NR 599 Final study guide NR599 {2022-2023} Completed For Final Exam.
Ethical decision making
○ When making choices about ethical issues based on
... [Show More] the standards of right
vs wrong.
○ It requires a systematic framework for addressing the complex and often
controversial moral questions.
● Bioethical standards
○ The study of healthcare ethics
○ Bioethics takes on relevant ethical problems seen by healthcare providers
in relation to care
● Telehealth
○ wide range of health services that are delivered by telecommunications
ready tools, such as telephone, videophone, and computer
○ is needed to help fill the nursing shortage allowing nursing to see more
patients quicker, as well as the aging population
○ Telecommunication technologies used to deliver health-related services or
to connect patients and healthcare providers to maximize patients’ health
status.
○ A relatively new term in the medical/nursing vocabulary, referring to a wide
range of health services that are delivered by telecommunications-ready
tools such as the telephone, videophone, and computer.
● Medical Applications
○ Software developed for medical purposes, including home
medical monitoring system, medical databases for healthcare
professionals, etc.
● Medical Devices
○ is any device intended to be used for medical purposes
● FDA Oversight for Medical Devices
● Privacy
○ An important issue related to personal information
○ Restricted access of patient information or data
● Confidentiality
○ To ensure that all personal information is protected by ensuring that limited
access is only given to those who are authorized to view that information.
■ Protecting privacy of personal information or data
● Cybersecurity
○ the state of being protected against the criminal or unauthorized use of
electronic data, or the measures taken to achieve this.
○ With the expansion of technology. Facilities are taken more precautions to
prevent cyber attacks. With the move towards advancing cybersecurity is
important, technology continues to grow.○ Ensure all systems are adequately protected and patients remain safe
from harm
○ NI are frequently called on to evaluate the safety and effectiveness of new
devices and software.
● Computer-aided translators
○ is a form of language translation in which a human translator uses
computer hardware to support and facilitate the translation process.
● HIPPA
○ was established in the U.S. in 1996 to protect an individual's
personal health care information.
○ Signed by Pres. Bill Clinton
○ Healthcare institutions are required to meet all standards and
comply with the appropriate security measures in order to
safeguard patient data.
○ Four parts to HIPAA's Administrative Simplifcation
■ Electronic transactions and code sets standards
requirements.
■ Privacy requirements.
■ Security requirements.
■ National identifer requirements.
● ICD-10 Coding
○ An alphanumeric code used by doctors, health insurance
companies, and public health agencies across the world to
represent diagnoses.
○ The system offers accurate and up-to-date procedure codes to
improve health care cost and ensure fair reimbursement policies
○ The current codes specifcally help healthcare providers to
identify patients in need of immediate disease management and
to tailor effective disease management programs.
■ Similarly ICD and CPT coding go together
● Is a medical code set that is used to report medical,
surgical, and diagnostic procedures and services to
entities such as physicians, health insurance
companies and accreditation organizations.
● Evaluation and Management Coding
○ Is a medical coding process in support of medical billing
○ Practicing health care providers in the United States must use E/M coding
to be reimbursed by Medicare, Medicaid programs, or private insurance
for patient encounters.
● Reimbursement Coding○ Is based on claims and documentation fled by providers using
medical diagnosis and procedure codes.
○ Commercial payers must use standards defned by the U.S.
Department of Health and Human Services (HHS) but are largely
regulated state-by-state.
● Clinical Support Tools
○ are designed to help sift through enormous amounts of digital
data to suggest next steps for treatments, alert providers to
available information they may not have seen, or catch potential
problems, such as dangerous medication interactions
○ Such as CDS clinical decision support, a program used by
providers.
○ Or various applications use by healthcare professionals to allow
for communicate between provider to provider and provider to
patient
○ The tools are all used to beneft patient outcome
● Workflow analysis
○ Not an optional part of clinical implementations, but rather a necessity for
safe patient care fostered by technology.
○ The ultimate goal of workflow analysis is not to “pave the cow path,” but
rather to create a future-state solution that maximizes the use of
technology and eliminates non–value-added activities.
○ Although many tools and methods can be used to accomplish workflow
redesign, the best method is the one that complements the organization
and supports the work of clinicians.
○ needs to be done as well as working in optimization (moving conditions
past their current state into a more effective method of performing.
WEEK FIVE READING/ KEY POINTS
Key points from the lessons and modules
● Clinical Decision Support (CDS)
○ Generate patient specific interventions, assessments and
recommendations
○ CDS tools existed prior to development of EHRs
○ The primary goal of implementing a CDS tool is to leverage data and the
scientific evidence to help guide appropriate decision making
● CDS improving healthcare
○ Reducing clinical variation and duplicative testing
○ Ensuring patient safety○ Avoiding complications that may result in readmissions
○ Create alerts about drug-drug interactions
○ Drug allergy contraindications
● CDS challenging healthcare
○ Alarm fatigue
○ Clinical burnout
○ Occur with poorly implemented CDS features
○ Financial burden
● Workflow Design
○ Used to describe the action or execution of a series of tasks in a
prescribed sequence
○ Progression of steps (tasks, events, interactions) that constitute a work
process
○ In a sequential workflow, each step depends on the occurrence of the
previous step; in a parallel workflow, two or more steps can occur
concurrently.
○ Nursing informatics is uniquely positioned to engage in the analysis and
redesign of processes and tasks surrounding the use of technology.
● Changes in workflow, poor system design and usability issues, lack of
understanding about these systems and their capabilities, user errors and system
errors, and lack of defined protocols can all lead to process breakdowns and
errors.
McGonigle Chapter 13
● EHR and information systems provide POC decision support to prevent medical
errors to save lives and money
● Workflow must be considered before implementing technology or it can be more
dangerous
○ Computerized provider order entry (CPOE) focuses on considering the
workflow
● Barriers to implement technology: cost & length of time to incorporate it, frequent
upgrades interrupting the workflow
● American Recovery and Reinvestment Act (ARRA)- used financial incentives to
implement Meaningful Use (MU) rules and regulations
○ Stage 1: data capturing and sharing
○ Stage 2: advanced clinical processes
○ Stage 3: improve outcomes
● Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) took over and
created a quality payment program (QPP) to replace Medicare reporting
programs○ Merit Based Incentive Payment (MIPS or Alternative Payment Models
(APM) to allow clinicians to choose what suites their needs the best,
simplify process for achievement, align with Health IT Certification criteria,
emphasize interoperability, information exchange, security measures, and
patient access to information, reduce number of measures, and exempt
clinicians from reporting if EHR is not applicable to their practice
● Hospitals have small profit margins so they need to work smarter and not harder
with the help of technology to keep the margins from getting smaller
○ Workflow analysis needs to be done as well as working in optimization
(moving conditions past their current state into a more effective method of
performing.
● More research is needed in the area of financial implications of workflow
inefficiencies and their impact on patient care
○ This is hard due to lack of standardized terminology in this area
● Workflow redesign- one of the fundamental skills sets that make up the discipline
of an informatics nurse
● Process owners: those that directly engage in the workflow to be analyzed and
redesigned
● Six Sigma or Lean Departments: efficient and effective delivery of care
○ Key underpinning is the removal of waste
● Variation: when workers perform the same function in different ways- should be
eliminated when possible
● Involve operational staff when possible to ensure the buy-in of staff
● To move from current state to future state gap analysis is necessary-- zeros in on
the major areas most affected by the change
● Chapter 13 Workflow and Beyond Meaningful Use
○ Alternative Payment Models (APM)’s
■ The Reauthorization Act of 2015 (MACRA) reformed Medicare
payments by making changes that created a quality payment
program (QPP) to replace the hodgepodge system of Medicare
reporting programs.
■ The MACRA QPP has two paths—merit-based payment system
(MIPS) or alternative payment models (APMs)—that will be in effect
through 2021 and beyond.
■ The APMs are not just incentives, but fundamental changes in how
we pay for health care in the United States. It is these models,
particularly those dealing with total cost of care, that have the
potential to fundamentally alter the value we receive from health
care.
○ Clinical transformation■ The complete alteration of the clinical environment; widespread
change accompanies transformational activities, and clinical
transformation implies that the manner in which work is carried out
and the outcomes achieved are completely different from the prior
state, which is not always true in the case of simply implementing
technology.
■ Technology can be used to launch or in conjunction with a clinical
transformation initiative; however, the implementation of technology
alone is not justifiably transformational ability. Therefore, this term
should be used cautiously to describe redesign efforts.
○ Events
■ Occurrences that might be significant to other objects in a system
or to external agents
■ for example, creating a laboratory request is an example of a
healthcare event in a laboratory application.
■ An event is defined and could be a triggering event for the task or
workflow; a task or workflow can have several triggering events.
○ Information systems
■ The manual and/or automated components of system of users or
people, recorded data, and actions used to process the data into
information for a user, group of users, or an organization.
○ Lean
■ Lean and Six Sigma are a complementary combination of activities
that focus on doing the right steps and actions (Lean) and doing
them right the first time
○ Medical home models
■ An information technology platform that enables the seamless
exchange of important patient information among many providers in
a healthcare system.
■ Typically the primary care physician (medical home) initiates the
collection of patient data, coordinates the care of the patient, and
helps to maintain the accuracy of such data.
■ Other care providers access the information and add to it as they
provide services to patients.
○ Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
■ An act that reformed Medicare payment by making changes that
created a quality payment program (QPP) to replace the
hodgepodge system of Medicare reporting programs.
○ Metrics■ Measurements or a set of measurements to quantify performance;
they provide understanding about the performance of a process or
function.
■ Typically, within clinical technology projects, one identifies and
collects specific metrics about the performance of the technology or
metrics that capture the level of participation or adoption. Equally
important is the need for process performance metrics.
■ Process metrics are collected at the initial stage of a project or
problem identification.
○ Process analysis
■ Breaking down the work process into a sequential series of steps
that can be examined and assessed to improve effectiveness and
efficiency; explains how work takes place, gets done, or how it can
be done.
○ Process map
■ A visual depiction of the output of workflow analysis process.
○ Process owners
■ Those persons who directly engage in the workflow to be analyzed
and redesigned and have the ultimate responsibility for the
performance of the process.
■ These individuals can speak about the intricacy of the process,
including process variations from the normal.
○ Qualified Clinical Data Registries (QCDRs)
■ Introduced for the Physician Quality Reporting System (PQRS)
beginning in 2014, a QCDR will complete the collection and
submission of PQRS quality measures data on behalf of individual
eligible professionals (EPs) and PQRS group practices.
■ For 2016, a QCDR is a Centers for Medicare and Medicaid
Services–approved entity that collects medical and/or clinical data
for the purpose of patient and disease tracking to foster
improvement in the quality of care provided to patients.
○ Quality
■ A level or grade of excellence; relative merit; a distinct or essential
characteristic, attribute, or property.
○ Quality payment program (QPP)
■ To replace the hodgepodge system of Medicare reporting programs
○ Six Sigma
■ Business management tactic that seeks to improve the quality of
process outputs by identifying and removing the causes of errors
and reducing inconsistency and variability in processes
○ Workflow/Work process■ A progression of steps (tasks, events, and interactions) that
constitute a work process; involve two or more persons; and create
or add value to the organization’s activities.
■ In a sequential workflow, each step depends on the occurrence of
the previous step; in a parallel workflow, two or more steps can
occur concurrently.
■ The term “workflow” is sometimes used interchangeably with
“process” or “process flow,” particularly in the context of
implementations.
■ A sequence of connected steps in the work of a person or team of
people—that is, the process or flow of work within an organization;
a virtual illustration of the “real” work or steps (flow) that workers
enact to complete their tasks (work).
■ The purpose of examining and redesigning workflow is to
streamline the work process by removing any unnecessary steps
that do not add value or might even hinder the flow of work.
○ Workflow analysis
■ Not an optional part of clinical implementations, but rather a
necessity for safe patient care fostered by technology.
■ The ultimate goal of workflow analysis is not to “pave the cow path,”
but rather to create a future-state solution that maximizes the use of
technology and eliminates non–value-added activities.
■ Although many tools and methods can be used to accomplish
workflow redesign, the best method is the one that complements
the organization and supports the work of clinicians.
McBride, S., & Tietze, M. (2018).
● Chapter 6 Computers in Health Care
○ application software
■ generally has a purpose or function specific to its use (e.g.,
accounting/financial applications
○ Database
■ are defined as a large collection of data organized for rapid search
and retrieval
○ hardware
○ hardware configuration■ Various system settings that allow for computers or other hardware
to work
○ human factors
■ the field of study focused on understanding human elements of
systems, in which ‘systems’ may be defined as software, medical
devices, computer technology, and organizations
○ network typology
■ Network topology is the arrangement of the elements of a
communication network.
■ Network topology can describe the arrangement of various types of
telecommunication networks, including command and control radio
networks, industrial field busses and computer networks.
● Tree network
○ one builds off the switch and connects a switch to
switch, and this configuration works using the
Internet.
■ Expansion is available with this network
● Star network
○ Typically connected via a switch or hub, with a limited
number of computers on the network
● Ring network
○ set up in a circular configuration with the signals
transmitting around the ring until the envelope
containing the data, or package of information, finds
the designated address.
○ Difficult to add to a computer
○ When one computer goes down the whole network
goes down
● Bus network
○ Bus configurations are dependent on the total length
of the network and the distance the computers are
spaced within the network.
○ Total distance, number of computers, and spacing are
relevant to the efficiency with a bus configuration.
■ Various networks have pros and cons depending on the
configuration.
○ programming languages
■ is a mechanism for transforming information into a computer in the
form of machine code, which instructs the computer to do some
type of task
■ First generation● Referred to as the “low language”
● consists of binary 0s and 1s
■ Second generation
● One step higher and constitutes assembly languages that
use reserved words and symbols that have special and
unique meaning
● It is considered a low-level language similar to machine
language
● Uses symbolic operation code to represent the machine
operation code
● The assembly code is specific to the machines, including
computers
■ Third generation
● Intended to be easier to use, and higher level languages
provided a programmer-friendly language.
● Some examples of this type of code include FORTRAN,
BASIC, Pascal, and the C-family
■ Fourth generation
● More in line with the “human language” and therefore easier
to work with than 3GL
● Domain-specific and high-productivity languages and include
aspects such as database queries and report generators, as
well as GUI creators, database programming, and scripts.
● Many of the 4GL are data oriented and use structured query
language (SQL) developed by IBM and also adopted by the
American National Standards Institute
■ Fifth generation
● Utilize visual tools to support programming
● One such frequently used language is Visual Basic
● 5GL to be a type of constraint logic or problem-solving-based
programming
● PROLOG is a programming language that fits into this
description
○ Query
■ computer languages used to make queries in databases and
information systems
■ programming language that requests and retrieves data from
database and information systems by sending queries
○ reports
○ Software types
■ Business software● Used by and for specific business functions in healthcare
● Embedded within the EHR
■ Messaging software
● Used to exchange files and messages between systems
remotely
● Healthcare systems require encryption of data to meet
HIPAA regulatory requirements when using communications
■ Data-management software
● Source software with the primary function of managing a
database in a particular structure, usually relational or object
oriented
■ Graphics software
● allows the end user to manipulate graphic images on the
computer
■ Simulation software
● allows the end user to model real phenomena with a set of
mathematical formulas used in healthcare professional
training to simulate events rather than have students
practice on patients
■ Gaming software
● uses interaction with a user interface to generate visual
feedback on a video device
■ Spreadsheet software
● allows data to be analyzed in a tabular format with data
organized in rows and columns that can be manipulated by
formulas
■ Word processors
● performs processing of text (words) to compose, edit,
format, or print written material
■ Workflow software
● reflect a process or steps within a process that provides
functionality to create workflows with a diagram-based
graphical designer approach
■ Presentation software
● used to create slide presentations that allow typesetting and
graphical design to create a professional-looking
presentation quickly
○ system software
■ Used to start and run a computer
■ is related to what the software does within the computer system to
support the use of the computer○ Usability
■ The degree to which something is able or fit to be used
● Chapter 19 Clinical Decision Support System
○ CDS: provides clinicians, staff, patients, or other individuals with
knowledge and person-specific information, intelligently filtered or
presented at appropriate times to enhance healthcare
○ Successful implementation is done using leadership, executive support,
and interprofessional teams representing stakeholders most impacted by
changes to workflow
○ Five rights framework: right information (what), right person (who), right
CDS information format (how), right channel (where), right point in the
workflow (when)
○ Key strategy within HITECH and MU act
○ Primary goal of CDS is to leverage data and the scientific evidence to help
guide appropriate decision making
○ Predictive vs prescriptive analytics
■ Predictive: take available data and apply logic or algorithm to
calculate the likelihood of an event (falls risk tool)
■ Prescriptive: lead the clinician on a defined pathway to address the
identified issue (hundreds of data points to give a weighted sepsis
score- trigger a sepsis guideline order set)
○ Qualitative evaluation strategy after implementing CDS program may
include focus groups or surveys-- Quantitative measures include flow
charts and may be used to report back to leadership
○ CDS teams must design and deploy CDSS’s so they are most helpful for
their purposes as EHR directly from the vendor do not automatically
capture certain information to find trends and suggest interventions
■ Finding common ground terminology is important as what one thing
means to IT staff is something totally different from a doctor or even
different to the nurse
■ The team must work together, as clinicians can have unrealistic
expectation for the capability of technology/computer, and the
informatics team needs to know what is important to the front line
staff
○ The most important issue with regard to liability/legal concerns is whether
CDS tools are well designed and well implemented, but clinicians are held
to the same level of accountability with the EHR as with the paper-based
record- alerts should be clinically relevant
■ Also recommended that a stronger government regulation of CDS
and the development of clinical practice guidelines
○ Challenges to implementing CDS■ Timing of when to receive alerts within provider workflow
■ Speed and ease of access to alerts
■ Autonomy desired by clinician related to how much control end
users have over their response to CDS (whether the CDS alert is a
hard stop preventing them from moving forward in the EHR until
alert is addressed & whether it takes significant effort to override
WEEK SIX READING/ KEY POINTS
● McGonigle Chapter 18 Telenursing and remote access telehealth
○ Telehealth: wide range of health services that are delivered by
telecommunications ready tools, such as telephone, videophone, and
computer
○ Foundation of knowledge model and home telehealth
■ Knowledge acquisition: receiving information from telehealth device
such as vital signs taken in home and patients response to
customized questions- information goes to remote server and
accessed by telehealth nurse
■ Knowledge processing: take vital signs, subjective data, with pt
history to get picture of the clinical situation
■ Knowledge generation: uses nursing skills & knowledge along with
information from the patient to decide the best course of action to
take and acts on the data. The nurse will reflect upon the situation
to see if any more information needs to be gathered or if the
physician needs to be consulted regarding tx plan. Additional
questions may be asked if needed.
■ Knowledge dissemination: may include calling the doctor,obtaining
change in med order, calling pt to notify of the change, education,
continued monitoring
○ Allow easier and faster access to patients conditions ex. Pt’s response to
medications in hours rather than in days
○ Telehealth is needed to help fill the nursing shortage allowing nursing to
see more patients quicker, as well as the aging population ( 50+ years ⅘
old live with at least one chronic disease or condition). The amount of
chronic conditions and number of people affected by chronic conditions is
expected to continue rising-- of people of all ages have limited ability to ⅓
go to school or live independently due to chronic conditions
○ The U.S healthcare system spends $1.4 trillion each year on conventional
medical care and will increase in the coming decades-- one solution is todevelop a new clinical model for American health care that includes
technology
○ Telemedicine: use of medical information exchanged from one site to
another via electronic communications to improve patients health status--
Telehealth is similar but is a broader definition that does not always
involve clinical services
○ Telehealth: use of technology to deliver healthcare, health information, or
health education at a distance
■ Ex: teleradiology- test results are forwarded to another facility for dx
○ Store and forward telehealth transmissions: digital images, video, audio,
and clinical data are captured and stored on the client computer or devicethen data are transmitted securely to a specialist or clinician at another
location where they are studied, if applicable they will transmit it back
○ Real-time telehealth: telecommunications link to provide live interaction to
take place
○ Telephony: telephone monitoring, most basic type of telehealth
● McBride Chapter 7 EHR and POC technology
○ Adoption
■ refers to how well the staff and users actually use and embrace the
system as part of their routine daily activities
■ Adoption of the EHR by stakeholders, including leadership,
clinicians, support staff, and patients, aligns with more mature
stages in accordance with the diffusion of an innovation theoretical
framework
■ Today, the adoption of EHRs has become routine, given that most
organizations and providers have an EHR
○ barcode medication administration
■ Have removed many of the process and human factor effects of
patient care, leading to a reduction in errors and improved quality
■ Medication is prepared and delivered to the patient by scanning the
patient’s armband and the medication, after which an electronic
process occurs that verifies the five rights of medication
administration using a barcode reader.
○ early adopters
■ Early adopters may also be champions, nursing informaticists, or
superusers, and represent about 13.5% of the organization’s
population
■ They may also be users who are engaged and ready to start using
the system to its fullest potential and offer a positive response on
the implementation■ Early adopters look for the bugs in the system and seek to find
solutions
■ They are willing to support the system with their peers and other
staff, and to promote the use of the system.
■ They follow the defined workflows and ask questions in areas of
uncertainty
■ Early adopters may look for better ways to perform specific
workflows, if they feel the workflows are not optimized or could
work better
■ They are supportive of the system but are also realistic in their
approach, yet they remain positive while looking for solutions to
problems or issues.
○ electronic health record
■ Is the systematized collection of patient and population
electronically-stored health information in a digital format
■ These records can be shared across different health care
settings
■ EHRs are real-time, patient-centered records that make
information available instantly and securely to authorized
users
○ Evaluation
■ An evaluation of how effective the adoption of an EHR has been
can be measured through qualitative studies, such as surveys,
questionnaires, focus groups or ethnographic observational
methods, staff interviews, and workflow analysis before and after
the implementation of the system.
■ An evaluation of the implementation should be done by all
members of the project team, as well as by the staff using the
system
○ Implementation
■ The implementation of an EHR follows a very specific process
called SDLC
■ SDLC is used by engineers and developers in creating systems,
but it is also the accepted process for managing a project, such as
an EHR implementation, from decision making, to beginning a
project, to the completion of the project
■ An SDLC approach has a definite time frame—a beginning or
initiation point and an end or closure point. This section reviews the
SDLC approach to EHR implementation■ There are several different constructs for managing projects of the
magnitude and scope of an EHR implementation, but SDLC follows
a very specific group of activities defined within each phase, thus
further defining the project steps and requirements
■ During the implementation phase, policies [Show Less]