WGU Nursing Informatics

WGU Nursing Informatics 2023 Mutlidisciplinary Team Terminology Ans- (SNOMED-CT) Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms- clinical terms covering nurisng, medicine, & allied health Standardized Terminology Supports Ans- Data Mining PHR - Private Health Record Ans- Lifetime health record, supplied by ind., healthcare providers, pharmacies, therapist, lab test, - Controlled by the consumer, E-Sign Ans- Same legal status as a hand written signature MIPPA - Medicare Improvement for Patients & Providers Act provides Ans- financial incentive for eprescribing to providers HIPPA provides Ans- 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 Ans- provide funds for adoption of technology & provides the right for every individual to receive and electronic copy of EHR HITECH provides Ans- strengthened HIPPA security & privacy protection, & provides financial incentive for the user of EHR EMR -electronic medical record provides Ans- Legal record often restricted to a Single episode of care , building block of EHR, EHR- Electronic Health Record is Ans- 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 Ans- guarantee access to healthcare, encourage PCP, Data is Ans- collection of #, characters, or facts (body weight- 128lb), little meaning alone Information is Ans- Collection of data examined for patterns or structure that can be interpreted. ex notes prior BP and informs doc Knowledge is Ans- Synthesis of info from several sources to produce a single concept or idea, ex read a journal about BP Computer Technology is Ans- 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 Ans- 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 Ans- Managing nonclinical, client-related information (demographics, codes for procedures, & Insurance Hippa - Compliant Codes inlcude Ans- (ICD) International Classification of Disease, Common Procedural Terms, (ABC) Alternative Billing Codes, ANA recognizes these terminologies Ans- (CCC) Clinical Care Classification, (ICNP) International Classification of Nursing Practice, NANDA, NIC, NOC, the Omaha System, (PNDS) Perioperative Nursing Data Set Teleconferencing is Ans- 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 Ans- electronic media to present instruction, it allows users to skip information they already know Distance Education is Ans- 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 Ans- the attributes & resources of the internet to deliver & support education Telehealth is Ans- 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 Ans- telecommunications & computer technology for the delivery of nursing care & services to clients at other sites Issues with telehealth & telenursing are Ans- lack of reimbursement, infrastructure, plug-play standard, license & liability issues, & concerns r/t to client privacy & confidentiality EBP- Evidence Based Practice is Ans- 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 Ans- standardized best practices, reduce time that the nurse spends gathering & assessing data, provide care w/ clinical research EBP contributes Ans- increased job satisfaction, improved quality of care how a nurse uses data Ans- 1. accessing information 2. collecting data 3. Inputting Data 4. analyzing data quantitative research Ans- 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 Ans- 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 Ans- 1. standard 2. general 3. targeted 4. personalized 5. tailored Standard patient information is Ans- describes procedures that all patients will encounter, ex temperature or weight General patient information is Ans- ask consumers to follow a PREVENTIVE course of treatment that applies to everyone ex yearly physical Targeted patient information is Ans- geared toward ppl who are a SUBSET of the general population ex men 40 prostate exam Personalized information is Ans- gives info about a SPECIFIC condition the consumer has been diagnosed with ex. DMII Tailored Information is Ans- information that focuses Specifically on Ind Based on Specific Conditions , it is typically gleaned from EHR or EMR Telemedicine Ans- 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 Ans- Technology Informatics Guiding Education Reform ARRA means Ans- American Recovery & Reinvestment Act HITECH Ans- Health Information Technology for Economic & Clinical HEalth CPOE Ans- Computerized Physician order entry - needs downtime procedure or policy prior to implementation - DSS Ans- Decision Support Software Info Life Cycle is Ans- 1. Needs assessment 2. System selection 3. Implementation 4. Maintence Input devices Ans- enter info into the computer such as keyboard, touchscreen, mouse, microphone 2nd storage examples Ans- hard disk, usb, dvd out put devices Ans- use to see info such as computer screen, printer, projector, speakers Software Ans- interprets data by binary code, tells the computer what to do at a given moment, operating system Ans- tells how to move, share, and treat files. It also provides a user interface that enables the user to enter info, ex windows application Ans- to perform a certain function; designed to document pt & provider activity ex physician orders network Ans- connect mult computers in different locations LAN Ans- connect a few computers to the server, over large area ex docs place orders remotely at home IntrAnet and extranet Ans- 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 Ans- help guide thru data collection process, ex. patient allergies to prevent conflict EDI Electronic data interchange Ans- permits mult systems to acquire & share data Nursing Information System Ans- 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 Ans- between hardware & software interfacing types Ans- 1. point to point - enables to sys to communicate 2. Interface PACS Ans- allows digital manipulation