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