Informatics in Healthcare Chapter 15 - 17
clinical data network
A clinical data network is a database where information obtained during a clinical trial but could be applied to any information obtained from a patient in the course of treatment or examination from many different information systems is stored and managed allowing retrieval of elements without regard of their point of origin.
PHR definition
A PHR is a free or very cheap web based personal health record a way to keep track of all your most important records and give access to whomever you would like to view them
What are the advantages of HIE models?
Advantages are HIE's are local, community-wide, regional, state-wide, and even global.
(ANA) stands for
American Nurses Association (ANA)
standardized terminologies used for the different parts of the nursing process and their similarities and differences.
Assessment the process of nursing assessment includes items such as vital signs physiological sign, and patient symptoms within the realm of nursing practice. Nursing Diagnosis/Problem and Coding after the patient has been assessed, a nursing diagnosis or problem is determined. Nursing Intervention nursing interventions are acts performed by or with the client. Goals and Potential nursing outcomes a goal is the desired outcome for the future, is a scheduled observation in the future.
Demonstrate how standard terminologies facilitate the use of evidence-based practice and decision-support rules.
By using standard terminologies it helps facilitate the use of evidence-based practice and decision-support rules because it supports data mining which is a process of analyzing healthcare data from different perspectives, and summarizing it into useful information that can be used to improve patient safety and quality of car and cut costs.
What are the disadvantages of HIE models?
Disadvantages are sustaining the process over time with the funding that is available
Describe clinical terminology
Clinical terminology are concepts that support clinical concepts such as diagnostic studies, history and physical examinations, visit notes, ancillary department info, nursing notes, assessments, flow sheets, vital signs, and outcome measures. Can be mapped to a broader classification system for administrative regulatory, and fiscal reporting requirements. It enable the capture of data at a level of detail necessary for patient care documentation and is used to describe health condition and healthcare activities
What are the different HIE models
Government-led HIE mode Public utility HIE model Private sector-led HIE model Public authority HIE model
what is HIE's
HIE Health information exchange is electronic sharing of patient information such as demographic data, allergies, presenting complaint, diagnostic test values, and other relevant data between providers such as primary physicians, specialist, hospitals, and ambulatory care settings according to nationally recognized standards
What is the concept of health information exchanges
HIE Health information exchange is electronic sharing of patient information such as demographic data, allergies, presenting complaint, diagnostic test values, and other relevant data between providers such as primary physicians, specialist, hospitals, and ambulatory care settings according to nationally recognized standards.
(ICNP) stands for
International Classification of Nursing Practice
Name one way that an HIE will impact healthcare delivery in the future.
It will reduce duplication and provide reuse of patient health information.
large health systems using PHRs
Kaiser Permanente Group Health Cooperative Palo Alto Medical Foundation
What is meaningful use?
Meaningful use is the use of health information technology (HIT) legislated by the American Recovery and Reinvestment Act of 2009 to collect specific data with the intent to improve care, engage patients, improve population health, and ensure privacy and security
(NANDA) stands for
North American Nursing Diagnosis International
(NIC) stands for
Nursing Interventions Classification
(NOC) stands for
Nursing Outcomes Classification (NOC)
Define the term Personal Health Record (PHR).
PHI demographic and insurance information, medical history, test and laboratory results, and other data collected by healthcare professionals in order to determine appropriate care, may also be known as protected health information.
PHR
Personal Health Record
What are obstacles to HIE development and sustaining their operation?
Some obstacles to HIE development is the expenses and the underestimating the size of the mass of data to exchange, also the resistance to changes in workflow and the numbers of unskilled workforce with HIT. Getting a good governing board is difficulty because those who contribute lots financially want more say so on what's going on while those directly affected but don't contribute much financially have less say so. Also the funding for the education to complete these task is low.
What is standardized healthcare terminology
Standardized healthcare terminology are structured and controlled languages that have been developed according to terminology development guidelines and have been approved by an authoritative body, often referred to as controlled terminologies.
Illustrate how using standardized healthcare terminologies correlates to the U.S. Meaningful Use criteria.
Standardized terminology beneficiaries include the patient, provider, organization, and the healthcare industry. The used of standardized terminology provides access to complete and accurate healthcare data and ensures compliance with standards coming forth for meaningful use which collects specific data with the intent to improve care, engage patients, improve population health, and ensure privacy and security, as well as quality measures and interoperability.
(SNOMED-CT) stands for
Systematized Nomenclature of Human and Veterinary Medicine Clinical
Describe the American Nurses Association (ANA) recognition criteria established for recognizing standardized terminologies.
The ANA recognition criteria established for recognizing standardize terminologies through the Committee for Nursing Practice Information Infrastructure and the terminologies must meet defined criteria for approval, the criteria must be used to support nursing practice reflecting the nursing process. Nursing process data elements include assessment, diagnosis, outcome identification (goal), planning, implementation and evaluation terminologies have to contain concepts that are clear and unambiguous with a unique identifier.
why is standardized healthcare terminology important to nursing?
They are important to nursing because we treat patients in a variety of settings across the healthcare continuum and requires the ability to share accurate and up to date info, amongst care providers and care settings in a common language
5. List two concerns related to patient self-entered data.
Two concerns related to patient self-entered data are patients may incorrectly assume provider is viewing the information and the patient may be unclear how to integrate with electronic health record (HER).
Identify the benefits of using structured terminologies within electronic healthcare records.
Using structured terminologies within electronic healthcare records gives a uniform language that all providers can understand, also providers and nurses will benefit by having access to complete and accurate data along the continuum of care.
Define Codes
are letters, numbers, or a combo thereof, that represents concepts in a computers system.
HIE stands for
health information exchanges
Define Codified
is a concept with an assigned code
Systematized Nomenclature of Human and Veterinary Medicine Clinical terms (SNOMED-CT)
is a multidisciplinary terminologies classification system that includes signs and symptoms of disease, diagnoses, and procedures for the integration of all medical information in an electronic medical record.
International Classification of Nursing Practice (ICNP)
is a system that serves to unify various approved nursing languages and classification systems to ensure the acceptance of common meanings across different settings, which is nursing terminology
A tethered PHR
is connected to a specific health system's EHR (electronic health record that patients can view and access data stored by one institution or organization through a secure connection. Great for people who get the bulk of care done at one place.
A standalone PHR
isn't tied to any particular healthcare system, and the individual or caregiver is to enter his or her own health information, sometimes data can be uploaded or scanned into the system by a payer or provider.
problems/barriers related to the use of PHRs
patient self entered date issues when a client may hesitate to disclose info, delegation issues a patient may accidently release information intended to be private. There are privacy concerns, clinician visit notes may be confusing or misunderstood, appointment request may not always be accurate, such as the level or type of care needed could be misinterpreted. Lab results could confuse or worry patients, someone would have to make sure sensitive results such as HIV and cancer are given in person, also medication management is a challenge if they have multiple prescribers they could be incomplete or inaccurate.
Nursing Outcomes Classification (NOC)
which is a nursing terminology is classification system that describes patient outcomes sensitive to nursing interventions.
Nursing Interventions Classification (NIC)
which is a nursing terminology is standardized classification of interventions that describes the activities that nurses perform
North American Nursing Diagnosis International (NANDA)
which is a nursing terminology recognized by ANA. Represents nursing diagnoses as data elements within SNOMED-CT
Integrated PHRs
will be able to draw info from a network of data dispersed across multiple locations, and access data residing in multiple location, ranging from providers to health plans to others such as health record banks or labs.
