D029 NURSING INFORMATICS Study Guide Review Rated 100%

D029 NURSING INFORMATICS Study Guide Review Rated 100% Mutlidisciplinary Team Terminology *** (SNOMED-CT) Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms- clinical terms covering nurisng, medicine, & allied health Standardized Terminology Supports *** Data Mining PHR - Private Health Record *** Lifetime health record, supplied by ind., healthcare providers, pharmacies, therapist, lab test, - Controlled by the consumer, E-Sign *** Same legal status as a hand written signature MIPPA - Medicare Improvement for Patients & Providers Act provides *** financial incentive for e-prescribing to providers HIPPA provides *** legal protection for personal health info, set standards for elect. data interchange of claims data, named specific code sets for use in Medicare related transactions, & Privacy ARRA provides *** provide funds for adoption of technology & provides the right for every individual to receive and electronic copy of EHR HITECH provides *** strengthened HIPPA security & privacy protection, & provides financial incentive for the user of EHR EMR -electronic medical record provides *** Legal record often restricted to a Single episode of care , building block of EHR, EHR- Electronic Health Record is *** Longitudinal record that includes client data, demographics, clinician notes, medications, diagnostics. - Major driver for US Adoption are "Meaningful Use" financial incentives from HITECH part of ARRA Affordable Care Act provides *** guarantee access to healthcare, encourage PCP, Data is *** collection of #, characters, or facts (body weight- 128lb), little meaning alone Information is *** Collection of data examined for patterns or structure that can be interpreted. ex notes prior BP and informs doc Knowledge is *** Synthesis of info from several sources to produce a single concept or idea, ex read a journal about BP Computer Technology is *** collection of data for analysis, which can be used to justify the efficacy of particular interventions & improve quality of care HIS HEalthcare Information System is *** Administrative System + Clinical Information System, Clinical Systems include: order entry, radiology, pharmacy, physician management system Adm system : non clinical, demographics, scheduling, risk mgmt, decision support, Administrative System includes these functions *** Managing nonclinical, client-related information (demographics, codes for procedures, & Insurance Hippa - Compliant Codes inlcude *** (ICD) International Classification of Disease, Common Procedural Terms, (ABC) Alternative Billing Codes, ANA recognizes these terminologies *** (CCC) Clinical Care Classification, (ICNP) International Classification of Nursing Practice, NANDA, NIC, NOC, the Omaha System, (PNDS) Perioperative Nursing Data Set Teleconferencing is *** use of computers, audio, & video equip. and high-grade dedicated telephone line, cable/sat connections to provide interactive communication between 2+ ppl at 2+ sites Elearning provides *** electronic media to present instruction, it allows users to skip information they already know Distance Education is *** the use of print, audio, video, computer, or teleconference capability to connect faculty & students; Can take place in real time or on a delayed basis Web Based Instruction is *** the attributes & resources of the internet to deliver & support education Telehealth is *** use of telecommunication technologies & computers to provide healthcare info & services to clients at another location - consumers are chronically ill, isolated, assisted living families - decrease er visits, decrease LOS, decrease Admissions, increased productivity for clinical Telenursing is *** telecommunications & computer technology for the delivery of nursing care & services to clients at other sites Issues with telehealth & telenursing are *** lack of reimbursement, infrastructure, plug-play standard, license & liability issues, & concerns r/t to client privacy & confidentiality EBP- Evidence Based Practice is *** the use of research & evidence to inform clinical practice, an approach to provide care that integrates nursing experience & intuition with valid and current clinical research to achieve the best patient outcomes EBP provides *** standardized best practices, reduce time that the nurse spends gathering & assessing data, provide care w/ clinical research EBP contributes *** increased job satisfaction, improved quality of care how a nurse uses data *** 1. accessing information 2. collecting data 3. Inputting Data 4. analyzing data quantitative research *** concerned with objectivity, tight control over situations, define relationships between variables, seek correlation between data, ex. tries to discover how an intervention has impacted subjects IN DEPTH, tangible relations between variables, qualitative research *** concerned w/ finding out more about the human experience, accomplished thru interviews & over a long period of time, ex. how an intervention could impact an entire population, content analysis, computers can code responses to questionnaires which then can be inputted in the informatics sys for analysis, types of patient information are *** 1. standard 2. general 3. targeted 4. personalized 5. tailored Standard patient information is *** describes procedures that all patients will encounter, ex temperature or weight General patient information is *** ask consumers to follow a PREVENTIVE course of treatment that applies to everyone ex yearly physical Targeted patient information is *** geared toward ppl who are a SUBSET of the general population ex men >40 prostate exam Personalized information is *** gives info about a SPECIFIC condition the consumer has been diagnosed with ex. DMII Tailored Information is *** information that focuses Specifically on Ind Based on Specific Conditions , it is typically gleaned from EHR or EMR Telemedicine *** improve pt outcomes by permitting pts to remain at home, allows pts to communicate w/ provider about blood glucose test or video conference w/ them directly to develop pt specific education opportunities, directed by doctors TIGER means *** Technology Informatics Guiding Education Reform ARRA means *** American Recovery & Reinvestment Act HITECH *** Health Information Technology for Economic & Clinical HEalth CPOE *** Computerized Physician order entry - needs downtime procedure or policy prior to implementation - DSS *** Decision Support Software Info Life Cycle is *** 1. Needs assessment 2. System selection 3. Implementation 4. Maintence Input devices *** enter info into the computer such as keyboard, touchscreen, mouse, microphone 2nd storage examples *** hard disk, usb, dvd out put devices *** use to see info such as computer screen, printer, projector, speakers Software *** interprets data by binary code, tells the computer what to do at a given moment, operating system *** tells how to move, share, and treat files. It also provides a user interface that enables the user to enter info, ex windows application *** to perform a certain function; designed to document pt & provider activity ex physician orders network *** connect mult computers in different locations LAN *** connect a few computers to the server, over large area ex docs place orders remotely at home IntrAnet and extranet *** IntrAnet- private networks that can not be accessed outside the organization Extranet- network outside the company that enables customers & suppliers access to the services System Check *** help guide thru data collection process, ex. patient allergies to prevent conflict EDI Electronic data interchange *** permits mult systems to acquire & share data Nursing Information System *** standardized nursing language (SNL), 2 main approaches, 1. Nurisng Process Approach & Critical Pathway- mult discp. teams thru out, physicians orders are present for the multdisc team to observe & follow, allows the the multdisc. team to update the plan of care when variances in the pts condition are noted 2. Protocol Approach- streamline doc of assessment, med info, discharge info, education Firewall *** between hardware & software interfacing types *** 1. point to point - enables to sys to communicate 2. Interface PACS *** allows digital manipulation Store & Forward *** Part of telehealth, ex xray from clinic sent to hospital clincal codes *** designate concepts to facilitate development of EBP clinical term *** enables the capture of data for patient care documentation Clinical Decision Support System *** designed to support health care providers in making decisions about the delivery & mgmt of patient care Consultant *** expert advice, opinions, & recommendations 4 concepts of nursing informatics *** 1. data 2. information 3. knowledge 4. wisdom Decision Support *** recommendations for interventions based on computerized care protocols. ex additional screening, medication interactions, drug dosages Informatics Innovator *** process of making enhancements or improvements, creative, Informatics Nurse *** RN w/ an interest or experiece working in an informatics field Novice *** beginner w/ no experience with the situations in which they are expected to perform a task - taught rules to guide actions 3 sciences of informatics *** 1. nursing science 2. information science 3. computer science Clinical Decision Support System Examples *** reminders, alerts, drug checking, guidelines, protocols, image recognition, allergy to drug CPU *** consist of computer chip that processes all the computers functions & uses "brain" Data integrity *** means that whenever the data are accessed by a user, the data are as complete as when entered or created Information Mgmt *** to ensure that the right info. is available to the people at the right time; information is managed properly, Knowledge Mgmt *** system that enables organizations to learn from their staff to improve performance, help accumulate & store the collective knowledge Experienced Nurse *** expected to more fully integrate informatics throughout the course of practice, not just for basic data entry & retrieval Informatics Nurse *** advance knowledge & profienciency in the use of IT as it applies to nursing practice Internet Security Measures *** 1. Firewall- prevent unwanted access to the sys & its information 2. Limit web page access 3. Server Security- information is stored should not be able to access other systems if attacked 4, Update Security Software Considerations for New Informatics System *** 1. Technical Specifications - How much downtime for maintenance 2. Response Time- time it takes the sys to process a request 3. Architecture-structure of the sys, open system to communicate together 4. Connectivity-able to interface with the sys in mult ways 5. Testing- tested in different place than it is being used, no sys maintenance can be done w/ little inconvience 6. Compatibility- w/ other systems, Interfacing 2 Types *** 1. Point to Point- enables 2 sys to communicate, expensive, has to have completely customized program 2. Interface Engine -interfacing across several different sys Smart Technology *** links, syncs, & compiles disparate bits of info from different sys into a coherent one stop, real time documentation, provides reminders, Stages of EMR adoption *** 0- organization has not installed all 3 key ancillary department sys (lab, pharm, & radiology) 1- all 3 key ancillary are installed 2- CDR-clinical data repository provides physician access for reviewing orders & results, Possibly HIE capable 3- Nursing/Clinical Documentation, eMAR, first level of clinical decision support is implemented 4-CPOE implemented 5- Closed loop med administration w/ Bar codes is implemented, 5 rights of medication adm 6. Full Physician Documentation , Full radiology PACS 7-No more paper charts, P4P *** Pay for Performance is an outgrowth of Affordable Health Care Act, reward providers when pts have good outcomes Single Risk Pool *** prevent insurers from using insurance pools with markets to get around market reforms & charge ppl w/ greater health problems higher premiums by increasing their premiums at higher rates Catastrophic *** lower premiums, protect against high out of pocket costs, and cover recommended preventative services Needs to be integrated *** ICD-9, G-Codes, ICD-10, CPT, HCSPC Does not need to be integrated *** C-3P0, RUGs Telehealth Options *** 1. Store & Forward- items are transferred to experts who read and interpret information and send back results 2. Real Time- interactive conferencing Nursing Informatics Definition *** integration of nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom into nursing practice Computer Literacy vs Information Literacy *** Computer Lit- a familiarity with the use of personal computers Information Lit- Ability to recognize when information is needed as as the skills to find, evaluate, and use information Computer System consist of *** hardware, software, data, procedures, and users Computer Hardware consist of *** input device, the CPU, secondary storage, and output device Network *** a combination of hardware and software that allows communication and electronic transfer of information between computers Example of Operating System *** Windows Xp Example of application System *** Microsoft Word Bit *** Smallest unit of data WWW *** an information service that provides access to Internet resources by content instead of file name Services of the internet include *** file transfer, email, instant messaging Web 2.0 *** online tool that permits collaboration and sharing online, such as facebook, twitter; Provides education- wikis, web logs, virtual worlds, facebook HIS *** group of systems used within a hospital that support and enhance client care CIS- *** used to access client data that are used to plan, implement, and evaluate care EMR *** electronic version of the client data found in the traditional medical record Basic Components of the EMR *** clinical messaging & email, data repository, and clinical documentation EHR information includes *** past medical history, demographics, immunizations, and medication history Bar Code Arm Bands provide *** patient health record, medications Registration System *** HIS is used to collect and store client identification and demographics data that are verified and updated at the time of each visit