D220 Informatics

Clinical Care Classification (CCC)

"Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings"

American Recovery and Reinvestment Act (ARRA)

**Authorized INCENTIVE PAYMENTS to specific types of hospitals & healthcare professionals for adopting & using interoperable Health Information Technology and EHR's. The purposes of this act include the following: (1) To preserve/create jobs and promote economic recovery. (2) To assist those most impacted by the recession. (3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health. (4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits. (5) To stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases.

Informatics Innovator

Conducts information and RESEARCH & generate THEORY & have advanced understanding in info management & computer technology

Continuous Quality Improvement (CQI)

Continuous monitoring of performance and supports audit capability also known as QUALITY ASSURANCE SYSTEM

HIE (Health Information Exchange)

Electronic sharing of pt info (demographic data, allergies, diagnostic tests, and other revelant data between providers, specialists, hospitals, and insurance companies.

Clinical Information Systems

Ex: May be specific to certain departments. Lab, radiology, pharm(Both), or particular pt population. Functions may include order entry, results reporting, scheduling and documentation. Lg computerized database used to access the pt data that are needed to plan, implement and evaluate care.

Clinical Nurse Specialist

Expert clinician in a specialized area of practice who engages in research and helps direct practice change.

Data

Facts, figures, and other evidence gathered through observations.

Functional Testing

Final process in Project Management Phase 2 (planning) that ensures the innovation works as designed.

Change Control

Helps to prioritize limited resources and ensures system standards are upheld.

PHR (personal health record)

Lifelong tool for managing health info, controlled by pt - data can be provided by MD or pharmacy. (conditions, allergies, meds, surgeries) Barriers: Poor or no internet, poorly designed apps, limited clinical integration Predictors: Awareness of PHR's, ease of access, personal motivation, increased levels of education and health literacy.

EMRAM (Electronic Medical Record Analytical Model)

Measures clinical outcomes, pt engagement & clinical use of EMR technology to strengthen organizational performance & health outcomes across pt populations "Basically, evaluates Health Information System"

HIT - Health Information Technology

Technology that is used to record, store, and manage patient healthcare information. Ex: CDS, CPOE, EMR, EHR, PHR, Telehealth, E-scribe National & Global implications

Computer Literacy

The ability to use computers for basic tasks, such as developing documents, sending emails and searching the internet for information.

Data Integrity

The correctness of data after processing, storage or transmission. Ability to store, retrieve, correct and complete data are available to authorized users

Authorization

The process of giving someone permission to do or have something

Change Management

The process, tools and techniques that help people implement changes to achieve a desired outcome. (Supports the adoption of a medication Administration System)

Chief Nursing Officer (CNO)

The senior manager (usually a registered nurse with advanced education and extensive experience) responsible for administering patient care services

Ergonomics

The study of workplace equipment design or how to arrange and design devices, machines, or workspace so that people and things interact safely and most efficiently.

Administrative Information System

can include registration and scheduling; tracking through admission, transfer and discharge; patient acuity and staff scheduling; financial or accounting systems; risk management; payroll and human resources; quality assurance; and contract management functions.

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.

Gantt Chart

A time and activity bar chart that is used for planning, managing, and controlling major programs that have a distinct beginning and end.(used for a glance at management)

HL7 (Health Level 7)

Acronym used to refer a standard of interoperability and exchange of clinical data (HL7 & DICOM-Standardization)

CPOE (Computerized Physician Order Entry)

An order entry and decision support system that allows direct entry of orders and immediately shared w/ others

Alarm Fatique

Becoming desensitized to patient care alarms and missing or delaying their response to the alarm.

HIS Health Information System

Broad term used to describe administrative and clinical systems to streamline work flow processes efficiency. Hardware/software dedicated to the collection, storage, processing, retrieval and communication of patient care info.

device integration

Capturing data from patient monitors and anesthesia machines, and filing them directly to a patient's chart in EHR. Ex: entering VS, cardiac monitor download data into EHR

Fish boning

Cause/effect diagram, can help in brainstorming to identify possible causes of a prob.

5 rights of clinical decision support

Right information Right person Right intervention format Right channel Right time in workflow

Barcode Scanning Technology

Scans drug and patients wristband to verify medication order, inventory control, + pt identification, correct med admin

CCR (Continuity of Care Record)

Snapshot/standardized summary of the most relevant and timely health information about pt and shared to a physician who does not have access to pts EHR.

EMR (electronic medical record)

a record of one episode of care, source data for EHR, Brings together diagnositc & Tx info in a specific healthcare setting.

Audit trail

a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed

Information System

a set of hardware, software, data, people, and procedures that work together to produce information "Data Collection"

Gap Analysis

a type of analysis that compares the differences between the consumer's expectations about and experiences with a service based on dimensions of service quality (Planning)

DSS (decision support system)

an interactive, flexible, computerized information system that enables managers to obtain and manipulate information as they are making decisions r/t patient care

Bioinformatics

application of mathematics and computer science to store, retrieve, and analyze biological data

Data cleansing/scrubbing

A process that weeds out and fixes or discards inconsistent, incorrect, or incomplete information

Clinical Decision Support System

A special subcategory of clinical information systems that is designed to help healthcare providers make knowledge-based clinical decisions Ex: Alerts for abnormal VS, labs results, med contraindications, screenings, standing orders, reminders in EHR ect...

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

2009 ARRA includes HITECH - promote adoption and meaningful use to HIT. Goal: Improve quality care, Pt safety, Decrease costs by using meaningful use *Improves Population Health Outcome*

EHR system

3 elements: Data, Info, Knowledge. Decrease med errors, increase provider documentation. Function ex: Bar Code Admin.

Database

A collection of data organized in a manner that allows access, retrieval, and use of that data

Change Control Board (CCB)

A committee that evaluates the worthiness of a proposed change and either approves or rejects the proposed change.

information

A continuum of progressively developing and clustered data. Collection of data that has been interpreted & examined for patterns and structures

Authentication

A method for confirming users' identities

Business Continuity Plan

A plan for how an organization will recover and restore partially or completely interrupted critical function(s) within a predetermined time after a disaster or extended disruption

C-CDA (Consolidated Clinical Document Architecture)

Allows interoperability of health information exchange between to hospitals.

DIKW theory

Data, Information, Knowledge, Wisdom (data is most discrete) Data=pt monitoring, labs, diagnostic systems (CT scans) Information=Clinical Info systems, & DSS (alerts/reminders) Knowledge=Lg databases (med articles) & Artificial Intelligence

HIE forms

Direct - send/recieve secure info electronically between providers ex: immunization data, quality measures sent to Medicaide/Medicare Query - find & request info, often used for unplanned care (ER, pregnancy) Consumer mediated - pts to aggregate and control the use of health info among providers (correcting info, tracking their health, providing providers w/ info)

Clinical Research Informatics

Discovery and management of new knowledge pertinent to health and disease from clinical trials via secondary data use.

Business Intelligence

Information collected from multiple sources such as suppliers, customers, competitors, partners, and industries that analyzes patterns, trends, and relationships for strategic decision making

Critical Care Information System

Integrates captured physiological data w/ practitioner documentation and clinical data management functions, as well as access and communication w/ remote experts.

HIPAA (Health Insurance Portability and Accountability Act)

Kennedy Kassebaum Bill, Federal legislation to protect client records & mandate that all electronic transactions included only HIPAA compliant codes. Sets nation standards of PHI, legal protection of PHI. (signing in devices requires encryption)

Asynchoronous Applications

No contact with patient for data collection. EX: Remote pt monitoring, Using health technologies to share health metrics and data w/ providers. STORE & FORWARD APPS (ex: photos)

Data Warehousing

Powerful method of managing and analyzing data

information science

Primarily focused on input processing output and feedback through technology intergration

AHQR (Agency for Healthcare Research and Quality)

Produced evidence making healthcare safer, improve quality, accessibility and affordability

ANA (American Nurses Association)

Professional organization for all RNs. Concerned with licensure, collective bargaining and education

EHR

Pt data stored in electronic form(collection of pt healthcare data) **Successful if pt needs met

configurability

Refers to the extent that a given software product can be adapted or changed to meet a user's preference

Confidentiality

Relationship has been established where private info shared but NOT disclosed w/out permission

5 rights of Informatics

Right - Information Person Intervention Channel Time in workflow

Information Technology (IT)

Transmit Data Ex: EHR, CDST (clinical decision support tool)

DICOM (Digital Imaging and Communications in Medicine)

Transmits digital imaging (DICOM & HL7 support standardization in health care data

Expert Systems

Type of CDS/DDS but does NOT need human intervention (artificial intelligence) Ex: Personal Insulin Pump

Consumer Health Informatics

Use of electronic info & communication to improve medical outcomes & healthcare decision making from pt perspective. Patient view and structures and process that enable consumer to manage their own care.

ICD-10

Used to classify mortality and morbidity data from inpatient/outpatient records, used for reimbursement

EBP (evidence based practice)

Using current best evidence for pt care decision in order to improve pt outcomes (found in standing orders) Ex: sepsis protocols & CDS

HIS (Hospital Information System)

What is the name of the computer system that tracks admission and discharge information, diagnostic and treatment services, pharmaceutical and equipment information, and billing information? Advantages: Better communication, decreased errors & better access to info.

Big Data

a collection of large, complex data sets, including structured and unstructured data, which cannot be analyzed without the use of information technology

Connected health

a model of health care delivery using technology to provide services including information and education. Technology assisted healthcare is delivered between at least 2 points involving either asynchronous or synchronous exchange.

Health literacy definition

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

disruptive innovation

a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors

Disease Registries

collections of secondary data related to patients with a specific diagnosis, condition, or procedure.

Clinical Informatics

concentration on the delivery of timely, safe, effective , EB and pt centered care.

Affordable Care Act

law passed in 2010 to expand access to insurance, address cost reduction and affordability, improve the quality of healthcare, and introduce the Patient's Bill of Rights, increasing the number of insured persons.

Doctorate of nursing practice (DNP)

degree w/ emphasis on EBP, quality improvement and system leadership

healthcare terminology standards

designed to enable and support widespread interoperability among healthcare software applications for the purpose of sharing information

21st Century Cures Act

designed to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently. Provisions that will improve workflow & exchange of electronic info. ONC (responsible for implementing) seamless & secure access, exchange and use of electronic health info.

Health Informatics Management

focus on info technology needed to store and retrieve pt data accurately, securely and management of the people & processes.

HIMSS Healthcare Information & Management Systems Society

formal group of healthcare organizations that seek to improve delivery of healthcare by advancing technology & data management. *work almost exclusively w/ data *They protect & handle pt data of all kinds (diagnosis, symptoms, test results, med hx, procedures) *They ensure info is accurate, accessible, secure and of high quality *Cause-based, Nonprofit, Global organization focused on better health through info & tech.

Firewalls

hardware, software, or both designed to prevent unauthorized persons from accessing electronic information, while allowing authorized communication.

Contextual Inquiry

involves studying customers' use of a product at their place of work Focusing on users point of view.

Finacial system

uses pt demographic data and insurance info to charge for services & reimbursment

emerging trends

• Secondary data • Technology-based data management • Digital information acquisition and retrieval • International client base • Information management (patient safety & error reduction)

feature creep

occurs when developers add extra features that were not part of the initial requirements

Data Analysis

processing of data that identifies trends and patterns of relationships

Data Governance

refers to the overall management of the availability, usability, integrity, and security of company data

Information Epidemiology

science of distribution of information in an electronic format w/ te ultimate aim to inform public health and public policy

clinical terminology

standardized terms and their synonyms used to record pt data with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement, flow sheets, vital signs, assessments and nursing notes.

Implementation Science

study how interventions, which have been shown to be effective in one setting, can be applied to sustain improvements to population health

information literacy

the ability to figure out the type of information you need, find that information, evaluate it, and properly use it * Ability to read and understand works/numbers and ability to recognize when info is needed.

Informatics Competencies

the ability to perform the tasks associated w/ informatics

Dissemination

the act of spreading widely or scattering data including research knowledge.

Data Mining

the application of statistical techniques to find patterns and relationships among data for classification and prediction using software.

Biometrics

the identification of a user based on a physical characteristic, such as a fingerprint, iris, face, voice, or handwriting

Go Live

the official time and date that the facility begins using the new system (Implementation Phase)

Data Modeling

the process of determining the users' information needs and identifying relationships among the data to support processes for an info system (key step in design of EHR)

Informatics

the science and art of turning data into information *Interdisciplinary field Data to info, Info to knowledge, Knowledge to wisdom