NR 599 Nursing Informatics Final Exam Study Guide
Nursing Informatcs NR-599 Final Exam Study Guide
Ethical decision making: The process of making
... [Show More] informed choices about ethical dilemmas based
on a set of standards differentatng right from wrong. The decision making reflects an
understanding of the principles and standards of ethical decision making, as well as
philosophical approaches to ethical decision making. It requires a systematc framework for
addressing the complex and ofen controversial moral questons.
Ethical Model for Ethical Decision Making
E Examine the ethical dilemma (conflictng values exist).
T Thoroughly comprehend the possible alternatves available.
H Hypothesize ethical arguments.
I Investgate, compare, & evaluate the arguments for each alternatve.
C Choose the alternatve you would recommend.
A Act on your chosen alternatve
L Look at the ethical dilemma & examine the outcomes while reflectng on the ethical
decision.
Bioethical standards: Bioethics is the study and formulaton of healthcare ethics. Bioethics
takes on relevant ethical problems experienced by healthcare providers in the provision of care
to individuals and groups.
Bioethics Principles
Early founders of bioethics put forth 4 principles which form the framework for moral reasoning:
1. Autonomy: The right of an individual to choose for themselves. Refers to the individual’s
freedom from controlling interferences by others and from personal limitatons that
prevent meaningful choices, such as adequate understanding. Two conditons are
essental for autonomy: liberty (meaning the independence from controlling influences)
and the individual’s capacity for intentonal acton.
2. Nonmalefcence: Doing no harm. Asserts an obligaton not to inflict harm intentonally
and forms the framework for the standard of due care to be met by any professional.
Obligatons of nonmalefcence are obligatons of not inflictng harm and not imposing
risks of harm. (Negligence—a departure from the standard of due care toward others—
includes intentonally imposing risks that are unreasonable and unintentonally but
carelessly imposing risks.)
3. Benefcence: Actons performed that contribute to the welfare of others. Two principles
underlie benefcence: Positve benefcence requires the provision of benefts, and utlity
requires that benefts and drawbacks be balanced. One must avoid negatve
benefcence, which occurs when constraints are placed on actvites that, even though
they might not be unjust, could in some situatons cause detriment or harm to others.4. Justce: Fairness. Treatment of everyone in the same way. Refers to fair, equitable, and
appropriate treatment in light of what is due or owed to a person. Distributve justce
refers to fair, equitable, and appropriate distributon in society determined by justfed
norms that structure the terms of social cooperaton.
E-Health Code of Ethics
8 standards for the ethical development of health-related Internet sites:
1. Candor: Disclose informaton that if known by consumers would likely affect consumers’
understanding or use of the site or purchase or use of a product or service.
2. Honesty: Be truthful and not deceptve.
3. Quality: Provide health informaton that is accurate, easy to understand, and up to date.
AND Provide the informaton users need to make their own judgments about the health
informaton, products, or services provided by the site.
4. Informed consent: Respect users’ right to determine whether or how their personal data
may be collected, used, or shared.
5. Privacy: Respect the obligaton to protect users’ privacy.
6. Professionalism: Respect fundamental ethical obligatons to patents and clients. AND
Inform and educate patents and clients about the limitatons of online health care.
7. Responsible partnering: Ensure that organizatons and sites with which they afliate are
trustworthy.
8. Accountability: Provide meaningful opportunity for users to give feedback to the site.
AND Monitor their compliance with the e-Health Code of Ethics.
Telehealth: Telecommunicaton technologies used to deliver health-related services or to
connect patents and healthcare providers to maximize patents’ health status. A relatvely
new term in the medical/nursing vocabulary, referring to a wide range of health services
that are delivered by telecommunicatons-ready tools such as the telephone, videophone,
and computer.
“Telehealth” is intended to encompass 3 broad methods of digital care delivery that are
“away” from the patent:
1. Telemedicine (statonary scheduled remote diagnostcs of health status)
2. Remote management/monitoring/coaching (statonary home or facility based, with
scheduled and as-needed remote transmission of health status)
3. Mobile health (mHealth) “community” groups/social media (wearable mobile patentgenerated health data with scheduled and as-needed remote transmission of health
status)
Telemedicine: Health services delivered by telecommunicatons-ready tools, supervised or
directed by a physician.Teleradiology: Use of telecommunicatons technology to electronically transmit and
exchange radiographic patent images with the consultatve text or radiologist reports from
one locaton to another.
Telepathology: Use of telecommunicatons technology to facilitate the transmission and
transfer of pathology data for the purposes of diagnoses, educaton, and research.
Transmission and exchange of image-rich pathology data between remote locatons.
Telemonitoring: Remote measurement of patents’ vital signs and other necessary data.
Telehealth care: Health services delivered by telecommunicatons-ready tools, usually
supervised by a nurse or other clinician.
Store-and-forward telehealth transmission: An applicaton of telehealth care in which
images and other clinical data are captured and transmited to specialist clinicians.
Real-tme telehealth: Live interactons between two or more clinicians, usually performed
with videoconferencing equipment.
Telephony: Telephone monitoring of patents at their residences by off-site telenurses.
Telenursing: Health services delivered by telecommunicatons-ready tools, supervised or
directed by a nurse.
Home telehealth care: Home healthcare clinical and educatonal services provided via
telecommunicatons-ready tools.
Peripheral biometric (medical) devices: A variety of telecommunicatons-ready
measurement devices, such as blood pressure cuffs and blood glucose meters, that typically
use the household telephone jack to transmit patent data to a central server locaton.
Personal emergency response systems: Signaling devices that enable patents to access
emergency and other care needs.
Sensor and actvity-monitoring systems: Systems for tracking actvites of daily living of
seniors and other at-risk individuals in their place of residence. For example, applicatons
use sensors to detect anomalies or problems such as faucets and stoves lef turned on.
Medicaton management devices: Range of telecommunicatons-ready medicaton devices
to remind or otherwise alert patents to medicaton compliance needs.
Clinical Uses of Telehealth
A few clinical uses for telehealth technologies and some sample clinical applicatons: Transmitng images for assessment or diagnosis. One example is transmission of
digital images, such as images of wounds for assessment and treatment consults.
Transmitng clinical data for assessment, diagnosis, or disease management. One
example is remote patent monitoring and transmitng patents’ objectve or
subjectve clinical data, such as monitoring of vital signs and answers to disease
management questons.
Providing disease preventon and promoton of good health. Examples include case
management provided via telephone or smartphone app and patent educaton
provided through asthma and weight management programs conducted in schools.
Using telephonic or video interactve technologies to provide health advice in
emergent cases. One example is performing teletriage in call centers or real-tme
stroke consultaton between a rural health center and an academic medical center.
Using real-tme video. One example is exchanging health services or educaton live
via videoconference.
Medical applicatons: Mobile Health, also known as mHealth, is defned as the use of wireless
communicaton to support efciency in public health and clinical practce. To facilitate mHealth,
mobile applicatons (apps) have been developed, which can be executed either on a mobile
platorm or on a web-based sofware applicaton that is tailored to a mobile platorm but is
executed on a server. Mobile medical apps are accessories to a regulated medical device or are
sofware that transforms a mobile platorm into a regulated medical device. These mobile
devices may include, but are not limited to, mobile phones or smartphones, tablet computers,
smart watches, and point-of-care (POC) devices.
o Apps Providing Access to Electronic Copies: Mobile apps that are intended to provide
access to electronic “copies” (e.g., e-books, audio books) of medical textbooks or other
reference materials with generic text search capabilites. These apps are not considered
medical devices because they are intended to be used as reference materials and are
NOT intended for use in the diagnosis of disease or other conditons, or in the cure,
mitgaton, treatment, or preventon of disease by facilitatng a health professional’s
assessment of a specifc patent, replacing the judgment of clinical personnel, or
performing any clinical assessment.
o Apps for General Patent Educaton: Mobile apps that are intended for general patent
educaton and facilitate patent access to commonly used reference informaton. These
apps can be patent specifc (i.e., flters informaton to patent-specifc characteristcs),
but are intended for increased patent awareness, educaton, and empowerment, and
ultmately support patent-centered health care. These apps are not considered medical
devices because they are intended generally for patent educaton.
o Generic Aids of General Purpose Apps: Mobile apps that are generic aids or general
purpose products. These apps are not considered medical devices because they are not
intended for use in the diagnosis of disease or other conditons, or in the cure,
mitgaton, treatment, or preventon of disease.o Apps as Educatonal Tools: Mobile apps that are intended for healthcare providers to
use as educatonal tools for medical training or to reinforce training previously received.
These may have more functonality than providing an electronic copy of text (e.g.,
videos, interactve diagrams), but are not considered medical devices because they are
intended generally for user educaton.
o Apps Automatng Ofce Operatons: Mobile apps that automate general ofce
operatons in a health care setng. These apps are not intended for use in the diagnosis
of disease or other conditons, or in the cure, mitgaton, treatment, or preventon of
disease.
Medical devices: Many mobile apps are not medical devices, meaning such mobile apps do not
meet the defniton of a device by the Federal Food, Drug, and Cosmetc Act (FD&C Act);
therefore, the FDA does not regulate them. Some mobile apps may meet the defniton of a
medical device but because they pose a lower risk to the public, the FDA intends to exercise
enforcement discreton over these devices (meaning it will not enforce requirements). One
example is a mobile app that makes a LED operate. If the manufacturer intends the system to
illuminate objects generally (i.e., without a specifc medical device intended use), the mobile
app would not be considered a medical device. If, however, through marketng, labeling, and the
circumstances surrounding the distributon, the mobile app is promoted by the manufacturer
for use as a light source for providers to examine patents, then the intended use of the light
sources would be similar to a conventonal device such as an ophthalmoscope.
The following examples represent mobile apps for which the FDA intends to exercise
enforcement discreton:
Mobile apps that provide or facilitate supplemental clinical care, by coaching or
promptng, to help patents manage their health in their daily environment
Mobile apps that provide patents with simple tools to organize and track their health
informaton
Mobile apps that provide easy access to informaton related to patents’ health
conditons or treatments (beyond providing an electronic “copy” of a medical
reference)
Mobile apps that are specifcally marketed to help patents document, show, or
communicate to providers potental medical conditons
Mobile apps that perform simple calculatons routnely used in clinical practce
Mobile apps that enable individuals to interact with PHR systems of EHR systems
Mobile apps that meet the defniton of Medical Device Data Systems
FDA Oversight for Medical Devices: The United States Food and Drug Administraton (FDA)
oversees medical applicatons and assesses their potental misuse or malfuncton in order to
reduce these risks to the public. This growing risk factor prompted the FDA to introduce a
guidance in 2011. In 2013, the FDA released its fnal guidance enttled “Mobile Medical
Applicatons Guidance for Industry and Food and Drug Administraton Staff”. The guidance
offers clear distncton between an unregulated “mobile applicaton” and a “mobile medicalapplicaton” which are subject to overt FDA regulaton. This guidance also focuses on apps that
possess a greater risk to patents if they don’t functon as they intended.
Privacy: An important issue related to personal informaton, about the owner or about other
individuals, that focuses on sharing this informaton with other electronically and the
mechanisms that restrict access to this personal informaton.
Through HIPAA to protect the privacy and security of health informaton, two sets of federal
regulatons were implemented. The Privacy Rule became effectve in 2003, and the Security
Rule became effectve in 2005. Many practtoners that refer to HIPAA are not referring to the
comprehensive federal statute enacted in 1996, but rather to the Privacy Rule and the Security
Rule—that is, the federal regulatons that were adopted years afer HIPAA became law.
Under the Privacy Rule, patents have a right to expect privacy protectons that limit the use and
disclosure of their health informaton. This applies to protected health informaton (PHI),
defned as any physical or mental health informaton created, received, or stored for a “covered
entty” that can be used to identfy an individual patent, regardless of the form of the health
informaton (i.e., it can be electronic, handwriten, or verbal). Covered enttes include hospitals
and other healthcare providers that transmit any health informaton electronically, as well as
health insurance companies and healthcare clearinghouses.
Confdentality: The mandate that all personal informaton be safeguarded by ensuring that
access is limited to only those who are authorized to view that informaton.
An organizaton must follow a well-defned policy to ensure that private health informaton
remains appropriately confdental. The confdentality policy should clearly defne which data
are confdental and how those data should be handled. Employees also need to understand the
procedures for releasing confdental informaton outside the organizaton or to others within
the organizaton and know which procedures to follow if confdental informaton is accidentally
or intentonally released without authorizaton. In additon, the organizaton’s confdentality
policy should contain consideraton for elements as basic as the placement of monitors so that
informaton cannot be read by passersby. Shoulder surfng, or watching over someone’s back as
that person is working, is stll a major way that confdentality is compromised.
Cybersecurity: The practce of defending computers, servers, mobile devices, electronic
systems, networks, and data from malicious atacks.
Another federal regulatory agency with a role in the privacy and security of healthcare data is
the FDA. The FDA oversees the safety of medical devices, which includes addressing the
management of cybersecurity risks and hospital network security. Recent guidelines
recommend that medical device manufacturers and healthcare facilites take steps to ensure
that appropriate safeguards are in place to reduce the risk of failure caused by a cyber atack.
Cyber atacks can be initated by the introducton of malware into the medical equipment or
unauthorized access to confguraton setngs in medical devices and hospital networks. Theconsequences of not adequately addressing these risks could be dire. As medical devices are
increasingly integrated within healthcare environments, there will be a need for vigilance
toward cybersecurity practces to ensure all systems are adequately protected and patents
remain safe from harm. Nurse Informatcists are frequently called on to evaluate the safety and
effectveness of new devices and sofware. Consideratons of cybersecurity must be included in
any evaluaton process.
Computer-aided translators: Form of language translaton in which a human translator uses
computer hardware to support and facilitate the translaton process.
Health Informaton Portability and Accountability Act (HIPAA): Law signed by President Bill
Clinton in 1996 addressing the need for standards to regulate and safeguard health informaton
and making provisions for health insurance coverage for employed persons who change jobs.
While it is best known among consumers and healthcare professionals for its protecton of
personal health informaton (PHI) and the additonal forms that each of us are asked to sigh
when we go to provider ofces, HIPAA also ensures portability of insurance for individuals
moving from one job to another, legal protecton for PHI, and mandates standards for the
electronic data interchange of healthcare date for encounter and claims informaton, and was
intended to simplify the claims submission process by eliminatng paper claims. HIPAA
established legal sanctons for insttutons and individuals who fail to protect PHI. As healthcare
professionals, we are cognizant of HIPAA requirements before we share PHI via writng,
electronic means, faxes, telephone, or in person. Specifc measures to protect PHI include
limitng record access to individuals with a right to know, signed disclosures to release
informaton, encrypton of e-mail and fles, fax cover sheets, designated persons who may
receive PHI, and the use of passwords to guarantee that PHI is only disclosed with persons
designated by the consumer as having a right to know. HIPAA has also changed sign-in
procedures for patents, disposal of forms containing PHI, and how we use whiteboards to show
patent informaton.
ICD-10 Coding (Internatonal Classifcaton of Diseases): The most common code sets used are
the diagnostc and procedural coding or classifcaton systems. The oldest and most established
system is the ICD, which is promulgated and maintained by the World Health Organizaton
(WHO). The United States converted to ICD-10-CM on October 1, 2015. This is the 10th revision
of the system, and therefore the classifcaton system is known as ICD-10. ICD-10 codes are
shorthand for the patent’s diagnoses, which are used to provide the payer informaton on the
necessity of the visit or procedure performed. This means that every CPT (Common Procedural
Terminology) code must have a diagnosis code that corresponds. The CPT codes were
designated by the American Medical Associaton (AMA). The primary purpose of these
classifcaton systems in the United States is reimbursement or claims processing. These systems
are classifcaton systems, meaning they classify diseases or procedures into groups or
categories. Categorizaton, though, is not ofen adequate to meet other needs requiring more
detail.Evaluaton and Management (E&M) Coding: This is important to understand because you will
be inputng this informaton as evidence for the types of patents seen in your clinical encounter
logs.
Before you can determine your E&M code, you must frst identfy the place of service, type of
service, and the patent status. The place of service refers to where the service was rendered.
There are several categories to choose from, but the two most common are the inpatent and
outpatent setngs. The type of service refers to the type of service provided. Some examples
of types of services include consultaton, hospital admission, ofce visit, and so forth. As a
student in your practcum rotatons, nearly all of your places and types of service will be
outpatent ofce visits. Finally, you need to identfy the patent’s status. Patent status refers to
whether or not the patent is a new patent or an established patent of your practce. By
defniton, a new patent is one who has not received professional service from a provider from
the same group practce within the past 3 years. Conversely, an established patent has received
professional service from a provider of your ofce within the last 3 years.
There are several E&M codes that are available to choose from for an outpatent, ofce-based
visit. The codes are chosen based on patent status (whether they are new or established) as
well as the complexity of the visit. The codes are ordered from lowest complexity to highest. So,
99205 and 99215 are the highest levels of complexity for a new and established patent.
OUTPATIENT—OFFICE VISIT
New Established
Minimal/RN visit 99201 99211
Problem focused 99202 99212
Exp. Problem focused 99203 99213
Detailed 99204 99214
Comprehensive 99205 99215
Once you have determined the status of the patent (new or established), you can then
determine which one of the fve E&M codes correspond with the visit. To do this, we are going
to apply the principles of risk-based coding.
There are three key components that determine risk-based E&M codes:
1. History (Hx)
2. Physical (PE)
3. Medical Decision Making (MDM)
Although you will not be required to know the requirements for each visit level for an exam, you
must be able to understand and communicate that each level has a minimum requirement of Hx
and PE elements that must be met, and that the higher the level, the more documentaton
required.The third element that is needed to determine the level of a visit is Medical Decision Making
(MDM). Medical decision making is another way of quantfying the complexity of the thinking
that is required for the visit. Complexity of a visit is based on three criteria:
1. Risk
2. Data
3. Diagnosis (Dx)
The MDM score gives us credit for the excess work involved in management of a more complex
patent. Your documentaton MUST match the requirements for that level of service. If you are
audited and your documentaton does not support the level of service, then this is considered
to be fraud and is subject to repayment of fees, additonal fnes, and sanctons. This is just one
reason why documentaton is so important.
There are different codes for patents being seen for a complete physical exam. These are
considered preventatve visits, and additonal reimbursement applies for your tme spent on
assessing health risks and providing educaton. Using the correct codes in your clinical
encounter log is especially important because it provides evidence of the populaton of patents
that you have seen.
Reimbursement Coding: Reimbursement codes are assigned contngent upon data input from
clinical team members based on a summatve review of the clinical record by trained coders.
This is a critcally important intersecton between the clinical and administratve teams. If the
patent encounter, procedure, or diagnosis are incorrectly entered into a clinical management
system, the billing and coding process will also be incorrect. Providers play an important role in
ensuring the success of the business by clearly identfying the diagnosis and service codes that
are appropriate for each patent visit. Therefore, it is imperatve for APNs to have knowledge of
the link between billing, coding, and the EHR.
Diagnosis-related groups (DRGs) or major diagnostc categories (MDCs) systematcally group
these more specifc codes into meaningful broader categories. The purpose of the DRG group is
to facilitate payment through the prospectve payment system, whereas MDCs organize
diagnoses that affect similar physiological systems. Although administratve data reflect
diagnoses and utlizaton, it is important to remember that their primary purpose is for billing.
Clinical Support Tools: Clinical decision support (CDS) is a process designed to aid directly in
clinical decision making, in which characteristcs of individual patents are used to generate
patent specifc interventons, assessments, recommendatons, or other forms of guidance that
are then presented to a decision-making recipient(s) that can include clinicians, patents, and
others involved in case delivery. CDS tools existed prior to development of EHRs. Historical
examples include practce guidelines carried in clinicians’ pockets, patent cards used by
providers to track a patent’s treatments, and tables of important medical knowledge. The
primary goal of implementng a CDS tool is to leverage data and the scientfc evidence to helps
guide appropriate decision making. CDS tools include but are not limited to: Computerized alerts and reminders for providers and patents
Drug-drug interacton alerts
Underdose or overdose alerts based on renal or liver functon, or age, or drug levels
Actonable clinical guidelines
Conditon-specifc order sets
Focused patent data reports and summaries
Diagnostc support
Contextually relevant reference informaton
Smart documentaton forms (tailored based on patent data to emphasize data
elements pertnent to the patent’s conditons & healthcare needs)
Order sets, care plans, and protocols (structured approaches to encourage correct &
efcient ordering, promote EBP, & provide different management recommendatons for
different patent situatons)
Parameter guidance (algorithms to promote correct entry of orders and documentaton)
Critques and “immediate” warnings (alerts that are presented just afer a user has
entered an order, a prescripton, or a documentaton item to show a potental hazard or
a recommendaton for further informaton)
Relevant data summaries (a single patent view that summarizes, organizes, & flters a
patent’s informaton to highlight important management issues)
Multpatent monitors (a display of actvity among all patents on a care unit, which
helps providers prioritze tasks & ensures that important actvites are not omited while
providers are multtasking among patents)
Predictve and retrospectve analytcs (analytc methods that combine multple factors
using statstcal & artfcial intelligence techniques to provide risk predictors, stratfy
patents, & measure progress on broad initatves)
“Info” butons (fltered reference informaton & knowledge resources within felds or
“butons” where informaton is provided to the end user in the context of the current
data display, also referred to as metadata, or “data about data”)
Expert workup and management advisors (diagnostc & expert systems that track &
advise a patent workup & management of the patent based on evidence-based
protocols)
Event-triggered alerts (warnings triggered within the system based on data that alert
the clinical user to a new event occurring asynchronously, such as an abnormal lab
value)
Reminders (tme-triggered events within the system reminding the clinical user of a task
needed to be based on predetermined tme within the system)
Workflow analysis:
Workflow is a progression of steps (tasks, events, and interactons) that consttute a work
process; involve two or more persons; and create or add value to the organizaton’s actvites. In
a sequental 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 sometmes used
interchangeably with “process” or “process flow”, partcularly in the context ofimplementatons. 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 organizaton; a virtual illustraton 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 is the observaton and documentaton of workflow to beter understand
what is happening in the current environment and how it can be altered. Workflow design is a
critcal aspect of the informatcs role. Nursing informatcs is uniquely positoned to engage in
the analysis and redesign of processes and tasks surrounding the use of technology.
Workflow analysis is not an optonal part of clinical implementatons, but rather a necessity for
safe patent care fostered by technology. The ultmate goal of workflow analysis is not to “pave
the cow path”, but rather to create a future-state soluton that maximizes the use of technology
and eliminates non-value-added actvites. Although many tools and methods can be used to
accomplish workflow redesign (e.g., Six Sigma, Lean), the best method is the one that
complements the organizaton and supports the work of clinicians. [Show Less]