Informatics, Legal Issues

Computerized information systems should contain in the following functionality:

- Reporting -Secure electronic communication and connectivity -order management -decision support

Two types of advance directives are available

:living wills and durable power of attorney for health care.

is a legal document that designates a person or persons of one's choosing to make health care decisions when patients can no longer make decisions on their own behalf. A DNR (DO NOT RESUSCITATE or no CPR wish fits into this category. When advance directives exist, they need to be written into the patient care record/chart. Nurses must follow the patient's wishes and leave their own personal thoughts/emotions behind.

A durable power of attorney for health care (DPAHC)

*Provides support and management on the business side of health care. *Includes human resources, financial data, materials management, risk management, and quality performance. *Scheduling, coding, billing, contracts with insurance companies, and accurate data such as laboratory and diagnostic information can be easily accessed.

Administrative Systems

Provides support and management on the business side of health care.

Administrative Systems

Scheduling, coding, billing, contracts with insurance companies, and accurate data such as laboratory and diagnostic information can be easily accessed.

Administrative Systems

The ability to manage schedules, insurance information, and inventory can help healthcare facilities focus on client- centered care.

Administrative processes

-increased tine to spend with patients -better access to information - enhanced quality of documentation -reduced errors of omission -reduced errors of omission -increased nurses job satisfaction -compliance with accrediting agencies -common clinical database development

Advantages of NISs

ANA

American Nursing Association

*Access to healthcare is increased *Health outcomes are improved *Healthcare costs can be reduced *Telehealth may help with shortages of healthcare providers.

Benefits of Telehealth

computer science, information science, cognitive science, social science, and engineering are examples of?

Biomedical informatics

the interdisciplinary science that deals with biomedical information, its structure, acquisition and use.

Biomedical informatics

Monitoring systems, order entry, and laboratory, radiology, and pharmacy systems

CIS- Clinical Information

Center for Medicare and Medicaid Services

CMS

Improves accuracy Speeds implementation Improves productivity Saves money

CPOE

provide guidelines on a national level for safe and healthy communities and work environments.

Centers for Disease Control and Prevention (CDC) and the Occupational Safety Health Administration (OSHA)

clients should be able to access their health records.

Client support

*Allows the nurse to record or chart information based on the assessment of the client's current condition at the "point-of-care". *Provides access to the most current diagnostic data about the client. *Provides pharmacy information and records of the client in "real-time". Includes "safety" features about drug interactions, etc. *Contain clinical decision support (setting alarms, etc

Clinical Information System Benefits

Allows multiple disciplines to simultaneously access the client's chart and record data that can be viewed and analyzed by a number of healthcare providers in real time, providing the most accurate and current information about the client so the best decisions can be made about the care of that client.

Clinical Information Systems

A hospital information system consists of two major types of information systems:

Clinical Information Systems (CISs) and administrative information systems

Client support-clients should be able to access their health records. Health Information and data Administrative processes Records management Reporting Secure electronic communication connectivity Order management Decision support

Computerized Information Systems should contain the following functinality:

CISs

Computerized clinical information systems

Nursing informatics consists of one or more

Computerized clinical information systems (CISs) Administrative information systems

the care of the client can be enhanced through the use of a clinical decision support system. These systems can display best practice standards, notifications for preventive screenings, and alerts for drug interactions

Decision support

*A digital version of a patient's medical record *Integrates all of a patient's information in one record *Improves continuity of care

Electronic health record (EHR)

*Nurses must be aware that many employers are monitoring their employee's activity on social media *Nurses must way the option of "friending" clients that they care for ( especially in areas with long term interaction)

Ethical dilemmas/ Patient rights

. Nurses act as Good Samaritans when providing care at the scene of an accident. All states have Good Samaritan Acts. Provisions may vary among states; however, these laws limit liability and offer legal immunity for nurses who help at the scene of an accident. At least two states, Minnesota and Vermont, require nurses to stop and help in an emergency.

Good Samaritan Laws

It is necessary to keep protected health information confidential and to ensure that the information entered in a client's health record is accurate?

HIPPA

provides rights to patients and protects employees. It protects individuals from losing their health insurance when changing jobs by providing portability. The privacy section of HIPAA has established rules for patients' rights to consent to use and to disclose protected health information, to inspect and copy one's own medical records, and to amend mistaken or incomplete information. Privacy and confidentiality are important factors of the privacy section

HIPPA

*Nurses must be aware of HIPPA and HITECH rules among the most critical activities *Keep passwords private. * Do not leave screens containing protected health information unattended. * Access charts only of clients to whom you are assigned. * Always verify that you are charting on the correct client's chart and that the information is recorded accurately

HIPPA laws

HIPPA

Health Insurance Portability and Accountability Act

HIS

Health care information system

•In health care settings, it is a challenge to easily access data and information about patients. The ____________________________________ has been developed to make this process easier

Health care information system

a group of systems used in a health care organization to support and enhance health care

Health care information system (HIS

*Application of computer and information science for managing health-related data *Focus on the patient and the process of care *Goal is to enhance the quality and efficiency of care provided. *Driven by the Health Information Technology for Economic and Clinical Health Act (HITECH)

Health informatics

Important data such as chronic and acute medical and psychiatric diagnoses, medications, allergies, and diagnostics tests, can help clinicians make rapid decisions if necessary.

Health information and data

IQC

Improved Quality of care

Electronic tracking and Improved Quality of Care are examples

Informatics and Service Delivery Benefits

*Improves care coordination *Reducing health disparities among U.S citizens, by improving the saftey and quality of care *Ensuring the security and privacy of protected medical information * Engaging clients and their families in the client's care

Informatics and health policy

are written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition.

Living wills

*Patient injuries can involve medical bills, lost wages, pain and suffering, perinatal damage, and wrongful death damages.

Malpractice

the conduct deviating from the standard of practice dictated by the profession?

Malpractice

forbids health care plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits.

Mental Health Parity Act

Nursing Information Systems

NISs

*Privacy, confidentiality, and security mechanisms Legal risks *Handling and disposal of information *Protection of the confidentiality of patients' health information and the security of computer systems are top priorities that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information.

NISs ( Nursing information systems)

Electronic tracking is an example of?

Narcotics

Act describes and defines the legal boundaries of nursing practice in each state

Nurse Practice Act

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

Nursing Informatics

What Supports the way that nurses function and work & supports and enhances nursing practice through improved access to information and clinical decision making

Nursing informatics

Two designs of NISs

Nursing process design Protocol or critical pathway design

Office of the National Coordination for Health Information Technology

ONC

*Episode-oriented ( each time time you have a new health folder) *Key information may be lost from one episode of care to the next.

Paper record

2 methods of Recording

Paper record, Electronic health record (EHR)

requires health care institutions to provide written information to patients concerning their rights under state law to make decisions, including the right to refuse treatment, and to formulate advance directives.

Patient Self-Determination Act of 1991

Under the health code, state legislatures enact statutes that describe the reporting laws for communicable diseases, specify necessary school immunizations, and mandate other measures that promote health and reduce health risks in communities.

Pubic Health Laws

Access to past and current diagnostic tests can help clinicians recognize changes in a client's state of health faster.

Results management

Legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care Best known comes from the American Nurses Association (ANA) Set by every state Set by state and federal laws that govern where nurses work Joint Commission requires policies and procedures (P&P).

Standards of care

telemedicine utilizes telecommunication technologies (videoconferencing, live streaming video, land based and wireless communication) to allow individuals access to care that they might not otherwise have available.

Telehealth

Provides a higher acuity of care to clients who might not have immediate access to meet their acute health needs (such as, rural settings, and in home).

Teleheath

a very broad civil rights statute. It protects the rights of disabled people. Included in this statute are people who have HIV and AIDS.

The 1990 Americans With Disabilities Act (ADA)

the "patient dumping act." Hospitals are mandated to treat and stabilize patients before transferring or discharging them.

The Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA)

gave residents in certified nursing homes the right to be free of unnecessary and inappropriate restraints.

The Federal Nursing Home Reform Act

requires that hospitals have written nursing polices and procedures

The Joint Commission

Who regulate the use of restraints. Inappropriate use of restraints violates both state and federal regulations. Use constitutes abuse.

The Joint Commission and Centers for Medicare and Medicaid Services

licenses all registered nurses in the state where they practice. The requirements for licensure vary among states, but most states have minimum educational requirements. You will be preparing to take the NCLEX-RN®.

The State Board of Nursing

TJC is

The joint commission

Lynette Donovan, a 15-year-old female African American, was a passenger in a motor vehicle collision and is now admitted to the hospital with a fractured right femur. The emergency department health care provider applied a cast to the affected leg with insufficient padding. Lynnette told the nurses that her right leg felt numb, was swollen, and looked discolored. The nurses recognized that these symptoms indicate impaired circulation in the extremity with the cast. (Potential malpractice incident) What is the next step for the nurses involved?

The nurse was unable to reach Lynette's health care provider despite several calls. The nurse has not notified the nursing supervisor of the patient's situation

states that an individual who is at least 18 years old has the right to make an organ donation. Donors need to make their wishes known in writing. Many states allow adults to sign the back of their driver's license indicating their intent for organ donation

Uniform Anatomical Gift Act

Clinical decision support systems (CDSSs)

Used to support decision making

Example of Clinical Informatics Systems?

a nurse and a nurse practitioner assessing a client's chart simultaneously access the client's chart and record data

a written statement of a person's wishes regarding medical treatment. Made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.

advanced directives

Statutory laws are derived

from the Nurse Practice Act found in all states

•For example, a small community hospital uses a nursing information system (NIS); an order entry system; and laboratory, radiology, and pharmacy systems to coordinate its core patient care services.

is and example of nursing informatics

encompasses the rights, responsibilities, and scope of nursing practice as defined by the states nurse practice act and as legislated through criminal and civil

legal issues

NIS

nursing information system

computerized physician order entry helps with accuracy and decreases times from order to treatment

order management

Healthcare facilities can comply more easily with regulatory requests and help report disease surveillance and client safety matters such as medical device recalls

reporting

An example of Improved Quality of Care is ?

reporting of clinical quality measures, joint commission

Secure and accurate communication between medical providers at the different facilities that are caring for the same client help wit

secure electronic communication and connectivity

remote medical monitoring

telemedicine

Client support is important because?

when clients are able to access their health records they have the abillity to have an active role in theor care