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.