D220 Definitions Flashcards
1
Q
Access Levels
A
User can only see information that they have access to. (Ex. CNA cannot see everything an RN can).
2
Q
Administrative Safeguards of Electronic Health Information
A
Restricting access of all authorized users of the EHR according to their position within the healthcare system.
3
Q
Admission-Discharge-Transfer (ADT) System
A
Classified under the hospitals’ administrative info system. It’s one foundational system that allows operational activities such as bed placement, transportation, coordination, room readiness, and the general coordination of services focused on the patients phase of movement. Tracks patients activities and location from admission to discharge.
4
Q
American Recover & Reinvestment Act (ARRA)*
A
Authorized incentive payments to specific types of hospitals and healthcare professionals for adopting and using interoperable Health Information Technology & EHRs. ARRA provides economic stimuli and incentives for the adoption of EHRs.
5
Q
Health Information Technology for Economic and Clinical Health Act (HITECH Act)***
A
The HITECH Act provides funds and incentives to increase EHRs by providers, improve policy decisions and allocate services, funded workforce training, and new technology research. HITECH strongly recommends increasing meaningful use of HIT to decrease overall healthcare cost and to improve population health.
6
Q
Differentiate the focus of the ARRA and the HITECH technology for economic and clinical health acts
A
ARRA: Established incentive payment for eligible pros (EPs), eligible hospitals, and critical access hospitals (CAHs) to promote the adoption and meaningful use of Certified Electronic Health Record.
HITECH: Provided economic stimuli and incentives for the adoption of EHRs. It also insured the collection of aggregate data that could be used to improve policy decisions relative to allocation of services and population health.
7
Q
What is the difference between ARRA and HITECH?
A
ARRA: Authorized incentive payments to certain hospitals and health care professionals for adopting and using HIT and EHRs. Helps to stimulate the economy.
HITECH: Is a provision of ARRA that helped to ensure that healthcare organizations were not only adopting EHRs but were only using them for the following recommendations of Meaningful use which includes better quality, safety, and accuracy and by reducing inconsistencies in health care and improving patient outcomes.
8
Q
HITECH info*
A
-Directs eligible healthcare providers and healthcare organizations to adopt electronic health records to improve the exchange of information and to improve privacy and security protections for healthcare data.
-The HITECH Act of 2009 provides the Department of Health and Human Services (HHS) with the authority to establish programs to improve care quality, safety, and efficiency through the promotion of health IT, including electronic health records and private and secure electronic health information exchange.
9
Q
Which barrier to healthcare informatics use does the HITECH Act aim to reduce?
A
Financial
10
Q
Meaningful Use***
A
Use of health information technology (HIT) legislated by ARRA of 2009 to collect specific data with the intent to improve care and population health. engage patients, ensure privacy and security, with financial incentive from Medicare and Medicaid to providers.
**Goals: engage patients, exchange data in an accurate/complete way, improve healthcare overall.
**Used by inpatient and outpatient settings. Enable providers to be financially compensated.
**Requires standardized terminology (allows for uniformity and easier retrieval of nursing-related data.
11
Q
What were two objective of meaningful use as defined by the American reinvestment and recovery act (ARRA)?
A
Document patient collected data directly into the EHR and submit electronic data to health information exchanges (HIEs).
12
Q
Meaningful Use (MU) Care Requirements***
A
*Centers for Medicare and Medicaid Services (CMS) developed core criteria that defined basic functions of EHRs must demonstrate. Basic entry of clinical information, requiring standardized terminology across the board, use of several software applications, entry of clinical orders with safety measures.
13
Q
MU Core Requirement Stages
A
Stage 1: Electronic capturing and sharing of data between hospitals/providers.
Stage 2: Requires patients to view, download, or transmit their health information online, capability for secure messaging between providers/patients, and reporting public health measures, advancing clinical processes.
Stage 3: Focus on the enhanced use of EHRs to promote health information exchange and improve care, and improving patient outcomes (ex. electronic prescribing) implemented in 2018.
14
Q
Which government organization describes the application of meaningful use?
A
The Centers for Medicare and Medicaid Services (CMS).
-One of the goals of the 2016 CMS Quality Strategy calls for improving safety and reducing unnecessary and inappropriate care, by teaching healthcare professionals how to better communicate with people who have low health literacy and by more effectively linking healthcare decisions to person-centered goals.
15
Q
Which statement describes the application of Meaningful Use?
A
Provider needs to show the use of EHRs technology.
16
Q
Which act in 2009 did Meaningful Use originate?
A
ARRA act in 2009
17
Q
What Meaningful Use stage can you generate and transmit prescriptions electronically?
A
Stage 3
18
Q
What did Meaningful Use promote?
A
Increased interoperability
19
Q
Which statement describes the application of Meaningful Use?
A
Patient satisfaction improved, which results in better patient satisfaction scores.
20
Q
What described the goal of EHR incentive programs, such as Meaningful Use?
A
To promote the achievement of quality, safety, and efficiency measures.
21
Q
Identify five rights associated with Meaningful Use
A
Right information
Right person
Right intervention format
Right channel
Right time and workflow
22
Q
Identify the importance of standardized terminologies for Meaningful Use
A
Improves better communication among nurses and other healthcare providers. It also improves patient care leading to patient satisfaction and treatment adherence.
23
Q
Relationship between standardized terminologies, quality improvement, and financial awards related to Meaningful Use?
A
Use of health information technology legislative by ARRA of 2009 to collect specific data with the intent to improve patient care, engage patients in their own care, and to ensure privacy and security with financial incentives for Medicare and Medicaid to providers. If providers are all using the same standard of terminology this will in turn give patients a better understanding and they will engage more in their own care. This will help meet Meaningful Use requirements, thus providing financial rewards to providers.
24
Q
The 21st Century Cures Act
A
Is designed to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently. It also requires patient electronic health information be made available to patients without delay (with few exceptions), at no cost.
25
What is the focus of the 21st Century Cures Act?
Recognizes that patients need more power in their healthcare and access to information is key to making that happen.
26
What act puts patients in charge of their healthcare records?
The 21st Century Cures Act
27
21st Century Cures Act Info:
One of the provisions of the 21st Century Cures Act is the elimination of information blocking. Information blocking is defined as a practice by a health IT stakeholder that, except as required by law or specified by the Secretary of Health and Human Services (HHS) as a reasonable and necessary activity, is likely to interfere with access, exchange, or use of electronic health information from provider to provider or provider to patient.
28
The American Nurses Association Code of Ethics Provision 3:
Stresses that a nurse's obligation is to protect patients from harm. Protecting the patients right to privacy and confidentiality protects the patient from harm.
29
***Merit-Based Incentive Payment Systems (MIPS) - Quality***
Ensures Medicare patients get the right care at the right time. Uses PQRS (physician quality reporting systems) and Medicare EHRs that will be measured on quality, resource use, clinical-practice environment, and meaningful use of EHRs technology. For physicians to qualify for MIPS, they must bill Medicare more than $90,000/year and see more than 200 Medicare patients annually.
30
Which MIPS merit-based incentive payment system performance replaces MU for physicians?
HITECH Act
31
Which merit-based incentive payment system (MIPS) performance category replaces MU for physicians?
Quality of care
32
What do the goals of MU and merit-based incentive programs have in common?
Improving quality of care
33
***Joint Commission - Accreditation***
Key standards of information management: protect and aggregate data, uniform definitions/language, teach information management (training), and address disaster and preparedness.
34
An informatics nurse is on a task force planning committee to ensure data storage measures are safe and accessible. Besides the provider and the client, which groups needs are important to consider?
The Joint Commission
35
What is the Affordable Care Act of 2010?
US legislation intended to improve healthcare quality through using information technology, ensuring affordable care, and increasing the number of insured persons.
36
Patient Protection and Affordable Care Act
Guarantees access to healthcare for all Americans and incentives to change clinical practice to encourage better coordination and quality care.
37
Which legislative act that mandated research become accessible to facilitate better decisions based on evidence?
Affordable Care Act
38
Technology Informatics Guiding Education Reform (TIGER Initiave)
Formed in 2004 to advance nurses' competencies related to informatics. Primary objective to develop a US nursing workforce capable of using electronic health records to improve delivery of health care.
39
Analytical Science
Uses variety of methods and instruments to answer two basic questions: What do I have? How much of it do I have?
Environment, pharmacy, safety and security, fraud detection, and healthcare diagnostics.
40
***Audit Trails***
Software that is used for detecting security violations, performance problems, and flaws. Records activity by users and system. **Goal is to improve/ensure data integrity.*** An audit trail must contain the name of the user, the application triggering the audit, the workstation, the specific document, a description of event being audited, and the date/time to determine integrity of data.
41
Authentication
Action that verifies the authority of users to receive specified data.
42
FDASIA
Has improved the FDAs ability to speed patient access to digital records and improve the safety of drugs, medical devices, and biological products.
43
***Benchmark***
Continual process of measuring services and practices against the toughest competitors in the healthcare industry or comparing the performance of an organization or clinician to others.
44
Metrics related to stroke care and compare them across the country in a presentation?
Benchmarking
45
Big Data
Very large data sets beyond human capability to analyze or manage without the aid of information technology. Considered data originating from very large data sets that help identify patterns and trends. Big data cannot be managed without the use of technology to analyze its output.
5 properties: Variety, velocity, volume, value, veracity.
Velocity in big data refers to how fast it can be processed to generate knowledge.
46
Big Data Center
A term that refers to achieving the centralized processing, storage, transmission, exchange, and management of information within a physical space, in which computers, servers, and network and storage devices are generally considered the key equipment for the core of a data center.
47
Change Management/Change Control
Involves employees in the decision-making process. Helps prioritize limited resources and ensure systems standards are upheld. For example, medication administration. Should exclude subject matter experts when discussing change control. This should be internal people only; people who are doing and dealing with the problem directly.
48
***Clinical Decision Support System (CDSS)***
Supports healthcare practitioners in making patient care decisions by integrating patient data with current clinical knowledge. Provides recommendations for care and must be balanced with professional judgment, not used in place of it.
49
***Decision Support Tool/Clinician Decision Support (CDS)
Decision Support System/Software (DDS)***
Software app to help in human decision process. Software will look at the patients data and suggest appropriate medical/nursing interventions. Can also trigger prompts/alerts to user. Requires human user input. Decreases patient safety risk and increases positive patient outcomes (alerts for abnormal vital signs, lab results, medication contraindications, etc.). The right components of a CDS include a trigger, such as med order; input data, such as lab values, intervention information, such as other options provided, and action step, such as action selected by the doctor.
50
Expert System
A type of CDS/DDS but does not need human intervention, uses artificial intelligence (ex. insulin pump).
51
What term refers to the intelligent application of data manipulation which empowers nurses to work more efficiently with enhanced communication and informed decision support?
Artificial intelligence
52
What is the intent of the CDSS (Clinical Decision Support System)?
This is an application that supports healthcare in practitioners in making patient-care decisions and providing clinicians with knowledge and person - specific information.
53
What are two barriers of adopting the CDS in an EHR?
Limited resources and communication information exchange.
54
Five Right to Clinical Decision Support
Right information
Right person
Right intervention
Right time in the workflow
Right place
55
What is considered to be clinical decision support (CDS) within the EHR?
The condition or disease-specific order sets.
56
What is the primary purpose of a clinical decision support system (CDSS)?
It provides clinicians with suggested care information.
57
How is clinical decision support system (CDSS) represented in the EMR?
Through alerts and reminders
58
What to do when CDSS is ignored
Educate the staff on the importance.
Review each alert's determinant significance and make a decision to maintain or eliminate. it recognizes unnecessary alert is dangerous because it might make that much less likely that a clinician will pay attention to the next alert that is necessary. Explore the possibility of the machines talking to each other to establish congruence and interpreting specific patient input that is aligned with the need for the alert to fire.
59
Four components of CDSS:
Trigger, input data, intervention information, action step.
60
Name two visual cues with CDSS. Why are visual ques important?
Order sets, reminders, checklist, data driven triggers.
These are important in preventing medication errors and promote patient safety.
61
What describes the role of decision support within the EHR?
It is designed to assist with timely clinical decision making.
62
***Clinical Information System (CIS)***
Software used to access client data, plan, implement and evaluate care. May be specific to certain departments: lab, radiology, pharmacy, or patient populations. Provides patient centered decision making functionality to help guide RN with decision making. Acquires patient data so that healthcare professionals can review it and use information to deliver care.
63
Define the term "Clinical Information System"
Large computerized database management systems used to access the patient data that are needed to plan, implement, and evaluate care.
64
The pharmacy information system:
Is clinical information system (not administrative information system) because it also manages order entry tracking of drug dispensing, alerting practitioners and pharmacists of prescription errors and potential interactions, patient education, and providing access to clinical information.
65
Computer Literacy
Familiarity with the use of personal computers. The knowledge and ability to use computers and technology efficiently. Computer literacy allows patients to interact with the internet.
66
Computerized Provider Order Entry (CPOE)
Prescribers decisions to enter orders and immediately share orders with appropriate health professionals who execute orders and departments that need to dispense, schedule, or immediately deliver services to patients. CPOE can check for duplicate orders, alert departments to carry out orders, and provide the status of each order.
67
Barcode Medication Administration
Mandated by the FDA
68
What is the effective use of a barcode administration system?
Combine it with CPOE, a pharmacy system, and eMAR.
69
Barcoding scanning. How it affects inventory with pharmacy?
Alters ordering and information data
70
What facility first used the BCMA?
Veterans Hospital of Topeka, Kansas
71
If your patients barcode bracelet is not working and you need to pass meds, what would you do?
Check with the armband for damage, change the band if necessary.
72
Which government agency recommended the use of the barcode medication administration?
ONCHIT - The US Office of the National Coordinator for Health Information Technology
73
What are 3 purposes of using bar code medication administration (BCMA)?
It alerts the nurse to drug-drug interactions, it reduces errors of administration and it supports the 5 rights of medication administration.
74
***Confidentiality***
Unspoken understanding that private information shared in a situation, in which a relationship has been established for the purpose of treatment or delivery of services will remain protected.
75
Configurability
Extent that a given software product can be adapted or changed to meet a users preference.
76
Connected Health
Refers to the delivery of technology assisted care that occurs outside the traditional face-to-face setting between a patient and a healthcare provider. Connected health is differentiated by two categories: synchronous and asynchronous.
77
Synchronous Applications
Connected health modalities that facilitate real-time, video and voice interaction and bidirectional communication between patients and healthcare providers.
Videoconferencing - leveraging synchronous options allows immediate access to services or specialists that might otherwise be inaccessible. The uses are varied, but the result is the delivery of timely care to those in need. For example, remote ICU, direct care robotics, peripheral devices connected to a videoconferencing unit aiding the practitioner is assessment and diagnosis at a distance and in real time.
78
Asynchronous Applications
Patient centered and allows for consumers to participate in their own care by using designated health technology to share health metrics and data with their healthcare provider via technology (remote patient monitoring - the use of devices to capture patient data at one location and then transmit it electronically to healthcare professionals at a different location, allowing the review of data for clinical decision-making), ex. mobilehealth, RPM.
79
Remote Patient Monitoring (RPM)
(Asynchronous) Is a patient centric, emerging technology that allows patients to participate in their own care by using a designated health technology to share health metrics and data with their healthcare provider or monitoring professional. The healthcare data are stored and accessed on demand by the healthcare professional.
80
Remote Patient Monitoring
IS the use of devices to capture patient data at one location and then transmit it electronically to healthcare professionals at a different location, allowing the review of data for clinical decision making.
81
Store-and-Forward Applications
(Asynchronous) Transmit recorded health information through a secure communication network to a provider (photos). For example, a nurse takes a photo of a wound to send to a wound doctor.
82
***Consolidated-Clinical Document Architecture (C-CDA)***
Allows interoperability of health information exchange between hospital systems.
83
Consumer Health Informatics (CHI)
Use of electronic information and communication to improve medical outcomes and health-care decision making from the patient/consumer perspective.
3 barriers include: Privacy issues, cognitive disabilities, low health literacy.
Five examples: Personal health records, telehealth, mobile health, games for health, and health 2.0.
84
Mobile Health, also known has mHealth
Is the collection of emerging technologies that use mobile communications and network technologies for healthcare systems. mHealth is changing the landscape of healthcare because its focus on patient-centric needs is allowing the improvement of patient education, preventative care, and diagnosis and research-based treatment. Additionally, it is showing the capacity to lower healthcare costs and enable patients to manage long-term conditions. For example, Smartphone connected devices, wearable sensors, lab-on-a-chip, implantable and ingestible sensors and remote patient monitoring.
85
The Internet of Things (IoT)
In healthcare refers to the collection of internet connected devices, including wearables, implants, skin sensors, home monitoring tools, and mHealth applications. The IoT has the potential to connect to patients and their providers in a variety of ways and has the ability to maximize the power of big data analytics through ongoing innovation. The Internet of Things (IoT) in healthcare refers to a subset of the internet that deals with medical information and literature for the advancement of health information technology.
86
***Continuity of Care Document (CCD)***
Summary of a patients health and healthcare to provider who does not have access to the persons EHR.
87
Continuity of Care Record (CCR)
This record is intended to improve continuity and quality of care, including reductions in errors, when patients move between various points of care.
88
Where is the continuity of care documented
The EHR
89
Which item enhances interoperability between organizations when exchanging patient data electronically?
Continuity of Care Document (CDD) or Continuity of Care Record (CCR) via direct messaging.
90
Primary database used for nursing literature
Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medicine
91
The National Library of Medicine
Manages the worlds largest biomedical and health library and offers courses on how to validate healthcare information found on the internet.
92
Data
Collection of numbers, characters, or facts are gathered according to some perceived need for analysis.
93
***Data Analysis***
The processing of data that identify trends and patterns of relationships.
94
Data Information Knowledge Wisdom (DIKW) Framework
Data is most discrete components of the DIKW framework. Mostly presented as discrete observations with little interpretation. Information is a continuum of progressively developing and clustered data. Relations and interactions are not yet evident in information alone. Knowledge is information that is processed and organized so relations and interactions are identified. Wisdom is appropriate use of knowledge to manage and solve human problems. Wisdom includes ethics or knowing why certain things/procedures should/should not be implemented in specific cases.
95
Describe the progression of data using the DIKW framework:
The DIKW guides the development of the scope and standards of practice in nursing informatics. It is how data is used to produce the wisdom to be applied to nursing.
96
Differentiate between data and information:
Data: The most discrete components of the DIKW framework. These are the smallest factors describing the patient, disease state, health environment, and so forth.
Information: Can be described as data plus meaning. Information is a continuum of progressively developing and clustered data.
97
Wisdom in DIKW framework
Is the level at which AI-driven predictive analytics is used to support decision-making by nurses.
98
Predictive analytics
As opposed to reactive analytics, predictive analytics involves proactive management of the patient at the bedside and in the community to prevent further deterioration of health and avoidance of unnecessary cost of care. It's another technology that is trending as a priority for the future.
99
Best way to analyze a single piece of data in multiple ways?
Predictive analysis because it is based on recognized trends of patients prior and current information, not just a static view of current information.
100
Knowledge
Synthesizing information from different sources to produce a concept of idea.
101
Knowledge Management
Generation, storage, distribution, and application of both tacit knowledge (personal experience) and explicit knowledge (evidence).
102
Knowledge Work/Workflow
The work of gathering data to create information. Knowledge of the workflow is essential of the implementation team.
103
Knowledge Worker
Individual with a high degree of expertise, education, or experience who creates, distributes, and applies knowledge.
104
***Data Integrity***
Ability to collect, store, retrieve correct, complete, and current data so that the data is available to authorized users when needed. Can be compromised by incorrect entry of information, data tampering, and system failure. Prevention by implementing security measures, audit trails, and having detailed policies and procedures. Data integrity is the state wherein data is uncorrupted, accurate, and valid.
105
Action that demonstrates data mining to improve patient outcomes?
HbA1c
105
Data Scrubbing
Process to remove incorrect, incomplete, duplicate, or improperly formatted items using special software designated for this purpose/
105
***Electronic Health Record (EHR)***
Is a digital version of a patients paper chart. Database of individuals healthcare data during healthcare encounters. It's compromised of any patient data stored in electronic form. Electronic form/database of a patients past medical history, medical test, medications, images etc. stored in electronic form. Enables many functions needed to create and maintain EHRs. You will know if the EHR is successful if the customers needs were met.
106
Which area of the EHR is used to guide a nurse on the task that needs to be completed during the shift?
Workflow
106
What plays a primary role in the usability of an electronic health record (EHR)?
Clinical workflow and efficiency
106
At a nursing facility, the recent quality report details only 30% of patients received the influenza vaccine in the prior flu season. Nurses within the medical unit state the result is too low. Which area should an informatics nurse review to understand the quality report results?
EHR charting data
107
***Electronic Medical Record (EMR)***
Legal record created in hospitals and ambulatory settings of single encounter/visit that is source of data for EHR. Brings together diagnostic and treatment information for an individual in specific healthcare setting. **Usually found in a physician's office.***
108
The operating room uses a different system than what in integrated in the EMR. What do you do?
Chart in one system and it will automatically show up in both systems/
109
Which information in EMR will help the nurse manage post op care for appendectomy?
Doctors orders
110
Best method of EMR charting for nursing?
Cascading
111
Data entry fields?
Cascading
112
Electronic Medical Record Adoption Model (EMRAM)
Measures clinical outcomes, patient engagement, and clinical use of EMR technology to strengthen organizational performance and health outcomes across patient populations. Basically evaluates health information systems.
113
Ergonomics
Scientific study of work and space, including details that impact productivity and health.
114
***Evidence Based Practice (EBP)***
Current, best evidence for patient care. Improves consistency and quality of patient outcomes. Foundation of clinical practice and guides clinicians. Found in standing orders (ex. Sepsis protocol).
115
HIS system for patient to manage their own stuff?
An app.
116
A physicians group would like to change the current EBP protocol for treating asthma. How should the informatics nurse determine validity of the new EBP protocol?
Solid clinical trials
117
When deciding on a technology tool for the delivery of EBP informatics, which information should the nurse informaticist seek?
Information that is accurate, timely, complete, concise, and relevant.
118
***Fishbone***
Or cause and effect, is a tool to identify and trace problems and then track the cause back to the root. This is also called root-cause analysis. The first step in the process is to state what the problem is, then ask "why" any number of times until the source or cause has been identified.
119
What is a fishbone diagram and what benefit does it provide?
A tool for analyzing the organization processes and its effectiveness. Helps team members visually diagram a problem or conditions root causes, allowing them tp truly diagnose the problem rather than focusing on symptoms.
120
Process for discovering root causes of problems and identify the solution?
Root cause analysis
121
EBP is essential for clinical decision making. Which model supports EBP?
Problem, intervention, comparison, outcome, time (PICOT)
122
What is a structured method used to analyze serious adverse events?
A root cause analysis (RCA)
123
Failure modes and effects analysis (FMEA)
Involves is a systematic method of proactively investigating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.
124
***Health Information Exchange (HIE)***
Electronic sharing of patient information between healthcare providers according to nationally recognized standards, allows insurance companies, and providers to share data, must be secure and maintain integrity. Works by improving speed, quality, safety, and cost of patient care.
Query-based exchanges: often used for unplanned events. Ex. ER, it allows providers to find and request information based on a patient from other providers.
Directed exchange: is used to support coordinated care and allows the ability to send and receive secure information electronically between care providers. A directed exchange is when providers send laboratory orders and results, patient referrals, or discharge summaries to another provider of healthcare entity.
Consumer-mediated exchange: allows the ability for patients to review, manage, and control the use of their health information among providers. Allows insurance companies and providers to share data (or across delivery settings). Nationally recognized standards/federal legislation demands for safer, more efficient healthcare. Increased efficiency and quality care. All states have implemented health information exchange. Must be secure and maintain integrity.
125
Query-Based Exchange
Is often used for unplanned events. Like a visit to the emergency department. It allows providers to find and request information on patients from other providers.
Directed exchange is used to support coordinated care and allows the ability to send and receive secure information electronically between care providers.
Consumer-medicated exchange allows the ability for patients to review, manage, and control the use of their health information among providers.
126
Identify and explain the 3 types of health information exchange:
A way of sharing patient information between health care providers electronically while following national recognized standards. It must be secure and maintain integrity.
3 forms: Directed, consumer mediated, and query based.
127
When can you get notes from provider quickly?
HIE, query based transfer
128
Physical taking care of a patient whose established care is somewhere else talking about HIE?
Query-based
129
How does HIE impact cost of patient care?
A means to reduce redundant tests, improve quality of care, and improve public confidence.
130
How does the health information exchange (HIE) improve interoperability within a healthcare organziation?
It allows patient information to be accessible despite where the patient is receiving care?
131
Situation where nurse carries out an HIE?
NP reviews patient records/reads diagnosis test results from remote facility.
132
What is the goal of Health Information Exchange?
To allow insurance companies and providers to be able to share data.
133
***Health Information Technology (HIT)***
Various systems and technology used to record, monitor, and deliver patient care, as well as perform managerial and organizational functions. HIT is used to support systems that collect data needed for patient care, population health management, and for the sharing of this information within a secure system. Large datasets resulting from Meaningful Use (MU) and other incentives will provide increased evidence to support HIT policy decisions that weight national, as well as global implications.
134
HIS vs HIT?
Health information systems (HIS): manage health information for specific areas of healthcare. Health information systems are categorized as clinical information systems or administrative information systems.
Health information technology (HIT): is what is involved in the design, development implementation, integration, creation, use, and maintenance of health information systems. HIT also refers to the area of healthcare that uses computer hardware, software, or infrastructure to record, retrieve, analyze, archive, secure, and share clinical administrative, and financial information. HIT is the backbone and foundational structure of many advancements in healthcare such as clinical decision support, computerized disease registries, computerized provider order entry, consumer health IT applications, electronic medical record systems (EMRs, EHRs, and PHRs), electronic prescribing, and telehealth.
135
***Health Insurance Portability and Accountability Act (HIPAA)
Sets the national Standard of Personal Health Information. Legal protection for PHI. Electronic transactions need to have HIPAA compliant codes. Signing into devices should require authentication encryption and should never be left unattended. Email and instant messaging may carry PHI that can be intercepted. Fines prior to 2/18/2009 are $100/violation with a max of $25K yearly. If after 2009 fines can be $100-$50K+/violation, with a max of $1.5million yearly. Criminal penalty fines can be up to $50K and 1-year in jail.
136
What legislation provides more rigorous enforcement of HIPAA and requires notification of breaches and allow patient access to their electronic records?
HIPAA Breach Notification Rule. US department of Health and Human Services (HHS) and Office for Civil Rights (OCR) is responsible for enforcing HIPAA.
137
What are 3 common reasons for HIPAA violation citations?
Lost or stolen unencrypted devices, social media postings, taking a patient photo with a personal phone.
138
Lab results qualify as?
PHI because they can give an indication of a patients underlying condition.
139
Which area is an example of where information and data privacy issues may arise?
Informed consent records because it records detail specific information such as tests, procedures, lab results, etc., and may compromise privacy if improperly handled.
140
Best practice for HIPAA:
Required password
141
Employee falls and gets hurt at work:
Do not provide info because HIPAA.
142
HIPAA protection?
Name and DOB
143
Hiker information given to newspaper?
Hospital violates HIPAA because they did not follow their guidelines.
144
Input patient data information journal?
HIPAA
145
How to protect patient data:
Marinating HIPAA protocols, encrypted EHR storage, training employees on a need-to-know basis.
146
AHIMA Guideline
One of the guiding principles of the AHIMA Code of Ethics is to advocate, uphold, and defend the consumers' right to privacy and the doctrine of confidentiality in the use and disclosure of information. While this guiding principle is focused on the health information management professional, it also applies to the nursing profession.
147
The use of standardized data sets is critical for EHR. Which 2 standards supports the interoperability of healthcare data?
DICOM (Digital Imaging and Communications in Medicine) and HL7 (Health Level 7) standards.
148
***Health Level 7 (HL7)***
A standard/framework for the exchange of data (PHI) between information systems with extensive set of rules that applies to all data that is exchanged, shared, integrated, or retrieved. Refers to both organization and its standards to exchange data. Specifies how the data is coded.
149
***International Classification of Diseases 10th Revision (ICD-10)
Is the international standard diagnostic classification for health-management purposes and clinical use. The ICD diagnoses are used to classify mortality and morbidity data from input and output records. Also used for reimbursement.
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What are the ICD10 international classification of diseases?
LOINC and SNOMED
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***SNOMED Clinical Terms***
Globally recognized, controlled healthcare vocabulary that provides a common language for EHRs. Enables a consistent way of capturing, sharing, and aggregating health data across all specialties and sites of care. Supports interoperable data collection and exchange.
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LOINC
is terminology specific to lab tests, orders, and results.
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What is the reason to have standardized terminology within a healthcare setting?
It provides the effective exchange of information between providers.
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Which two statements define healthcare informatics?
Standardized languages and terminologies to ensure consistent meanings across all settings.
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