Final Exam Flashcards
1
Q
Ethical decision making
A
- process that requires striking a balance between science and morality
- making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong
2
Q
American Nurses Association (ANA) - Code of Ethics for nurses with Interpretive statements
A
- provides specific guidance for ethical decision making and provides a valuable framework that can be used when working with HIT (health information technology)
3
Q
Bioethical standards
A
Autonomy Freedom Veracity Privacy Beneficence Fidelity
-all are maximally appropriate to the health care setting
4
Q
Autonomy
A
- the right to choose for himself or herself
- respecting clients opinions, perspectives, values, & beliefs
5
Q
Freedom
A
- the ability of an individual to act independently w/o coercion or constraint in ones choice and action
6
Q
Veracity
A
- being completely truthful with patients
- a patient’s right to truth
7
Q
Privacy
A
- the right to be left alone when you want to be
- to have control over your own personal possessions
- the right to not be observed w/o your consent
8
Q
Beneficence
A
- actions performed that contribute to the welfare of others
- action of doing good or right by and for the patient
9
Q
Fidelity
A
- right to what has been promised
- keeping to one’s promise
10
Q
Telehealth
A
- use of electronic information and telecommunications technologies to support:
- long-distance clinical healthcare
- patient and professional health-related education
- public health
- health administration
technologies include:
- videoconferencing
- the internet
- store-and-forward imaging
- streaming media
- terrestrial & wireless communications
11
Q
Telemedicine
A
- remote clinical health services
12
Q
mHealth
A
- Mobile health
- the practice of medicine and public health supported by mobiles devices such as:
- mobiles phones
- tablets
- personal digital assistants
- the wireless infrastructure
- the use of wireless communication to support efficiency in public health and clinical practice
13
Q
Mobile Medical Applications (Apps)
A
- accessories to a regulated medical device or are software that transforms a mobile platform into a regulated medical device
- facilitates mHealth
14
Q
Medical devices
A
- any equipment, instrument, implant, material, or apparatus used for the diagnosis, treatment, or monitoring of patients
15
Q
Rationale APP is NOT considered medical devices
A
Apps that are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease
16
Q
FDA Oversight for Medical Devices
A
- regulatory body that oversees mobile apps that are medical devices and whose functionality could pose a risk to a patient’s safety if the mobile app were to not function as intended
- also oversees the cybersecurity management of these devices as well as the hospital network security
17
Q
Point of care (POC)
A
- testing and diagnosis at the patient’s side and can be conducted anywhere the patient is such as:
- home
- -physician office
- -ambulance
- -hospital bedside
18
Q
Privacy
A
- practice of maintaining the security and confidentiality of patient records
19
Q
Confidentiality
A
- the act of holding information in confidence, not to be released to unauthorized individuals
20
Q
Cybersecurity
A
- measures taken to protect a computer or computer system against unauthorized access or attack
- FDA is main regulatory agency
21
Q
Computer-aided translators
A
- language translation in which a human translator uses computer hardware to support and facilitate the translation process
22
Q
Health Insurance Portability and Accountability Act (HIPPA)
A
- enacted in 1996
- federal law that required the creation of national standards to protect sensitive patient health information from being disclosed w/o the patient’s consent or knowledge
23
Q
ICD-10 Codes
A
- alphanumeric codes used by doctors, health insurance companies, and public health agencies across the world to represent diagnoses
- shorthand for the patient’s diagnosis, which are used to provide the payer information on the necessity of the visit or procedure performed
24
Q
Current procedural terminology (CPT)
A
- official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non-physician providers
25
Q
Evaluation and Management Coding (E/M coding)
A
- process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing
26
Q
Necessity for establishing E/M codes
A
- place of service
- type of service
- patient status
27
Q
Components of risk-based E/M coding
A
- history
- physical
- medical decision making
28
Q
Medical decision making (MDM)
A
- 1 of 3 components to establishing E/M codes
- way of quantifying the complexity of thinking that is required for the visit
29
Q
3 key elements to medical decision making
A
- risk
- data
- diagnosis
30
Q
Reimbursement coding
A
- claims and documentation filed by providers using medical diagnosis and procedure codes
- assigned contingent upon data input from clinical team members based on a summative review of the clinical record by trained coders
31
Q
Clinical support tools
A
- found in EHR software that when applied effectively can:
- enhance patient care quality and outcomes
- improve efficiency
- help to ensure regulatory compliance
- process designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient-specific:
- interventions
- assessments
- other forms of guidance for clinicians, patients, and others involved in care delivery
32
Q
Alert fatigue
A
- main challenge to effective implementation of CDS tools
33
Q
Primary goal of CDS tools
A
- leverage data and the scientific evidence to help guide appropriate decision making
34
Q
Workflow
A
- term used to describe the action or execution of a series of tasks in a prescribed sequence
- the progression of steps (tasks, events, interactions) that constitute a work process, involve two or more persons and create or add value to the organization’s activities
- used interchangeably w/ process or process flows
35
Q
Workflow analysis
A
- study of the way work (inputs, activities, and outputs) moves through an organizations
- observation and documentation of workflow to better understand what is happening in the current environment and how it can be altered
36
Q
Sequential workflow
A
- each step depends on the occurrence of the previous step
37
Q
Parallel workflow
A
- two or more steps in a process can occur concurrently
38
Q
Workflow design
A
- a critical aspect of the informatics role in workflow analysis
39
Q
American Recovery and Reinvestment Act of 2009 (ARRA)
A
- provided funds to government agencies for improving information-technology systems
- provisions include the right for every person to receive an electronic copy of their EHR and to have a copy of their EHR transmitted to a party that they designate
40
Q
Patient Protection and Affordable Care Act (ACA)
A
- guarantees healthcare for all Americans
- expands Medicaid
- provides incentives intended to improve care coordination and quality
- restructures healthcare payment
- provides additional information to patients so that they can make value-based decisions
41
Q
Administrative data
A
- include billing information derived from insurance claims, inpatient discharges (or hospital bills) and outpatient visits
42
Q
National Prevention Strategy: America’s Plan for Better Health and Wellness
A
- comprehensive plan that sets forth evidence-based and achievable means for improving health for all Americans at every stage of life
- these efforts are designed to stop disease before it starts and to create strategies for a healthy and fit nation, recognizing that prevention must be part of daily life
43
Q
Fee-for-Service Model
A
- a provider is given a set amount of monetary reimbursement for a specific visit or procedure performed that is adjusted for geographical location
44
Q
Medical coding
A
- use of codes to communicate with payers about which procedures were performed and why
45
Q
Medical billing
A
- process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider
46
Q
General principles of nursing informatics
A
- essential skills related to informatics deemed appropriate
47
Q
Nursing informatics
A
- integrates nursing science with multiple information and analytical sciences to identify, define, manage, and communicate data information knowledge and wisdom and nursing practice
48
Q
Nomenclature
A
- naming system
49
Q
Classification system
A
- assistant that captures categories that are used for cost or clinical documentation
50
Q
International statistical classification of diseases and related health problems (ICD)
A
- ICD is used as a standard terminology (ST) parentheses not always accepted
51
Q
Standard terminology
A
- structured controlled languages developed to represent concepts in a given domain in a clear fashion
52
Q
Taxonomy
A
- used classification according to a predetermined system to provide a framework for discussion
53
Q
Data set
A
- a named collection of data consisting of individual information organized in a prescribed fashion
54
Q
Benefits of using a data set
A
- efficiency, accuracy, and effectiveness resulting in improved patient care and outcomes
- has an effect on cost information visibility and transformation/health care reform
55
Q
Knowledge
A
- the awareness and understanding of a set of information and ways that information can be made useful to support a specific task or arrive at a decision
56
Q
Wisdom
A
- knowledge applied in a practical way
- this highest form of common sense
- entails knowing when and how to apply knowledge
- it is through efforts to understand the nature of knowledge in its evolution that one can conceive of to build and implement informatics tools to enhance and mimic the mind’s processes to facilitate decision-making and job performance
57
Q
Scientific underpinning
A
- the foundation of nursing science through research data evidence and idea creation
58
Q
The Foundation of Knowledge Model
A
- a model proposing that humans are organic information systems constantly acquiring, processing, generating, and disseminating information or knowledge in both their professional and personal lives
59
Q
Computer science
A
- studies the theory underpinning information and computation and their implementation and computer systems
60
Q
Cognitive science
A
- how the human mind works from an information processing perspective
61
Q
Information science
A
- the retrieval and management of information as well as human-computer interaction
62
Q
Two types of informatics competencies
A
- generalist: knowledgeable with experience
- nurse specialist: graduate-level education specialized education
63
Q
Information literacy
A
- the ability to identify when information is needed as well as the skills to find, evaluate, and effectively use the same information
64
Q
Health literacy
A
- the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
65
Q
Meaningful use (MU)
A
- using technology and health information to increase the quality of care delivered
66
Q
Patient-centered information systems
A
- patient-centered information systems focused on collecting data and disseminating information related to direct care
67
Q
Four most common types of PCS systems
A
- clinical documentation systems
- pharmacy information systems
- laboratory information systems
- radiology information systems
68
Q
Clinical decision support systems
A
- a computer-based program designed to assist clinicians in making clinical decisions by filtering or integrating vast amounts of information and providing suggestions for clinical interventions
69
Q
Electronic medical records (EMR)/ electronic health records (EHR)
A
- a database of an individual’s healthcare data during healthcare encounters and/or comprised of any patient data stored in electronic form
70
Q
Electronic health record system
A
- the database management software enabling the many functions needed to create and maintain an EHR
71
Q
POE
A
- practitioner order entry
72
Q
CPOE
A
- computerized practitioner order entry
73
Q
CDS
A
- clinical decision support
74
Q
Human technology interface
A
- the hardware and software through which the user interacts with any technology
- for example:
- computers, patient monitors, telephones
- the human-technology interface addresses the user’s ability and technologies functionality to complete the task demand
75
Q
Health Information Technologies (HIT)
A
- hardware/software integrated technologies are related licenses, intellectual property upgrades, or packaged solutions sold as services that are designed for or support the use by healthcare entities
- patients for the electronic creation, maintenance, access, or exchange of health information
76
Q
Alarm fatigue
A
- multiple false alarms by smart technology that cause workers to ignore or respond slowly to them
77
Q
Digital natives
A
- a person born or brought up during the age of digital technology and therefore familiar with computers and the internet from an early age
78
Q
Information literacy competency standards for nursing
A
- able to recognize when information is needed and having the ability to locate, evaluate, and use effectively the needed information
79
Q
HITECH Act of 2009
A
- provided incentive payments to hospitals and healthcare providers to adopt health IT
80
Q
TIGER based nursing informatics competencies model
A
- technology informatics guiding education reform team
- a plan to include informatics courses and all levels of nursing education
- when the effort is complete they will examine how to get the information out to practicing nurses who are not currently enrolled in an academic program
81
Q
Meaningful use (MU)
A
- the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare/Medicaid
