passed in 2010 to expand access to insurance, address cost reduction and affordability, improve the quality of healthcare, and introduce the Patient’s Bill of Rights, increasing the number of insured persons.
Alarm Fatique
Becoming desensitized to patient care alarms and missing or delaying their response to the alarm.
ANA (American Nurses Association)
Professional organization for all RNs. Concerned with licensure, collective bargaining and education
Analytics
A term describing the extensive use of data, statistical and quantitative analysis, explanatory and predictive models, and fact-based management to drive decisions and actions.
Audit trail
a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed
Authentication
A method for confirming users’ identities
Authorization
The process of giving someone permission to do or have something
Barcode Scanning Technology
Scans drug and patients wristband to verify medication order, inventory control, + pt identification, correct med admin
Big Data
a collection of large, complex data sets, including structured and unstructured data, which cannot be analyzed without the use of information technology
Bioinformatics
application of mathematics and computer science to store, retrieve, and analyze biological data
Biometrics
the identification of a user based on a physical characteristic, such as a fingerprint, iris, face, voice, or handwriting
Business Continuity Plan
A plan for how an organization will recover and restore partially or completely interrupted critical function(s) within a predetermined time after a disaster or extended disruption
Business Intelligence
Information collected from multiple sources such as suppliers, customers, competitors, partners, and industries that analyzes patterns, trends, and relationships for strategic decision making
Change Control Board (CCB)
A committee that evaluates the worthiness of a proposed change and either approves or rejects the proposed change.
Chief Nursing Officer (CNO)
The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services
Clinical Care Classification (CCC)
“Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings”
CPOE (Computerized Physician Order Entry)
An order entry and decision support system that allows direct entry of orders and immediately shared w/ others
Change Management
The process, tools and techniques that help people implement changes to achieve a desired outcome. (Supports the adoption of a medication Administration System)
Change Control
Helps to prioritize limited resources and ensures system standards are upheld.
Connected health
a model of health care delivery using technology to provide services including information and education.
Technology assisted healthcare is delivered between at least 2 points involving either asynchronous or synchronous exchange.
Consumer Health Informatics
Use of electronic info & communication to improve medical outcomes & healthcare decision making from pt perspective.
Patient view and structures and process that enable consumer to manage their own care.
Clinical Research Informatics
Discovery and management of new knowledge pertinent to health and disease from clinical trials via secondary data use.
C-CDA (Consolidated Clinical Document Architecture)
Allows interoperability of health information exchange between to hospitals.
21st Century Cures Act
designed to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently.
Provisions that will improve workflow & exchange of electronic info. ONC (responsible for implementing) seamless & secure access, exchange and use of electronic health info.
5 rights of clinical decision support
Right information
Right person
Right intervention format
Right channel
Right time in workflow
Clinical Informatics
concentration on the delivery of timely, safe, effective , EB and pt centered care.
C
Clinical Decision Support System
A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions
Ex: Alerts for abnormal VS, labs results, med contraindications, screenings, standing orders, reminders in EHR ect…
Clinical Information Systems
Ex: May be specific to certain departments. Lab, radiology, pharm(Both), or particular pt population.
Functions may include order entry, results reporting, scheduling and documentation.
Lg computerized database used to access the pt data that are needed to plan, implement and evaluate care.
Clinical Nurse Specialist
Expert clinician in a specialized area of practice who engages in research and helps direct practice change.
clinical terminology
standardized terms and their synonyms used to record pt data with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement, flow sheets, vital signs, assessments and nursing notes.
Computer Literacy
The ability to use computers for basic tasks, such as developing documents, sending emails and searching the internet for information.
Confidentiality
Relationship has been established where private info shared but NOT disclosed w/out permission
configurability
Refers to the extent that a given software product can be adapted or changed to meet a user’s preference
Contextual Inquiry
involves studying customers’ use of a product at their place of work
Focusing on users point of view.
CCR (Continuity of Care Record)
Snapshot/standardized summary of the most relevant and timely health information about pt and shared to a physician who does not have access to pts EHR.
Continuous Quality Improvement (CQI)
Continuous monitoring of performance and supports audit capability also known as QUALITY ASSURANCE SYSTEM
Critical Care Information System
Integrates captured physiological data w/ practitioner documentation and clinical data management functions, as well as access and communication w/ remote experts.
Data
Facts, figures, and other evidence gathered through observations.
Database
A collection of data organized in a manner that allows access, retrieval, and use of that data
Data cleansing/scrubbing
A process that weeds out and fixes or discards inconsistent, incorrect, or incomplete information
Data Governance
refers to the overall management of the availability, usability, integrity, and security of company data
Data Integrity
The correctness of data after processing, storage or transmission.
Ability to store, retrieve, correct and complete data are available to authorized users
Data Mining
the application of statistical techniques to find patterns and relationships among data for classification and prediction using software.
Data Analysis
processing of data that identifies trends and patterns of relationships
Data Warehousing
Powerful method of managing and analyzing data
DICOM (Digital Imaging and Communications in Medicine)
Transmits digital imaging
(DICOM & HL7 support standardization in health care data
DIKW theory
Data, Information, Knowledge, Wisdom
(data is most discrete)
Data=pt monitoring, labs, diagnostic systems (CT scans)
Information=Clinical Info systems, & DSS (alerts/reminders)
Knowledge=Lg databases (med articles) & Artificial Intelligence
Data Modeling
the process of determining the users’ information needs and identifying relationships among the data to support processes for an info system (key step in design of EHR)
DSS (decision support system)
an interactive, flexible, computerized information system that enables managers to obtain and manipulate information as they are making decisions r/t patient care
device integration
Capturing data from patient monitors and anesthesia machines, and filing them directly to a patient’s chart in EHR. Ex: entering VS, cardiac monitor download data into EHR
Disease Registries
collections of secondary data related to patients with a specific diagnosis, condition, or procedure.
disruptive innovation
a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors
Dissemination
the act of spreading widely or scattering data including research knowledge.
Doctorate of nursing practice (DNP)
degree w/ emphasis on EBP, quality improvement and system leadership
EHR system
3 elements: Data, Info, Knowledge.
Decrease med errors, increase provider documentation.
Function ex: Bar Code Admin.
EMR (electronic medical record)
a record of one episode of care, source data for EHR, Brings together diagnositc & Tx info in a specific healthcare setting.
Ergonomics
The study of workplace equipment design or how to arrange and design devices, machines, or workspace so that people and things interact safely and most efficiently.
EHR
Pt data stored in electronic form(collection of pt healthcare data) **Successful if pt needs met
PHR (personal health record)
Lifelong tool for managing health info, controlled by pt – data can be provided by MD or pharmacy.
(conditions, allergies, meds, surgeries)
Barriers: Poor or no internet, poorly designed apps, limited clinical integration
Predictors: Awareness of PHR’s, ease of access, personal motivation, increased levels of education and health literacy.
emerging trends
- Secondary data
- Technology-based data management
- Digital information acquisition and retrieval
- International client base
- Information management
(patient safety & error reduction)
EBP (evidence based practice)
Using current best evidence for pt care decision in order to improve pt outcomes (found in standing orders) Ex: sepsis protocols & CDS
Expert Systems
Type of CDS/DDS but does NOT need human intervention (artificial intelligence) Ex: Personal Insulin Pump
EMRAM (Electronic Medical Record Analytical Model)
Measures clinical outcomes, pt engagement & clinical use of EMR technology to strengthen organizational performance & health outcomes across pt populations “Basically, evaluates Health Information System”
feature creep
occurs when developers add extra features that were not part of the initial requirements
Finacial system
uses pt demographic data and insurance info to charge for services & reimbursment
Functional Testing
Final process in Project Management Phase 2 (planning) that ensures the innovation works as designed.
Fish boning
Cause/effect diagram, can help in brainstorming to identify possible causes of a prob.
Firewalls
hardware, software, or both designed to prevent unauthorized persons from accessing electronic information, while allowing authorized communication.
Gantt Chart
A time and activity bar chart that is used for planning, managing, and controlling major programs that have a distinct beginning and end.(used for a glance at management)
Gap Analysis
a type of analysis that compares the differences between the consumer’s expectations about and experiences with a service based on dimensions of service quality (Planning)
Go Live
the official time and date that the facility begins using the new system (Implementation Phase)
HIE (Health Information Exchange)
Electronic sharing of pt info (demographic data, allergies, diagnostic tests, and other revelant data between providers, specialists, hospitals, and insurance companies.
HIS Health Information System
Broad term used to describe administrative and clinical systems to streamline work flow processes efficiency.
Hardware/software dedicated to the collection, storage, processing, retrieval and communication of patient care info.
healthcare terminology standards
designed to enable and support widespread interoperability among healthcare software applications for the purpose of sharing information
HIPAA (Health Insurance Portability and Accountability Act)
Kennedy Kassebaum Bill, Federal legislation to protect client records & mandate that all electronic transactions included only HIPAA compliant codes.
Sets nation standards of PHI, legal protection of PHI.
(signing in devices requires encryption)
HIT – Health Information Technology
Technology that is used to record, store, and manage patient healthcare information.
Ex: CDS, CPOE, EMR, EHR, PHR, Telehealth, E-scribe
National & Global implications
Health literacy definition
a person’s capacity to learn about and understand basic health information and services, and to use these resources to promote one’s health and wellness
HIS (Hospital Information System)
What is the name of the computer system that tracks admission and discharge information, diagnostic and treatment services, pharmaceutical and equipment information, and billing information?
Advantages: Better communication, decreased errors & better access to info.
HITECH (Health Information Technology for Economic and Clinical Health Act)
2009 ARRA includes HITECH – promote adoption and meaningful use to HIT.
Goal: Improve quality care, Pt safety, Decrease costs by using meaningful use
Improves Population Health Outcome
HL7 (Health Level 7)
Acronym used to refer a standard of interoperability and exchange of clinical data
(HL7 & DICOM-Standardization)
HIMSS
Healthcare Information & Management Systems Society
formal group of healthcare organizations that seek to improve delivery of healthcare by advancing technology & data management.
*work almost exclusively w/ data
*They protect & handle pt data of all kinds (diagnosis, symptoms, test results, med hx, procedures)
*They ensure info is accurate, accessible, secure and of high quality
*Cause-based, Nonprofit, Global organization focused on better health through info & tech.
Health Informatics Management
focus on info technology needed to store and retrieve pt data accurately, securely and management of the people & processes.
HIE forms
Direct – send/recieve secure info electronically between providers ex: immunization data, quality measures sent to Medicaide/Medicare
Query – find & request info, often used for unplanned care (ER, pregnancy)
Consumer mediated – pts to aggregate and control the use of health info among providers (correcting info, tracking their health, providing providers w/ info)
Informatics
the science and art of turning data into information
*Interdisciplinary field
Data to info, Info to knowledge, Knowledge to wisdom
Implementation Science
study how interventions, which have been shown to be effective in one setting, can be applied to sustain improvements to population health
Information Epidemiology
science of distribution of information in an electronic format w/ te ultimate aim to inform public health and public policy
Informatics Competencies
the ability to perform the tasks associated w/ informatics
information
A continuum of progressively developing and clustered data.
Collection of data that has been interpreted & examined for patterns and structures
information literacy
the ability to figure out the type of information you need, find that information, evaluate it, and properly use it
- Ability to read and understand works/numbers and ability to recognize when info is needed.
Information System
a set of hardware, software, data, people, and procedures that work together to produce information
“Data Collection”
Information Technology (IT)
Transmit Data
Ex: EHR, CDST (clinical decision support tool)
information science
Primarily focused on input processing output and feedback through technology intergration
5 rights of Informatics
Right –
Information
Person
Intervention
Channel
Time in workflow
Informatics Innovator
Conducts information and RESEARCH & generate THEORY & have advanced understanding in info management & computer technology
ICD-10
Used to classify mortality and morbidity data from inpatient/outpatient records, used for reimbursement
Integration
Process of two systems exchanging data in a way that is seamless to end user.
Interoperability
Ability of 2 entities, human/machine to exchange & predictably use data/info while retaining original meaning of data
Ex: Dr-Dr, Hosp-Hosp(C-CDA), escript-pharm
Interface
Bridge/connector to send info from 2 different systems
interoperable systems
Expected outcomes=error reduction, improved revenue, increased communication.
Systems share limited processes and data
Information Security
Security Rule – Nation set of security standards health info in electronic form
GOAL: Protect privacy while adopting new technologies to improve quality & efficiency of pt care
“Need to KNow basis”
The Joint Comission Standards
Standard
The hospital respects the patient’s right to receive information in a manner he or she understands.
Elements of Performance
The hospital provides language interpreting and translation services
Note: Language interpreting options may include hospital employed language interpreters, contract interpreting services, or trained bilingual staff, and may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population.
–do not have family or children translate!
-don’t have to have one there the whole time – but having one there for discharge would be very important
Joint Commision
ACCREDIATATION
key standard of information management: Protect & aggregate data, uniform language, teach info management (training), disaster and preparedness
knowledge
Skills, experience, and expertise coupled with information and intelligence that creates a person’s intellectual resources
Knowledge Database
A database that not only manages raw data but also integrates them with information from various reference works
knowledge translation
applying research to practice
Knowledge Management (KM)
structed process for the generation, storage, distribution and application of both tacit(personal) knowledge and explicit (evidence) knowledge
knowledge workers
Generate knowledge as product
Knowledge work
gathering data which is then used to create info and knowledge
Kotter’s 8 steps for leading organizational change
- establish a sense of urgency
- create the guiding coalition
- develop a vision and strategy
- communicate the change vision
- empower the broad-based action
- generate short-term wins
- consolidate gains and produce more change
- anchor new approaches in the culture
Lewin’s Change Model
- Unfreezing
- Changing
- Refreezing
Leading others through planned change
malicious software (malware)
Software that is designed to infiltrate or affect a computer system without the owner’s informed consent. The term “malware” is usually associated with viruses, worms, Trojan horses, spyware, rootkits, and dishonest adware.
Meaningful Use (MU)
Part of the requirements of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is meant to increase the use of an electronic health record through monetary incentives provided the HER is used in a meaningful way to improve patient care. At the time of publication, the Meaningful Use regulations are undergoing revision.
Meaningful use requirements
Requirements established by the Centers for Medicare and Medicaid Services (CMS) as part of the Electronic Health Records (EHR) Incentives Program. The program provides financial incentives for healthcare organizations that “meaningfully used” their certified EHR technology. The requirements include implementing security measures to ensure the privacy of patients’ EHRs.
Meaningful Use Stages
Stage 1: Data capture and sharing
(between hosp/providers)
Stage 2:Advance clinical processes
(standardized lang/terminology, Requires patients to view, download, or transmit their health info online. Capability for secure messaging between providers/pts)
Stage 3:Improved outcomes
Focused of the enhanced use of EHR’s to promote HIE & improve care. Ex: electronic Rx
(clinical Quality Measures)
MU defined by ARRA
a certified EHR used in a meaningful way to use HIT to collect specific data w/ the intent to IMPROVE CARE & POPULATIONS HEALTH, ENGAGE PTS & ENSURE PRIVACY/SECURITY.
*Inpatient/Outpatient.
Mission Planning
purpose of an organizations existence, representing the fundamental and unique aspirations that differ it from others.
LONG RANGE PLAN (not short term)
MIPS (Merit-Based Incentive Payment System)
Program that combines other physician quality reporting system (PRRS) & Medicare EHRs based on QUALITY, resource use, clinical practice environment & meaningful use of EHR tech.
“Quality”
Meaningful use requirements by CMS
*Basic entry of clinical information/REQUIRES STANDARDIZED TERMINOLOGY (ALLOWS FOR UNIFORMITY & EASIER RETRIEVAL OF NURSING RELATED DATA)
*Use of several software apps
*Entry of clinical orders w/ safety measures
M-Health (mobile health)
the use of wireless communication devices to support public health and clinical practice
medical informatics
Application of informatics to all of the healthcare disciplines as well as to the practice of medicine
LOINC (Logical Observation Identifiers Names and Codes)
Standard for identifying laboratory and clinical observation for exchange (LAB)
NANDA
North American Nursing Diagnosis Association, purpose is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses.
- Standardized data language for nursing diagnosis
Nursing Interventions Classification (NIC)
A listing of research-based nursing intervention labels that provides standardization of expected nursing interventions.
National Library of Medicine (NLM)
Helps to provide validity of health information
MACRA
Medicare Access and CHIP Reauthorization Act
GOAL: drive healthcare reform towards providing improved reimbursement for care based on volume and quality rather than quantity.
Omaha System
A research-based taxonomy designed to generate data following routine client care.
Used in homecare, hospice, public health, school health and prisons.
Ontology
system that organizes concepts by meaning, describing their definitional structure as well as organizing the concept for storage and retrieval of accurate data
Patient Protection and Affordable Care Act (PPACA)
2010 federal legislation designed for comprehensive health reform, with an intent to expand coverage, control health care costs, and improve the health care delivery system
*Guarantee’s access to healthcare for ALL Americans & incentives to change clinical practice to encourage better coordination & quality care. Insures can’t charge for preexisting conditions or demographic status (Except age)
personal health record (PHR)
An electronic record of health-related information about an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources but that is managed, shared, and controlled by the individual.
Pharmacy information system (PIS)
A key tool in providing optimal patient care and assisting providers in ordering, allocating, and administering medication, with a focus on patient safety issues, especially medication errors
Predictive Analytics
Uses past and current data to forecast the likelihood that an event will occur.
Privacy
the right of people not to reveal information about themselves
Project Management Life Cycle (PMLC) stages
“Initiating/Design, Planning, Executing/Implementing, Monitoring and Controlling, Evaluation and Lessons learned with knowledge transfer”
PMLC
(1) Design/Plan: Scope document: Official document that details how the project will be managed & what the project requirements are.
Scope Creep- Unapproved change, which can cause serious delays or even project failure.
As the scope & charter are developed, a GAP analysis is completed. Used to identify needed changes in workflow.
GAP Analysis: A list of features & functions desired, but not immediately available in the new system as identified.
(2) Implementation: Training the staff/ end-users in this phase. With change, different behaviors can develop. For example, Resignation, resistance, feelings of loss, etc.
Lewin’s Change Theory- One of several foundational theories for leading other through planned change. Identifies 3 Steps: Unfreezing, Changing, Refreezing. INVOLVE EMPLOYEES IN THE DECISION-MAKING PROCESS!!
Kotter’s Change Management
Big Bang Conversion: “All-at-Once” implementation
Rollout: Gradual/ staggered implementation
Pilot: Small groups of individuals to evaluate potential issues
Parallel Conversion: Operates both the old and new systems for a limited time.
(3) Monitor & Control
(4) Evaluation
(5) Lessons learned with knowledge transfer
Project Implementation Team/Committee
The First Task of this Committee is to Develop a Timeline!!
· Compromised of representatives from the user departments. The project team needs to be actively involved as an end-user. The implementation Committee determines the project implementation strategy. Interdisciplinary will plan, test, train, etc. after the EHR is purchased.
Project Scope
describes the business need (the problem the project will solve) and the justification, requirements, and current boundaries for the project
*Defines the size and details of a collaborative effort.
Public Health Informatics
application of information and computer science and technology to public health practice, research, and learning
Project Planning
The SECOND phase of the project management process that focuses on defining clear, discrete activities and the work needed to complete each activity within a single project.
Phishing
Deceptive method to steal sensitive info via internet.
(1st email, 2nd open email, 3rd Hackers have info
Physical Security
The protection of physical items, objects, or areas from unauthorized access and misuse.
patient data
personal information about a patient, as well as information about the patient’s medical insurance coverage.
Name, age, wt, VS
PGHD (Patient-generated health data)
Health related data created, recorded, or gathered by the pt/cg to help address health concerns.
Logical Security
uses technology to limit access to only authorized individuals to the organization’s systems and information, such as password controls
Quantitative Research
Focus on #’s and frequencies
GOAL: Finding relationships or variables specific to outcome
Qualitative Research
Variable (not focused on counting)
Questionnaire’s, survey’s, interviews, lists “Data Capturing”
Ex: personal digital assistants/laptops
QSEN (Quality and Safety Education for Nurses)
focus on competency needed to continuously improve quality of care in their work environment
Patient centered
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics-Electronic charts
Quality indicators 4 Types:
- Prevention
- Inpatient
- Patient Safety
- Pediatric
Real time analytics
the provision of analyzed data relatively instantly to support decision making. IBM’s Watson is the best example we have today
RMS Risk Management System
identifies and documents potential risks and develops strategies to deal w/ them
Shared electronic health record
a type of EHR supported by an EHR system that allows clinicians to access an individual patients EHR data located in different facilities
Scope Creep
The uncontrolled expansion to product or project scope without adjustments to time, cost, and resources.
SNOWMED CT
systematized nomenclature of medicine clinical terms
enables consistent way of capturing sharing aggregating health data across specialties site of care
teminology for anatomy dx med problems nursing
- Provides common language for EHR.
Standardized Terminologies
Structured, controlled languages developed according to terminology development guidelines and approved by an authoritative body.
Strategic Planning
the process of determining the major goals of the organization and the policies and strategies for obtaining and using resources to achieve those goals
NOT SHORT TERM GOALS
System Development Life Cycle (SDLC) Stages
(1) Design
(2) Plan (Where S.W.O.T. Analysis is done)
(3) Implement
(4) Analyze (Look at technical requirements)
(5) Evaluate
SDLC (Systems Development Life Cycle)
(1) Needs Assessment: Determine the needs & wants in an Information System
(2) Selection System Phase: An organization seeks out a vendor company that provides a system that best fits the needs.
· 3 Documents are used:
- Request for Information Document: Initial contact with a vendor. Get essential information about the company’s history.
- Request for Proposal Document: Organization priorities or rates their needs & wants. Send an outline to vendors & see if request can be met.
- Request for Quote Document: Pricing, finance, and contract terms.
(3) System Implementation Phase: Go live PLANNING. Train staff, including end-users. Analysts start building screens and templates according to the organization and its policies, then apply any changes and go live.
(4) Maintenance Phase: Problem solving, any debugging, files are backed up & updates (security protections) are installed routinely, to ensure the program is working as intended.
S.W.O.T. Analysis: Done in the PLANNING phase of the Information System Life Cycle. It’s a type of strategic planning. Helps identify gaps in the current system, as well as potential opportunities if a new or updated system is implemented. S.W.O.T. is a process that examines the strengths, weakness, opportunities, and threats of a given situation.
Steps in SDLC
- Needs – Needs/wants in system
- System selection phase:
-Request Info Doc
- Request Proposal Doc
- Request Quote Doc
- System Implementation Phase – GO Live, train
staff/end users - Maintanence Pharse: Prob solving, debuggin, file back up, security
SWOT analysis
identifying internal strengths (S) and weaknesses (W) and also examining external opportunities (O) and threats (T)
(Planning Phase)
Telenursing
use of telecommunications and information technology to provide nursing practice at a distance
Telehealth
the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, health-related education, public health, and health administration
*Does not always involve clinical services
Telemedicine
Involves the use of video, audio, and computer systems to provide medical and/or health care services.
Translational Bioinformatics
Ex: DDS/Decision Support System
Relatively new term that supports the National Institute for Health road map for medical research
Ability to translate voluminous biomedical data into proactive, predictive, preventive, and participatory health
Information disseminated to a variety of stakeholders, including biomedical scientists, clinicians, and patients
TIGER (Technology Informatics Guiding Educational Reform)
2004, Advance RN competencies in informatics
Develop US workforce capable of using EHR to improve delivery of care.
Wisdom
Application of knowledge to manage and solve problems
User inference
Allows humans and computers to cooperatively perform tasks/goals
value-based model
Policy Reform 2008, focused on incentives to providers on quality (value) vs Volume.
Value vs volume
Hope is to reduce the number of unnecessary or limit value tests and treatments.
Usability
The quality of the users experience when interacting w/ a product system software or application.
EFFECTIVENESS, EFFICIENCY AND USER SATISFACTION
DRA (Deficit Reduction Act of 2005)
“Do Not Pay” CMS oversee’s the Hosp Acquired Conditions present on Admit (HAC-POA) Program
Ex: stage III & IV pressure ulcer, Falls, Trauma, Cath assoc infection, surgical site infections, DVT’s, Vasc. Cath Assoc Infections.
(ONCHIT) Office of the National Coordination for Health Information Technology
Federal government driving healthcare Info standards.
2 Federal Advisory Committees:
HITPC – framework for nationwide infrastructure & HIT standards for communities
HITSC – develop standards, certifications and implementations strategies.
AHIMA Standards of Ethical Coding
Standards developed by the Council on Coding and Classification of the American Health Information Management Association (AHIMA) to give health information coding professionals ethical guidelines for performing their coding and grouping tasks.
Barcode Medication Administration (BCMA)
: Mandated by the FDA Real-time, automated documentation of patient’s medication. Needs CPOE, A pharmacy system, & an EMAR system to function.
Interoperability
When 2 or more systems (Human or Machine) exchange data or information while retaining the original meaning of data. A nurse informaticist can increase interoperability by promoting standardized vocabulary & coding. ** Using an interoperable system, you can expect a reduction in errors, increase in revenue, and increased communication**
Types of Interoperability
Technical Interoperability-ability to exchange the data from one point to another
Semantic Interoperability-exchange of data in wh/ the meaning remains the same at both ends.
Process Interoperability – Coordinates systems enabling business processes at organizations & allowing systems to work together.
Benchmarking
The continual process of measuring services and practices against the toughest competitors in the healthcare industry
Store and Forward Applications
Asynchronous. Transmit recorded health information through a secure communications network to a provider (Photos).
de-indentified health information/HIPAA
There are no restrictions on the use or disclosure of de-identified health information.14 De-identified health information neither identifies nor provides a reasonable basis to identify an individual. There are two ways to de-identify information; either: (1) a formal determination by a qualified statistician; or (2) the removal of specified identifiers of the individual and of the individual’s relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual.
Required Disclosures
A covered entity must disclose protected health information in only two situations: (a) to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information; and (b) to HHS when it is undertaking a compliance investigation or review or enforcement action
Permitted uses and disclosures of PHI
A covered entity is permitted, but not required, to use and disclose protected health information, without an individual’s authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3) Opportunity to Agree or Object; (4) Incident to an otherwise permitted use and disclosure; (5) Public Interest and Benefit Activities; and (6) Limited Data Set for the purposes of research, public health or health care operations.18 Covered entities may rely on professional ethics and best judgments in deciding which of these permissive uses and disclosures to make.
disclosures of psychotherapy notes
Most uses and disclosures of psychotherapy notes for treatment, payment, and health care operations purposes require an authorization as described below.23 Obtaining “consent” (written permission from individuals to use and disclose their protected health information for treatment, payment, and health care operations) is optional under the Privacy Rule for all covered entities.24 The content of a consent form, and the process for obtaining consent, are at the discretion of the covered entity electing to seek consent.
Disclosure to Covered entities
Covered entities may disclose protected health information to:
(1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect;
(2) entities subject to FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post-marketing surveillance;
(3) individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law; and
(4) employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance, because such information is needed by the employer to comply with the Occupational Safety and Health Administration (OHSA), the Mine Safety and Health Administration (MHSA), or similar state law
Disclosure – Victims of Abuse, Neglect or Domestic Violence
Victims of Abuse, Neglect or Domestic Violence. In certain circumstances, covered entities may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence
Disclosure – Workers Compensation
Workers’ Compensation. Covered entities may disclose protected health information as authorized by, and to comply with, workers’ compensation laws and other similar programs providing benefits for work-related injuries or illnesses.4
Disclosure – Limited Data Set
Limited Data Set. A limited data set is protected health information from which certain specified direct identifiers of individuals and their relatives, household members, and employers have been removed.43 A limited data set may be used and disclosed for research, health care operations, and public health purposes, provided the recipient enters into a data use agreement promising specified safeguards for the protected health information within the limited data set.
Authorized Uses
A covered entity must obtain the individual’s written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.44 A covered entity may not condition treatment, payment, enrollment, or benefits eligibility on an individual granting an authorization, except in limited circumstances.45
Examples of disclosures that would require an individual’s authorization include disclosures to a life insurer for coverage purposes, disclosures to an employer of the results of a pre-employment physical or lab test, or disclosures to a pharmaceutical firm for their own marketing purposes.
Disclosure of Psychotherapy Notes
A covered entity must obtain an individual’s authorization to use or disclose psychotherapy notes with the following exceptions48:
The covered entity who originated the notes may use them for treatment.
A covered entity may use or disclose, without an individual’s authorization, the psychotherapy notes, for its own training, and to defend itself in legal proceedings brought by the individual, for HHS to investigate or determine the covered entity’s compliance with the Privacy Rules, to avert a serious and imminent threat to public health or safety, to a health oversight agency for lawful oversight of the originator of the psychotherapy notes, for the lawful activities of a coroner or medical examiner or as required by law.
Limiting Uses and Disclosures to the Minimum Necessary
A central aspect of the Privacy Rule is the principle of “minimum necessary” use and disclosure. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure, or request.50 A covered entity must develop and implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary. When the minimum necessary standard applies to a use or disclosure, a covered entity may not use, disclose, or request the entire medical record for a particular purpose, unless it can specifically justify the whole record as the amount reasonably needed for the purpose.
The minimum necessary requirement is not imposed in any of the following circumstances: (a) disclosure to or a request by a health care provider for treatment; (b) disclosure to an individual who is the subject of the information, or the individual’s personal representative; (c) use or disclosure made pursuant to an authorization; (d) disclosure to HHS for complaint investigation, compliance review or enforcement; (e) use or disclosure that is required by law; or (f) use or disclosure required for compliance with the HIPAA Transactions Rule or other HIPAA Administrative Simplification Rules.
Privacy Practices Notice
Privacy Practices Notice. Each covered entity, with certain exceptions, must provide a notice of its privacy practices. The Privacy Rule requires that the notice contain certain elements. The notice must describe the ways in which the covered entity may use and disclose protected health information. The notice must state the covered entity’s duties to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice. The notice must describe individuals’ rights, including the right to complain to HHS and to the covered entity if they believe their privacy rights have been violated. The notice must include a point of contact for further information and for making complaints to the covered entity. Covered entities must act in accordance with their notices. The Rule also contains specific distribution requirements for direct treatment providers, all other health care providers, and health plans.
Personal Representatives – Disclosure
Personal Representatives. The Privacy Rule requires a covered entity to treat a “personal representative” the same as the individual, with respect to uses and disclosures of the individual’s protected health information, as well as the individual’s rights under the Rule.84 A personal representative is a person legally authorized to make health care decisions on an individual’s behalf or to act for a deceased individual or the estate. The Privacy Rule permits an exception when a covered entity has a reasonable belief that the personal representative may be abusing or neglecting the individual, or that treating the person as the personal representative could otherwise endanger the individual.
Special Case: Minors – Disclosure
Special Case: Minors. In most cases, parents are the personal representatives for their minor children. Therefore, in most cases, parents can exercise individual rights, such as access to the medical record, on behalf of their minor children. In certain exceptional cases, the parent is not considered the personal representative. In these situations, the Privacy Rule defers to State and other law to determine the rights of parents to access and control the protected health information of their minor children. If State and other law is silent concerning parental access to the minor’s protected health information, a covered entity has discretion to provide or deny a parent access to the minor’s health information, provided the decision is made by a licensed health care professional in the exercise of professional judgment.
Civil Penalty $$
Civil Penalty Amount
$100 to $50,000 or more per violation
$1,500,000 Calender Yr CAP
A penalty will not be imposed for violations in certain circumstances, such as if:
the failure to comply was not due to willful neglect, and was corrected during a 30-day period after the entity knew or should have known the failure to comply had occurred (unless the period is extended at the discretion of OCR); or
the Department of Justice has imposed a criminal penalty for the failure to comply
Criminal Penalties
Criminal Penalties. A person who knowingly obtains or discloses individually identifiable health information in violation of the Privacy Rule may face a criminal penalty of:
- up to $50,000 and up to one-year imprisonment.
*$100,000 and up to five years imprisonment if the
wrongful conduct involves false pretenses,
*and to $250,000 and up to 10 years imprisonment if the
wrongful conduct involves the intent to sell, transfer,
or use identifiable health information for commercial
advantage, personal gain or malicious harm.
The Department of Justice is responsible for criminal prosecutions
Which three common policies, laws, or regulations affect health information technology?
ARRA (American Recovery and Reinvestment Act),
21st Century CURES Act, and
FDASIA (Food and Drug Administration Safety and Innovation Act)
HITECH Act
The HITECH Act directs eligible healthcare providers and healthcare organizations to adopt electronic health records to improve the exchange of information and to improve privacy and security protections for healthcare data.
FDASIA (FDA Safety and Innovation Act)
FDASIA has improved the FDA’s ability to speed patient access to digital records and improve the safety of drugs, medical devices, and biological products.
The 21st Century CURES Act is designed to
The 21st Century CURES Act is designed to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently. It also requires patient electronic health information be made available to patients without delay (with few exceptions), at no cost.
One of the provisions of the 21st Century CURES Act is the elimination…….
One of the provisions of the 21st Century CURES Act is the elimination of information blocking. Information blocking is defined as a practice by a health IT stakeholder that, except as required by law or specified by the Secretary of Health and Human Services (HHS) as a reasonable and necessary activity, is likely to interfere with access, exchange, or use of electronic health information from provider to provider or provider to patient. TRUE
Promoting Interoperability Program (MU renamed in 2018 by CMS)
The shift moved the program beyond meaningful use into a new phase with increased focus on interoperability and improving patient access to health information.
The program objectives include:
Immunization Registry Reporting
Syndromic Surveillance Reporting
Electronic Case Reporting
Public Health Registries Reporting
Clinical Data Registries Reporting
Electronic Reportable Laboratory Test Reporting (for Hospitals only)
medical device data systems (MDDS) devices (per FDA)
MDDS is a device that is intended to transfer, store, convert or display medical device data without controlling or altering the functions or parameters of any connected medical devices. An MDDS may include software, electronic or electrical hardware, modems, interfaces, and a communications portal.
The Picture Archiving and Communication System (PACS)
The Picture Archiving and Communication System (PACS) facilitates storage, trans-mission, and sharing of medical images. including x-rays, magnetic resonance imag-ing (MRI), computerized tomography, and ultrasound.
During Downtime or Natural Disasters r/t charting
procedures are implemented that all must use, which often includes reverting back to documenting on paper until the system can be fixed and brought back up.
This disruption causes major obstacles since data is not readily accessible, orders cannot quickly flow to appropriate departments, and there may be duplicate orders and documentation when the system does come back up because there are both paper and electronic versions of the same items.
How often should computer systems be upgraded?
Implementing and maintaining computer systems is very expensive, as they must be upgraded every two to three years
Smart technology
the functionality behind the scenes that provides the capability of the electronic system to send real-time messages to all of the various areas required during a patient visit, where providers document the visit, order the medications while also checking alerts for errors, schedule appointments, and generate bills, to name just a few of the functions of an EHRS.
All of this is done because the different systems are tied or interfaced together so the electronic messages can cross systems.
3 textual knowledge representations for concepts in medicine and nursing
Systematized Nomenclature of Medicine (SNOMED), Current Procedural Terminologies (CPT),
and Nursing Interventions Classification (NIC)
Current functionality of EHR includes:
- Point of care (POC) access by practitioners.
- Support for multiple users to view data on same
patient at the same time. - Results review (laboratory, pathology, imaging, notes,
etc.)
. • Quality metrics. - Dashboards.
- Documentation.
- Electronic communication.
- Order management.
- Patient monitoring in real time.
- Patient summary displays.
- Patient support.
- Medication administration record.
- Population health.
- Bar code medication administration.
- External reference resources.
- Billing
Meaningful use requires that use of an EHRS results in
improved quality, safety and
efficiency while reducing inconsistencies in healthcare; increases patients’ and families’ active involvement in their care; increases the coordination of healthcare; advances the health of the public; and safeguards the privacy and security of personal health data and information
Remaining challenges to using EHRS include
: • Integration of behavioral health and primary care
workflows.
- Information exchange.
- Limited resources.
- Work-arounds.
Work-arounds
variations in procedures and processes created to accomplish work when systems or workflows are deficient or inefficient which can, and fre-quently do, defeat positive features such as safety.
EHRS implementation considerations include:
- Compliance with requirements including ONC Certification for MU, as well as other regulatory and accreditation demands.
- The creation of the electronic infrastructure, necessary policies and procedures to provide access to patient information.
- Funds for purchase costs, improvements, ongoing maintenance and support. • Standardization of terms. • Security, privacy, and confidentiality.
- Measures to ensure data integrity including creating
and maintaining master files and data dictionaries. - Backup options
- Ownership of patient information.
mHealth
a form of health information technology, not a health information system. It is used to analyze, aggregate, share, and protect health information data derived from or used in portable devices.
HIT is used to …..
used to support systems that collect data needed for patient care, population health management, and for the sharing of this information within a secure system.
The health information exchange (HIE) infrastructure
is a process for bi-directional sharing of patient health-related information among primary providers (nurse practitioners, physicians, and physician assistants), consulting specialists, hospitals, ambulatory centers, nursing homes, dentists, audiologists, optometrists, and occupa-tional-and school-health professional
CONCERN CDS
identifies nursing documentation patterns that are for patient deterioration and generates a predictive early warning score. The CONCERN CDS consists of two main components:
- the decision engine, which uses AI models to analyze the content and patterns of nursing EHR data (such as flow sheet entries and nursing notes)
- front-end interfaces that display the predicted CONCERN levels (green, yellow, red), with red indicating that a patient is at the highest risk for deterioration. A web application provides tracking of the CONCERN level over time and facilitates transparency of the AI models by displaying what factors contributed most to the current calculation.
Information management CDSS includes
patient education material, info buttons, or guidelines for practice
CDSS examples:
paper decision support tools, order sets, parameters for patient care, patient data, and patient monitors, Nursing literature
CDSS providing patient specific decision support
Elements such as depression scoring, patient goals, and body mass index provide information that could enhance patient specific decision support.
How is the use of predictive analytics better than the use of standard alerts for nurses’ decision-making?
Predictive analytics can provide a risk estimate of the patient for morbidity or mortality and acuity, providing a higher level of decision support for the nurse.
How does the HIE support informed decision-making for nurses and providers?
The timely sharing of patient information and at the point of care allows: the avoidance of readmissions the avoidance of medication errors the improvement of problem identification the improvement of diagnosis accuracy the reduction of duplicate testing
What does interoperability in healthcare mean?
It is the ability of different information systems and health information technologies to securely access, exchange, integrate, and cooperatively use data in a coordinated manner using a standardized format across several national and global boundaries.
Interoperability allows timely and seamless portability of information and optimizes the health of individuals and populations globally through this seamless exchange.
What is the difference between health information systems and health information technologies?
Health information systems manage health information for specific areas of healthcare. Health information systems are categorized as clinical information systems or administrative information systems.
Health information technology (HIT) is what is involved in the design, development, implementation, integration, creation, use, and maintenance of health information systems. HIT also refers to the area of healthcare that uses computer hardware, software, or infrastructure to record, retrieve, analyze, archive, secure, and share clinical administrative, and financial information. HIT is the backbone and foundational structure of many advancements in healthcare such as clinical decision support, computerized disease registries, computerized provider order entry, consumer health IT applications, electronic medical record systems (EMRs, EHRs, and PHRs), electronic prescribing, and telehealth.
Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
identifies three domains as indirectness, inconsistency, and imprecision.
GRADE refers to quality of evidence
PARIHS framework defines three key elements that, when used together, will mutually influence each other for a successful EBP implementation…they are:
The three elements are: (1) evidence—sources of knowledge from multiple stakeholders, (2) context—quality of the environment EBP is to be implemented, and (3) facilitation—how change will be supported
Examples of four different types of tools frequently used when defining or monitoring a process include
workflows, cause-and-effect diagrams, checklists, and scatter diagrams.
This is a category of diagramming techniques to use when identifying risks and quality management concerns.
workflow
Using this process, defines what needs to be completed first, working through an entire sequence of activities step by step.
*moves through steps, then identifies a decision that
needs to be made before continuing
cause-and-effect diagram/fishbone diagram
is used to identify and trace problems and then track the cause back to the root.
*also called root-cause analysis.
*The first step in the process is to state what the problem is, then ask “why” any number of times until the source or cause has been identified. Examples of items on the arrows or causes might be people, technology, a process, or different environments.
Checklists
these are another simple way of gathering data in order to organize facts in an easy way so an issue or problem can be reviewed in more detail.
*Some of the most common examples are checklists for FREQUENCIES of an EVENT or CONSEQUENCES of using a particular PROCESS.
A scatter or correlation chart
provides a quick, visual way of looking at how one variable or item relates to another, either in a positive, negative way or no correlation.
The x-axis could represent something as simple as temperature, and the y-axis something like time.
EX: temperature goes up over time.
(RACI) checklist
known as responsible, accountable, consulted, and informed
When a group is assigned different levels of responsibilities where each member has a different task, it is important to track who is doing what; for example, who is responsible and who might just be consulted or just kept informed about the task.
A Gantt chart is
another way to track different tasks and provide a quick visual representation of due dates, including duration times and start and end dates as well as tasks, subtasks, and who is responsible for making sure the task is completed
Regression Testing
If anything is changed on an already-tested module, regression testing is done to be sure that this change has not introduced a new error into code that was previously correct.
The strategic plan supports the
mission, scope, vision, goals, and objectives of the organization.
Strategic planning is guided by
upper-level administrators and stakeholders including the CEO, CIO, CNO, and CNIO.
Evidence-Based Practice Council (EPC) refers to
strength of evidence
The following databases are commonly used when searching for original research articles:
- CINAHL.
- MEDLINE.
- Proquest Nursing & Allied Health.
- PsychINFO.
- PubMed.
The following databases are specific to systematic research reviews:
- Cochrane Library.
- Joanna Briggs Institute EBP Database.
- Database of Abstracts of Reviews of Effects (DARE).
Stetler Model
(1) preparation, (2) validation, (3) comparative evaluation/decision-making, (4) translation and application, and (5) evaluation. The model can be oriented toward the individual or team approach
Remaining challenges to using EHRS include
- Integration of behavioral health and primary care
workflows. - Information exchange.
- Limited resources.
- Work-arounds
Beginning nurse:
—expected to have fundamental information-management and computer-technology skills and use existing information systems and established information-management practices.
Experienced Nurse
expected to have a specific area of expertise (e.g., public health, education, administration); be skilled in using information management and computer technology; have strong analytic skills to learn from relationships between different data elements; and be able to collaborate with the informatics nurse specialist to suggest improvement to systems.
Informatics specialist:
defined as a nurse with advanced skills specific to health-information management and computer technology.
*focus on information needs for the practice of nursing, which included education, administration, research, and clinical practice and use critical thinking, process skills, data-management skills, expertise in the systems development life cycle, and computer skills.
Informatics innovator:
expected to be educationally prepared to conduct informatics research and generate informatics theory, have advanced understanding, skills in information management and computer technology. (e.g., developing innovative and analytic techniques for scientific inquiry, applying advanced analysis and design concepts to the system life cycle process), and fiscal management
Contact precautions diseases examples: (how are they diagnosed)
examples include:
norovirus, rotavirus and C-diff- stool
draining abscesses – look for worsening s/sx
MRSA – tissue sample/nasal
Droplet precautions examples (how are they diagnosed)
scarlet fever – rapid strep
pneumonia – CXR
pertussis/whooping cough – swab
influenza – swab
(Private room and mask)
Airborne precautions examples (how are they diagnosed)
chickenpox (varicella) – PCR/fluid from lesions
Herpes zoster/shingles – fluid from lesions/labs for antibodies
TB- CXR/Mantoux skin test/labs
GRADE
Grading of Recommendations Assessment, Development and Evaluation
*Goal is to address level of evidence
Radio Frequency Identification (RFID)
An example of this includes a mobile workstation that uses a Bluetooth device to connect the scanner to the computer. The nurse scans the patient identification band or a medication and verifies the right patient or the right medication with the right medical record.
*small chip in device as identifier
*Grant from the FCC to develop
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.
Which information in a patient’s medical record will help a nurse plan and manage the patient’s pain?
Physician orders
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
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
A nurse admits an infant with a severe hacking cough, vomiting, and a fever for the past two weeks. Which data in the electronic medical record (EMR) informs the decision to implement infection-control precautions?
The nasopharyngeal swab culture results indicate the patient is positive for Bordetella pertussis.
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.
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.
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 medical record will provide a cross-reference to the impacted patient population?
Patient demographic records
Which view in the electronic medical record (EMR) confirms a patient’s blood pressure is stabilizing?
Graphical trending
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
Which data set in the electronic medical record (EMRs) will assist in evaluating the number of positive influenza tests at a facility within the past year?
Laboratory records
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 medical record will help the nurse further evaluate and manage the patient’s blood pressure?
The intake and output record
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.
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.
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
Which barrier to healthcare informatics use does the HITECH Act aim to reduce?
Financial
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.
Which patients are ideally positioned to fully engage in their care?
Patients that are recovering well after a full night of sleep.
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
What is true about improving health literacy?
Improving health literacy leads to better patient outcomes.
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
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.
What does the informatics nurse recommend to increase attendance to follow-up appointments?
Automated text or email reminders
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)
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)
What is a patient safety benefit of a pharmacy information system (PIS)?
Alerts regarding allergies and interactions
Standardized terminology was implemented to promote interoperability across electronic health records (EHRs). Which terminology is specific to laboratory tests, orders, and results?
LOINC
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.
What are patient portals?
Patient portals are facility-owned and associated with an electronic health record.
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