American Recover and Reinvestment Act (ARRA)
Authorized INCENTIVE PAYMENTS to specific types of hospitals and healthcare professionals for adopting and
... [Show More] using interoperable Health Information Technology and EHR's. ARRA provides economic stimuli and incentives for the adoption of EHRs.
Admission-Transfer-Discharge (ADT) System
Classified under the hospitals' administrative info system. It's one of the foundational systems that allows operational activities such as bed placement, transportation coordination, room readiness, and the general coordination of services focused on the patient's phase of movement. Tracks a patient's activities and location from admission to discharge.
Analytical Science
Uses a variety of methods and instruments to answer 2 basic questions: What do I have? How much of it do I have? Environment, pharmacy, safety & security, fraud detection, and healthcare diagnostics.
Asynchronous Applications
Patient-centered and allows consumers to participate in their own care by using designated health technology to share health metrics and data with their healthcare provider via technology (remote patient-monitoring - the use of devices to capture patient data at one location and then transmit it electronically to healthcare professionals at a different location, allowing the review of data for clinical decision-making, i.e. MobileHealth).
Audit Trails
Software that is used for detecting security violations, performance problems, and flaws. Records activity by users and system. Goal is to improve data integrity. Audit trails are only one of the ways to ensure data integrity. An audit trail must contain the name of the user, the application triggering the audit, the workstation, the specific document, a description of the event being audited, and the date and time to determine the integrity of data.
Authentication
Action that verifies the authority of users to receive specified data.
Barcode Medication Administration
MANDATED BY FDA
Benchmark
The continual process of measuring services and practices against the toughest competitors in the healthcare industry. Comparing the performance of an organization or clinician to others.
Big Data
Very large data sets that are beyond human capability to analyze or manage without the aid of information technology. Big data is considered data originating from very large data sets that help identify patterns and trends. Big data cannot be managed without the use of technology to analyze its output.
Clinical Decision Support System (CDSS)
Supports healthcare practitioners in making patient-care decisions by integrating patient data with current clinical knowledge. CDSS is technology that provides recommendations for care and must be balanced with professional judgment, not used in place of it.
Clinical Information System
Software used to access client data, plan, implement, and evaluate care. May be specific to certain departments: lab, radiology, pharmacy, or particular patient populations. Provides patient centric decision-making functionality to help guide a nurse with decision-making while caring for a patient. Acquires patient data so that healthcare professionals can review it and use the information to deliver care.
Computer Literacy
Familiarity with the use of personal computers. Computer literacy is defined as the knowledge and ability to use computers and technology efficiently. Computer literacy allows patients to interact with the internet.
Computerized Provider Order Entry (CPOE)
The prescriber's decisions to enter orders and immediately share the orders with appropriate health professionals who execute the orders and departments that need to dispense, schedule, or immediately deliver services to patients.
Confidentiality
Unspoken understanding that private information shared in a situation, in which a relationship has been established for the purpose of treatment or delivery of services will remain protected.
Configurability
Refers to the extent that a given software product can be adapted or changed to meet a user's preference.
Connected Health
Model or platform by which technology assisted healthcare is delivered between at least two points, involving either synchronous or asynchronous exchange.
Consolidated-Clinical Document Architecture (C-CDA)
Allows interoperability of health information exchange between hospital systems.
Consumer Health Informatics (CHI)
Use of electronic information and communication to improve medical outcomes and health-care decision making from the patient/consumer perspective. Three barriers include: Privacy issues, cognitive disabilities, low health literacy. Five examples: Personal Health Records, Telehealth, Mobile Health, Games for Health, and Health 2.0. Telehealth is defined as healthcare at a distance through the use of technology that connects the patient and the clinician in real time.
Continuity of Care Record (CCD)
Snapshot of a person's health and healthcare to a provider who does not have access to the person's EHR.
Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Primary database used for nursing literature.
Data
Collection of numbers, characters, or facts that are gathered according to some perceived need for analysis.
Data Analysis
The processing of data that identify trends and patterns of relationships.
Data Information Knowledge Wisdom (DIKW) Framework
Data are the most discrete components of the DIKW framework. They are mostly presented as discrete observations with little interpretation. Information is a continuum of progressively developing and clustered data. Relations and interactions are not yet evident in information alone. Knowledge is information that is processed and organized so that relations and interactions are identified. Wisdom is an appropriate use of knowledge to manage and solve human problems. Wisdom includes ethics or knowing why certain things or procedures should or should not be implemented in specific cases.
Data Integrity
Ability to collect, store, and retrieve correct, complete, and current data so that the data are available to authorized users when needed. Can be compromised by incorrect entry of information, data tampering, and system failure. Prevention by implementing security measures and audit trails. Data integrity is the state wherein data are uncorrupted, accurate, and valid.
Data Mining
Technique that look for hidden patterns and relationships in large groups of data using software.
Data Scrubbing
Data scrubbing is the process by which incorrect, incomplete, duplicate, or improperly formatted items are removed using special software designated for this purpose.
Data Warehouse - Provides a powerful method of managing and analyzing data
Decision Support Tool / Clinician Decision Support (CDS) / Decision Support System/Software (DDS)
Software/app to help in the human decision process. The software will look at the patient's data and suggest appropriate medical/nursing interventions. It can also trigger prompts/alerts to the user. Requires human user input. Decreases patient safety risk and increases positive patient outcomes (ex: alerts for abnormal vitals, lab results, medication contraindications, etc.) The right components of a CDS include a trigger, such as a medication order; input data, such as lab values; intervention information, such as other options provided; and an action step, such as the action selected by the clinician.
Electronic Health Record (EHR)
A database of an individual's healthcare data during healthcare encounters. It's comprised of any patient data stored in electronic form.
Electronic Medical Record (EMR)
Legal record created in hospitals and ambulatory settings of a single encounter or visit that is the source of data for the electronic health record. Brings together diagnostic and treatment information for an individual in a specific healthcare setting.
Electronic Medical Record Adoption Model (EMRAM)
Measures clinical outcomes, patient engagement, and clinical use of EMR technology to strengthen organizational performance and health outcomes across patient populations. Basically, it evaluates Health Information Systems.
Ergonomics
Scientific study of work and space, including details that impact productivity and health
Evidenced Based Practice (EBP)
Current, best evidence for patient care. Improves the consistency and quality of patient outcomes. Foundation of clinical practice and guides clinicians. Found in stand orders (ex. Sepsis protocol).
Expert System
A type of CDS/DDS but does NOT need human intervention, uses artificial intelligence (ex. Insulin pump).
*Fishbone
A tool for analyzing the organizational processes and its effectiveness. Helps team members visually diagram a problem or condition's root causes, allowing them to truly diagnose the problem rather than focusing on symptoms
Health Information Exchange (HIE)
Electronic sharing of patient information between healthcare providers according to nationally recognized standards, allows insurance companies and providers to share data, must be secure and maintain integrity. It works by improving the speed, quality, safety, and cost of patient care. Query-based exchange is often used for unplanned events. Like a visit to the emergency department. It allows providers to find and request information on a patient from other providers. Directed exchange is used to support coordinated care and allows the ability to send and receive secure information electronically between care providers. Consumer-mediated exchange allows the ability for patients to review, manage, and control the use of their health information among providers.
Health Information Technology (HIT)
Various systems and technology used to record, monitor, and deliver patient care, as well as perform managerial and organizational functions. HIT is used to support systems that collect data needed for patient care, population health management, and for the sharing of this information within a secure system.
Health Information Technology for Economic & Clinical Health Act (HITECH Act)
The HITECH Act provides funds and incentives to increase EHRs by providers, improve policy decisions, and allocate services, funded workforce training, and new technology research. HITECH strongly recommends increasing meaningful use of HIT to decrease overall healthcare cost and to improve population health.
Health Insurance Portability and Accountability Act (HIPAA) -
Sets the national Standard of Personal Health Information. Legal Protection for PHI. Electronic transactions need to have HIPAA compliant codes. Signing into devices should require authentication encryption and should never be left unattended. Fines prior to 2/18/09 are $100/violation with a max of $25000 yearly. If after 2009, fine can be $100-50000+/violation, with a max of $1.5 million yearly. Criminal penalty fines can be up to $50000 and 1-year in jail. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
Health Level 7 (HL7)
A standard/framework for the exchange of data (PHI) between information systems with an extensive set of rules that applies to all data that is exchanged, shared, integrated, or retrieved. Refers to both an organization and its standards to exchange data. Specifies how the data is coded
Health Literacy
Health literacy is more than just the ability to read and understand basic medical terminology and instructions. It is also the capacity of an individual to express their needs and preferences and to respond to the need for information about services provided for them. Low health literacy is not language dependent since it is also highly impacted by culture, ethnicity, race, environment, and social class. Health literacy involves teaching patients enough information about their illnesses and about how the health system works so that they can be legitimate partners in the appropriate management of their health. The most common challenge in advancing health literacy is assuming that patients understand the medical terminology that healthcare professionals are comfortable with. Health literacy is not restricted to knowing how to interact with the internet for their health information.
Informatics
INTERDISCIPLINARY FIELD. It is the science and art of turning data into information. Combines computer/decision/information/management/cognitive sciences and organizational theory.
Informatics Innovator
Expected to be educationally prepared to conduct informatics research, generate informatics theory, and have advanced understanding and skills in information management and computer technology.
Informatics Specialist
A nurse with advanced skills specific to health information management and computer technology with expertise in systems development life cycles.
Information - Data that has been interpreted.
Information Literacy
Ability to recognize when information is needed as well as the skills to find, evaluate, and use needed information effectively. Information literacy is the knowledge and ability to locate, organize, use, communicate, and interpret print and electronic sources of information.
Information Security
Information has value and requires protection.
Confidentiality
Relationship has been established where private information is shared but not disclosed unless the patient givens permission.
Phishing
Deceptive method used to steal sensitive information. In phase 1, the recipient typically receives a phish, or e-mail. Phase 2 involves the victim following through on what they are asked to do, such as completing a form. Once the recipient completes the information, the hackers now have information that they can use for nefarious purposes.
Privacy
The right to control access, disclosure, nondisclosure, and the timing and extent to which information is disclosed.
Integration
Process by which two different information systems are able to exchange data in a way that is seamless to the end-user.
Interface
Computer program that tells 2 different systems how to exchange data.
International Classification of Diseases-10th Revision (ICD-10)
Is the international standard diagnostic classification for health-management purposes, and clinical use. The ICD diagnoses are used to classify mortality and morbidity data from inpatient and outpatient records. Also used for reimbursement.
Interoperability
The ability of two entities, human or machine, to exchange and predictably use data or information while retaining the original meaning of the data. A nurse informaticist can increase interoperability by promoting standardized vocabulary and coding. This reduces errors, increases revenue, and increases communication. Interoperability allows timely and seamless portability of information and optimizes the health of individuals and populations globally through this seamless exchange.
Joint Commission
ACCREDITATION. Key standards of information management: protect and aggregate data, uniform definitions/language, teach information management (training), and address disaster and preparedness.
Knowledge
Synthesizing information from different sources to produce a concept of idea.
Knowledge Management
The generation, storage, distribution, and application of both tacit knowledge (personal experience) and explicit knowledge (evidence).
Knowledge Work/Workflow
The work of gathering data to create information.
Knowledge Worker
Individual with a high degree of expertise, education, or experience who creates, distributes, and applies knowledge.
Lewin's Change Model
One of several foundational theories for leading others through planned change; identifies three steps: unfreezing, changing, and refreezing.
Logical Security
Non-tangible protocols used for identification, authentication, authorization, and accountability (ex: automatic sign-off after a period of inactivity).
*Meaningful Use (MU)
Use of health information technology (HIT) legislated by ARRA of 2009 to collect specific data with the intent to improve care and populations health, engage patients, and ensure privacy and security, with financial incentive from Medicare and Medicaid to providers. (Goals - engage patients, exchange data in an accurate/complete way, improve patient care in a cost-effective way, improve healthcare overall).
Meaningful Use (MU) Core Requirements
Centers for Medicare and Medicaid Services (CMS) developed core criteria that defined basic functions of EHRs must demonstrate. Basic entry of clinical information, requiring standardized terminology across the board, use of several software applications, entry of clinical orders with safety measures. (Three required stages include: stage 1 - electronic capturing & sharing of data between hospitals/providers; stage 2 - requires pts to view, download, or transmit their health information online, capability for secure messaging between providers/patients, and reporting public health measures, advancing clinical processes; stage 3 - focuses on the enhanced use of EHRs to promote Health Information Exchange & Improve care, and improving patient outcomes (ex: electronic prescribing)).
Medical Informatics
Application of informatics to all of the healthcare disciplines as well as to the practice of medicine.
Merit-Based Incentive Payment System (MIPS)
QUALITY. Ensures Medicare patients get the right care at the right time. Uses PQRS (physician quality reporting systems) and Medicare EHRs that will be measured on quality, resource use, clinical-practice environment, and meaningful use of EHRs technology. For physicians to qualify for MIPS, they must bill Medicare more than $90,000/year and see more than 200 Medicare patients annually.
Mission
Purpose or reason for an organization's existence, representing the fundamental and unique aspirations that differentiate it from others.
National Quality Forum (NQF)
Nonprofit, membership-based organization that works to improve healthcare through meaningful measurement.
Nurse Informatics Specialist
A nurse with advanced computer technology skills with expertise in system development life cycles. The nurse needs to: play an active role in the adoption of standard technologies, be aware of legislation, educate users, assist users on troubleshooting, provide advice and recommendations, act as a liaison between nurses and technology, serve as a resource, manage data and information, develop tools and methods, and monitor data security, accuracy, and integrity by monitoring for patterns & exceptions.
Nursing Informatics
Uses nursing knowledge along with information and communication technology to promote the health of individuals, families, and entire populations.
Nursing Role in Informatics:
Assessment - analysis of what is needed Developing - develop the care/project plan Implementing - implement the plan Monitoring - monitor the outcomes Evaluating - lessons learned with knowledge transfer
Patient-Generated Health Data (PGHD)
Health-related data created, recorded, or gathered by the patient/caregivers to help address health concerns. Without in-person enrollment, verifying that a patient is eligible to participate in a study can be difficult.
Patient Protection & Affordable Care Act
Guarantees access to healthcare for ALL Americans and incentives to change clinical practice to encourage better coordination and quality care.
Personal Health Record (PHR)
Lifelong tool for managing health information, such as conditions, allergies, medications, past surgeries, and other relevant information. (Potential barriers include poor or no internet, poorly designed applications, limited clinical integration)
Physical Security
The protection of physical items, objects, or areas from unauthorized access and misuse. Measures include the placement of computers, file servers, routers, switches, and computers in restricted areas. Other examples include physical locks on devices.
Privacy
The right to control access and disclosure or nondisclosure of information pertaining to oneself and to control the circumstances, timing, and extent to which information may be disclosed.
Process Interoperability
Coordinates systems enabling business processes at organizations and allowing systems to work together.
Project Implementation Team / Committee
FIRST TASK IS TO DEVELOP A TIMELINE - Comprised of representatives from the ser departments. Project team needs to be actively involved as an end-user. Implementation committee determines the project implementation strategy. Interdisciplinary will plan, test, train, etc. after the EHR is purchased.
Project Management Lifestyle Cycle (PLMC
1) Design/Plan - Scope document: Official document that details how the project will be managed and what the project requirements are. Scope Creep - Unapproved change, which can cause serious delays or project failure. As the scope and charter are developed, a GAP analysis is completed and used to identify needed changes in workflow. GAP Analysis - A list of features & functions desired, but not immediately available in the new system as identified. 2) Implementation - Training the staff/end-users in this phase. With change, different behaviors can develop (ex: resignation, resistance, feelings of loss, etc.) Lewin's Change Theory - One of several foundational theories for leading others through planned change. Identifies 3 steps: Unfreezing, changing, refreezing. INVOLVES EMPLOYEES IN THE DECISION-MAKING PROCESS Big Bang Conversion - "All-at-once" implementation Rollout - Gradual/staggered implementation Pilot - Small groups of individuals to evaluate potential issues Parallel Conversion - Operates both the old and new systems for a limited time. 3) Monitor & Control 4) Evaluation 5) Lessons learned with knowledge transfer
QSEN
Identified quality & safety competencies for nurses that fit well with an informatics culture (patient centered care, teamwork, EBP, quality improvement, safety, informatics).
Scope Creep
Unexpected and uncontrolled growth of user expectations as a project progress.
Security Rule
National set of security standards health information in electronic form. Goal is to protect the privacy while adopting new technologies to improve quality and efficiency of patient care. On a need-to-know basis.
Semantic Interoperability
The exchange of data in which the meaning remains the same on both ends of the transaction.
SNOMED Clinical Terms
Globally recognized, controlled healthcare vocabulary that provides a common language for electronic health records (EHRs). Enables a consistent way of capturing, sharing, and aggregating health data across all specialties and sites of care. Supports interoperable data collection and exchange.
Standardized Terminologies
Structured, controlled languages developed according to terminology guidelines and approved by an authoritative body.
Store-and-Forward Applications
Asynchronous. Transmit recorded health info through a secure communications network to a provider (photos).
SWOT Analysis
Occurs during PLANNING of SDLC. It is a strategic type of planning and helps to identify gaps in the current system, as well as potential opportunities. This system evaluates strengths, weaknesses, opportunities, and threats of a given situation.
Synchronous Applications
Connected health applications that facilitate real-time, video and voice interaction and bidirectional communication between patients and healthcare providers (video-conferencing).
Systems Development Life Cycle (SDLC)
Steps are design, plan, implement, analyze, evaluate. 1) Needs assessment: Determine the needs/wants in an information system 2) Selection System Phase: An organization seeks out a vendor company that provides a system that best first the needs with 3 documents (1 - Information Document - initial contact with vendor to get essential info about the company's history; 2 - Proposal document - organization priorities or rates their needs/wants and send outline to vendors to see if request can be met; 3 - Quote document - pricing, finance, and contract terms) 3) System Implementation Phase: Go live PLANNING, with training and building. 4) ** Maintenance Phase: Problem solving, any debugging, filed backed up and updates are installed routinely, to ensure the program is working as intended.
Technical Interoperability
The ability to exchange the data from one point to another.
Technology Informatics Guiding Education Reform (TIGER Initiative)
Formed in 2004 to advance nurses' competencies related to informatics. Primary objective was to develop a US nursing workforce capable of using electronic health records to improve the delivery of health care.
Telehealth
Delivery of information to healthcare providers and consumers and the delivery of services to clients at remote sites through the use of telecommunication and computer technology. Does not always involved clinical services. (Telehealth encompasses telemedicine but is a broader term that emphasizes the provision of information to healthcare providers and consumers).
Telemedicine
Medical information exchanged from one site to another via electronic communications to improve a patient's health status. *Legal & Ethical issues from telehealth/telemedicine: lack of reimbursement, privacy & confidentiality concerns, licensure, & liability issues.
Telenursing
Being a nurse while using technology.
Usability
Specific issues of human performance in achieving specific goals during computer interactions within a particular context.
User Interface
Allows humans and computers to cooperatively perform tasks and specific goals.
Value-Based Reimbursement
Diagnostic tests and treatment options were based on the value of those tests and treatments to patient and organizational outcomes. The hope was to reduce the number of necessary or limited-valued test and treatments. The value-based model rewards providers and organizations for quality-driven care based on their ability to meet set quality measures and indicators.
Vision
Future-oriented, high-level view of what an organization would like to become that provides direction for planning purposes.
Wisdom
Using knowledge and experience to manage and solve problems.
Audit trails
are only one of the ways to ensure data integrity. An audit trail must contain the name of the user, the application triggering the audit, the workstation, the specific document, a description of the event being audited, and the date and time to determine the integrity of data. The name of the auditor is not part of an audit trail.
American Health Information Management Association (AHIMA)
One of the guiding principles of the AHIMA Code of Ethics is to advocate, uphold, and defend the consumer's right to privacy and the doctrine of confidentiality in the use and disclosure of information. While this guiding principle is focused on the health information management professional, it also applies to the nursing profession. The AHIMA Code of Ethics serves six purposes: Promotes high standards of HIM practice. Summarizes broad ethical principles that reflect the profession's core values. Establishes a set of ethical principles to be used to guide decision-making and actions. Establishes a framework for professional behavior and responsibilities when professional obligations conflict or ethical uncertainties arise. Provides ethical principles by which the general public can hold the HIM professional accountable. Mentors practitioners new to the field to HIM's mission, values, and ethical principles.
Artificial Intelligence
operates in an intentional and adaptive manner learning from acquired data and becoming more accurate over time in the identification of trends and patterns. The acquired data it learned from identified trends and patterns help it to make recommendations or to provide answers for the healthcare professional's decision-making.
Affordable Care Act (ACA)
US legislation intended to improve healthcare quality through using information technology, ensuring affordable care, and increasing the number of insured persons.
Alert/Alarm fatigue-
the clinician to the Phenomenon that occurs when the volume of alerts, alarms, or warning messages acts contrary to intention through desensitizing indicators and/or the purpose.
Analytics-
Discovery, interpretation, and communication of meaningful patterns from data to offer solutions and drive decisions.
ARRA (American Recovery and Reinvestment Act)
was enacted in 2009 as an attempt to revive the nation's economy, create jobs, and address widely neglected challenges that impact the future. Many of the provisions to the ARRA were directed toward improving healthcare such as reduced COBRA health-insurance premiums, a tax credit for health coverage to encourage greater compliance, and federal funding or incentives for healthcare organizations to upgrade HIT systems. In 2011, healthcare systems began the transition from paper documentation to electronic documentation with the intent to show meaningful use and receive incentives for successful EHRS adoption. Organizations that adopted EHRSs were given funding for the system itself, for staff education, and for evaluation tools to ensure successful implementation.
Big data
Very large data sets that are beyond human capability to analyze or manage without the aid of information technology. (Big data is considered data originating from very large data sets that help identify patterns and trends. Big data cannot be managed without the use of technology to analyze its output.)
Best of breed
-which refers to using only one specific vendor for all desired functionality or selecting the best technology from a number of vendors. P. 155
Business associate
is an individual or organization that creates, receives, maintains, or transmits protected health information (PHI) on behalf of a covered entity. State three examples of a business associate.
Clinical decision support system (CDSS)
Supports healthcare practitioners in making patient-care decisions by integrating patient data with current clinical knowledge.
Clinical information systems (CIS)-
Large computerized database management systems used to access the patient data that is needed to plan, implement, and evaluate care. May also be known as patient care information systems.
Connected Health-
Model or platform by which technology-assisted healthcare is delivered between at least two points, involving either synchronous assessment or asynchronous exchange.
Data integrity
Ability to collect; store; and retrieve correct, complete, and current data so that the data are available to authorized users when needed.
Data scrubbing
is the process by which incorrect, incomplete, duplicate, or improperly formatted items are removed using special software designated for this purpose.
Data Sources:
Medical records offer information such as medical history, drug history, diagnostic and therapeutic procedures, lab tests, health problems, and any other information collected during the patient's encounter with their medical provider or healthcare organization. Used to monitor outbreaks of specific diseases and conditions. Surveillance is a data source used when specifically monitoring trending rates or outbreaks of specific diseases or conditions. Collects information directly from participants and relies on the participants' interpretation of what they recall and not necessarily what transpired. Surveys collect health and social science information from a sample of people in a standardized way to better understand a larger population. Used to provide information on fixed data elements at the state and national level. Vital records provide information on fixed data elements at the state and national level.
Data warehouse
Provides a powerful method of managing and analyzing data.
Decision-support software
Computer programs that organize information to aid choices related to patient care or administrative issues.
Descriptive analytics
is a statistical method that is used to search and summarize historical data in order to identify patterns or meaning.
Data Information Knowledge Wisdom (DIKW) Framework
Data are the most discrete components of the DIKW framework. They are mostly presented as discrete observations with little interpretation. Information is a continuum of progressively developing and clustered data. Relations and interactions are not yet evident in information alone. Knowledge is information that is processed and organized so that relations and interactions are identified. Wisdom is an appropriate use of knowledge to manage and solve human problems. Wisdom includes ethics or knowing why certain things or procedures should or should not be implemented in specific cases.
Ethical judgment
is a deliberative process reflecting knowledge of ethical principles, theories, and codes. It is also reasoning about the possible actions in the situation and judging which action is most ethical. (Four-component model)
Ethical dilemma or ethical paradox
is a decision-making problem between two possible moral imperatives, neither of which is unambiguously acceptable or preferable. The complexity arises out of the situational conflict in which obeying one would result in transgressing another.
Ethical sensitivity
is described as the ability to recognize an ethical problem. Attention to a nurse's feelings can be important evidence that the nurse is facing an ethical dilemma. These feelings are triggered even when nurses do not have a personal interest in any given event.
Failure Mode and Effects Analysis (FMEA)
is a structured way to identify and address potential problems, or failures and their resulting effects on the system or process before an adverse event occurs.
Four Component Model
he FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action: ethical sensitivity, ethical judgment, ethical motivation, and ethical action
Gap analysis
Comparison of actual performance with potential or desired performance.
GRADE
stands for grading of recommendations, assessment, development, and evaluations. The GRADE approach was to get input from many contributors, including representatives of other grading systems. The thought behind this strategy was to bring forward previous work and ideas and promote the development of a transparent approach for grading research evidence (It is an approach used for developing and presenting summaries of evidence of healthcare-related recommendations and guidelines). The GRADE approach rates four areas as high, moderate, low, and very low. The four areas are, the number of participants, risk of bias of trials, heterogeneity, and methodological quality of the review. Pg76
Healthcare Information Exchange (HIE)
Electronic sharing of patient information such as demographic data, allergies, presenting complaints, diagnostic test values, and other relevant data between providers such as primary physicians, specialists, hospitals, and ambulatory care settings according to nationally recognized standards. It must be secure and maintain integrity. It works by improving the speed, quality, safety, and cost of patient care. There are three key forms of health information exchange. Query-based exchange is often used for unplanned events. Like a visit to the emergency department. It allows providers to find and request information on a patient from other providers. Directed exchange is used to support coordinated care and allows the ability to send and receive secure information electronically between care providers (when providers send laboratory orders and results, patient referrals, or discharge summaries to another provider or healthcare entity). Consumer-mediated exchange allows the ability for patients to review, manage, and control the use of their health information among providers.
Health information technology (HIT)
Information systems and other information technology are used to record, monitor, and deliver patient care as well as perform managerial and organizational functions.
HITECH ACT (Health Information Technology for Economics and Clinical Health)-
The HITECH Act of 2009 provides the Department of Health and Human Services (HHS) with the authority to establish programs to improve health care quality, safety, and efficiency. It directs eligible healthcare providers and healthcare organizations to adopt electronic health records, the development of health information technology, and to support HIPAA rules and regulations to improve the exchange of information and to improve privacy, confidentiality, and security protections for healthcare data. It offers financial incentives and imposes penalties depending on compliance measures achieved or missed. HITECH strongly recommends increasing meaningful use of HIT to decrease overall healthcare cost and to improve population health.
Hospital/Health information system (HIS)
Group of information systems used within a hospital or enterprise that support and enhance patient care and consists of two major types of information systems: clinical and administrative.
Information blocking-
is the practice by a health IT stakeholder that, except as required by law or specified by the Secretary of Health and Human Services (HHS) as a reasonable and necessary activity, is likely to interfere with access, exchange, or use of electronic health information from provider to provider or provider to patient. Anything that interferes with, prevents, or materially discourages access, exchange, or use of electronic health information (EHI).
The Internet of Things (IoT)
in healthcare refers to the various wireless, interrelated, and connected digital devices that can collect, send, and store health data over a network without requiring human-to-human or human-to-computer interaction. the collection of internet-connected devices, including wearables, implants, skin sensors, home monitoring tools, and mHealth applications. The IoT has the potential to connect patients and their providers in a variety of ways and has the ability to maximize the power of big data analytics through ongoing innovation.
Meaningful Use
Use of health information technology (HIT) legislated by the American Recovery and Reinvestment Act of 2009 to collect specific data with the intent to improve care and population health, engage patients, and ensure privacy and security.
Metadata-
Set of data that provides information about how, when, and by whom data are collected, formatted, and stored.
Moral distress-
results from knowing what is right, being in a situation that constrains acting on that knowledge, and the psychological distress resulting from that inability to do the right thing.
North American Nursing Diagnosis International (NANDI)
-Terminology to identify human responses to health promotion, risk, and disease that is recognized by the American Nurses Association.
Predictive analytics
Uses past and current data to forecast the likelihood that an event will occur; also known as predictive modeling
Scope creep-
Unexpected and uncontrolled growth of user expectations as a project progress.
Standardized terminologies
Structured, controlled languages developed according to terminology development guidelines and approved by an authoritative body.
Survivability
Capability of a system, as a whole, to fulfill its mission in a timely manner, in the presence of attacks, failures, or accidents.
SWOT analysis
A process that examines the strengths, weaknesses, opportunities, and threats of a given situation.
The 21st Century Cures Act-
signed into law in 2016 contains several provisions that are specific to informatics. In general, the Cures Act was designed to provide funding streams and promote research into preventing and curing serious illnesses, ensure medication and medical device development, support community mental health efforts, and improve interoperability and health information exchange by providing seamless access to improved EHRs. the 21st Century Cures Act asserts that putting patients in charge of their health records is a key piece of patient control in healthcare; therefore, barriers to their health information must be addressed through the use of advanced information technology measures.
Translational bioinformatics
is the "development of storage, analytic, and interpretive methods to optimize the transformation of increasingly voluminous biomedical data and genomic data, into proactive, predictive, preventive, and participatory health"
Vision-
Future-oriented, high-level view of what an organization would like to become that provides direction for planning purposes.
The value-based model (VBM)
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