The Electronic Health Record and Clinical Informatics Flashcards
The Health Information Management Competency Model is divided into six levels:
Personal Effectiveness Competencies
Academic Competencies
Workplace Competencies
Industry-Wide Technical Competencies
Industry-Sector Technical Competencies
Management Competencies level shared with Occupation-Specific Requirements
The drive to adopt EHRs was underscored with the passage of the
Health Information Technology for Economic and Clinical Health Act of 2009
It is essential that ________________ be developed if nurses are to participate fully in the changing world of health care information technology
EHR competency
In _________________, _____________________ raised the profile of EHRs in his State of the Union Address by outlining a plan to ensure that most Americans have an EHR by ______
January 2004; President George W. Bush; 2014
The ________________________________________________________ has been tracking EHR adoption since 2005 through its ________________________
Health Information Management Systems Society; Stage 7 award
This legislation included the HITECH Act, which specifically sought to incentivize health organizations and providers to become meaningful users of EHRs.
American Recovery and Reinvestment Act of 2009
Initially, HHS granted two organizations the authority to accredit EHRs:
Drummond Group and Certification Commission for Healthcare Information Technology
IOM definition of EHR 8 components:
- health information and data
- results management
- order entry management
- decision support
- electronic communication and activity
- patient support
- administrative processes
- reporting and population health management
8 certification criteria categories
- Clinical Processes
- Care Coordination
- Clinical Quality Measurement
- Privacy and Security
- Patient Engagement
- Public Health
- Health IT Design and Performance
- Electronic Exchange
According to the Federal Register, the _________________________________ changed the 2015 criteria
21st Century Cures Act
are the economic and social conditions, in relation to their diffusion and distribution, among the population that actually influence individual and group differences and disparities in health status
Social Determinants of Health
they are the conditions of the environment in which people are born and play, grow, learn, live, work, and age that impact and affect a wide range of health, functioning, and quality-of-life outcomes and risks
Social Determinants of Health
HealthyPeople.gov (2020) stated that there 5 key domains for the SDOH:
- Economic Stability
- Education
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
developed to identify and attend to the SDOH needs that affect healthcare utilization and costs
Accountable Health Communities Model
this addresses a critical gap between clinical care and community services in the current health care delivery system
Accountable Health Communities Model
this is based on the emerging proof that tackling health-related social needs through improved clinical-community relationships can improve health outcomes and decrease costs
Accountable Health Communities Model
is an example of data analytics being used to guide our actions on the data and information that exist at our fingertips
Accountable Health Communities Model
compromise the patient data required to make sound clinical decisions, including demographics, medical and nursing diagnoses, medication lists, allergies, and test results
Health information and data
is a digital, or electronic, record that can provide a comprehensive health information about patients
EHR
are designed to disseminate patient information to healthcare providers, laboratories, imagine centers, pharmacies, etc.
EHR systems
is the ability to manage results of all types electronically, including both current and historical laboratory and radiology procedure reports
Results Management
is the ability of a clinician to enter medication and other care orders
Order Entry Management
entails the use of computer reminders and alerts to improve the diagnosis and care of a patient
Decision Support
include the online communication among healthcare team members and their care partners and with their patients
Electronic communication and connectivity
encompasses patient education and self-monitoring tools, including computer-based patient education, home telemonitoring, and telehealth systems
Patient Support
are activities carried out by the electronic scheduling, billing and claims management systems
Administrative processes
are the data collection tools that support public and private reporting requirements, including data represented in a standardized terminology and machine-readable format
Reporting and population health management
Health Level 7 International was founded in ?
1987
is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information
Health Level 7 International
This group concentrates on developing the behind the scenes programming standards for interfaces to ensure interoperability and connectivity among systems
Health Level 7 International
Early in the development of EHRs, their 4 most common benefits cited were
- increased delivery of guidelines-based care
- enhanced capacity to perform surveilance and monitoring for disease conditions
- reduction in medication errors
- decreased use of care
refers to U.S medical hospitals and clinics that have a mission, legal duty, or obligation to affor health care to individuals irrespective of their ability to pay or health insurance status, thus making all of these facilities provide access and acre to all of the U.S population
Safety net
recognizes healthcare organizations that have achieved both excellence in implementation and value from health information technology
Davies Award
is a technology-based system applied at the point of care and designed to support care by providing instance access to information for clinicians
Clinical Information System
can be thought of as the integration of clinical expertise and best practices based on systematic research to enhance decision-making and improve patient care
Evidence-based Practice
EHRs will lead to the following benefits:
- Better health care
- Better health
- Improved efficiences and lower healthcare costs
- Better clinical decision making
interface terminologies
NANDA, NIC, NIC
reference terminologies
SNOMED CT, LOINC
Administrative (Billing) Terminologies
ICD-10, CPT
medical diagnosis code set
ICD-10
used to code procedures for billing
CPT
Clinical Terminologies
SNOMED CT, LOINC, RxNorm, Unified Medical Language System (UMLS) and the Methathesaurus
comprehensive clinical terminology
SNOMED CT
universal codes for laboratory and clinical observations
LOINC
terminology system for drug names, which provides links to drug vocabularies and intercation software
RxNorm
support terminology integration efforts and online searches
Unified Medical Language System (UMLS) and the Methathesaurus
a payment incentice program established by the CMS
Accountable Care Organizations
Applications: Enhancing the EHR
AI, Patient Engagement, Blockchain
is a secure technology that could cure this transactional inefficiency and bring all of these pieces of information concerning a patient together so that all the records are in sync all the time
Blockchain Technology
