WGU Information Management - C468

Information literacy Ans- Defined as the ability to recognize when information is needed as well as the skills to find, evaluate and use needed information effectively Information Ans- Term used to describe data that has been interpreted Information science Ans- Focus on how to gather, process and transform information into knowledge. It also incorporates features from 5 other sciences -communication science -computer science -social science -library science -cognitive science Information systems Ans- Using the EHR to document care of a patient with a fractured femur is an example of using the EHR in which way Simulation Technology Improving patient outcomes. Ans- Allowing them hands-on practice and immediate feedback of the skill being learned Knowledge worker Ans- Nurses in this type of role -are continuous learners -use technology to support and inform nursing practice -generate knowledge as a product Expert/Experienced Nurse Ans- Expected to fully integrate informatics throughout the course of his/her practice, not just for basic data entry and retrieval. They also know how to pull trends out of data Nursing informatics Ans- Nursing informatics as a specialty does have its own National certification exam Clinical practice guidelines Ans- Clinical practice guidelines can allow for the creation of nursing policies. True rooted in evidenced based research Information technologies, not systems but functions within a system Ans- CPOE, bar code medication administration, and clinical decision support are all examples of what Computerized Physician Order Entry (CPOE) Ans- The name used to describe the process by which the physician or provider enters orders electronically into the EHR RFID Ans- A radio frequency identifier (RFID) is a type of (information) technology that is used to identify and track supplies and medications within a healthcare environment Informatics affecting Nursing Practice Ans- Clinical pathways and computer generated care plans are examples of how informatics can affect nursing practice True, examples of clinical decision support Nursing informatics Ans- The use of technology and information to help support all aspects of nursing practice The foundation of knowledge model Ans- The basis for which knowledge is used to meet the needs of the healthcare delivery system It is derived from its 3 key elements of knowledge acquisition, knowledge processing and knowledge dissemination Data (not information until it has been analyzed) Ans- A patients height, weight, code status, and date of birth are all examples of what Less consumer accountability Ans- Not an emerging trend in healthcare Mission Ans- The purpose or reason for an organizations existence Strategic planning, long-range Ans- The development of a comprehensive long range plan for guiding the activities and operations of an organization They will need to be trained on the system Ans- Why is it not important that selection committee board members understand software and electronic processes Strategic Planning Ans- Strategic planning is not driven by short term goals as Strategic Planning is a LONG TERM GOAL Blogging Ans- Not a national trend related to nursing informatics Needs assessment Ans- During which phase of the information life cycle should the "musts" and "wants" be determined Information Life Cycle Phases Ans- 1. Needs assessment phase 2. System selection phase 3. System implementation phase 4. Maintenance phase Project scope Ans- Term that defines the size and details of a collaborative effort Nurses active participation in Electronic Information Importance Ans- To ensure the information is current and accessible to the healthcare team Project Implementation Team Responsibilities Ans- Execution of system changes, active involvement in user participation, knowledge of current workflows Company history Ans- A common request contained in a request for information (RFI) document includes what System Implementation Role Ans- Go-live planning, applying system changes as needed, end-user training Continuous Ans- Term that best describes the life cycle of an information system EHR Essential Components Ans- Evidence-based decision support, assessment findings, vital signs, demographic data EHR Function Ans- Bar-code medication administration EHR Benefits Ans- Reduces medication errors, improves provider documentation Patient Support Example Ans- Providing education material EHR Primary Benefit Ans- One primary benefit of the EHR is a decreased wait time for diagnostic testing...FALSE EHR Main Goal Ans- Primary goal of EHR functionality in contrast to that of a health information system is promoting patient safety HIS Health Information System Ans- Broad term used to describe administrative and clinical systems to streamline work flow processes efficiency Barrier to patient centered care Ans- Is waiting until the end of the shift to chart patient assessments a barrier to patient centered care...Yes, chart in real time. Computer position can be a barrier if it is placed between the provider and the patient...pay attention to your patient. Standardization of Data and Different data needs of each clinic Ans- What potential challenge can occur when implementing an EHR in a medical center with various outpatient clinics Local Area Network (LAN) access Ans- What is the type of connection is needed to access the EHR when an internet connection is lost EHR Information Includes Ans- Immunization history, CT scan results, date of birth EHR Quality Care Between Facilities Ans- By providing continuity of care, interoperability EHR Ans- The EHR is a longitudinal electronic patient record of all health care encounters...carries with the patient (longitudinal) Medication Administration System (Pyxis) Access Ans- Barcode ID badge, fingerprint Order entry system Ans- Type of health information system that ensures the accuracy of physician orders ADT System (Admission, discharge, transfer) Ans- A registration system is also commonly refereed to as Health information systems Ans- A group of systems used within the hospital to support and enhance healthcare HIS Implementation Nursing Ans- It is important to secure staff nurses active participation when implementing a health information system b/c the nurses knowledge of current patient care workflow may improve implementation decisions Standardized Terminologies important to nursing Ans- They improve communication within the interdisciplinary team HIS Examples Ans- Laboratory system, pharmacy system, registration system Perioperative nursing data set (PNDS) Ans- Which nursing terminology contains a nursing diagnosis, interventions and outcomes specific to the perioperative experience Standardized Terminologies in Nursing Informatics Development is Driven by what Principles Ans- Accessibility, ubiquity, longevity, reusability Collaboration when selecting a Health Care System Ans- Collaboration leads to knowledge sharing Administrative Information System Examples Ans- Scheduling system, financial system, admission, discharge and transfer (ADT) system Clinical Information Systems Examples of Effectiveness Ans- The information retrieved can be used to foster research, improves nursing documentation compliance, It can improve clinician workflow HL7 (Health Level 7) Ans- Acronym used to refer a standard of interoperability and exchange of clinical data Financial Systems are designed to do what Ans- Manage the expenses and revenue of providing healthcare, report and track fiscal outcomes as they relate to organizational goals, help to determine the organizations strategic direction EHR implementation challenges in a medical center with various specialties Ans- Identifying the different data needs for each specialty practice Clinical Decision Support Tool Characteristics Ans- Takes specific patient data, analyzes it and provides recommendations (next action) Clinical Decision Support Tool Examples Ans- Computer generated care plans, alerts, smart pumps, electronic drug references Culture of Safety Principles Ans- 1. Commitment of resources 2. Cross collaboration 3. Blame free environment Security Threats to data/information Ans- 1. Unauthorized personal accessing equipment 2. Use of removable storage devices Governing Authorities protecting Information Ans- 1. HIPPA 2. ANA code of ethics HIPPA Privacy Act Ans- 1. Patients have ownership rights to their records 2. Patients can amend own records if information is incorrect Physical/Logical Means of Protecting Information Ans- Physical - surveillance cameras, restricted areas, hard copy records being shredded Logical - firewall protection, biometrics, authentication, automatic sign off on computers Telehealth (Store and Forward Technology) Ans- Means of transferring data or images from one location to another, most often used for pathology reports and radiology images Telehealth Driving Factors Ans- Access to care (removing geographical barriers), continuity of care, mobile devices, follow up calls, more patients than providers, increase in chronic diseases Telehealth (Ethical and Legal Implications) Ans- Need for extensive documentation to avoid malpractice, providers need to be licensed in every state they practice Telehealth Telehealth (Clinical vs Non-Clinical Applications) Ans- Clinical - imaging that needs to be read, mobile device to monitor patient, live video conferencing Non-clinical - online database search, administrative team using video conferencing Nursing Informatics Concepts Ans- Data, Information, Knowledge, Wisdom Informatics System Considerations Ans- Technical Specifications - Downtime for Maintenance Response Time - Time it takes system to process request Architecture - Structure of system, open comm. each other Connectivity - Interface the system in multiple ways Testing - In different place than being used Compatibility - With other systems Computer Technology Ans- Collection of data for analysis used to justify the efficiency of particular interventions & improve quality care Computer Hardware Ans- Input device, CPU, Secondary Storage, Output Device ANA Terminologies Ans- NANDA, NIC, NOC, CCC, ICNP, PNDA, Omaha System ARRA (American Recovery & Reinvestment Act Ans- Provides funds for adoption of technology and provides the right for every individual to receive electronic copy of EHR EMR Basic Components Ans- Clinical messaging, email, data repository, clinical docum CIS Ans- Access to client data to Plan, Implement, Evaluate Care Clinical Term Ans- Enables the capture of data for patient care docum Computer System Ans- Hardware, Software, Data, Procedures, Users CPOE Ans- Needs downtime procedure or policy prior to implement CPU Ans- BRAIN, computer chip processes all computer functions and uses NO integration Ans- C-3PO and RUG's EBP Attributes Ans- Increased job satisfaction, improved quality of care EBP Ans- The use of research and evidence to inform clinical practice, an approach to provide care that integrates nursing experience and intuition with valid and current clinical research to achieve the best PT outcomes EDI Electronic Data Interchange Ans- Permits multiple systems to acquire and share data EBP Provides Ans- Standardized best practices, reduces time nurses spend gathering and assessing data, and provide care w/ clinical research EMR Ans- Electronic version of the client data found in the traditional medical record EMR Provides Ans- Legal record often restricted to a single visit of care, building block of EHR HIPPA Compliant Codes Ans- ICD, ABC, Common Procedural Terms HIPPA Provides Ans- Legal protections for personal health info, set standards for electronic data interchange of claims data, named specific code sets for use in Medicare related transactions and priv HITECH (Health Information Technology for Economic and Clinical Health) Ans- Strengthened HIPPA security and privacy protection, provides financial incentive for user of EHR Nurse uses Data Ans- Accessing Information, Collecting Data, Inputting Data, Analyzing Data Informatics Innovator Ans- Process of making enhancements or improvements..creative Informatics Nurse Ans- Advance knowledge and proficiency in the use of IT as it applies to nursing practice. Interfacing Types Ans- 1. Point to Point - Enables 2 systems to communicate, expensive, has to have customized program 2. Interface Engine - Interfacing across several different systems. Internet Security Measures Ans- 1. Firewall - Prevents unwanted access to the system and it's information 2. Limit web page access 3. Server Security - Information stored is not accessible to other systems if they are attacked 4. Update security software Intranet/Extranet Ans- Intranet - Private networks that cannot be accessed outside the organization Extranet - Network outside the organization that enables customers and suppliers access to the services. MIPPA (Medicare Improvement for Patients and Providers Act) Ans- Financial Incentive for e-prescribing physicians Telehealth Issues Ans- Lack of reimbursement, infrastructure, plug-play standard, license and liability issues, concerns r/t privacy confident. Knowledge Ans- The synthesis of information from several sources to produce a single concept or idea Ex. journal about BP LAN Ans- Connect a few computers to the server over a large area ex. doc's placing orders from home. Needs to be Integrated Ans- ICD-9, G-Codes, ICD-10, CPT, HCSPC Network Ans- Combination of hardware and software that allows communication & electronic transfer between computers Connects Multiple computers in different locations Novice Ans- Beginner w/ no experience with situations in which they are expected to perform a task...taught rules to guide actions Nursing Informatics Ans- Integration of nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom into nursing practice. Nursing Information System Ans- Standardized nursing language (SNL) 2 approaches 1. Nursing Process Approach & Critical Pathway - Multi Disciplinary teams throughout. Physician orders are present for the team to observe and follow, allows the team to update the POC when variances in the PT condition are noted. 2. Protocol Approach - Streamline documentation of assessment, med info, discharge info and education Qualitative Research Ans- Concerned with finding out more about the human experience, accomplished through interviews and over a long period of time. EX How interventions could impact an entire population, content analysis, computers can code responses to questionnaires which can them be inputted in the informatics system for analysis. Quantitative Research Ans- Concerned with objectivity, tight control over situations, define relationships between variables, seek correlation between data. EX Tries to discover how an intervention has impacted subjects IN DEPTH, tangible relations between variables. EMR Adoption Stages Ans- 0-Organization 1. All 3 key ancillary departments (lab, pharm, radiology) installed 2. CDR - Clinical Data Repository provides physician access for reviewing orders and results. Possibly HIE Capable. 3. Nursing/Clinical Documentation - EMAR, first level of clinical decision support is implemented. 4. CPOE implementation 5. Closed loop med administration w/ bar codes is implemented, 5 rights of med. administration 6. Full physician documentation, full radiology and PACS 7. No more paper charts Patient Information Ans- Standard (temp, weight), General, Targeted, Personalized (specific info on condition pt has been dx with ex DII), Tailored (Gleaned from EMR EHR focuses specifically on conditions IND Based) Telemedicine Ans- Improve pt outcomes by permitting pts to remain at home, allows pts to communicate w/ provider about blood glucose test or video conference w/ them directly to develop pt specific education opportunities, directed by doctors Telehealth Options Ans- 1. Store & Forward- items are transferred to experts who read and interpret information and send back results 2. Real Time- interactive conferencing Teleconferencing Ans- Use of computers, audio, & video equip. and high-grade dedicated telephone line, cable/sat connections to provide interactive communication between 2+ ppl at 2+ sites Telehealth Ans- Use of telecommunication technologies & computers to provide healthcare info & services to clients at another location - consumers are chronically ill, isolated, assisted living families - decrease er visits, decrease LOS, decrease Admissions, increased productivity for clinical Web 2.0 Ans- Online tool that permits collaboration and sharing online, such as facebook, twitter; Provides education- wikis, web logs, virtual worlds, facebook TIGER Ans- Technology Informatics Guiding Education Reform Standardized Terminology Supports Ans- Data Mining (the practice of examining large databases in order to generate new information)