C468 Information Management and Application of Technology

C468 Information Management and Application of Technology Project management life cycle (PMLC) - C ORRECT ANSWER design/plan: scope and charter documents, which guide how the system will be implemented and what officially can and cannot be done, metrics for evaluation , then evaluated including adding metrics to monitor measures of success progress; resource availability, team selection/consultants implementation: WBS/Gantt chart, communication plan, risk assessment plan, change management monitoring and control evaluation lessons learned w/knowledge transfer information science - C ORRECT ANSWER originally a subdiscipline of computer science, supports the collection and management of informationand applies technology to make information usable Information system - C ORRECT ANSWER system comprised of the hardware and software that make up an organization's infrastructure The Beginning Nurse - C ORRECT ANSWER fundamental information management and computer technology skills and use existing information systems and established information management practices Information literacy - C ORRECT ANSWER the ability to read and understand the written word and numbers as well as the ability to recognize when information is needed Technology Informatics Guiding Education Reform (TIGER) - C ORRECT ANSWER (2004), called for improving nursing education competencies for the development of a workforce capable of delivering patient care through health information technology admission/discharge/transfer (ADT) system - C ORRECT ANSWER system integrated with other administrative and clinical systems and tracks a patient's activities and locations from hospital or clinic Implementation team or committee - C ORRECT ANSWER interdisciplinary team tasked with planning, testing, training, and other responsibilities when an EHRS has been purchased North American Nursing Diagnosis Association International (NANDA-I) - C ORRECT ANSWER first standardized nursing terminology recognized by the ANA and used for nursing diagnosis Personal Health Record (PHR) - C ORRECT ANSWER a collection of patient data controlled by the patient and accessible by patient and providers; allows users to electronically collect, track, and share current and past information about their health or someone in their care; can stand alone or be tethered to a health plan or EHRS portal. Interface - C ORRECT ANSWER computer program that tells two different systems how to exchange data Interoperability - C ORRECT ANSWER the ability of two entities, human or machine, to exchange and predictably use data or information while retaining the original meaning of that data Integration - C ORRECT ANSWER the process by which different information systems are able to exchange data in a fashion that is seamless to the end user Standardized Terminology - C ORRECT ANSWER the implementation of SI within the EHR is essential for healthcare organizations to meet the criteria of meaningful use (MU) Systemized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) - C ORRECT ANSWER globally recognized controlled healthcare vocabulary that provides a common language for electronic health applications to exchange data Knowledge of workflow - C ORRECT ANSWER primary reason nursing participation is essential on the implementation team Continuity of Care Record (CCR) - C ORRECT ANSWER record that provides a snapshot of a person's current healthcare to a provider who does not have direct access to the EHR; intended to improve continuity and reduce errors Data mining - C ORRECT ANSWER AKA escience; process that uses software to look for hidden patterns and relationships in larger data sets; analyzing data to extract information not offered by raw data alone Physical threat - C ORRECT ANSWER Example: unauthorized access to a server room Health Insurance Portability and Accountability Act (HIPAA) - C ORRECT ANSWER any breach of confidentiality within the healthcare environment is subject to the penalties of this act Automatic sign off - C ORRECT ANSWER security measure that protects the healthcare provider if they leave the computer abruptly Audit trails - C ORRECT ANSWER software used for detecting security violations, performance problems, and flaws in applications by recording activity by users and systems Health Information Technology for Economic and Clinical Health (HITECH Act) - C ORRECT ANSWER authorized incentive payments for early EHR adopters and led to the development of meaningful use (MU) criteria (part of ARRA) Blame-free environment - C ORRECT ANSWER encourages reporting of errors or near misses and focuses on a systematic view of errors rather than individual causation Culture of informatics - C ORRECT ANSWER a vision to develop policies, funding, infrastructure, and education to instill knowledge and skills needed by all healthcare executives, clinicians, and informaticists, and the tools to gather and analyze amassed data Decision-support software (DSS) or Clinical decision support software (CDSS) - C ORRECT ANSWER facilitate the human (provider) decision making process and saves healthcare dollars by aiding in diagnosis and providing access to practice guidelines which decrase LOS and cost of treatment; alerts, clinical pathways, order sets, dashboards, diagnostic support, and drug-drug interaction tools are examples Alert fatigue - C ORRECT ANSWER too many insignificant CDSS warnings or recommendations are presented and providers begin to dismiss them regardless of importance Core Requirements of Meaningful Use (MU) *all required since 2018 - C ORRECT ANSWER demographic info CPOE CDS and ability to track compliance real time drug-drug interaction and allergy checks active med list active med allergy list record and retrieve VS ages 2-20 smoking status age 13 and up mechanisms to protect EHR info electronic exchange of info between entities/providers supply patient w/copy of chart and/or d/c instructions per request report clinical quality measures to CMS up to date problem list/patient diagnoses Telehealt