Health Information Technology

The RN is listening to a lecture on Medicare part D requirements for technologically enhanced prescribing. Which statement indicates that teaching has been effective? "Physician entry order systems in the hospital." "Drug plans must support electronic prescribing." "Automatic conversion from brand to generic drugs." "Online, 24-hour Internet pharmacist support."

"Drug plans must support electronic prescribing." Medicare Part D requires drug plans participating in the new prescription benefit to support electronic prescribing. Internet pharmacy support, physician order entry systems, and conversion to generic drugs are not parts of Medicare Part D.

Give examples of patient data found in health information:

-demographics -assessment findings -flow sheets that include point-of-care results -diagnoses -nursing treatments -a medication profile listing historical and currently active medication orders.

Negative Consequences would include things such as:

-sentinel events -errors in patient care -documentation errors -breach in confidentiality -inaccurate decisions.

Nursing Informatics Competencies include: (list 3 things)

-technical -utility -leadership

State the 5 pillars of the purpose of meaningful use in healthcare organizations

1) Improve quality, safety, efficiency, and reduce health disparities 2) Engage patients and families 3) Improve care coordination 4) Improve population and public health 5) Ensure privacy and security protection for personal health information

The ______________________ states that the specialty of nursing informatics integrates nursing computer and information science for the management and communication of data, information, knowledge, and wisdom.

American Nurses Association

In the ___________________________________ , the government mandates the use of a certified EHR for each person in the United States by 2014.

American Recovery and Reinvestment Act of 2009

______________skills include computer, information, and web literacy; fundamental skills in information management and computer technology; and the ability to identify and collect relevant data.

Beginner

refers to the tools used for achieving quality outcomes, including electronic health records, clinical data repositories, decision support programs, and handheld devices, not to the data.

Certified clinical information systems (CISs)

provide for the development of direct approaches to patients and their families that can be used by a staff nurse to promote quality patient care.

Clinical healthcare informatics and the subset nursing informatics

What does CIS stand for?

Clinical information systems (CIS)

a branch of engineering that studies computation and computer technology, hardware, and software, as well as the theoretical foundations of information and computation techniques

Computer science

a branch of engineering that studies computation and computer technology, hardware, software, and the theoretical foundations of information and computation techniques.

Computer science

allows clinicians to enter orders in a computer that are sent directly to the appropriate department.

Computerized provider order entry

Which nursing action demonstrates the category of utility in the informatics competency classification system? Computer and software use. Maintenance of privacy. Critical thinking and evidence-based practice. Application of accountability and quality assurance.

Critical thinking and evidence-based practice.

facts, observations, and measurements that can be used as a basis for reasoning, discussion, or calculation, but until they are organized and processed, data are meaningless.

Data

are established by each health care organization's policies and procedures.

Data Standards and Terminology

List the 3 stages of meaningful use

Data capture and sharing Advanced clinical processes Improved outcomes

Giddens Ch 46 Questions When discussing the purposes of nursing healthcare informatics with a staff nurse during orientation, a nurse educator should be concerned if the nurse orientee stated that which is a primary purpose of informatics? Develop a data management system. Improve a health provider's work flow. Improve disease tracking. Increase administrative efficiencies.

Develop a data management system. Data management is an exemplar of health informatics, but it would not be a primary purpose for a bedside nurse. The nurse educator would use this incorrect response to plan additional teaching about the primary purposes of healthcare informatics for the staff nurse. Purposes of information health technology include improving health provider work flow, improving healthcare quality, preventing medical errors, reducing healthcare costs, increasing administrative efficiencies, decreasing paper work, and improving disease tracking.

is a system used to classify hospital admissions.

Diagnostic-related groups

______________________ in the electronic health record requires nurses to be skilled in the use of flow sheets and narrative formats for recording patient information.

Documentation

Adoption of an ____________________ system produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status.

Electronic Health Record

__________________________________ are becoming widely used for individual health care encounters and for maintaining patients' health records over long periods

Electronic Health Records

With ______________________________________, doctors, nurses, pharmacists, other health care providers and the patients can access and securely share a patient's vital medical information electronically—improving the speed, quality, safety and cost of patient care.

Electronic health information exchange (HIE)

Examples of CIS tools include:

Electronic health records Decision support programs Handheld devices.

Informatics Nurse Specialists are nurses with specialized, advanced knowledge of information methods for enhancing the quality and delivery of health care through the use of digital information. Their roles include all of the following EXCEPT: The collection and analysis of data. Planning the design of information systems. Ensuring that information is protected by securing computers and computer components. Training nurses and administrators in the use of information systems

Ensuring that information is protected by securing computers and computer components.

Giddens Ch 46 Questions Which concepts should a nurse consider to have the strongest links to technology and informatics? (Select all that apply.) Select all that apply. Professionalism Ethics Safety Leadership Clinical judgment

Ethics Safety Leadership Clinical judgment

The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care data, information, and knowledge for communication and decision making.

Health Information Technology

Under the _______________________several key programs, like the Medicare and Medicaid Electronic Health Record Incentive Program and the Regional Extension Program, have been established to facilitate adoption of Electronic Health Records including the Medical Home model.

Health Information Technology for Economic and Clinical Act known as HITECH,

the application of information processing involving both computer hardware and computer software that deals with the storage, retrieval, sharing, and use of healthcare data, informatio

Health Information technology (health IT)

___________________________ facilitates the integration of data, information, knowledge, and wisdom to support patients, nurses, and other providers in decision making in all roles and settings

Health care informatics

a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology.

Health informatics

an application of information processing that deals with the storage, retrieval sharing, and use of healthcare data, information, and knowledge for communication and decision making.

Health information technology

This system is published by the World Health Organization (WHO) and is used worldwide to promote international comparability in the collection, processing, classification, and presentation of statistics.

ICD-10 International Statistical Classification System of Diseases and Related Health Problems

a broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science.

Informatics

is the science that encompasses information science and computer science to study the process, management, and retrieval of information.

Informatics

allows the Role of Nursing and Health Information Technology to work in tandem and be well designed by effective multi-disciplinary teams.

Informatics Workforce

organized and processed data that can be communicated and are meaningful and useful to the recipient.

Information

Nurses need a working knowledge of how________________________ can support and improve clinical processes.

Information Technology

an interprofessional science primarily concerned with the analysis, collection, classification,

Information science

Zerwekh Ch 23 Questions A nursing student is confused and frustrated working with NIC/NOC/NANDA language on care plans. What advantage of this system does the nursing faculty explain to the student? It is an easy-to-implement nursing-focused language that all systems will eventually use. Its specific nomenclature and wording increase the visibility of nursing as a profession. It is a common language that can be incorporated into clinical information systems. It provides an avenue for understandable billing practices for health care costs.

It is a common language that can be incorporated into clinical information systems. In 1995, the ANA approved the establishment of the Nursing Information and Data Set Evaluation Center (NIDSEC) to review, evaluate against defined criteria, and recognize information systems from developers and manufacturers who support documentation of nursing care in automated nursing information systems (NIS) or in computer-based patient record systems (CPR). If the unique nomenclature of these classification systems is used consistently, gathered data elements can be captured, stored, and manipulated accurately in the electronic medical record. Without a common language, data cannot be aggregated into useful language. Being easy to use is not an advantage; the advantage lies in the use of common language. NIC/NOC/NANDA was not designed primarily for billing purposes or to increase the visibility of nursing as a profession.

is organized and processed information that can be applied to problem solving and decision making.

Knowledge

____________________competencies address the ethical and management issues related to using Information Technology in nursing practice, education, research, and administration.

Leadership

___________________initiatives provided HIT implementation with incentives and requirements for meaningful use.

Legislation

is said to improve patient care and also make it more cost effective.

Meaningful use of an Electronic Health Record

deals with the resources, devices, and methods required for the acquisition, storage, retrieval, and use of information in health and biomedicine. • In addition to computers, informatics tools in health care include clinical

Medical informatics

refers to informatics related to health care and describes a distinct specialty in the discipline of medicine

Medical informatics

assist the diagnostic process and include recommendations for treatment

More sophisticated decision support systems

_____________________supports reimbursement to health care agencies through accurate accounting of the use of services and equipment and medications administered.

Nursing documentation

Giddens Ch 46 Questions The specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice is known as which specialty? Health information technology Nursing informatics Health informatics Computer science

Nursing informatics The specialty is nursing informatics. Computer science is a branch of engineering that studies computation and computer technology, hardware, software, and the theoretical foundations of information and computation techniques. Health informatics is a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology. Health information technology is an application of information processing that deals with the storage, retrieval sharing, and use of healthcare data, information, and knowledge for communication and decision making.

a specialty area of informatics that addresses the use of health information systems to support nursing practice.

Nursing informatics is

are experts who assume a variety of roles, including training others and supervising the use of information systems, designing systems particularly for use by nurses, and using data for establishing best-practice guidelines.

Nursing informatics specialists

A nurse is administering medications using bar code technology. One of the medications does not have a full bar code on it. Which action by the nurse is best? Bypass the bar code system and give the drug. Have a second nurse verify the drug information. Fill out a variance report and administer the drug. Obtain a new dose; return the old one to the pharmacy.

Obtain a new dose; return the old one to the pharmacy. Technology only works when it is used, and safety mechanisms such as bar coding can't provide safety if the nurse works around problems with the system. A medication with an incomplete bar code cannot be scanned. The nurse should obtain a new dose of the drug and return the old one to the pharmacy. The pharmacy can relabel the medication or dispose of it. Bypassing the bar code eliminates an important safety feature. Giving the drug without scanning it eliminates an important safety feature. If there were no way to return the drug or get a second dose, this would be the best alternative, but human error can still lead to drug errors. If possible, the nurse should return the drug and get a new dose so it can be scanned, thereby using the safety mechanisms built into the scanning technology.

Zerwekh Ch 23 Questions A staff nurse is interested in informatics and wishes to become an Informatics Nurse Specialist (INS). What step should the nurse take to obtain that certification? Obtain graduate education in informatics or a related specialty. Get on-the-job training in software from a software vendor. Earn a bachelor's degree in computer science or informatics. Take the certification exam offered by the National League of Nursing.

Obtain graduate education in informatics or a related specialty. The INS has a graduate-level education degree in informatics or a related field. A certification exam is offered by the American Nurses Association Credentialing Center. The certification exam is not offered by the National League of Nursing. A graduate-level education is required. On-the-job training is not part of the certification.

____________________Skills is a key component to the successful implementation of health information technology and include issues such as: productivity, teamwork, group dynamics, project management, organizational factors, human interface design, humanmachine interaction and much more.

Organizational

include establishment of national policies and standards and have been developed to outline how technology is applied and used

Policies and Procedures

refers to the attributes and behaviors of a nurse as a representative of the nursing profession and as a healthcare professional

Professionalism

is the domain that relates information, computer science, and technology to public health science to improve the health of populations; this domain would provide data for a nurse working with communities.

Public health/population informatics

Giddens Ch 46 Questions To address a goal of improving the health of populations, a nurse is most likely to use which domain of informatics? Translocational bioinformatics Public health/population informatics Clinical healthcare informatics Certified clinical information systems

Public health/population informatics Public health/population informatics is the domain that relates information, computer science, and technology to public health science to improve the health of populations; this domain would provide data for a nurse working with communities. Certified clinical information systems (CISs) refers to the tools used for achieving quality outcomes, including electronic health records, clinical data repositories, decision support programs, and handheld devices, not to the data. Clinical healthcare informatics and the subset nursing informatics provide for the development of direct approaches to patients and their families that can be used by a staff nurse to promote quality patient care. Translational bioinformatics refers to the research science domain where biomedical and genomic data are combined; it is a new term that describes the domain where bioinformatics meets clinical medicine and generally applies to healthcare research rather than direct patient care.

An important part of the _____________ vision is the reform of nursing education to provide the 21st-century nurse with informatics skills that enable the use of Information Technology to provide the most knowledgeable and safe care possible.

TIGER

________________competencies pertain to the use of computers and other technological equipment and the use of a variety of software programs for word processing, spreadsheet and database development, presentation, referencing, and e-mail.

Technical

the knowledge and use of tools, machines,

Technology

What does the CARS acronym stand for?

The CARS acronym stands for Credibility Accuracy Reasonableness Support.

What is the primary goal of Nursing Informatics? The daily maintenance of multiple clinical information systems at distant locations. The creation of an efficient information handling system that can store and retrieve clinical data. To make patient data easier to access. To make the latest technologies available to hospitals and other patient care environments.

The creation of an efficient information handling system that can store and retrieve clinical data.

is a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings

The electronic health record (EHR)

is a record of one episode of care, such as an inpatient stay or an outpatient appointment.

The electronic medical record (EMR)

is a clinical data archive

The medical record

serves as the major communication tool between staff members and is a single data access point for everyone involved in the patient's care.

The medical record

refers to the research science domain where biomedical and genomic data are combined; it is a new term that describes the domain where bioinformatics meets clinical medicine and generally applies to healthcare research rather than direct patient care.

Translational bioinformatics

__________________competencies address critical thinking and evidence-based practice applications.

Utility

addresses the use of knowledge and experience to manage and solve problems.

Wisdom

is the appropriate application of knowledge.

Wisdom

Quality documentation is:

accurate detailed timely incorporates precise measurements correct spelling proper use of abbreviations

where all the parts match one another and therefore function efficiently as a whole.

an integrated system

generally means that there are different parts to the system that functions with the parts they are connected to, but do not function as a whole.

an interfaced system

The ________________ of patient information supports efficient delivery of effective care.

availability

Documentation of a safe plan for ________________ includes information given on medications, diet, community resources, follow-up care, and contact information for whom to call with questions or in case of an emergency.

discharge

Accurate _______________ is necessary for hospitals to be reimbursed according to diagnostic related groups (DRGs).

documentation

Each Diagnostic-related group is reimbursed at a specific rate, and payment is often based on the _____________________ supporting the hospital stay.

documentation

The ________________ provides connectivity to enhance communication between all members of the health care team, who can access and update the record simultaneously.

electronic record

Patient safety is enhanced when health care professionals __________________the use of dangerous abbreviations, acronyms, symbols, and dose designations from their documentation.

eliminate

The goal of HIT is that ________________will have Electronic Health Records (EHR).

everyone

The nurse at the ________________ level of informatics competencies is able to see data relationships and make judgments based on trends and patterns in data, is skilled in information management and the use of computer technology, and is able to suggest areas for Information Technology system improvement.

experienced

If data is _____________or ______________, the quality of the derived information may be poor, and decisions may be inappropriate and possibly even harmful to the patient.

faulty incomplete

HIT is a ________________practice area for nurses with certifications for those who specialize.

growing

The ____________________provides a legal and financial record of care, aids in clinical education and research, and guides professional and organizational performance improvement.

health care record

Goals of the nurse informatics specialists are to:

include the training of others supervising the use of information systems designing systems particularly used by nurses using data for establishing best-practice guidelines

a person who works in the field of informatics, sometimes called an Informaticist.

informatician

In health care, treatment decisions are based on _______________derived from data

information

The actions nurses take depend on the _________________and _____________available.

information knowledge

The Nurse with ___________________ skills conducts the research based on information trends or patient data, devise applications for computer technology in nursing, and even develops new software to enhance nursing care.

innovator

Specific _______________competencies include the application of accountability, maintenance of privacy and confidentiality, and quality assurance.

leadership

Effective nursing documentation limits __________through objective description of what happened to a patient and clearly indicates that individualized, goal-directed nursing care was provided based on nursing assessment

liability

The __________________ data allows the nurse to see trends in responses to specific interventions and patterns of vital signs and laboratory results.

longitudinal

The Multiple Patient Data is Available in the ___________________.

medical record.

The _____________ approach involves having all members of the health care team sharing the same patient information.

multidisciplinary

When information relevant to care is communicated by telephone, verification of information through use of a _______________ process should be documented in the health care record.

read-back

At the _______________level of competency, the nurse focuses on information needed for nursing practice by integrating and applying information science, computer science, and nursing science.

specialist

The nurse _______________ applies skills in critical thinking, data management, processing, and system development.

specialist

HIT will require a ________________of Health Records.

standardization

Use of ________________________________ provides consistency, improves communication among nurses and with other health care providers, increases the visibility of nursing interventions, improves patient care, enhances data collection to evaluate nursing care outcomes, and supports adherence to care standards.

standardized language

Positive Outcomes can include things such as

support practice, confidentiality, information transferability, continuity of care, accurate information at the point of care and reduction in practice errors.

Technology at the point of care can provide:

the right data on the right patient at the right time.

There are _______________stages of "meaningful use" for the Electronic Health Record and each stage gets progressively ________________to drive healthcare towards the ultimate goal of IMPROVED Quality of Patient Care.

three harder

Nurses who have a ________________ competency recognize the relevance of nursing data for improving practice and can access multiple information sources for gathering evidence for clinical decision making.

utility

At the _________________________ level, a nurse uses critical thinking to interpret and evaluate nursing knowledge.

wisdom