NR 599 NP Nursing Informatics for Advanced Practice

Evaluation and Management (E/M) Coding

-A medical coding process in support of medical billing -Practicing health care providers in the US must use this coding to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters.

Firewall

-A tool commonly used by organizations to protect their corporate networks when they are attached to the internet. -It can be software or hardware, or a combination of the two. -It examines the all incoming messages or traffic to the network.

Mobile Medical Applications (Apps)

-Accessories to a regulated medical device or are a software that transforms a mobile platform into a regulated medical device. -Facilitates mHealth

ICD-10 Codes

-Alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses. -Shorthand for the patient's diagnosis, which are used to provide the payer information on the necessity of the visit or procedure performed

American Recovery and Reinvestment Act (ARRA) of 2009

-An economic stimulus packaged enacted in February 2009 that was intended to create jobs and promote investment and consumer spending during the recession. -Also referred to as the Stimulus or Recovery Act.

Privacy

-An important issue related to personal information -Restricted access of patient information or data

Protected Health Information (PHI)

-Any and all information about a person's health that is tied to any type of personal identification.

Non-Medical Devices

-Applications within a device not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. -Does not require FDA oversight

Reimbursement Coding

-Codes assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders. -Reimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes.

Clinical Support Tools

-Designed to help sift through enormous amounts of digital data to suggest next steps for treatments, alert providers to available information they may have not seen, or catch potential problems -On various applications used by healthcare professionals to allow for communication between provider to provider and provider to patient -Used to benefit patient outcomes

Information Literacy Competency Standards for Nurses

-Determine the extent of information needed -Access the needed information effectively and efficiently -Critically evaluate the information and sources -Utilize information effectively to accomplish a specific purpose -Understand implications from the economic, legal, and social perspectives surrounding the access and use of information

Four Parts to HIPPA Administrative Simplification

-Electronic transactions and code sets standard requirements -Privacy requirements -Security requirements -National Identifier requirements

HIPPA

-Enacted in 1996; federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. -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.

HITECH Act

-Health Information Technology for Economic and Clinical Health Act was enacted to promote the adoption and meaningful use of health information technology. -Monetarily Incentivize health organizations and providers to become meaningful users of EHR. -Introduced in 2009 as part of the American Recovery and Reinvestment Act (ARRA)

Cybersecurity

-Measures taken to protect a computer or computer system against unauthorized access or attack. -FDAs main regulatory agency

Ethical Decision Making

-Process that requires striking a balance between science and morality. -Making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong.

American Recovery and Reinvestment Act of 2009 (ARRA)

-Provided funds to government agencies for improving information-technology systems -Provisions include the right for every person to receive an electronic copy of their EHR and to have a copy of their EHR transmitted to a party that they designate -Legislation included the HITECH Act

Food and Drug Administration (FDA)

-Regulatory body that oversees mobile apps that are medical devices and whose functionality could pose a risk to a patient's safety if the mobile app were to not function as intended. -Also oversee the cybersecurity management of these devices as well as the hospital network security.

Workflow Analysis

-Study of the way work (inputs, activities, and outputs) moves through an organization. -Observation and documentation of workflow to better understand what is happening in the current environment and how it can be altered

Patient Centered Information System

-Systems focused on augmenting traditional approaches to health information management -Designed to support patient participation in health care decision making and treatment activities.

Workflow

-Term used to describe the action or execution of a series of tasks in a prescribed sequence. -The progression of steps (tasks, events, interactions) that constitute a work process, involve two or more persons, and create or add value to the organization's activities. -Used interchangeably w/ process or process flows.

Confidentiality

-The act of holding information in confidence, not to be released to unauthorized individuals. -Protecting privacy of personal information or data.

Health Disparities

-The health status difference between different groups of people, especially minorities and non-minorities. -The gap between the different people is an ongoing problem even with the advances in technology and healthcare practices.

mHealth (Mobile Health)

-The practice of medicine and public health supported by mobile devices such as mobile phones, tablets, personal digital assistants and the wireless infrastructure. -The use of wireless communication to support efficiency in public health and clinical practice.

Cybersecurity

-The state of being protected against the criminal or unauthorized use of electronic data, or the measures taken to achieve this. -Ensures all systems are adequately protected and patients remain safe from harm

Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)

-Under this act, healthcare organizations can qualify for financial incentives based on the level of meaningful use achieved -It specifically incentivizes health organizations and providers to become "meaningful users"

Clinical Information Management

-Uses clinical decision making (CDS) and system safeguards to protect patients and protected health information (PHI) -Able to request and evaluate reports for the purpose of informed decision making -Participate in the selection, design, and evaluation of clinical information systems and patient-care technologies -Uses available technologies to communicate appropriately and effectively

Fee-for-Service Model

-a provider is given a set amount of monetary reimbursement for a specific visit or procedure performed that is adjusted for geographical location -gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care.

Medical Decision Making (MDM)

1 of 3 components to establishing E/M codes; way of quantifying the complexity of thinking that is required for the visit.

Workflow Design

A critical aspect of the informatics nurse in a workflow analysis

Ethical Dilemma

A difficult issue that requires the use of standards to solve issues. Ethically challenged.

computer-aided translators

A form of language translation in which a human translator uses computer hardware to support and facilitate the translation process.

Principlism

A foundation for ethical decision making by rational individuals and beliefs

Malware

A malicious program or software that infects a device and is intended to steal information, take control or destroy data, information, or the device.

Computer-aided Translators

A person who uses computer software to convert source code to target text; A conversion of computer language from one to another

Casuistry

A specific ethical reasoning method that analyzes the facts of a case in a sound, logical, and ordered or structured manner.

Analytics

A term describing the extensive use of data, statistical and quantitative analysis, explanatory and predictive models, and fact-based management to drive decisions and actions. Can improve marketing or in healthcare, services for the demographics served.

Information Literacy

Ability to identify when information is needed as well as the skills to find, evaluate, and effectively use the same

Beneficence

Actions performed that contribute to the welfare of others; Action of doing good or right by and for the patient.

Casuist Approach

An approach to ethical decision making that grew out of the concern for methods of examining ethical dilemmas.

Medical Devices

Any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients.

Medical Coding

Assignment of codes to communicate to payers (insurance companies) in relation to services performed by a healthcare provider and for what reason they were performed

Bioethical Standards

Autonomy, freedom, veracity, privacy, beneficence, and fidelity are maximally appropriate to the health care setting.

Computer Literacy

Basic familiarity with computer uses and common applications, ability to navigate hyperlinks, able to set up and use a database to collect and retrieve information

Veracity

Being completely truthful with patients; a patient right to truth.

American Nurses Association

Code of Ethics for Nurses with Interpretive Statements. provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT

Informatics Nurse Specialist (INS)

Completed graduate level education in informatics or related field

CPT

Current Procedural Terminology: Unique billing codes for services rendered; Maintained by the American Medical Association

Point-of-care (POC) Technology

Encompasses the devices and systems that support health-care professionals in their daily activities of monitoring patients, caring for them, and documenting their health progress.

Clinical Support Tools

Found in EHR software that when applied effectively, can enhance patient care quality and outcomes, improve efficiency, and help to ensure regulatory compliance.

Levels of Nursing Informatics Practice

Generalist and Informatics Nurse Specialist

Patient Protection and Affordable Care Act (ACA)

Guarantees healthcare for all Americans, expands Medicaid, provides incentives intended to improve care coordination and quality, restructures healthcare payment, and provides additional information to patients so that they can make value-based decisions.

Components of Risk Based E/M Coding

History; Physical; Medical Decision Making

Administrative Data

Include billing information derived from insurance claims, inpatient discharges (or hospital bills), and outpatient visits

TIGER Based Nursing Informatics Competency Model

Includes (3) pillars: Information Literacy, Computer Literacy, Clinical Information Management

(3) Pillars of TIGER Based Nursing Informatics Competency Model

Information Literacy, Computer Literacy, Clinical Information Management

ICD

International Statistical Classification of Diseases and Related Health Problems; Maintained by the WHO and provides a description and classification of known diseases and injuries.

Firewall

It can be set up to allow only messages from known senders into the corporate network; it can also be set up to look at outgoing information from the corporate network.

TIGER Initiative

Key purpose was to create a vision of nursing that bridges the quality chasm w/ information technology, enabling nurses to use informatics in practice and education to provide safer, higher quality of care

Alert Fatigue

Main challenge to effective implementation of CDS Tools

ICD and CDL

Medical code sets that are use to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations

Foundation of Knowledge Model

Model that proposes that humans are organic information systems constantly acquiring, processing, and generating information or knowledge in both their professional and personal lives.

Telehealth

Needed to help fill the nursing shortage allowing nursing to see more patients quicker, as well as the aging population

Electronic Medical Record (EMR)

Patient medical record from a single medical practice, hospital, or pharmacy

Necessity prior toe establishing Evaluation and management Codes

Place of Service; Type of Service; Patient Status

Clinical Support Tools

Process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific interventions, assessments, recommendations, or other forms of guidance for clinicians, patients, and others involved in care delivery

Medical Billing

Process of submitting and following up on claims made to a payer to receive payment for medical services rendered by a healthcare provider

Nursing Informatics Roles

Project Manager, Consultant, Educator, Researcher, Product Developer, Decision Support/Outcomes Manager, Advocate/Policy Developer, Clinical Analyst/System Specialist, Entrepreneur

Scientific Underpinning

Provide the basis of knowledge to advance nursing practice; include sciences such as biology, physiology, psychology, ethics, and nursing. -DIKW Paradigm (Data, Information, Knowledge, Wisdom)

Data Set

Refers to a named collection of data consisting of individual information organized in a prescribed fashion

Nomenclature

Refers to a system of rules and procedures for adding names used in an art or science, such as nursing.

Telemedicine

Remote clinical health services

Fidelity

Right to what has been promised, keeping to one's promise

Medical Applications

Software developed for medical purposes, including home medical monitoring system, medical databases for healthcare professionals, etc.

Standard Terminologies

Structured, controlled languages developed to represent concepts in a given domain in a clear, unambiguous fashion that conveys the exact same meaning for data, information, and knowledge across settings, regions, and even different countries

Cognitive Science

Studies how the mind works from an information processing perspective.

Computer Science

Study of storage, conversion, and transformation transfer or transmission of information in computers through algorithms and practical implementation problems

Diagnosis-related groups (DRGs)

System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay

Classification

Systems that capture categories, which are then used to determine costs or outcomes but are insufficient in detail for clinical documentation purposes

Point of Care (POC)

Testing and diagnosis at the patient's side and can be conducted anywhere the patient is, such as the home, physician office, ambulance, or hospital bedside

FDA Oversight for Medical Devices

The FDA oversees the safety of medical devices, which includes addressing the management of cybersecurity risks and hospital network security. Recent guidelines issued (FDA, 2013) recommend that medical device manufacturers and health care facilities take steps to ensure that appropriate safeguards are in place to reduce the risk of failure caused by cyberattack.

Freedom

The ability of an individual to act independently, without coercion or constraint in ones choice and action

Knowledge

The awareness and understanding of a set of information and the ways that information can be made useful to support a specific task or reach a decision.

Nursing Informatics Competencies

The integration of knowledge, skills, and attitudes in the performance of various nursing informatics activities within prescribed levels of nursing practice

Telephone

The most basic form of Telehealth

Human Technology Interface (HTI)

The portion of the assistive technology system with which the user interacts; The hardware and software through which the user interacts with any technology

Privacy

The right to be left alone when you want to be, to have control over your own personal possessions, and not to be observed without your consent.

Autonomy

The right to choose for himself or herself, respecting the clients opinions, perspectives, values and beliefs.

Meaningful Use (MU)

The set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of EHRs and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.

Information Science

The study of the retrieval, application, use and management of information as well as the human-computer interaction.

ICD-10 Coding

The system offers accurate and up-to-date procedure codes to improve health care cost and ensure fair reimbursement policies -The current codes specifically help healthcare providers to identify patients in need of immediate disease management and to tailor effective disease management programs

TIGER Initiative

The work of the Technology Informatics Guiding Education Reform Team. This team of nursing leaders developed a vision for utilizing information technology to transform nursing practice.

Knowledge Workers

Those who work with information and generate knowledge as a product. Nurses are an example of such.

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

Telehealth

Use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

Taxonomy

Uses classification according to a predetermined system, with the resulting catalog used to provide a conceptual framework for discussion, analysis, or information retrieval.

Digital Natives

a generation of people born after 1980 who have been raised in a digital age

Health Literacy

a person's capacity to obtain, process and understand basic health information and services, and to use these resources to promote one's health and wellness

National Prevention Strategy: America's Plan for Better Health and Wellness

comprehensive plan that sets forth evidence-based and achievable means for improving health for all Americans at every stage of life. These efforts are designed to stop disease before it starts and to create strategies for a healthy and fit nation, recognizing that prevention must be part of daily life.

Sequential Workflow

each step depends on the occurrence of the previous step

What are the 3 key components of E/M coding?

history, physical, and medical decision making

Primary Goal of CDS Tools

leverage data and the scientific evidence to help guide appropriate decision making

Major Diagnostic Categories (MDCs)

organized diagnoses that affect similar physiological systems used in reimbursement billing and coding

Evaluation and Management Coding

process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing.

Clinical Decision Support System (CDSS)

provides timely information, usually at the point of care, to help inform decisions about a patient's care.

3 keys elements to medical decision making (MDM)

risk, data and diagnosis

Nursing Informatics

specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

Wisdom

the ability to apply valuable and viable knowledge, experience, understanding and insight while being prudent and sensible. Sometimes considered the highest form of "Common Sense"

Parallel Workflow

two or more steps in a process can occur concurrently.